The results of EFA and CFA show that a seven-factor model best describes barrier constructs identified following assessment at a CIU using the BTI. The seven BTI factors represented three areas of Andersen's model of health care utilization: Absence of Problem (situational need); Negative Social Support, Fear of Treatment, and Privacy Concerns (enabling/inhibiting); and Time Conflict, Poor Treatment Availability, and Admission Difficulty (system).
As Andersen (1995)
noted, the barriers that influence health care utilization are “dynamic and recursive” and do not exist independently. Two observations about the barrier constructs illustrate this contention. First, each factor is comprised of items that make up different facets of a larger construct. For example, in Absence of Problem, both the substance abuser and the members of his social group may fail to see substance abuse as a problem. Similarly, the three system factors—Time Conflict, Poor Treatment Availability, and Admission Difficulty—are made up of both individual and system-based items. This suggests that assessment professionals assessing barriers with their clients need to pinpoint the exact source of barriers.
Furthermore, all of the barrier factors, except one, are significantly correlated. Although interaction and causal effects are not addressed in this study, a complex relationship between the barriers is likely. This serves as a reminder that potential clients need to make strategic decisions about what barriers to address and in what order. Careful planning may increase the effectiveness of barrier reduction strategies. Future studies should seek to clarify the interactions, particularly causal relationships, that exist among barriers. This may result in a more effective targeting of program interventions.
4.1. Convergent validity
The factors identified in the BTI are similar to constructs found elsewhere when substance abusers are asked about the treatment barriers they face.
Absence of a perceived problem is similar to the response, “wanting to conceal addiction from a spouse,” found among injection drug users (Appel et al., 2004
) and to problem drinkers' belief that treatment is not necessary (Tucker et al., 2004
Fear of Treatment and Privacy Concerns are also found elsewhere, although the specific items that make up the factors are sometimes different from those in the BTI. For example, privacy concerns cited by problem drinkers focused on documentation kept by the treatment provider, labeling, and confidentiality (Tucker et al., 2004
). Individual items that became Privacy Concerns in the BTI were keyed specifically to sharing personal information with others and talking about one's personal life.
Injection drug users identified barriers to treatment that included items such as an unspecified fear of treatment, bad previous treatment experience(s), and an aversion to specific types of treatment, usually methadone maintenance (Appel et al., 2004
). The BTI Fear of Treatment factor included fear of what might happen during treatment, embarrassment, fear of people in treatment, and a negative prior treatment experience.
4.2. Predicting barrier factors
As reported elsewhere (Hajema et al., 1999
; Hser et al., 1998
; Kleinman et al., 2002
), static characteristics such as age, sex, and educational level have weak and inconsistent associations with barrier factors. This finding may accurately represent the relationship between static characteristics and perceptions of barriers, but it may also suggest a limitation of this and other barrier studies. Static unitary measures of complex phenomena such as race/ethnicity may serve merely as a form of shorthand that does not describe the true relationship between personal, social, cultural, and environmental factors and perceptions of treatment barriers.
Situational need factors showed a much more robust relationship with several of the barrier factors. This finding may be due to the immediacy and relevance that each of the characteristics brings to the perception of barriers. Being court-referred and possibly resistant to entering treatment would be expected to increase the perception that there was no problem. Furthermore, substance abusers referred by the court would likely identify barriers such as fear, lack of time, and lack of availability. The immediate problems associated with having heroin, crack, or marijuana as a drug of choice predicted more problem recognition and less negative social support.
4.3. Practice applications
The BTI has practical implications for settings that conduct substance abuse assessments, most notably CIUs like the one where this study was conducted. The average of 15 minutes spent completing the BTI could provide benefits to both individual substance abusers and assessment programs. For the individual, a discussion of BTI results may improve the likelihood that barriers are successfully resolved and that linkage occurs. By increasing linkage rates, programs conduct fewer assessments that do not result in successful follow-through.
The BTI could also provide programs with aggregate information about the clients they assess. By identifying the barriers that could impact treatment entry, assessment programs are better able to develop effective interventions to facilitate treatment entry. For example, motivational interviewing has shown value in helping clients manage the ambivalence that often surrounds substance use and the decisions to seek treatment (Miller & Rollnick, 2002
; Rollnick & Miller, 1995
). Treatment mentors could be engaged to help prospective clients deal with their fears about treatment and their reticence about revealing personal information to others.
Similarly, strengths-based case management has shown potential in helping substance abusers negotiate both individual and system barriers to linkage, as well as in improving subsequent treatment engagement (Gardner et al., 2005
; Rapp et al., 1998
; Siegal, Rapp, Li, Saha, & Kirk, 1997
). Interestingly, case management was initially a component of CIUs for that reason before being eliminated from many CIUs due to financial considerations (Stephens, Scott, & Muck, 2003
4.4. Study limitations
The substance abusers who participated in this study represent a convenience sample that had recently been assessed and referred to a community treatment program. As such, they probably had already resolved some barriers to attend the assessment. Their view of the next set of barriers, those surrounding treatment entry, may be very different than those of substance abusers who have not recently been assessed. Substance abusers who do not identify a problem and have not participated in an assessment may be less likely to identify with barriers that pertain to the treatment-seeking process. System factors such as Poor Treatment Availability and Admission Difficulty may be irrelevant when a problem is not recognized and when treatment is not considered.
Other characteristics of this sample may also limit the generalizability of study findings. In this study, almost 75% of the sample had been previously treated for alcohol or drug abuse problems. This limits the applicability of our findings to substance abusers who had never entered treatment. Future testing of the stability of the BTI factor structure should include a broader sample of substance abusers who have never sought treatment.
The self-report nature of the study may be another limitation. Although there did not appear to be any incentive for study participants to exaggerate or fabricate their responses to items on the BTI, there is always the possibility that responses are biased, either overrepresenting or under-representing the presence of treatment barriers. Studies suggest that substance abusers tend to be reasonably reliable in reporting their drug use (Adair, Craddock, Miller, & Turner, 1995
; Needle et al., 1995
; Siegal, Falck, Wang & Carlson, 2002
). Items in the BTI seem to be of a less sensitive nature than questions about specific drug use.
An additional limitation of the study suggests a future area of research. The validity of the BTI in predicting treatment linkage has not been assessed. The BTI will also be used to assess the differential impact that the two study interventions (motivational interviewing and strengths-based case management) have on barriers to treatment and how this relates to subsequent treatment linkage. Validity assessment will be undertaken when a sufficient sample of subjects in the RBP completes the 3-month follow-up period.