Lynda Berends

Using multiple coders to enhance qualitative analysis: The case of interviews with consumers of drug treatment

This article describes strategies used to support a systematic, inductive analysis of interviews with consumers of drug treatment. Data analysis was based on phenomenology and grounded theory. A coding system was developed, with a codebook to explicate the system. The codebook comprised the code address, mnemonic and full name, the code definition and when it should be applied, as well as text examples. A multi-disciplinary coding team was formed, with individuals from research, clinical and service use backgrounds. Challenges in the team approach included the different skill levels brought to the task, resource needs across multiple coders, and time demands on team members. Benefits rested in the inclusion of multiple perspectives in researcher backgrounds and in the opportunities to discuss coding disagreements and refine the coding system. Having two primary coders reduced flexibility in the iterative process of coding analysis, particularly interpretive and pattern coding. The codebook was useful for coding and writing findings. The codebook structure could be applied to other projects and used as a comparison point during analysis.

A problematic drinker in the family: Variations in the level of negative impact experienced by sex, relationship and living status

A national survey on harms experienced from others’ drinking was administered by telephone to 2649 randomly selected adults (18–98 years) in Australia. This article is about responses from participants concerning the family member whose drinking had the most negative impact on them (referred to as the problematic drinker). Respondents were asked about their relationship with the drinker, if they shared a household, and the level of negative impact they experienced. Of the 1494 family members identified as ‘fairly heavy drinkers’/‘drinking a lot sometimes’, the drinking of 592 (39.6%) had negatively affected 415 respondents in the previous 12 months. The problematic drinker was usually male (72.0%) and a partner (22.2%), child (18.2%), or sibling (16.3%). Most problematic drinkers in the home were partners (45.9%) or children (23.5%); there was no significant difference between problematic drinking sons living at home (62.0%) compared with problematic drinking daughters (45.2%). One-third of the respondents (35.8%) were affected ‘a lot’ by the problematic drinker; of those affected a lot, 52.6% lived with the problematic drinker. Severity of impact was significantly associated with the living status of the drinker but not with the sex of the drinker. This population-based study shows negative effects are often experienced when people have a family member who drinks a lot. While partners are often involved, a substantial proportion of problematic drinkers are adult children or siblings.

Characteristics of individuals presenting to treatment for primary alcohol problems versus other drug problems in the Australian patient pathways study

BackgroundPeople seeking treatment for substance use disorders often have additional health and social issues. Although individuals presenting with alcohol as the primary drug of concern (PDOC) account for nearly half of all treatment episodes to the Australian alcohol and other drug (AOD) service system, previous treatment cohort studies have focused only on the profile of Australian heroin or methamphetamine users. While studies overseas indicate that clients seeking treatment primarily for their drinking are less likely to experience social and economic marginalisation than those seeking treatment primarily for illicit or pharmaceutical drug use, very little research has directly compared individuals presenting with alcohol as the PDOC to those primarily presenting with other drugs as their PDOC.MethodsSeven hundred and ninety-six participants were recruited at entry to specialist AOD treatment in Victoria and Western Australia, and completed measures of demographic and social factors, substance use, quality of life, service use, and criminal justice involvement. We compared those with alcohol as their PDOC to those with other drugs as their PDOC using Pearson chi-square and Mann–Whitney U tests.ResultsRates of social disadvantage, poor quality of life, high severity of substance dependence, and past-year AOD, mental health, acute health, and social service use were high in all groups. However, participants with alcohol as the PDOC were older; more likely to have an educational qualification; less likely to report criminal justice involvement, housing/homelessness service use, tobacco smoking, or problems with multiple substances; and reported better environmental quality of life; but were more likely to have used ambulance services, than those with other drugs as their PDOC.ConclusionsWhile those seeking treatment primarily for alcohol problems appear less likely to suffer some forms of social and economic disadvantage or to use multiple substances than those with a primary drug problem, they experience similarly high levels of substance dependence severity and mental health and AOD service use. These findings reinforce the need for AOD services to integrate or coordinate care with programs that address the many complexities clients frequently present with, while also acknowledging differences between those seeking treatment for alcohol versus other drug problems.

Substance use outcomes following treatment: Findings from the Australian Patient Pathways Study:

Background and Aims: Our understanding of patient pathways through specialist Alcohol and Other Drug treatment and broader health/welfare systems in Australia remains limited. This study examines how treatment outcomes are influenced by continuity in specialist Alcohol and Other Drug treatment, engagement with community services and mutual aid, and explores differences between clients who present with a primary alcohol problem relative to those presenting with a primary drug issue. Method: In a prospective, multi-site treatment outcome study, 796 clients from 21 Alcohol and Other Drug services in Victoria and Western Australia completed a baseline interview between January 2012 and January 2013. A total of 555 (70%) completed a follow-up assessment of subsequent service use and Alcohol and Other Drug use outcomes 12-months later. Results: Just over half of the participants (52.0%) showed reliable reductions in use of, or abstinence from, their primary drug of concern. This was highest among clients with meth/amphetamine (66%) as their primary drug of concern and lowest among clients with alcohol as their primary drug of concern (47%), with 31% achieving abstinence from all drugs of concern. Continuity of specialist Alcohol and Other Drug care was associated with higher rates of abstinence than fragmented Alcohol and Other Drug care. Different predictors of treatment success emerged for clients with a primary drug problem as compared to those with a primary alcohol problem; mutual aid attendance (odds ratio = 2.5) and community service engagement (odds ratio = 2.0) for clients with alcohol as the primary drug of concern, and completion of the index treatment (odds ratio = 2.8) and continuity in Alcohol and Other Drug care (odds ratio = 1.8) when drugs were the primary drugs of concern. Conclusion: This is the first multi-site Australian study to include treatment outcomes for alcohol and cannabis users, who represent 70% of treatment seekers in Alcohol and Other Drug services. Results suggest a substantial proportion of clients respond positively to treatment, but that clients with alcohol as their primary drug problem may require different treatment pathways, compared to those with illicit drug issues, to maximise outcomes.

The emergence of a specialist role in rural alcohol and drug service delivery: lessons from a review in rural Victoria, Australia.

Aim: Perspectives on rural alcohol and other drug (AOD) service provision were explored. Methods: A mixed methods approach included a document review, service monitoring data, regional group fora with AOD and other health providers (109), semi-structured interviews with stakeholders from health, policy and research (53), and interviews with rural AOD services users (21). Findings: Alcohol is the main drug used by people in rural Victoria, followed by cannabis and then heroin. Services are allocated within a unit cost funding model and distributed on a regional or statewide basis. AOD treatment is dominated by outpatient therapy, outreach and rural withdrawal. Pharmacotherapy and residential rehabilitation are in short supply. Distance, stigma, and confidentiality concerns are barriers to treatment. Recruiting and retaining workers is difficult. The system continues to develop; secondary consultations and networking strategies increase capacity in other care systems. Hospital involvement in AOD treatment varies according to other health demands. Conclusions: Many aspects of the rural AOD service providers role enhance service delivery by extending reach and capacity. This occurs through AOD models, such as outreach, as well as strategies for working with other systems that include networking and secondary consultation. While there is task diffusion beyond traditional understandings of AOD treatment, the service delivery role may be understood as specialist in its own right. Recognition of this role as specialist may support staff recruitment and retention, while building potential for career pathways.

A Systematic Review of Consumer-Providers’ Effects on Client Outcomes in Statutory Mental Health Services: The Evidence and the Path Beyond

Consumer-provider involvement in the delivery of mental health services has steadily increased in the past several decades; however, the effects on client and service outcomes have remained unclear. The objectives of this paper are to (a) summarize a Cochrane review of consumer-providers’ effects on client outcomes in statutory mental health services and (b) discuss several key issues that, if addressed, might strengthen evidence in this area. We searched The Cochrane Library, MEDLINE, EMBASE, PsycINFO, CINAHL, and Current Contents until March 2012 to identify relevant studies. Studies were eligible for inclusion if they randomized adult clients to statutory mental health services delivered with and without consumer-provider involvement. Eleven studies met the eligibility criteria and were divided into 2 separate comparison groups: studies comparing consumer-providers with professionals employed in the same role within a mental health service (5 studies) and studies comparing mental health services with and without consumer-providers as an adjunct to the service (6 studies). The limited outcome data available from the studies indicated no difference in quality of life, function, social relations, mental health symptoms, client satisfaction, or attrition in those receiving services from consumer-providers compared with those who did not. None of the studies reported any adverse outcomes for clients. Addressing several key issues could strengthen the evidence such as: core outcome measures, appropriate study designs for evaluating complex interventions, minimal cross-contamination of treatment groups for community-based interventions, improved trial reporting, and the use of systematic reviews to inform future research.

Syringe Disposal Bins: The Outcomes of a Free Trial for City Traders in an Inner-City Municipality Australia

Community responses toward discarded syringes have the potential to threaten the sustainability of harm reduction interventions. Many retailers in the central business district of Melbourne, Australia, have expressed concern about drug use and the associated discarded syringes. The Melbourne City Council has responded to these concerns through a variety of strategies. One such strategy was a 6-month free trial of syringe bins for businesses (2003–2004). The MCC commissioned an external evaluation of the trial. Eighteen business representatives and six key informants undertook semistructured interviews to monitor issues arising throughout the trial. Syringe disposal bins are a useful option for facilitating appropriate syringe disposal; 11 of the 13 businesses that participated in the trial continued with the maintenance of the syringe disposal bins beyond the free trial period.

Health expenditure on alcohol and other drug treatment in Australia (2012/2013)

INTRODUCTION AND AIMS Analysis of the health expenditure on alcohol and other drug (AOD) treatment provides important information regarding the funding sources and distribution of AOD treatment funds. This study aimed to provide an estimate of annual health expenditure on AOD treatment in Australia and document a methodology for future estimates. DESIGN AND METHODS The study followed international standards for health accounts and calculated health expenditure for the federal government, state/territory governments and private expenditure for the year 2012/2013. Multiple data sources were used to generate the estimates. RESULTS The total expenditure was estimated at AUD

Following the money: Mapping the sources and funding flows of alcohol and other drug treatment in Australia

1.2 billion in 2012/2013. The states/territories account for 51% of this total, the Commonwealth 31% and private sources 18%. In 2012/2013, AOD treatment represented 0.8% of total health-care spending. DISCUSSION AND CONCLUSIONS The higher proportion of expenditure in AOD treatment programs outside hospitals is consistent with the community-focused models of care for AOD treatment. The Commonwealths investment in AOD treatment funding resides predominantly in its dedicated AOD treatment grant programs. The analysis of health expenditure does not tell us whether the investment mix is effective in reducing AOD-related harm and producing positive health outcomes, but it provides the basis for analysis of the distributions of expenditure between funding sources and assessment of AOD treatment spending relative to all health areas, and creates a base for tracking trends over time.

It Seemed like a Good Idea at the Time: Experiences in centralised intake for alcohol and drug treatment across three jurisdictions

INTRODUCTION AND AIMS The structures of health systems impact on patient outcomes. We present and analyse the first detailed mapping of who funds alcohol and other drug (AOD) treatment and the channels and intermediaries through which funding flows from the funding sources to treatment providers. DESIGN AND METHODS The study involved a literature review of AOD treatment financing and existing diagrammatic representations of the structure of the Australian health system. We interviewed 190 key informants to particularise the AOD treatment sector, and undertook two case examples of government funded non-government organisations providing AOD treatment. RESULTS Funding sources include the Australian and state and territory governments, philanthropy, fund-raising and clients themselves. While funding sources align with the health sector generally and the broader social services sector, the complexity of flows from source to treatment service and the number of intermediaries are noteworthy. So too are the many sources of funding drawn on by some treatment providers. Diversification is both beneficial and disadvantageous for non-government treatment providers, adding to administrative workloads, but smoothing the risk of funding shortfalls. Government funders benefit from sharing risk. DISCUSSION AND CONCLUSIONS Circuitous funding flows multiply the funding sources drawn on by services and put distance between the funding source and the service provider. This leads to concerns over lack of transparency about what is being purchased and challenges for the multiply funded service provider in maintaining programs and service models amid multiple and sometimes competing funding and accountability frameworks. [Chalmers J, Ritter A, Berends L, Lancaster K. Following the money: Mapping the sources and funding flows of alcohol and other drug treatment in Australia. Drug Alcohol Rev 2016;35:255-262].