International Journal of Drug Policy - 2014

Volume 25 Issue 3 May 2014

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Page 98 of 153

D. Kao et al. / International Journal of Drug Policy 25 (2014) 598–607 599 individual health and behavior in the context of their surround- ing environments (Borrell, 2011). The influence of geography and other environmental factors on drug use, addiction, and treatment is still a relatively new, but emerging, field of inquiry (McLafferty, 2008). As recently as 2006, the Association of American Geogra- phers and the National Institute on Drug Abuse (NIDA) held a joint symposium to explore the linkages between geography and drug addiction. The report coming out of this symposium recommended several key areas for future research, including "the locational anal- yses of drug addiction treatment and service delivery facilities" and "the use of Geographic Information Systems to better understand and respond to drug addiction" (Thomas, Richardson, & Cheung, 2008, p. vi). Guided by these recommendations, we conducted an exploratory study to look at the spatial accessibility of outpa- tient drug treatment facilities and its potential relationship with internal locus of control, drug use, and treatment utilization among Mexican American current and former heroin users. The term "spatial accessibility" refers to the aspect of access that focuses on the geographic location of services (Guagliardo, 2004; Higgs, 2005, 2009). Two broad research questions guided this exploratory study: (1) What is the impact of spatial accessibility on drug addiction and treatment utilization among this population? and (2) Does spatial accessibility have a differential impact on current users, compared to former users and those currently in methadone treatment? To address these questions, this study used secondary data from a study of Mexican American current and former heroin users living in Houston, Texas. Findings from this exploratory study could inform drug policy in the funding and design of drug treatment programs in the community. Spatial accessibility, drug use, and treatment utilization Access to services is a multidimensional issue, reflecting the degree of "fit" between individuals and the service delivery sys- tem (Penchansky & Thomas, 1981). Spatial accessibility focuses on the geographic location of services and its potential effects on an individual's ability or willingness to utilize services (Guagliardo, 2004; Higgs, 2005, 2009). Spatial access is based on the concept of distance decay, which assumes that access or utilization decreases as the distance from the service increases, and is commonly opera- tionalized as distance to/from a service or the quantity or density of services within a certain area. Previous research on spatial accessi- bility has largely focused on the issue of "potential" accessibility (or the availability of services for individuals that might be in need), as opposed to "realized" accessibility (or the actual utilization of ser- vices by individuals) (Higgs, 2009). Despite increased attention, the potential relationship between the spatial organization of services, utilization, and outcomes is relatively unexplored. There is growing evidence regarding the spatial nature of drug treatment facilities (Perron, Gillespie, Alexander-Eitzman, & Delva, 2010), including the relationship between drug treatment facili- ties and minority communities (Guerrero et al., 2013). However, specific research on the spatial accessibility to drug treatment facil- ities and its effects on drug addiction and treatment utilization are limited. For example, Beardsley, Wish, Fitzelle, O'Grady, and Arria (2003) found that patients who traveled less than one mile to participate in substance abuse treatment programs in Baltimore, Maryland, USA were more likely to complete the program than those who traveled more than one mile. They also found that par- ticipants who lived more than four miles away from a program had shorter lengths of stay in treatment. Similarly, Fortney, Booth, Blow, Bunn, and Cook (1995) found that US veterans were less likely to participate in aftercare treatment (for alcoholism) if they lived further away (in miles) from the treatment program. In contrast, the spatial accessibility of drug treatment pro- grams may also be associated with poorer outcomes, such as increased drug use and decreased treatment adherence. For exam- ple, Archibald (2008) found that regions with greater density of services providers were associate with greater prevalence of sub- stance abuse while another study by Whetten et al. (2006) showed that among HIV-positive persons, greater distance from a clinic was associated with higher participation in substance abuse and mental health programs (although not with retention and engage- ment). Finally, Stahler et al. (2008) found that a high density of 12-step, self-help groups (Narcotics Anonymous and/or Alcoholics Anonymous) was associated with a decreased likelihood of patients diagnosed with comorbid mental health and substance abuse dis- orders in continuing treatment. Even less research exists with respect to the geography of treatment programs and its impact on minority populations, specif- ically Hispanics. Recent studies (Guerrero et al., 2011, 2013) have explored the use of GIS as a tool to identify specific Hispanic communities with less access to Spanish-serving treatment facili- ties in Los Angeles County, California, United States. For example, Guerrero and colleagues (Guerrero et al., 2013) used spatial auto- correlation analysis to identify five "hot spots" or communities, which had high concentrations of Hispanics (74–86%) and were sig- nificantly farther from Spanish-serving facilities than the rest of the county. Conceptual framework Bronfenbrenner's Ecological Systems Theory places individuals in the context of their surrounding environment, in which the interactions between multiple systems can influence individual health or well-being, as well as behaviors (Bronfenbrenner, 1974, 1979). The accessibility of services is not only a function of individ- ual characteristics; the capacity or willingness to utilize services is often influenced by one's environment. In the drug use con- text, a framework proposed by Jacobson (2004) emphasizes the importance of considering ecological factors in addition to personal characteristics when studying treatment outcomes. He suggests that neighborhood drug availability and community resources are important factors in treatment outcomes and relapse, and that neighborhood disadvantage can influence individual attitudes toward treatment through perceptions of reduced personal effi- cacy. In addition, the neighborhood in which a treatment facility is located may have an influence on the facility's clients; however, this influence can be either positive or negative. Finally, the distance and related travel burden from home to treatment are components of Jacobson's framework for place's role in treatment attrition. One potential mechanism could be the impact of neighbor- hood characteristics (e.g. the lack of resources) on an individual's drug-related locus of control (LOC), which focuses on whether an individual believes that outcomes in life are related to his or her "own behavior or attributes versus the degree to which he feels the reward is controlled by forces outside of himself and may occur independently of his own actions" (Rotter, 1966, p. 1). Individuals with a more internal LOC orientation believe in their own personal agency and those with a more external LOC orientation feel more powerlessness over their lives. In general, higher internal LOC is associated with more positive outcomes for drug use and mis- use (De Moja, 1997; Hall, 2001; Haynes & Ayliffe, 1991; Murphy & Bentall, 1992; Oswald, Walker, Krajewski, & Reilly, 1994). As it relates to the spatial accessibility of drug treatment facilities, the lack of resources and services in one's neighborhood may be related to one's perceptions of control or efficacy (Boardman & Robert, 2000; Christie-Mizell & Erickson, 2007; Ross, Mirowsky, & Pribesh, 2001).

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