- Email: [email protected]
Exploring the role of consumer participation in drug treatment
Drug and Alcohol Dependence 105 (2009) 172–175
Contents lists available at ScienceDirect
Drug and Alcohol Dependence journal homepage: www.elsevier.com/locate/drugalcdep
Short communication
Exploring the role of consumer participation in drug treatment Loren Brener ∗ , Ilyse Resnick, Jeanne Ellard, Carla Treloar, Joanne Bryant National Centre in HIV Social Research, Level 2, Webster Building, The University of New South Wales, Sydney 2052, NSW, Australia
a r t i c l e
i n f o
Article history: Received 26 February 2009 Received in revised form 9 June 2009 Accepted 12 June 2009 Available online 21 July 2009 Keywords: Consumer participation Drug treatment Treatment satisfaction Treatment goal achievement
a b s t r a c t Despite recognition of the benefits of involving consumers in their own treatment, there is little research on consumer participation in drug treatment. This paper focuses on clients who use illicit substances and the role of consumer participation in their self-reported satisfaction with their drug treatment and sense of goal achievement in that treatment. As part of a secondary analysis, the data from 492 participants who had previously or who were currently engaged in drug treatment were analysed to assess the importance of consumer participation in drug treatment. Participants who had a history of opiate or psychostimulant use were recruited at various treatment services and health care facilities for drug users located in five urban and rural/regional sites in Australia. They were asked to complete an interviewer-assisted questionnaire assessing a range of variables including five questions about consumer participation. Findings from this study illustrate that clients’ opportunity to participate in drug treatment is independently associated with greater satisfaction with drug treatment and a greater sense of achievement of treatment goals. This research provides evidence to support the importance of consumer activity in drug treatment and should encourage drug treatment programs to afford clients appropriate levels of consumer participation. © 2009 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Over recent decades consumer participation in the planning and delivery of health services has been increasingly incorporated into the policies, funding, structures and practices of the health sector in Australia and internationally (Barnes, 1999; Bastian, 1998; Crawford et al., 2002; Fischer and Neale, 2008). ‘Consumer participation’ is broadly defined as ‘the process of involving health consumers in decision making about health service planning, policy development, setting priorities and quality issues in the delivery of health services’ (National Resource Centre for Consumer Participation in Health, 2002: 1). It can occur at a range of levels including in structuring and reforming organizational policies and processes and informing individual treatment experiences. Activities described as consumer participation include client surveys and forums, suggestion boxes, consumer representatives on management committees, support for self-help groups, input into individual treatment plans, choices about treatment programs, choice of case worker, access to complaints processes and opportunities to provide feedback and input into the treatment process. In the United Kingdom the shift towards consumer involvement in health has provided opportunities to develop models of consumer participation in the drug treatment field (Fischer and Neale, 2008). In Australia, there has been little structural support for con-
∗ Corresponding author. Tel.: +61 29385 6530; fax: +61 29385 6455. E-mail address: [email protected] (L. Brener). 0376-8716/$ – see front matter © 2009 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.drugalcdep.2009.06.016
sumer participation in the drug treatment sector despite significant achievements in the mental health and the disability sector (Bryant et al., 2008a). A recent Australian study found that found that low level consumer participation activities aimed at information gathering, for example consumer surveys, suggestion boxes and forums were undertaken in many drug treatment services (Bryant et al., 2008b). Further, many services had a consumer charter of rights and a formal complaints process, that had frequently been instituted as part of the process of gaining accreditation (Bryant et al., 2008a). While the study found most services engaged consumers in low level consumer activities there was significant interest among both providers and consumers to increase the levels of consumer participation (Bryant et al., 2008b). Challenges to the implementation of consumer participation in the drug treatment field include limited resources, existing policies and the unwillingness of some professionals to give up status as experts (Fischer and Neale, 2008). Service providers have expressed concerns that drug dependence itself and the “chaotic” nature of some drug users’ daily lives may limit their capacity to engage in consumer participation (Fischer and Neale, 2008). While these concerns may in some cases be legitimate they can also be used to justify excluding consumers from sharing in decisions about their treatment (Sylvestre, 2003). Nonetheless consumer participation in drug treatment has yielded a number of positive benefits including longer stays in treatment, reduced heroin use, fewer criminal justice problems and an increased sense of empowerment by consumers (Fischer and Neale, 2008; Nabitz et al., 2005; Ning, 2005).
L. Brener et al. / Drug and Alcohol Dependence 105 (2009) 172–175
This study is a secondary analysis of data and aims to establish the role of consumer participation in clients’ satisfaction with their drug treatment service and in their perception of their treatment goal achievement. Patient satisfaction with treatment of other medical conditions has been shown to increase treatment adherence and to be positively associated with health outcomes (Holcomb et al., 1998; Renzi et al., 2001; Wickizer et al., 2004). This research hypothesises that those who have the opportunity to actively participate in their drug treatment program will be more satisfied with their treatment and will be more likely to report a greater sense of achievement of treatment goals. 2. Methods 2.1. Participants A sample of 492 participants was drawn from a larger study of 685 opiate or psychostimulant users assessing barriers and incentives to drug treatment (Treloar et al., 2004). The current analysis included only those participants who were or had previously been in a drug treatment program. Recruitment sites were located across Australia in urban and rural/regional areas. These sites were chosen based on their population size and ability to facilitate recruitment. Treatment facilities included residential rehabilitation, detoxification, pharmacotherapy and counselling services. Those participants who had experienced treatment, but were not currently in a program, were recruited through needle and syringe programs, drug user organizations, youth services, and through fliers placed in nightclubs. 2.2. Materials and procedure Two questionnaires were developed for the groups currently in treatment and the previous treatment groups, respectively. Both questionnaires assessed demographic variables; drug use history and networks; health and social wellbeing; past help seeking, treatment history and current treatment experiences; barriers to treatment, consumer participation and staff attitudes towards clients. The two questionnaires differed in the phrasing and order of questions and questions pertaining to current treatment experience. Questionnaires were interviewer-administered by researchers or trained peer interviewers. Interviews lasted approximately 60 min, and participants were reimbursed $20. This study had approval from the ethics committees of University of New South Wales and relevant health authorities. 2.3. Measures The outcome variables were participants’ level of satisfaction with their current or most recent treatment and their reports about whether they had achieved their goals in that treatment. Clients were asked whether they were satisfied with their current or most recent treatment. Reponses were measured on a five-point scale, ranging from very unsatisfied to very satisfied, with higher numbers indicating greater satisfaction. For perceived goal achievement, clients were asked if they felt that they had achieved what they had set as their treatment goal. This was assessed only in the group who had completed a treatment program and was measured on a six-point scale, ranging from not at all to completely, higher numbers indicative of greater reported achievement. The demographic variables addressed in this analysis included age, gender, ethnicity, education, recently in treatment (last 6 months) and type of most recent treatment (drug counselling, detoxification, residential rehabilitation, pharmacotherapy). Consumer participation was measured by five yes/no questions regarding client involvement in treatment. These questions addressed whether the participant: had input into their treatment plan; had a choice of treatment worker, i.e. could request a change of worker; had taken part in a review of the treatment provider for example completed a feedback survey or participated in a consumer forum; knew they had rights as a consumer of health services; and, they had seen a copy of the complaints procedure. Client reports of staff attitudes were measured on a 14 item scale (e.g. “The staff is very supportive of me” and “The staff treat me badly in front of others”). Responses to these items were provided on a five-point scale ranging from strongly disagree to strongly agree with lower numbers indicative of more negative staff attitudes. 2.4. Data analysis Ordinal regression was used to determine how well consumer participation predicted satisfaction and goal achievement. The assumption that the independent variables have proportional effect on each level of the dependent variables (test of parallel lines) was violated in the model predicting satisfaction (2 = 67.6, 48df, p = 0.03) but not in the model predicting goal achievement (2 = 64.0, 80df, p = 0.67). The satisfaction variable was collapsed from five to three categories (satisfied, neither satisfied nor unsatisfied, unsatisfied) in order to meet the assumption (2 = 13.7, 16df, p = 0.62).
173
Table 1 Sample characteristics. % (n) Age (mean, SD) Female Aboriginal
32.2 (7.8) 35.4 (174) 10.6 (52)
Highest education achieved Primary only Year 10 or 12 Post-secondary
9.1 (45) 69.1 (340) 20.9 (103)
In drug treatment (last 6 months)
66.9 (329)
Most recent drug treatment Counselling Detox Rehab Pharmacotherapy Other
18.5 (91) 20.3 (100) 20.1 (99) 31.9 (157) 8.1 (40)
Consumer participation Have a choice of worker Involved in treatment plan Review of services Know about rights Know about complaints procedure
18.7 (89) 52.9 (253) 34.0 (162) 80.5 (388) 21.5 (103)
Staff attitude scale (range)
38.6 (6.3)
3. Results Sample characteristics including recruitment area, gender, age, ethnicity, education, treatment status and type of treatment are reported in Table 1. Reported goal achievement was only measured for the 163 participants who had completed treatment. Levels of consumer participation, which were measured in relation to the current or most recent treatment experience, varied across the five different types of activities assessed (see Table 1). Many participants knew about their rights in treatment and just over half were involved in their treatment plan. However, fewer clients had participated in a review of their service, knew about a mechanism to address complaints or had a choice of worker at their most recent treatment facility. The role of consumer participation in clients’ satisfaction and their self-reported achievement of treatment goals were assessed via ordinal regression (see Table 2). While the consumer participation variables predicted independent variance for both outcome variables, different consumer participation variables were relevant for satisfaction and perceived achievement. Satisfaction with treatment was predicted by being involved in the treatment plan and knowing you have rights. Reported achievement of treatment goals was related to participating in a review of the service and knowing about complaints procedures. As can be seen in Table 2, the consumer participation variables were significantly related to satisfaction and achievement over and above type of treatment facility, treatment status and perceptions of staff attitudes. Additionally consumer participation was related to sense of goal achievement regardless of how satisfied the client felt with their treatment experience. 4. Discussion The findings of this study clearly support the hypotheses that greater client participation in drug treatment leads to greater client satisfaction with that treatment and a greater sense of goal achievement. Our findings contribute new insights: consumer participation plays an important role in determining client satisfaction and sense of achievement regardless of the type of drug treatment service the client is attending and regardless of clients’ reports of staff attitudes in that service (and for reported
174
L. Brener et al. / Drug and Alcohol Dependence 105 (2009) 172–175
Table 2 Ordinal regression for satisfaction (n = 492) and goal achievement (n = 163). Higher satisfaction
Higher achievement
Regression coefficient (SE)
p-Value
Regression coefficient (SE)
p-Value
Consumer participation Have a choice of worker Involved in treatment plan Review of services Know about rights Know about complaints procedures
−0.33 (0.23) −0.48 (0.17) −0.01 (0.18) −0.53 (0.18) −0.00 (0.21)
NS <0.01 NS <0.05 NS
−0.03 (0.23) 0.06 (0.19) −0.59 (0.12) 0.16 (0.23) −0.43 (0.22)
NS NS <0.05 NS <0.05
Age Female Aboriginal
−0.02 (0.01) −0.06 (0.17) 0.08 (0.26)
NS NS NS
0.01 (0.01) 0.37 (0.19) −0.14 (0.29)
NS <0.05 NS
Highest education achieved Primary only Year 10 or 12 Post-secondary
−0.49 (0.30) −0.43 (0.21) 0
NS <0.05
−0.27 (0.35) −0.09 (0.22) 0
NS NS
In drug treatment (last 6 months)
−0.93 (0.17)
<0.001
−0.42 (0.14)
NS
Most recent drug treatment Counselling Detox Rehab Pharmacotherapy Other
−0.34 (0.30) 0.31 (0.36) 0.67 (0.26) −0.52 (0.33) 0
NS NS <0.05 NS
0.15 (0.40) 0.80 (0.42) 0.03 (0.40) 0.46 (0.37) 0
NS NS NS NS
Staff attitude scale
0.07 (0.01)
<0.001
0.03 (0.02)
NS
NI
−2.00 (0.32) −2.04 (0.36) −1.17 (0.28) −0.47 (0.23) 0
<0.001 <0.001 <0.001 <0.05
Satisfied with service Very unsatisfied Somewhat unsatisfied Neither Somewhat satisfied Very satisfied Nagelkerke pseudo R2 2 (df), p-value
NI
0.25
0.29
109.9 (16), p < 0.001
148.1 (20), p < 0.001
NS: Not significant. NI: Not included.
achievement regardless of how satisfied the client is with the treatment). These results indicate the pervasive positive effects of the clients’ experience of active engagement with their treatment. While measures of consumer participation were significantly associated with both treatment satisfaction and with self-reported achievement of treatment goals, the particular consumer participation activities predicting satisfaction and achievement were different. Consumer participation activities such as having input into a treatment plan and knowing you have rights were associated with greater satisfaction with the treatment program. Being able to do a review of the service and knowing about complaints procedures were related to greater reported achievement of treatment goals. The literature on consumer participation in drug treatment is sufficiently nascent to offer little in the way of assistance for interpretation of these results. However, we note that these variables include examples of a mix of levels of consumer participation from those relating to individual treatments, to examples which relate more to organizational processes. Further research should consider and evaluate the various levels of participation in drug treatment that consumers can claim for example, choice of treatment, mechanisms for consumers to provide feedback, and user involvement in organizational decision making. Research of this type would allow assessment of the relative impact and effectiveness of different forms of consumer participation on health outcomes in drug treatment. Finally, it is important to highlight the limitations of the current research. Most notably, the study is exploratory and represents a first step in understanding the relationships between consumer participation, satisfaction with drug treatment and sense of achievement. The sample was not randomly selected hence results are subject to selection bias. Additionally data are cross-sectional and rely on the self-report of clients. Hence despite increases in
satisfaction and achievement there is no clear way to tell if greater consumer participation does lead to achievement of better health outcomes, or for example to less or no drug use after treatment. While the broader study on which this research is based included some questions on consumer participation in drug treatment, this was not a focus of the research. Given the current finding of the importance of consumer participation in client experience of drug treatment, it would be valuable to design a study which focuses on this issue. Similarly it would be important to use multi-dimensional measure of satisfaction, rather than the global measure used in this study. Although most multi-dimensional measures of satisfaction correlate strongly with global indicators (Diener and Diener, 1995), it would be useful to assess whether different dimensions of satisfaction influence different levels of consumer participation. Despite these limitations, this research has provided support for the importance of consumer participation in drug treatment programs. Drug treatment clients in this sample who have more input into their treatment at various levels were more likely to be satisfied with their treatment and to have a greater sense of goal achievement in treatment. It is hoped that that the relationships documented in the current research will have implications for the design of drug treatments in the future by including avenues for consumer participation. Role of funding Funding for this project was provided by the Commonwealth Department of Health and Ageing. The Commonwealth Department of Health and Ageing had no further role in study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication.
L. Brener et al. / Drug and Alcohol Dependence 105 (2009) 172–175
Contributors Authors Brener, Resnick, Ellard and Treloar were responsible for the conceptual design of the study. Authors Brener and Ellard managed the literature searches and literature review. Author Resnick under the supervision of Bryant undertook the statistical analysis of the data. Brener wrote the first draft of the manuscript with contributions from all of the other authors. All authors contributed to and have approved the final manuscript. Conflict of interest All other authors declare that they have no conflicts of interest. Acknowledgements The project was conducted in partnership with AIVL (the Australian peak body representing people who use illicit drugs) and LMS Consulting. The authors would also like to acknowledge the peer interviewers, drug treatment services and drug treatment clients who gave of their time to aid in recruitment and to participate in this research. References Barnes, M., 1999. Users as citizens: collective action and the local governance of welfare. Soc. Policy Admin. 33 (1), 73–90. Bastian, H., 1998. Speaking up for ourselves: the evolution of consumer advocacy in health care. Int. J. Tech. Assess. Health Care 14 (1), 3–23.
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Bryant, J., Saxton, M., Madden, A., Bath, N., Robinson, S., 2008a. Consumers’ and providers’ perspectives about consumer participation in drug treatment services: is there support to do more? What are the obstacles? Drug Alcohol Rev. 27, 138–144. Bryant, J., Saxton, M., Madden, A., Bath, N., Robinson, S., 2008b. Consumer participation in the planning and delivery of treatment services: the current arrangements. Drug Alcohol Rev. 27, 130–137. Diener, E., Diener, M., 1995. Cross-cultural correlates of life satisfaction and self esteem. J. Pers. Soc. Psychol. 66 (4), 653–666. Crawford, M.J., Rutter, D., Manley, C., Weaver, T., Bhui, K., Fulop, N., Tyrer, P., 2002. Systematic review of involving patients in the planning and development of health care. Br. Med. J. 325, 1263–1267. Fischer, J., Neale, J., 2008. Involving drug users in treatment decisions: an exploration of potential problems. Drugs Educ. Prev. Policy 15 (2), 161–175. Holcomb, W., Parker, J., Leong, G., Thiele, J., Higdon, J., 1998. Customer satisfaction and self-reported treatment outcomes among psychiatric inpatients. Psychiatr. Serv. 49, 929–934. Nabitz, U., van den Brink, W., Walburg, J., 2005. A quality framework for addiction treatment programs. Addict. Behav. 30, 1254–1260. National Resource Centre for Consumer Participation in Health, 2002. An Introduction to Consumer Participation. Fact sheet No. 1., www.participateinhealth. org.au/. Ning, A.M., 2005. Games of truth: rethinking conformity and resistance in narratives of heroin recovery. Med. Anthropol. 24 (4), 349–382. Renzi, C., Abeni, D., Picardi, A., Agostini, E., Melchi, A., Pasquini, P., Braga, M., 2001. Factors associated with patient satisfaction with care among dermatological outpatients. Br. J. Dermatol. 145 (4), 617–623. Sylvestre, D.L., 2003. Injection drug use and hepatitis C: from transmission to treatment. Psychiatry Ann. 33, 377–382. Treloar, C., Abelson, J., Cao, W., Brener, L., Kippax, S., Schultz, L., et al., 2004. Barriers and Incentives to Treatment for Illicit Drug Users. Commonwealth Department of Health and Ageing, Canberra. Wickizer, T., Franklin, G., Fulton-Kehoe, D., Turner, J., Mootz, R., Smith-Weller, T., 2004. Patient satisfaction, treatment experience, and disability outcomes in a population-based cohort of injured workers in Washington State: implications for quality improvement. Health Serv. Res. 39 (4), 727–748.
Contents lists available at ScienceDirect
Drug and Alcohol Dependence journal homepage: www.elsevier.com/locate/drugalcdep
Short communication
Exploring the role of consumer participation in drug treatment Loren Brener ∗ , Ilyse Resnick, Jeanne Ellard, Carla Treloar, Joanne Bryant National Centre in HIV Social Research, Level 2, Webster Building, The University of New South Wales, Sydney 2052, NSW, Australia
a r t i c l e
i n f o
Article history: Received 26 February 2009 Received in revised form 9 June 2009 Accepted 12 June 2009 Available online 21 July 2009 Keywords: Consumer participation Drug treatment Treatment satisfaction Treatment goal achievement
a b s t r a c t Despite recognition of the benefits of involving consumers in their own treatment, there is little research on consumer participation in drug treatment. This paper focuses on clients who use illicit substances and the role of consumer participation in their self-reported satisfaction with their drug treatment and sense of goal achievement in that treatment. As part of a secondary analysis, the data from 492 participants who had previously or who were currently engaged in drug treatment were analysed to assess the importance of consumer participation in drug treatment. Participants who had a history of opiate or psychostimulant use were recruited at various treatment services and health care facilities for drug users located in five urban and rural/regional sites in Australia. They were asked to complete an interviewer-assisted questionnaire assessing a range of variables including five questions about consumer participation. Findings from this study illustrate that clients’ opportunity to participate in drug treatment is independently associated with greater satisfaction with drug treatment and a greater sense of achievement of treatment goals. This research provides evidence to support the importance of consumer activity in drug treatment and should encourage drug treatment programs to afford clients appropriate levels of consumer participation. © 2009 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Over recent decades consumer participation in the planning and delivery of health services has been increasingly incorporated into the policies, funding, structures and practices of the health sector in Australia and internationally (Barnes, 1999; Bastian, 1998; Crawford et al., 2002; Fischer and Neale, 2008). ‘Consumer participation’ is broadly defined as ‘the process of involving health consumers in decision making about health service planning, policy development, setting priorities and quality issues in the delivery of health services’ (National Resource Centre for Consumer Participation in Health, 2002: 1). It can occur at a range of levels including in structuring and reforming organizational policies and processes and informing individual treatment experiences. Activities described as consumer participation include client surveys and forums, suggestion boxes, consumer representatives on management committees, support for self-help groups, input into individual treatment plans, choices about treatment programs, choice of case worker, access to complaints processes and opportunities to provide feedback and input into the treatment process. In the United Kingdom the shift towards consumer involvement in health has provided opportunities to develop models of consumer participation in the drug treatment field (Fischer and Neale, 2008). In Australia, there has been little structural support for con-
∗ Corresponding author. Tel.: +61 29385 6530; fax: +61 29385 6455. E-mail address: [email protected] (L. Brener). 0376-8716/$ – see front matter © 2009 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.drugalcdep.2009.06.016
sumer participation in the drug treatment sector despite significant achievements in the mental health and the disability sector (Bryant et al., 2008a). A recent Australian study found that found that low level consumer participation activities aimed at information gathering, for example consumer surveys, suggestion boxes and forums were undertaken in many drug treatment services (Bryant et al., 2008b). Further, many services had a consumer charter of rights and a formal complaints process, that had frequently been instituted as part of the process of gaining accreditation (Bryant et al., 2008a). While the study found most services engaged consumers in low level consumer activities there was significant interest among both providers and consumers to increase the levels of consumer participation (Bryant et al., 2008b). Challenges to the implementation of consumer participation in the drug treatment field include limited resources, existing policies and the unwillingness of some professionals to give up status as experts (Fischer and Neale, 2008). Service providers have expressed concerns that drug dependence itself and the “chaotic” nature of some drug users’ daily lives may limit their capacity to engage in consumer participation (Fischer and Neale, 2008). While these concerns may in some cases be legitimate they can also be used to justify excluding consumers from sharing in decisions about their treatment (Sylvestre, 2003). Nonetheless consumer participation in drug treatment has yielded a number of positive benefits including longer stays in treatment, reduced heroin use, fewer criminal justice problems and an increased sense of empowerment by consumers (Fischer and Neale, 2008; Nabitz et al., 2005; Ning, 2005).
L. Brener et al. / Drug and Alcohol Dependence 105 (2009) 172–175
This study is a secondary analysis of data and aims to establish the role of consumer participation in clients’ satisfaction with their drug treatment service and in their perception of their treatment goal achievement. Patient satisfaction with treatment of other medical conditions has been shown to increase treatment adherence and to be positively associated with health outcomes (Holcomb et al., 1998; Renzi et al., 2001; Wickizer et al., 2004). This research hypothesises that those who have the opportunity to actively participate in their drug treatment program will be more satisfied with their treatment and will be more likely to report a greater sense of achievement of treatment goals. 2. Methods 2.1. Participants A sample of 492 participants was drawn from a larger study of 685 opiate or psychostimulant users assessing barriers and incentives to drug treatment (Treloar et al., 2004). The current analysis included only those participants who were or had previously been in a drug treatment program. Recruitment sites were located across Australia in urban and rural/regional areas. These sites were chosen based on their population size and ability to facilitate recruitment. Treatment facilities included residential rehabilitation, detoxification, pharmacotherapy and counselling services. Those participants who had experienced treatment, but were not currently in a program, were recruited through needle and syringe programs, drug user organizations, youth services, and through fliers placed in nightclubs. 2.2. Materials and procedure Two questionnaires were developed for the groups currently in treatment and the previous treatment groups, respectively. Both questionnaires assessed demographic variables; drug use history and networks; health and social wellbeing; past help seeking, treatment history and current treatment experiences; barriers to treatment, consumer participation and staff attitudes towards clients. The two questionnaires differed in the phrasing and order of questions and questions pertaining to current treatment experience. Questionnaires were interviewer-administered by researchers or trained peer interviewers. Interviews lasted approximately 60 min, and participants were reimbursed $20. This study had approval from the ethics committees of University of New South Wales and relevant health authorities. 2.3. Measures The outcome variables were participants’ level of satisfaction with their current or most recent treatment and their reports about whether they had achieved their goals in that treatment. Clients were asked whether they were satisfied with their current or most recent treatment. Reponses were measured on a five-point scale, ranging from very unsatisfied to very satisfied, with higher numbers indicating greater satisfaction. For perceived goal achievement, clients were asked if they felt that they had achieved what they had set as their treatment goal. This was assessed only in the group who had completed a treatment program and was measured on a six-point scale, ranging from not at all to completely, higher numbers indicative of greater reported achievement. The demographic variables addressed in this analysis included age, gender, ethnicity, education, recently in treatment (last 6 months) and type of most recent treatment (drug counselling, detoxification, residential rehabilitation, pharmacotherapy). Consumer participation was measured by five yes/no questions regarding client involvement in treatment. These questions addressed whether the participant: had input into their treatment plan; had a choice of treatment worker, i.e. could request a change of worker; had taken part in a review of the treatment provider for example completed a feedback survey or participated in a consumer forum; knew they had rights as a consumer of health services; and, they had seen a copy of the complaints procedure. Client reports of staff attitudes were measured on a 14 item scale (e.g. “The staff is very supportive of me” and “The staff treat me badly in front of others”). Responses to these items were provided on a five-point scale ranging from strongly disagree to strongly agree with lower numbers indicative of more negative staff attitudes. 2.4. Data analysis Ordinal regression was used to determine how well consumer participation predicted satisfaction and goal achievement. The assumption that the independent variables have proportional effect on each level of the dependent variables (test of parallel lines) was violated in the model predicting satisfaction (2 = 67.6, 48df, p = 0.03) but not in the model predicting goal achievement (2 = 64.0, 80df, p = 0.67). The satisfaction variable was collapsed from five to three categories (satisfied, neither satisfied nor unsatisfied, unsatisfied) in order to meet the assumption (2 = 13.7, 16df, p = 0.62).
173
Table 1 Sample characteristics. % (n) Age (mean, SD) Female Aboriginal
32.2 (7.8) 35.4 (174) 10.6 (52)
Highest education achieved Primary only Year 10 or 12 Post-secondary
9.1 (45) 69.1 (340) 20.9 (103)
In drug treatment (last 6 months)
66.9 (329)
Most recent drug treatment Counselling Detox Rehab Pharmacotherapy Other
18.5 (91) 20.3 (100) 20.1 (99) 31.9 (157) 8.1 (40)
Consumer participation Have a choice of worker Involved in treatment plan Review of services Know about rights Know about complaints procedure
18.7 (89) 52.9 (253) 34.0 (162) 80.5 (388) 21.5 (103)
Staff attitude scale (range)
38.6 (6.3)
3. Results Sample characteristics including recruitment area, gender, age, ethnicity, education, treatment status and type of treatment are reported in Table 1. Reported goal achievement was only measured for the 163 participants who had completed treatment. Levels of consumer participation, which were measured in relation to the current or most recent treatment experience, varied across the five different types of activities assessed (see Table 1). Many participants knew about their rights in treatment and just over half were involved in their treatment plan. However, fewer clients had participated in a review of their service, knew about a mechanism to address complaints or had a choice of worker at their most recent treatment facility. The role of consumer participation in clients’ satisfaction and their self-reported achievement of treatment goals were assessed via ordinal regression (see Table 2). While the consumer participation variables predicted independent variance for both outcome variables, different consumer participation variables were relevant for satisfaction and perceived achievement. Satisfaction with treatment was predicted by being involved in the treatment plan and knowing you have rights. Reported achievement of treatment goals was related to participating in a review of the service and knowing about complaints procedures. As can be seen in Table 2, the consumer participation variables were significantly related to satisfaction and achievement over and above type of treatment facility, treatment status and perceptions of staff attitudes. Additionally consumer participation was related to sense of goal achievement regardless of how satisfied the client felt with their treatment experience. 4. Discussion The findings of this study clearly support the hypotheses that greater client participation in drug treatment leads to greater client satisfaction with that treatment and a greater sense of goal achievement. Our findings contribute new insights: consumer participation plays an important role in determining client satisfaction and sense of achievement regardless of the type of drug treatment service the client is attending and regardless of clients’ reports of staff attitudes in that service (and for reported
174
L. Brener et al. / Drug and Alcohol Dependence 105 (2009) 172–175
Table 2 Ordinal regression for satisfaction (n = 492) and goal achievement (n = 163). Higher satisfaction
Higher achievement
Regression coefficient (SE)
p-Value
Regression coefficient (SE)
p-Value
Consumer participation Have a choice of worker Involved in treatment plan Review of services Know about rights Know about complaints procedures
−0.33 (0.23) −0.48 (0.17) −0.01 (0.18) −0.53 (0.18) −0.00 (0.21)
NS <0.01 NS <0.05 NS
−0.03 (0.23) 0.06 (0.19) −0.59 (0.12) 0.16 (0.23) −0.43 (0.22)
NS NS <0.05 NS <0.05
Age Female Aboriginal
−0.02 (0.01) −0.06 (0.17) 0.08 (0.26)
NS NS NS
0.01 (0.01) 0.37 (0.19) −0.14 (0.29)
NS <0.05 NS
Highest education achieved Primary only Year 10 or 12 Post-secondary
−0.49 (0.30) −0.43 (0.21) 0
NS <0.05
−0.27 (0.35) −0.09 (0.22) 0
NS NS
In drug treatment (last 6 months)
−0.93 (0.17)
<0.001
−0.42 (0.14)
NS
Most recent drug treatment Counselling Detox Rehab Pharmacotherapy Other
−0.34 (0.30) 0.31 (0.36) 0.67 (0.26) −0.52 (0.33) 0
NS NS <0.05 NS
0.15 (0.40) 0.80 (0.42) 0.03 (0.40) 0.46 (0.37) 0
NS NS NS NS
Staff attitude scale
0.07 (0.01)
<0.001
0.03 (0.02)
NS
NI
−2.00 (0.32) −2.04 (0.36) −1.17 (0.28) −0.47 (0.23) 0
<0.001 <0.001 <0.001 <0.05
Satisfied with service Very unsatisfied Somewhat unsatisfied Neither Somewhat satisfied Very satisfied Nagelkerke pseudo R2 2 (df), p-value
NI
0.25
0.29
109.9 (16), p < 0.001
148.1 (20), p < 0.001
NS: Not significant. NI: Not included.
achievement regardless of how satisfied the client is with the treatment). These results indicate the pervasive positive effects of the clients’ experience of active engagement with their treatment. While measures of consumer participation were significantly associated with both treatment satisfaction and with self-reported achievement of treatment goals, the particular consumer participation activities predicting satisfaction and achievement were different. Consumer participation activities such as having input into a treatment plan and knowing you have rights were associated with greater satisfaction with the treatment program. Being able to do a review of the service and knowing about complaints procedures were related to greater reported achievement of treatment goals. The literature on consumer participation in drug treatment is sufficiently nascent to offer little in the way of assistance for interpretation of these results. However, we note that these variables include examples of a mix of levels of consumer participation from those relating to individual treatments, to examples which relate more to organizational processes. Further research should consider and evaluate the various levels of participation in drug treatment that consumers can claim for example, choice of treatment, mechanisms for consumers to provide feedback, and user involvement in organizational decision making. Research of this type would allow assessment of the relative impact and effectiveness of different forms of consumer participation on health outcomes in drug treatment. Finally, it is important to highlight the limitations of the current research. Most notably, the study is exploratory and represents a first step in understanding the relationships between consumer participation, satisfaction with drug treatment and sense of achievement. The sample was not randomly selected hence results are subject to selection bias. Additionally data are cross-sectional and rely on the self-report of clients. Hence despite increases in
satisfaction and achievement there is no clear way to tell if greater consumer participation does lead to achievement of better health outcomes, or for example to less or no drug use after treatment. While the broader study on which this research is based included some questions on consumer participation in drug treatment, this was not a focus of the research. Given the current finding of the importance of consumer participation in client experience of drug treatment, it would be valuable to design a study which focuses on this issue. Similarly it would be important to use multi-dimensional measure of satisfaction, rather than the global measure used in this study. Although most multi-dimensional measures of satisfaction correlate strongly with global indicators (Diener and Diener, 1995), it would be useful to assess whether different dimensions of satisfaction influence different levels of consumer participation. Despite these limitations, this research has provided support for the importance of consumer participation in drug treatment programs. Drug treatment clients in this sample who have more input into their treatment at various levels were more likely to be satisfied with their treatment and to have a greater sense of goal achievement in treatment. It is hoped that that the relationships documented in the current research will have implications for the design of drug treatments in the future by including avenues for consumer participation. Role of funding Funding for this project was provided by the Commonwealth Department of Health and Ageing. The Commonwealth Department of Health and Ageing had no further role in study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication.
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Contributors Authors Brener, Resnick, Ellard and Treloar were responsible for the conceptual design of the study. Authors Brener and Ellard managed the literature searches and literature review. Author Resnick under the supervision of Bryant undertook the statistical analysis of the data. Brener wrote the first draft of the manuscript with contributions from all of the other authors. All authors contributed to and have approved the final manuscript. Conflict of interest All other authors declare that they have no conflicts of interest. Acknowledgements The project was conducted in partnership with AIVL (the Australian peak body representing people who use illicit drugs) and LMS Consulting. The authors would also like to acknowledge the peer interviewers, drug treatment services and drug treatment clients who gave of their time to aid in recruitment and to participate in this research. References Barnes, M., 1999. Users as citizens: collective action and the local governance of welfare. Soc. Policy Admin. 33 (1), 73–90. Bastian, H., 1998. Speaking up for ourselves: the evolution of consumer advocacy in health care. Int. J. Tech. Assess. Health Care 14 (1), 3–23.
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