Cultural competence in outpatient substance abuse treatment: measurement and relationship to wait time and retention

Availability of substance use disorder treatment in Spanish: Associations with state-level proportions of Spanish speakers and treatment facility characteristics in the United States

BACKGROUND AND OBJECTIVES

Spanish is the second most spoken language in the United States. Not all substance use disorder (SUD) treatment facilities provide treatment in Spanish. This study examined factors associated with SUD treatment facilities having counselors that provide treatment in Spanish.

METHODS

State-level estimates of Spanish-speaking individuals were derived from the American Community Survey 2019. SUD treatment facility characteristics were captured from the National Survey of Substance Abuse Treatment Services 2020. We examined a sample of 15,246 facilities which included 12,798 outpatient, 3554 nonhospital residential, and 1106 with both outpatient and residential programs. Binary logistic regression models were used to observe state-level proportions of Spanish speakers and facility-level characteristics as factors associated with a facility having counselors that provide treatment in Spanish.

RESULTS

Approximately 23.3% of facilities had counselors able to provide treatment in Spanish. Among outpatient or nonhospital residential SUD facilities, those in a state with a larger proportion of Spanish-speaking individuals, facilities with pay assistance, facilities that accept Medicaid, and facilities that engage in community outreach had higher odds of having counselors that provide treatment in Spanish.

CONCLUSIONS

Considering that less than a quarter of facilities provide treatment in Spanish, increasing the availability of linguistically appropriate and culturally responsive services for SUD is imperative.

SCIENTIFIC SIGNIFICANCE

This national study is the first of its kind to examine associations between estimates of Spanish speakers and treatment facility characteristics associated with counselors that provide treatment in Spanish in outpatient and nonhospital residential SUD treatment.

Identifying the Heterogeneity in the Association between Workforce Diversity and Retention in Opioid Treatment among Black clients

Background

This study investigates the impact of workforce diversity, specifically staff identified as Black/African American, on retention in opioid use disorder (OUD) treatment, aiming to enhance patient outcomes. Employing a novel machine learning technique known as 'causal forest,' we explore heterogeneous treatment effects on retention.

Methods

We relied on four waves of the National Drug Abuse Treatment System Survey (NDATSS), a nationally representative longitudinal dataset of treatment programs. We analyzed OUD program data from the years 2000, 2005, 2014 and 2017 (n = 627). Employing the 'causal forest' method, we analyzed the heterogeneity in the relationship between workforce diversity and retention in OUD treatment. Interviews with program directors and clinical supervisors provided the data for this study.

Results

The results reveal diversity-related variations in the association with retention across 61 out of 627 OUD treatment programs (less than 10%). These programs, associated with positive impacts of workforce diversity, were more likely private-for-profit, newer, had lower percentages of Black and Latino clients, lower staff-to-client ratios, higher proportions of staff with graduate degrees, and lower percentages of unemployed clients.

Conclusions

While workforce diversity is crucial, our findings underscore that it alone is insufficient for improving retention in addiction health services research. Programs with characteristics typically linked to positive outcomes are better positioned to maximize the benefits of a diverse workforce in client retention. This research has implications for policy and program design, guiding decisions on resource allocation and workforce diversity to enhance retention rates among Black clients with OUDs.

Opioid treatment program culture and philosophy: Views of OTP staff and state officials on implementing interim methadone treatment

INTRODUCTION

People seeking treatment at opioid treatment programs (OTPs) can face admission delays. Interim methadone (IM) treatment, an effective approach to expedite admissions when programs lack sufficient counseling staff, has been seldom implemented. A study of implementation facilitation to spur the use of IM was conducted among six OTPs and their state opioid treatment authorities (SOTAs) in four US states. Between study recruitment and launch, organizational changes at three OTPs eliminated their need for IM. Two OTPs' requests to their states to provide IM (one prior to study launch and one following launch) were deferred by the states due to internal issues that required resolution to comply with federal IM regulations. During the study, another OTP's delays resolved, and one OTP streamlined its admissions procedures.

METHODS

Virtual interviews were conducted with 16 OTP staff and SOTAs from six OTPs in four US states following their participation in the parent study. Interviews focused on the feasibility and acceptability of the implementation intervention for IM. We analyzed data using a constant comparative approach.

RESULTS

Two overarching themes emerged from the qualitative data with respect to the role that organizational culture plays in OTP staff views of efforts to implement interim methadone: (1) the contrasting views of interim methadone based on whether staff adopt a traditional treatment vs. harm reduction philosophy and (2) the importance of reconciling these philosophies in addressing the culture shift that would accompany the process of implementing IM.

CONCLUSIONS

Organizational treatment philosophy and program culture emerged as important factors determining the OTPs' staff's willingness to adopt new approaches to expedite admissions. Participants noted a tension between traditional treatment and harm reduction philosophies that impacted their views of IM, in part based on when they entered the drug treatment field. While understanding and addressing treatment philosophy and organizational culture and willingness to change is of importance when implementing new approaches in OTPs, leadership at the state and OTP level are powerful drivers of change.

Organizational access points and substance use disorder treatment utilization among Black women: a longitudinal cohort study

INTRODUCTION

Health and social service organizations, including the emergency department (ED) and public assistance programs, constitute a social safety net that may serve as an "access point" for substance use treatment utilization. Racialization of substance use disorder (SUD) and gender disparities in access to treatment contribute to differences in health and social service utilization, including substance use treatment for Black women. We therefore explored the role of various access points in facilitating the use of substance use treatment among Black women with substance use and involvement in the criminal justice system.

METHODS

We used data from the Black Women in the Study of Epidemics (B-WISE) project (2008-2011), which recruited Black women who use drugs from community, probation, and prison recruitment settings in Kentucky. B-WISE is a three-wave panel survey collected on a six-month interval. We estimated dynamic panel models to understand whether time-varying use of services influenced women's substance use treatment utilization over 18-months, adjusting for time-invariant characteristics. We stratified the analysis based on where women were recruited (i.e., community, prison, and probation).

RESULTS

The sample included 310 persons and 930 person-waves. For the community and prison samples, the use of an ED in the 6 months prior decreased women's likelihood of subsequent substance use treatment use (Coef: -0.21 (95% CI: -0.40, -0.01); -0.33 (95% CI: -0.60, -0.06), respectively). For the probation sample, receiving support from public assistance (i.e., food stamps, housing, cash assistance) increased the likelihood of subsequent substance use treatment use (0.27 (95% CI: 0.08, 0.46)).

CONCLUSION

Interactions with health and social service organizations predicted Black women's use of substance use treatment services and varied based on their involvement in the criminal justice system. Public assistance venues for Black women on probation may be a point of intervention to increase their access to and use of substance use treatment.

Key person-centered care domains for residential substance use disorder treatment facilities: former clients' perspectives

BACKGROUND

While person-centered care (PCC) includes multiple domains, residential substance use disorder (SUD) treatment clients may value certain domains over others. We sought to identify the PCC domains most valued by former residential SUD treatment clients. We also sought to explore conceptual distinctions between potential theoretical PCC subdomains.

METHODS

We distributed an online survey via social media to a national convenience sample of former residential SUD treatment clients. Respondents were presented with ten PCC domains in an online survey: (a) access to evidence-based care; (b) integration of care; (c) diversity/respect for other cultures; (d) individualization of care; (e) emotional support; (f) family involvement in treatment; (g) transitional services; (h) aftercare; (i) physical comfort; and (j) information provision. Respondents were asked to select up to two domains they deemed most important to their residential SUD treatment experience. We used descriptive statistics to identify response frequencies and logistic regression to predict relationships between selected domains and respondents' race, gender, relationship status, parenting status, and housing stability.

RESULTS

Our final sample included 435 former residential SUD treatment clients. Diversity and respect for different cultures was the most frequently selected domain (29%), followed by integration of care (26%), emotional support (26%), and individualization of care (26%). Provision of information was the least frequently chosen domain (3%). Race and ethnicity were not predictive of selecting respect for diversity. Also, parental status, relationship status and gender were not predictive of selecting family integration. Employment and housing status were not predictive of selecting transitional services.

CONCLUSIONS

While residential SUD treatment facilities should seek to implement PCC across all domains, our results suggest facilities should prioritize (a) operationalizing diversity, (b) integration of care, and (c) emotional support. Significant heterogeneity exists regarding PCC domains deemed most important to clients. PCC domains valued by clients cannot be easily predicted based on client demographics.

The impact of organisational factors on treatment outcomes for those seeking alcohol or other drug treatment: A systematic review

INTRODUCTION

Organisational factors have been found to be associated with health outcomes in a number of health-care settings. Despite likely being an important influence on the quality of care provided within alcohol and other drug (AOD) treatment centres, the impact of organisational factors on AOD treatment outcomes have not been extensively explored. This systematic literature review examines the characteristics, methodological quality and findings of published studies exploring the association between organisational factors and client AOD treatment outcomes.

METHODS

Medline, Embase, PsycINFO and the Cochrane database were searched from 2010 to March 2022 for relevant papers. Studies meeting the inclusion criteria underwent quality assessment using the Joanna Brigg's Institute critical appraisal tool for cross-sectional studies, followed by data extraction of key variables pertaining to the aims. A narrative summary was used to synthesise the data.

RESULTS

Nine studies met the inclusion criteria. Organisational factors examined included cultural competency, organisational readiness for change, directorial leadership, continuity of care practices, service access, service to needs ratios, dual diagnosis training, therapeutic optimism and the funding model/health-care system that treatment was delivered in. Outcome measures included duration, completion or continuation of treatment; AOD use; and patient perceptions of treatment outcomes. Seven out of nine papers found a significant interaction between at least one organisational variable and AOD treatment outcomes.

DISCUSSION AND CONCLUSIONS

Organisational factors are likely to impact treatment outcomes for patients seeking treatment for AOD. Further examination of the organisational factors that influence AOD outcomes is needed to inform systemic improvements to AOD treatment.

Identification of the socio-cultural barriers of drug addiction treatment in Iran

Introduction

Socio-cultural norms can either be encouraging or a barrier to addiction treatment. More, rigorous research is needed on nonindigenous models in addiction treatment, to better understand the role of socio-cultural differences.

Methods

The present qualitative study is part of the project, "The Inclusive Assessment of the Barriers of Drug Addiction Treatment Services in Iran," which was conducted in Tehran from 2018 to 2021. The participants consisted of eight people who used drugs, seven individual family members of the people who used drugs participants, seven service providers, and four policymakers. A purposeful sampling method was used for the selection of the participants, and the process continued until reaching the theoretical saturation of data. Analysis used the Graneheim and Lundman methods, classifying primary codes, the sub-themes, and themes were classified according to the similarities and differences between primary codes.

Finding

The most important socio-cultural barriers to addiction treatment in Iran are: unrealistic expectations of the family and society from the people who use drugs, addiction stigma, mistrust between various components of the treatment system, perceptions that professional substance use disorder treatment is inefficient and low uptake of that treatment, the disturbed relational boundaries between the people who use drugs and their relatives, the interweaving of treatment and ethical and religious principles, low acceptance of maintenance treatments, treatment focusing on short-term outcomes, and presence of facilitating backgrounds of using drugs.

Conclusions

The Iranian socio-cultural characteristics play an important role in the addiction treatment of the people who use drugs, so it is necessary for treatment interventions to be sensitive to these characteristics.

Measuring the Cultural Competence of Latinx Domestic Violence Service Organizations

Domestic violence (DV) represents a significant public health concern in the United States, including among Latinx populations. Despite the negative consequences associated with experiencing DV, research has shown that Latinx DV survivors may be less likely than others to utilize important services. One potential barrier is cultural competence (CC) in the provision of services specific to Latinx survivors among DV organizations. Thus, a beneficial addition to the field of DV service provision for such survivors is a better understanding and measurement of CC for this unique population. The exploratory, cross-sectional study herein presents the development and evaluation of a novel instrument for measuring the CC of DV organizations. Exploratory factor analysis was used on a purposive sample of 76 organizations in North Carolina who completed a comprehensive survey on their characteristics, practices, norms, and values. Psychometric results found best support for a 29-item, 4-factor bifactor model with both a general CC factor as well as three sub-factors. The general scale was named "General Cultural Competence," while the three sub-scales were named "Organizational Values and Procedures," "Latinx Knowledge and Inclusion," and "Latinx DV Knowledge." The final measure also demonstrated convergent validity with key organizational characteristics. Overall, higher CC scores were associated with organizations having more DV services in Spanish, a higher percentage of staff attending CC training, a higher percentage of staff attending Latinx service provision training, and a medium or greater presence in the Latinx community, and a moderate or stronger relationship with the Latinx community. The development of this measure is particularly useful in addressing knowledge gaps regarding the measurement of CC for Latinx DV services. Implications have importance for both the measurement of organizational CC and the scope of the measure's associations with organizational, provider, and client outcomes.

Gender disparities in access and retention in outpatient methadone treatment for opioid use disorder in low-income urban communities

The purpose of this study was to detect and understand gender disparities in access and retention among outpatient methadone treatment programs located in low-income urban communities in Los Angeles, California. The study collected client- and program-level data in 4 waves in 2011, 2013, 2015, and 2017 from 34 publicly funded methadone treatment programs serving 11,169 clients with opioid use disorder (OUD). The sample included 29.8% female and 70.2% male clients, where 10.6% identified as Black or African American, 41.5% as Latino, 44.2% as non-Latino white, and 3.8% as Other. We conducted two multilevel negative binomial regression models to examine direct and moderated relationships related to both access (days on the waitlist) and retention (days in treatment) while accounting for clients clustered within programs. Gender disparities existed in both access and retention where women spent more time than men waiting to enter treatment but then remained in treatment longer. Further, female clients identifying as African American, Latino, and Other were at greater risk for shorter treatment duration than those who identified as non-Latino white and men. Overall, OUD clients receiving methadone treatment in low-income neighborhoods experienced barriers to access and retention in treatment associated with mental illness, family responsibilities, and use severity. OUD clients with MediCal insurance eligibility were consistently more likely to gain access to and remain in methadone treatment. Overall, findings call for improving treatment access and retention for women with OUD who receive methadone in outpatient methadone treatment programs through comprehensive, gender-specific, and evidence-based programming.

La Cultura Cura: Latino Culture, Shared Experiences, and Recovery in Northern Californian Anexos

This article examines the anexo's use of Latino culture and shared experiences to promote recovery and its appeal to 1.5- and second-generation Latinos. Anexos are grassroots recovery groups with origins in Mexico that offer a residential Alcoholics Anonymous program in Latino communities. Data were gathered from a two-year (2014-2016) ethnographic study of anexos in Northern California and were analyzed thematically. Despite having access to publicly funded treatment, many 1.5- and second-generation Latinos accessed anexos based on cultural familiarity, shared experiences, and a desire to recuperate cultural practices lost during their substance use.

Grassroots interventions for alcohol use disorders in the Mexican immigrant community: A narrative literature review

This narrative literature review addresses grassroots interventions for alcohol use disorders as practiced in Mexican immigrant communities. These organic efforts are 24-hour AA groups, or anexos, fourth and fifth step AA groups, juramentos, and curanderismo. Literature was identified using PubMed and CINAHL and limited to works published from 2000 to 2018. In all, three publications on 24-hour groups were found, two on fourth and fifth step groups, four on juramentos, and one on curanderismo use. The review offers insight on their practices and concludes that the interventions' cultural resonance provides advantages over cultural competency AUDs programs developed in public health.

Gender and Cultural Adaptations for Diversity: A Systematic Review of Alcohol and Substance Abuse Interventions for Latino Males

BACKGROUND

Latino men are disproportionately affected by the consequences of alcohol and substance abuse when compared to non-Latino white men. Latino men also face greater barriers to accessing, engaging, and completing alcohol and substance abuse treatment services. Culturally adapted interventions are promoted to overcome these barriers. However, the effectiveness of these efforts is unclear.

OBJECTIVES

The purpose of this review was to summarize the published evidence regarding gender-adapted and culturally adapted alcohol and substance abuse treatment that aims to improve physical, behavioral, and social outcomes in Latino men.

METHODS

A systematic literature search was conducted for articles reporting on culturally and/or gender-adapted alcohol and/or substance abuse interventions designed exclusively for Latino adults, including a Latino population sample of at least 10% and any proportion of Latino male participants. A thematic analysis based on predetermined themes was used to evaluate the nature of adaptations.

RESULTS

Searches yielded 2685 titles, resulting in 12 articles that fit review parameters. The most scientifically rigorous findings suggest culturally adapted interventions may outperform standard treatment. Nevertheless, a fraction of the interventions did not improve outcomes compared to standard treatment. Considering the scarce number of publications, it is difficult to discern if null findings reflect ineffective interventions or methodological limitations.

CONCLUSIONS

While studies are limited and findings are mixed, culturally tailored work shows promise. The growth rate of the Latino population and the current epidemic nature of substance abuse in the United States generate urgency to identify methods to diminish the disparate burden of alcohol and substance abuse in Latinos.

Barriers to and Correlates of Retention in Behavioral Health Treatment Among Latinos in 2 Different Host Countries: The United States and Spain

CONTEXT

Latino immigrants constitute a large portion of the Spanish and US immigrant populations, yet a dearth of research exists regarding barriers to retention in behavioral health care.

OBJECTIVES

To identify and compare perceived barriers related to behavioral health care among first- and second-generation Latinos in Boston, Madrid, and Barcelona, and evaluate whether the frequency of behavioral health care use in the last year was related to these barriers.

DESIGN, SETTING, AND PARTICIPANTS

Data were obtained from the International Latino Research Partnership project. First- or second-generation self-identified Latino immigrants aged 18 years and more who resided more than 1 year in the host country were recruited from community agencies and primary care, mental health, substance abuse, and HIV clinics.

MAIN OUTCOME MEASURES

Eleven barriers were assessed and compared across sites. The relationship between barriers and behavioral services visits within the last year was evaluated, adjusting for sociodemographics, clinical measures, degree of health literacy, cultural, and social factors.

RESULTS

Wanting to handle the problem on one's own, thinking that treatment would not work, and being unsure of where to go or who to see were the most frequently reported barriers for Latino immigrants. Previous treatment failure, difficulties in transportation or scheduling, and linguistic barriers were more likely to be reported in Boston; trying to deal with mental health problems on one's own was more commonly reported in Barcelona and Madrid. Two barriers associated with the number of visits were concerns about the cost of services and uncertainty about where to go or who to see.

CONCLUSIONS

After adjusting for sociodemographics, clinical measures, degree of health literacy, cultural, and social factors, barriers still differed significantly across sites. Efforts to improve behavioral health services must be tailored to immigrants' context, with attention to changing attitudes of self-reliance and outreach to improve access to and retention in care.

Response to culturally competent drug treatment among homeless persons with different living arrangements

This study investigated the association between program cultural competence and homeless individuals' drug use after treatment in Los Angeles County, California. Los Angeles County has the largest and most diverse population of homeless individuals in the nation. We randomly selected for analysis 52 drug-treatment programs and 2158 participants who identified as homeless in the Los Angeles County Participant Reporting System in 2011. We included their living arrangements (indoors and stable, indoors and unstable, and outdoors) and individual and program characteristics (particularly whether their programs used six culturally competent practices) in multilevel regression analyses. The outcome was days of primary drug use at discharge.Results showed that higher levels of staff personal involvement in minority communities (IRR=0.437; 95% CI=0.222, 0.861) and outreach to minority communities (IRR = 0.406; 95% CI=0.213, 0.771) were associated with fewer days of drug use at discharge. Homeless individuals living outdoors used their primary drug more often than any other group. Yet, compared to individuals with other living arrangements, when outdoor homeless individuals were treated by programs with the highest community resources and linkages (IRR=0.364; 95% CI=0.157, 0.844), they reported the fewest days of drug use. We discuss implications for program evaluation and community engagement policies and practices.

Does the implementation of evidence-based and culturally competent practices reduce disparities in addiction treatment outcomes?

RATIONALE

Research is limited on the extent to which implementation of evidence-based and culturally responsive practices reduces outcome disparities in substance use disorder treatment. We examined the role of contingency management treatment (CMT), medication-assisted treatment (MAT), and culturally competent practices on Mexican Americans' rate of successful completion of treatment.

METHODS

We analyzed a concatenated dataset from 153 publicly funded substance use disorder treatment programs in Los Angeles County, California, in 2011 and 2013. These data were merged with data from 15,412 adult clients in both periods, of whom we selected only Mexican Americans (46.3%) and non-Latino Whites (53.7%). The outcome was successful treatment completion. The main independent variables were client demographics, drug use severity, mental health issues, and program license and professional accreditation.

RESULTS

Less than half of the programs highly implemented CMT, MAT, and culturally competent practices. CMT and cultural competence were not associated with successful treatment completion. However, Mexican Americans in programs with high degree of implementation of MAT had higher odds of successfully completing treatment compared to non-Latino Whites and programs with low MAT (OR=1.389; 95% CI=1.018, 1.897).

CONCLUSIONS

Findings highlight the role of MAT in reducing the disparity in treatment completion between Mexican Americans and non-Latino Whites. Implications for health policy and the dissemination of MAT are discussed.

Reimagining Cultural Competence: Bringing Buried Dynamics Into the Light

Many organizations attempt to increase cultural competence as one way to foster organizational change to enhance equity and inclusion. But the literature on cultural competence is largely silent on the role of emotion, despite the strong feelings that inevitably accompany work in cross-racial dyads, groups, and institutions. We offer group relations theory as an approach rooted in the importance of emotions, especially anxiety, and offering a rich awareness of how unconscious processes, including defense mechanisms like splitting and projection, drive that anxiety. We show how this approach helps us both diagnose and address difficult dynamics, including by recognizing entrenched power inequities. We draw on examples from others’ research as well as our own research, teaching, and consulting to illustrate key concepts. Ultimately, we argue that buried emotions can create distance and inhibit change. Surfacing and addressing them can foster connection and provide a way for organizations to move forward.

Program Capacity to Eliminate Outcome Disparities in Addiction Health Services

We evaluated program capacity factors associated with client outcomes in publicly funded substance abuse treatment organizations in one of the most populous and diverse regions of the United States. Using multilevel cross-sectional analyses of program data (n = 97) merged with client data from 2010 to 2011 for adults (n = 8,599), we examined the relationships between program capacity (leadership, readiness for change, and Medi-Cal payment acceptance) and client wait time and treatment duration. Acceptance of Medi-Cal was associated with shorter wait times, whereas organizational readiness for change was positively related to treatment duration. Staff attributes were negatively related to treatment duration. Overall, compared to low program capacity, high program capacity was negatively associated with wait time and positively related to treatment duration. In conclusion, program capacity, an organizational indicator of performance, plays a significant role in access to and duration of treatment. Implications for health care reform implementation in relation to expansion of public health insurance and capacity building to promote health equities are discussed.

Abstinence at Successful Discharge in Publicly Funded Addiction Health Services

Abstinence at successful discharge in substance use disorder treatment is important to reducing relapse rates and increasing long-term recovery from substance use disorders. However, few studies have examined abstinence as an essential component of successful discharge. This study examined rates and correlates of reported abstinence (nonuse of drugs 30 days prior to successful discharge) among clients attending publicly funded treatment in Los Angeles County, California. Finding show that only 36% of clients who were successfully discharged reported abstinence. Black clients were less likely than non-Hispanic Whites to report abstinence at successful discharge. Clients in methadone treatment programs were less likely than outpatient clients to report abstinence, whereas clients referred to treatment through the legal system (Proposition 36) were more likely to report abstinence compared to self-referred clients. Findings underscore the importance of systematic assessment of abstinence in determining successful discharge and provide a basis for further examination of strategies to improve abstinence and reduce relapse.

Organizational implementation of evidence-based substance abuse treatment in racial and ethnic minority communities

We evaluated organizational factors associated with the implementation of contingency management treatment (CMT) and medication-assisted treatment (MAT) in substance abuse treatment (SAT) programs serving racial and ethnic minority communities. Analysis of cross-sectional data collected in 2010-2011 from a random sample of 148 publicly funded SAT programs showed that accepting private insurance was positively associated with CMT and MAT implementation, whereas larger programs were associated with greater implementation of MAT. Supervisorial openness to and expectations about implementing evidence-based practices (EBPs) and attributes for change were strongly associated with CMT, whereas the interactions between openness to EBPs and programs that accept private insurance and that are governed by parent organizations were positively associated with MAT. These external expectations and managerial attitudes supported the implementation of psychosocial and pharmacotherapy treatments in SAT. Implications for improving standards of care in minority communities are discussed.

Advances in Substance Abuse Prevention and Treatment Interventions Among Racial, Ethnic, and Sexual Minority Populations

Substance abuse research among racial, ethnic, and sexual minority populations historically has lagged behind that conducted with majority samples. However, interesting and potentially important advances in prevention, brief interventions, and treatment have been made in the last few years, at least among some minority populations, such as American Indian youth. New prevention efforts have focused on point-of-sale interventions for alcohol, as well as on family-unit interventions designed with subpopulation cultural values in mind. In addition, previously established evidence-based and culturally relevant interventions are being combined with computer technology. Empirical data support using brief interventions with patients of color in medical settings, capitalizing on teachable and reachable moments during a physical trauma or other health crisis. Finally, use of empirically supported treatment may be helpful, with a caveat that these interventions must appropriately match cultural traditions and respect the values of the clients. More research clearly is needed, especially among certain minority populations in the United States. A greater emphasis should be placed on developing novel, culturally grounded interventions in partnership with communities, in addition to adapting existing mainstream interventions for use by other cultures.

Drug use and service utilization among Hispanics in the United States

PURPOSE

To examine illicit drug use and service utilization patterns of US-born and foreign-born Hispanics in the United States.

METHODS

Hispanic respondents 18 years and older in the NESARC were categorized as being of Mexican (n = 3,556), Puerto Rican (n = 785), Cuban (n = 346), Central American (n = 513), or South American (n = 381) origin. We examined lifetime prevalence of drug use and substance abuse treatment utilization patterns for US-born and Hispanic immigrants across subgroups.

RESULTS

Lifetime prevalence of drug use was greater among US-born Hispanics than Hispanic immigrants after controlling for age, gender, income, education, urbanicity, parental history of drug use problems and lifetime DSM-IV mood/anxiety disorders. Both US-born and immigrant Hispanic drug users were less likely than non-Hispanic white drug users to have utilized any form of substance abuse treatment (US-born AOR = 0.89, immigrant AOR = 0.64) and more likely to have utilized family or social services (US-born AOR = 1.17, immigrant AOR = 1.19). Compared to US-born Hispanic drug users, Hispanic immigrant drug users were less likely to have used any form of substance abuse treatment (AOR = 0.81) and were more likely to have utilized family or social services (AOR = 1.22).

CONCLUSION

Strategies to increase engagement and retention of Hispanic drug users in substance abuse treatment include increasing access to linguistically and culturally competent programs that address unmet family and social needs. Further studies examining differences in drug use and service utilization patterns within Hispanic subgroups are needed.

Evaluating racial disparity in referral source and successful completion of substance abuse treatment

Health disparity is a significant problem in the United States, and particularly for substance abuse treatment programs. A better understanding of racial differences in treatment pathways associated with successful treatment completion is needed to reduce the existing health disparities. Referral source is a strong predictor of treatment success and most research on health disparities has focused on the criminal justice referrals. However, little research has examined other types of referral sources, and the interaction with race. The current study sought to compare the effect of referral sources on national substance abuse successful treatment completion rates between Black clients (n=324,625) and White clients (n=1,060,444) by examining the interaction of race on referral source and successful treatment completion. Race significantly moderated the difference between referral source and successful treatment completion (Wald χ(2)=1477.73, df=6, p<0.0001). Employment referral was associated with the greatest percentage of successful treatment completion for Black clients. Criminal justice referral was associated with the greatest percentage of successful treatment completion for White clients. Results from the present study support a reevaluation of incentives leading to successful treatment completion with a multicultural perspective.

Hispanic Subgroups, Acculturation, and Substance Abuse Treatment Outcomes

This study explored Hispanic subgroup differences in substance use treatment outcomes, and the relationship of acculturation characteristics to these outcomes. Data were from a multisite randomized clinical trial of motivational enhancement therapy versus treatment as usual in a sample of Spanish-speaking substance abusers. Participants were Cuban American (n=34), Mexican American (n=209), Puerto Rican (n=78), and other Hispanic American (n=54). Results suggested that Cuban Americans and individuals with more connection to Hispanic culture had lower treatment retention. Hispanics born in the U.S and those who spoke English at home had a lower percentage of days abstinent during weeks 5-16, although Puerto Ricans born in the U.S. and Cuban Americans living more years in the U.S. had a higher percentage of days abstinent in weeks 1-4 and 5-16, respectively. Results may inform future hypothesis-driven studies in larger Hispanic treatment seeking samples of the relationship between acculturation and treatment outcome.

Performance measures and racial/ethnic disparities in the treatment of substance use disorders

OBJECTIVE

A limited literature on racial/ethnic disparities in the treatment of substance use disorders suggests that quality of treatment may differ based on client's race/ethnicity. This study examined whether (a) disparities exist in the probability of treatment engagement, a performance measure for substance use disorders, and (b) treatment engagement is associated with similar reductions in likelihood of arrest for Whites, Blacks, Latinos, and American Indians.

METHOD

Adult clients who began an outpatient treatment episode in 2008 in public sector specialty treatment facilities in Connecticut, New York, Oklahoma, and Washington made up the sample (N = 108,654). Administrative treatment data were linked to criminal justice data. The criminal justice outcome was defined as an arrest within a year after beginning treatment. Engagement is defined as receiving a treatment service within 14 days of beginning a new outpatient treatment episode and at least two additional services within the next 30 days. Two-step Heckman probit models and hierarchical time-to-event models were used in the analyses.

RESULTS

Black clients in New York and American Indian clients in Washington had significantly lower likelihood of engagement than White clients. As moderators of engagement, race/ethnicity had inconsistent effects across states on the hazard of arrest.

CONCLUSIONS

Racial/ethnic minority groups may benefit from additional treatment support to reduce criminal justice involvement. States should examine whether disparities exist within their treatment system and incorporate disparities reduction in their quality improvement initiatives.

Evaluation of the organizational cultural competence of a community health center: a multimethod approach

Cultural competence is an important component of client-centered care in health promotion and community health services, especially considering the changing demographics of North America. Although a number of tools for evaluating cultural competence have been developed, few studies have reported on the results of organizational cultural competence evaluations in health care or social services settings. This article aims to fill this gap by providing a description of a cultural competence evaluation of a community health center serving a diverse population. Data collection included reviewing documents, and surveying staff, management, and the Board of Directors. The organization fully met 28 of 53 standards of cultural competence, partially met 21 standards, and did not meet 2 standards, and 2 standards could not be assessed due to missing information. The advantages and lessons learned from this organizational cultural competence evaluation are discussed.

Organizational capacity for service integration in community-based addiction health services

OBJECTIVES

We examined factors associated with readiness to coordinate mental health, public health, and HIV testing among community-based addiction health services programs.

METHODS

We analyzed client and program data collected in 2011 from publicly funded addiction health services treatment programs in Los Angeles County, California. We analyzed a sample of 14 379 clients nested in 104 programs by using logistic regressions examining odds of service coordination with mental health and public health providers. We conducted a separate analysis to examine the percentage of clients receiving HIV testing in each program.

RESULTS

Motivational readiness and organizational climate for change were associated with higher odds of coordination with mental health and public health services. Programs with professional accreditation had higher odds of coordinating with mental health services, whereas programs receiving public funding and methadone and residential programs (compared with outpatient) had a higher percentage of clients receiving coordinated HIV testing.

CONCLUSIONS

These findings provide an evidentiary base for the role of motivational readiness, organizational climate, and external regulation and funding in improving the capacity of addiction health services programs to develop integrated care.

Disparities in Latino substance use, service use, and treatment: implications for culturally and evidence-based interventions under health care reform

BACKGROUND

The goal of this systematic literature review was to enhance understanding of substance use, service use, and treatment among Latino subgroups to improve access to care and treatment outcomes in an era of health care reform.

METHODS

The authors used 13 electronic databases and manually searched the literature from January 1, 1978, to May 30, 2013. One hundred (69%) of 145 primary research articles met the inclusion criteria. Two blinded, independent reviewers scored each article. Consensus discussions and a content expert reconciled discrepancies.

RESULTS

Current rates of alcohol and substance abuse among Latinos are comparable to or surpass other U.S. ethnic groups. Disparities in access and quality of care are evident between Latinos and other ethnic groups. As a heterogeneous group, Latinos vary by geographic region in terms of substance of choice and their cultural identity takes precedence over general ethnic identity as a likely determinant of substance abuse behaviors. There is growing research interest in systems influencing treatment access and adherence among racial/ethnic and gender minority groups. However, studies on Latinos' service use and immediate treatment outcomes have been both limited in number and inconsistent in findings.

CONCLUSIONS

This review identified human capital, quality of care, and access to culturally responsive care as key strategies to eliminate disparities in health and treatment quality. Implications are discussed, including the need for effectiveness studies on Latinos served by systems of care that, under health care reform, are seeking to maximize resources, improve outcomes, and reduce variation in quality of care.

Spanish language proficiency among providers and Latino clients' engagement in substance abuse treatment

Quality of care, such as provision of services in Spanish, is a common factor believed to improve treatment engagement among Spanish-speaking Latinos in health care. However, there is little evidence that Spanish language proficiency among providers increases treatment access and retention in publicly funded substance abuse treatment. We analyzed client and program data collected in 2010-2011 from publicly funded treatment programs in Los Angeles County, California. An analytic sample of 1903 Latino clients nested within 40 treatment programs located in minority communities was analyzed using multilevel negative binomial regressions on days to initiate and spent in treatment. As hypothesized, Spanish language proficiency was negatively associated with client wait time and positively associated with retention in treatment, after controlling for individual and program characteristics. The path analysis models showed that Spanish language proficiency played a mediating role between professional accreditation and client wait time and retention. These preliminary findings provide an evidentiary base for the role of providers' Spanish language proficiency and Latino engagement in treatment for a population at high risk of treatment dropout. Implications related to health care reform legislation, which seeks to enhance linguistically competent care, are discussed.

Organizational structure, leadership and readiness for change and the implementation of organizational cultural competence in addiction health services

Increasing representation of racial and ethnic minorities in the health care system and on-going concerns about existing health disparities have pressured addiction health services programs to enhance their cultural competence. This study examines the extent to which organizational factors, such as structure, leadership and readiness for change contribute to the implementation of community, policy and staffing domains representing organizational cultural competence. Analysis of a randomly selected sample of 122 organizations located in primarily Latino and African American communities showed that programs with public funding and Medicaid reimbursement were positively associated with implementing policies and procedures, while leadership was associated with staff having greater knowledge of minority communities and developing a diverse workforce. Moreover, program climate was positively associated with staff knowledge of communities and having supportive policies and procedures, while programs with graduate staff and parent organizations were negatively associated with knowledge of and involvement in these communities. By investing in funding, leadership skills and a strategic climate, addiction health services programs may develop greater understanding and responsiveness of the service needs of minority communities. Implications for future research and program planning in an era of health care reform in the United States are discussed.

How the states stack up: disparities in substance abuse outpatient treatment completion rates for minorities

BACKGROUND

This study was an exploratory investigation of state-level minority disparities in successfully completing outpatient treatment, a major objective for attending substance abuse treatment and a known process outcome measure.

METHOD

This was a retrospective analysis of state discharge and admission data from the 2006 to 2008 Treatment Episode Datasets-Discharge (TEDS-D). Data were included representing all discharges from outpatient substance abuse treatment centers across the United States. All first treatment episode clients with admission/discharge records meeting inclusion criteria who could be classified as White, Latino, or Black/African American were used (n=940,058).

RESULTS

States demonstrated racial and ethnic disparities in their crude and adjusted completion rates, which also varied considerably among the states. Minorities typically showed a disadvantage. A few states showed significantly higher completion rates for Blacks or Latinos.

CONCLUSIONS

Realistically, a variety of factors likely cause the state race/ethnic differences in successful completion rates. States should investigate their delivery systems to reduce completion disparities.

Enhancing access and retention in substance abuse treatment: the role of Medicaid payment acceptance and cultural competence

BACKGROUND

Health insurance coverage and quality of care are common factors believed to improve access for and retention of racial and ethnic minority groups in health care. However, there is little evidence that acceptance of public insurance and provision of culturally responsive care decrease wait time and retention of minority populations in community-based substance abuse treatment.

METHODS

We analyzed client and program data collected in 2010-2011 from publicly funded treatment programs in Los Angeles County, CA. An analytical sample of 13,328 primarily African American and Latino clients nested within 104 treatment programs located in minority communities was analyzed using multilevel negative binomial regressions on count measures of days to initiate and days spent in treatment.

RESULTS

Programs that accepted public insurance (p<.001) and in which staff reported personal involvement (p<.01) and linkages and resources with minority communities (p<.001) were negatively associated with client wait time. Similarly, programs with culturally responsive policies and assessment and treatment practices (p<.05) were positively associated with retention in treatment, after controlling for individual and program characteristics.

CONCLUSIONS

These preliminary findings provide an evidentiary base for the role of community-based financial and cultural practices in improving accessibility and treatment adherence in a population at high risk of treatment dropout. Implications related to health care reform legislation, which seeks to expand public insurance and enhance culturally competent care, are discussed.

HIV infection among people who inject drugs: the challenge of racial/ethnic disparities

Racial/ethnic disparities in HIV infection, with minority groups typically having higher rates of infection, are a formidable public health challenge. In the United States, among both men and women who inject drugs, HIV infection rates are elevated among Hispanics and non-Hispanic Blacks. A meta-analysis of international research concluded that among persons who inject drugs, racial and ethnic minorities were twice as likely to acquire an HIV infection, though there was great variation across the individual studies. To examine strategies to reduce racial/ethnic disparities among persons who inject drugs, we reviewed studies on injection drug use and its role in HIV transmission. We identified four sets of evidence-based interventions that may reduce racial/ethnic disparities among persons who inject drugs: HIV counseling and testing, risk reduction services, access to antiretroviral therapy, and drug abuse treatment. Implementation of these services, however, is insufficient in many countries, including the United States. Persons who inject drugs appear to be changing drug use norms and rituals to reduce their risks. The challenges are to (a) develop a validated model of how racial/ethnic disparities in HIV infection arise, persist, and are reduced or eliminated over time and (b) implement evidence-based services on a sufficient scale to eliminate HIV transmission among all persons who inject drugs.

Do cultural and linguistic competence matter in Latinos' completion of mandated substance abuse treatment?

BACKGROUND

Increasing evidence suggests that culturally and linguistically responsive programs may improve substance abuse treatment outcomes among Latinos. However, little is known about whether individual practices or culturally and linguistically responsive contexts support efforts by first-time Latino clients to successfully complete mandated treatment.

METHODS

We analyzed client and program data from publicly funded treatment programs contracted through the criminal justice system in California. A sample of 5,150 first-time Latino clients nested within 48 treatment programs was analyzed using multilevel logistic regressions.

RESULTS

Outpatient treatment, homelessness, and a high frequency of drug use at intake were associated with decreased odds of treatment completion among Latinos. Programs that routinely offered a culturally and linguistically responsive practice-namely, Spanish-language translation-were associated with increased odds of completion of mandated treatment.

CONCLUSIONS

These preliminary findings suggest that concrete practices such as offering Spanish translation improve treatment adherence within a population that is at high risk of treatment dropout.

Travel distance to outpatient substance use disorder treatment facilities for Spanish-speaking clients

BACKGROUND

Travel distance and English proficiency skills are widely recognized factors associated with service access and treatment engagement. As Latino populations represent one of the most rapidly growing populations in the United States, methods are needed to better understand availability of linguistically appropriate services in Latino communities. Given regional variability in the density of Latino communities, the current study examines treatment access as travel distance to outpatient substance use disorder treatment facilities in one of the largest and most rapidly changing Latino communities in the United States - Los Angeles County, CA.

METHODS

Data from the 2010 U.S. Census and the National Survey of Substance Abuse Treatment Services were analyzed using a geographic information system approach to determine the street-level distance between treatment facilities with services in Spanish and Latino communities throughout L.A. County. This study used an innovative approach that included network analysis and spatial autocorrelation to identify "hot spots," i.e. clusters of census tracts with high-density Latino populations that were relatively far from treatment services in Spanish.

RESULTS

The analysis identified several key hot spots with significantly large Latino populations and far street distances to the closest facility offering Spanish-language services. The average distance between these hot spots and the closest facilities was 2.74 miles (SD=0.38), compared to a county average of 2.28 miles (SD=2.60). In several key hot spots, the distance was greater than 3 miles.

CONCLUSION

Despite the growing presence of Latinos in L.A. County in 2010, constrained access to services in Spanish was found in geographic locations highly represented by Latinos. The distances identified in this study are almost triple the 1-mile threshold representing reduced access to treatment as determined by other studies. Geographic information systems represent an innovative and user-friendly approach for effectively and efficiently identifying areas with the greatest service needs. This approach can inform policies to increase the capacity of ethnic minority communities to develop linguistically responsive social services.

Workforce diversity in outpatient substance abuse treatment: the role of leaders' characteristics

Although the outpatient substance abuse treatment field has seen an increase in referrals of African American and Latino clients, there have been limited changes in the diversity of the workforce. This discordance may exacerbate treatment disparities experienced by these clients. Program leaders have significant influence to leverage resources to develop staff diversity. Analysis of panel data from 1995 to 2005 showed that the most significant predictors of diversity were the characteristics of leaders. In particular, programs with managers with racially and ethnically concordant backgrounds and their education level were positively related to the percentage of Latino and African American staff. A high percentage of African American staff was positively associated with managers' tenure, but inversely related to licensed directors. Diversification of the field has increased, yet efforts have not matched increases in client diversity. Implications for health care reform legislation seeking to improve cultural competence through diversification of the workforce are discussed.

Organizational characteristics that foster early adoption of cultural and linguistic competence in outpatient substance abuse treatment in the United States

Recent years have seen an increased interest in developing culturally and linguistically responsive systems of care in substance abuse treatment in the United States. This study examines the extent to which external and internal organizational pressures contributed to the degree of adoption of culturally and linguistically responsive practices in the nation's outpatient substance abuse treatment system early in the period of development of this system of care. Findings show that a higher degree of adoption of culturally competent practices was most likely in treatment programs with high dependence on external funding and regulation. Internally, programs with a larger number of professionals were associated with the lowest degree of adoption, while managers' cultural sensitivity contributed significantly to a high degree of adoption of these responsive practices. Considering the passage of recent legislation enforcing the use of cultural and linguistic competence in health care, implications of these baseline findings on early adoption patterns are discussed for future research and health care policy evaluation.

Availability of substance abuse treatment services in Spanish: a GIS analysis of Latino communities in Los Angeles County, California

Background

The percentage of Latino clients entering outpatient substance abuse treatment (OSAT) in the United States has increased significantly in the past 10 years. Evidence suggests that a lack of services in Spanish is a significant barrier to treatment access among Latinos.

Methods

Using a geographic information system (GIS) approach, data from the U.S. Census Bureau and the National Survey of Substance Abuse Treatment Services (N-SSATS) were analyzed to determine the geographic distance between OSAT facilities with services in Spanish and Latino communities throughout Los Angeles County, CA. Data from N-SSATS were also analyzed using logistic regression models to examine organizational characteristics and their association with offering services in Spanish. Our GIS methods are tested in their ability to provide baseline measures to inform future analysis comparing changes in demography and service infrastructure.

Results

GIS analysis revealed cold spots representing high-density Latino communities with extensive travel distance to facilities offering services in Spanish. The average linear distance between Latino communities and facilities offering Spanish-language services ranged from 2 to 6 miles, while the location of the cold spots pointed to a need for services in Spanish in a particular subregion of the county. Further, secondary data analysis revealed that, on average, being privately owned (OR = .23, 95% CI = 0.06-0.90) was associated with a lower likelihood of providing services in Spanish compared to public facilities. Additionally, a facility with a state license (OR = 2.08, 95% CI = 1.12-3.88) or a higher number of Medicaid recipients (OR = 2.98, 95% CI = 1.76-5.05) was twice as likely to offer services in Spanish.

Conclusion

Despite the significant presence of Latinos in L.A. County in 2000, low capacity was found in discrete Latino communities in terms of offering OSAT services in Spanish. Funding and regulation play a significant role in facilities' capacity to offer these services. Future studies should build from our multi-method approach to compare changes in population demography and system infrastructure and inform health care policy that seeks to improve providers' capacity to provide linguistically competent care.