Social service delivery preferences among african american women who use crack cocaine

This article was downloaded by: [University of Tennessee, Knoxville] On: 16 April 2015, At: 10:35 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK

Journal of HIV/AIDS & Social Services Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/whiv20

Social Service Delivery Preferences Among African American Women Who Use Crack Cocaine Samuel A. Macmaster PhD

a

a

University of Tennessee, College of Social Work , Nashville, TN, USA Published online: 25 Sep 2008.

To cite this article: Samuel A. Macmaster PhD (2006) Social Service Delivery Preferences Among African American Women Who Use Crack Cocaine, Journal of HIV/ AIDS & Social Services, 5:3-4, 161-179, DOI: 10.1300/J187v05n03_11 To link to this article: http://dx.doi.org/10.1300/J187v05n03_11

PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content�) contained in the publications on our platform.

However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content.

Downloaded by [University of Tennessee, Knoxville] at 10:36 16 April 2015

This article may be used for research, teaching, and private study purposes.

Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions

Downloaded by [University of Tennessee, Knoxville] at 10:36 16 April 2015

Social Service Delivery Preferences Among African American Women Who Use Crack Cocaine: What Women Say They Need Before They Can Be Open to HIV Prevention Services?

Samuel A. MacMaster, PhD

ABSTRACT. African American women involved in high-risk, substance use-related behaviors are affected by extremely high rates of HIV infection. While research has demonstrated that HIV is preventable, in order for prevention efforts to be successful in reducing disparities, perceptions of African American women who use crack cocaine need to be taken into account. This qualitative study presents results of eleven focus groups with eighty-nine African American women respondents presenting their perceptions of service needs and preferences for service delivery. The results indicate two important findings for social service providers: the respondents’ lack of a perceived need for HIV prevention services as a spontaneously identified need, and respondents’ desires for more basic services such as childcare, safe shelter, basic necessities, and especially substance abuse treatment before they could be approached about HIV prevention services. The findings are relevant for developing Samuel A. MacMaster, PhD, is Assistant Professor, University of Tennessee, College of Social Work, Nashville, TN. Address correspondence to: Samuel A. MacMaster, College of Social Work, University of Tennessee, 193E Polk Avenue, Nashville, TN 37210 (E-mail: smacmast@ utk.edu).

This project was supported by funds from a Professional Development Award funded by University of Tennessee’s Provost’s Office.

Journal of HIV/AIDS & Social Services, Vol. 5(3/4) 2006 Available online at http://jhaso.haworthpress.com © 2006 by The Haworth Press, Inc. All rights reserved. doi:10.1300/J187v05n03_11

161

Downloaded by [University of Tennessee, Knoxville] at 10:36 16 April 2015

162

JOURNAL OF HIV/AIDS & SOCIAL SERVICES

gender- and culture-specific prevention strategies to reduce the spread of HIV. doi:10.1300/J187v05n03_11 [Article copies available for a fee from The Haworth Document Delivery Service: 1-800-HAWORTH. E-mail address: <docdelivery@haworthpress.com> Website: <http://www.HaworthPress.com> Š 2006 by The Haworth Press, Inc. All rights reserved.]

KEYWORDS. Substance abuse, women, HIV, crack cocaine

INTRODUCTION There is a growing awareness of general racial and gender disparities in access to health care that disproportionately affect African Americans (Institute of Medicine [IOM], 2003). Contributing to the health disparities of the African American community are the greater health disparities that affect African American women who use crack cocaine. These women are subject to a unique environmentalcontext with specific stressors that have a direct and dramatic effect on their health outcomes. One of their greatest health risks is HIV/AIDS. In order to reduce these disparities, it is necessary to develop programming that is specific to, and reflective of the needs and preferences of African American women who use crack cocaine. This study attempts to give voice to these women in describing HIV prevention services they would be willing to utilize. The respondents for this study are women from Tennessee who have been involved with using crack cocaine and who are involved in high-risk HIV-related behaviors.

While representing 12.3% of the U.S. population, African Americans represent the majority of individuals living with HIV (Centers for Disease Control and Prevention [CDC], 2004). For African American women this disparity is significantly increased, as African Americans represent 72% of all female cases nationally and experience rates at 23 times greater than Caucasian women (CDC). Currently AIDS is the leading cause of death of young, 25-34-year-old, African American women in this country (National Center for Health Statistics [NCHS], 2002). Of greater concern for this study, AIDS rates as reported by the Tennessee Department of Health in 2002 were 28 times greater for African American women compared with Caucasian women, and 3.5 times greater than other women of color.

Crack cocaine smokers have been found to be three times more likely to be infected with HIV than non-smokers (Friedman et al., 2003). Use of crack cocaine can contribute to the spread of the epidemic when users

Downloaded by [University of Tennessee, Knoxville] at 10:36 16 April 2015

Lessons Learned

163

trade sex for drugs or money, when they engage in risky sexual behaviors that they might not engage in when not under the influence, or when their use effects access to health care services (Cottler et al., 1998; Marx et al., 1991; Ross et al., 1999). Substance abuse treatment fortunately has been shown to be effective in reducing HIV risk among crack cocaine users (Hoffman et al., 1998).

Theoretical Perspective Underlying the Study Traditional HIV and substance abuse services have not met the needs of many women (Wechsberg et al., 2002). Historically, most HIV education and prevention programs have focused primarily on gay or bisexual male individuals or injection drug users with a resultant lag in the development and identification of successful programs addressing the needs and concerns of women (Amaro, 1995). Further, for African American women, traditional approaches to substance abuse and HIV prevention and treatment may be problematic among African Americans (Wechsberg et al., 2004), given unfavorable views of available treatments (Longshore, Hsieh, & Anglin, 1993) and distrust of mainstream social services (Aponte & Barnes, 1995). Due to these barriers, crack cocaine-using men are also more likely to enter substance abuse treatment than women (Zule, Lam, & Wechsberg, 2003), and men are also more likely to seek treatment services (Copeland, 1997). Further traditional middle-class Euro-American intervention and treatment models may be inconsistent with those of many African Americans (Cochran & Mays, 1993; Wechsberg et al., 2001) at risk as these models assume people have the necessary resources and do not consider the barriers to prevention and intervention.

The conceptual framework utilized in this study is the IOM (2003) Health Disparities Perspective. The IOM Health Disparities Perspectives model designed for providers describes the complex interactions between service recipients, health care providers, and system level factors that lead to inequalities in health services. These factors include social, economic, and cultural influences; stereotyping and prejudice by clinicians, and inaccurate communications between clinicians and service recipients that may lead to misunderstanding. Since there are disparities in health service access for African-American women who use crack cocaine, documenting these womenâ&#x20AC;&#x2122;s perceptions of their service needs and preferences for service delivery is a necessary first step to the development of appropriate services, in order to reduce health disparities for this at-risk population.

164

JOURNAL OF HIV/AIDS & SOCIAL SERVICES

Downloaded by [University of Tennessee, Knoxville] at 10:36 16 April 2015

METHODOLOGY This exploratory qualitative study was designed to discern the perceptions of service needs among the population. These perceptions were obtained through qualitative methodology of multiple focus group interviews based on the method of Morgan (1998). The following research question was developed to define the area of concern and interest: What are the perceptions of service needs among African American women who use crack cocaine?

Design This exploratory study utilized a non-experimental design that incorporates qualitative components consisting of semi-structured focus group interviews of African American women over 18 years of age who use crack cocaine. The interviews sought to gain the perceptions, impressions, and insights of current and former crack cocaine users from the Nashville, TN area. Snowball sampling techniques were utilized to access the population, who were often initially identified by their response to a flyer distributed to known crack cocaine users in the community. Participants were offered a $20 gift certificate as an incentive to participate in the focus group interview. Informed consent to participate was obtained from all participants and strict confidentiality of information was assured. All interviews were conducted in the late spring of 2004. The Institutional Review Board of the University of Tennessee approved the studyâ&#x20AC;&#x2122;s research protocols.

Procedures Project research staff contacted individuals who consented to participate in a focus group interview. Trained research assistants with indigenous knowledge of the specific neighborhoods conducted all interviews in a location convenient for the participants, a private room within a drop-in center located within a public housing project. A brief questionnaire was administered to gather demographic characteristics and background/control variables. The interviewer posed several broad questions designed to elicit data rich in detail. These questions encompassed service needs, barriers, and facilitators to service receipt, the manner in which these barriers were overcome, and the manner in which individuals would prefer to receive services. All interviews were completed in one session lasting approximately 60-90 minutes.

Lessons Learned

165

Downloaded by [University of Tennessee, Knoxville] at 10:36 16 April 2015

Data Entry and Analysis During the focus group, a research assistant transcribed the interview and immediately after the interview, focus group transcripts were reviewed for accuracy and ambiguities, and were summarized at the group level. Data at the group level were gathered by question and condensed by a second research assistant who again reviewed the transcripts before summarizing the data. Data were then compared across the eleven groups for emerging themes. In addition, the interviewers scrutinized drafts of the manuscript and the final document to ensure that the authentic voice of the participants was developed in the outputs.

Sample Analyses in this paper are based on summaries of eleven focus groups with a total of eighty-nine (89) African American women focus group participants who ranged in age from twenty-one to fifty-eight. The majority (77.5%, 69) of respondents reported household incomes less than $10,000, and only approximately a quarter (22) reported being employed full time. Only above a fifth (18) of the women reported that they were living alone, however, the majority (75.3%, 67) of women reported that they were single (i.e., Never Married, Separated, Widowed, or Divorced). As a group, participants were native-born to Tennessee (85.4%, 76) and most were long-term residents of the specific community in which they currently resided (M = 6.03 years, SD = 2.9). More complete demographic data regarding participants is presented in Table 1.

Organization of Themes The analysis of interview data are described in three categories and then by themes, which emerged from the data. These categories are organized around three questions asked of the focus group participants: 1. What were womenâ&#x20AC;&#x2122;s perceptions of service need?

2. What were womenâ&#x20AC;&#x2122;s preferences for service needs?

3. What were their additional ideas related to services and service delivery?

A fourth question was added when the women had not specifically addressed HIV services when asked the questions above:

Downloaded by [University of Tennessee, Knoxville] at 10:36 16 April 2015

166

JOURNAL OF HIV/AIDS & SOCIAL SERVICES

4. What were their experiences related to receiving HIV/AIDS services?

Emergent themes developed from each of these questions, and they are displayed in Table 2 and described in the analysis.

RESULTS Perceptions of Service Needs Individuals participating in the focus groups were not asked specifically about their own service needs; rather, they were asked about the service needs of African American women who use crack cocaine. None of TABLE 1. Participant Demographics Demographic

Categories

Age (Years) Sexual Orientation

37.8 (SD = 8.4) Heterosexual

84.7%

Homosexual

8.3%

Bisexual

6.9%

Education (Years) Employment Status

Marital Status

11.79 (SD = 1.9) Working Full-time

24.7%

Working Part-time

16.9%

Not Working

57.3%

Never Married

48.3%

Living with Partner

13.5%

Separated

12.4%

Married

11.2 %

Widowed Divorced Household Income

Tennessee Native Length of Time in Residence (Years)

7.9% 6.7%

Less than $10,000

77.7%

Between $10,000 and $29,999

14.8%

Between $30,000 and $50,000 Number of People in Household

Total Sample (n = 89)

10.0% 3.09 (SD = 1.8) 85.4% 6.03 (SD = 2.9)

Downloaded by [University of Tennessee, Knoxville] at 10:36 16 April 2015

Lessons Learned

167

TABLE 2. Emergent Themes for African American Women Who Use Crack Cocaine Section

Themes

Perceptions of Service Needs

A Safe Place to Rest Basic Necessities Childcare and Services for Dependent Children Substance Abuse Treatment-Related Needs Experiences with HIV/AIDS Services

Preferences for the Provision of Services

Types of Services Hours of Services Location of Services Characteristics of Service Providers Approach to Service Delivery

Other Common Themes Related to Service Delivery

Motivation Awareness of Services Long-term Nature of Service Needs

the groups spontaneously identified HIV/AIDS services as a need, despite the clear and expressed focus of the interviews. Later in the interview process, participants were asked specifically about their experiences in accessing HIV/AIDS services, these data are presented in this section, although it was not collected in the same format as the other data, as it may help to provide an understanding of why it may not have been initially addressed.

Themes A Safe Place to Rest. The need for a place where someone could take a break and rest for a while due to the rigors of crack cocaine use was the most consistently reported service need. Participants in several groups stated that this included a place where people can “go and get cleaned up” and/or “take a shower.” Another woman stated that she often needed, “A place where I could go, where I could go when I ran out of money and didn’t have no more dope.” One related a need to escape sexual demands: “[A] place where I can go and take a nap, where I ain’t gotta do nothing, ain’t gotta go give nobody some head.”

Downloaded by [University of Tennessee, Knoxville] at 10:36 16 April 2015

168

JOURNAL OF HIV/AIDS & SOCIAL SERVICES

Other respondents similarly stated that sometimes a woman simply needs a safe place to stay when people around her are actively using crack cocaine, where she is accepted as she is, a place to go without “preaching . . . [and] condemnation.” Another participant in another group similarly stated that women needed, “A place to go in and take a shower and get something to eat and ain’t got to go to a Bible study. A place where you can come in and out, without a lot of hassle. A place where you can wash your clothes, get something to eat, no strings attached.”

Basic Necessities. Consistent throughout all of the groups was the idea that service needs were much greater than just HIV services or substance abuse treatment. In almost all of the focus groups, participants reported the services that they felt were needed primarily included basic necessities, including housing, food, clothing and personal hygiene products, and transportation. As one woman stated, needs for women who use crack cocaine are “The same as women who don’t use crack cocaine . . . they just need it quicker.” Another woman said, “Maybe they need teeth, maybe they need to get some shoes, or get they license back, help them get themselves back together. Rehab and all that is good but people need other help, too.”

The need for safe and stable housing was the most consistent theme among basic necessities. This was primarily discussed as a long-term issue, but several participants discussed it as an immediate need, as one woman suggested, “If I wanted to get someplace today, where would we go? Where are you gonna send me? [My biggest concern would be] Where am I gonna sleep tonight?” Another woman simply stated that women needed to be in a location that was, “A place that’s away from all the dope.”

In discussing basic needs, some, but certainly not all, women reported that when using all of their basic necessities were sold or bartered for drugs. One participant reported that her mother would no longer give her money for necessities as she would use the money on cocaine, but that when she did receive items she needed from her own mother, she would sell them. Other women reported that this occurred on a regular, or typical, basis, but were clear that they personally were not involved in doing this. Several women in the groups reported that male users and/or dealers had provided them with everything they had needed in terms of basic needs, while other stated that they simply stole what they needed.

Childcare and Services for Dependent Children. Many participants focused on women with children, reporting that these women needed access to childcare or day care. This was also consistently discussed across groups. Several women in the groups stated they were simply in need of someone to take care of their children when they were using.

Downloaded by [University of Tennessee, Knoxville] at 10:36 16 April 2015

Lessons Learned

169

Other participants stated that while services are available for women with children, some do not use them or do not use them for what they were intended. For example, one participant stated that when some individuals receive food stamps, their children still go hungry because the children do not receive food and the food stamps are sometimes sold. Another participant reported that her children were able to access services for her when she couldnot.Onewoman described how her children had changed her life, I needed somewhere to wash up and sit up under the air conditioning for a minute. I got so bad nobody would open they door for me.

I would send my kids around so somebody would let me in, it got so bad people wouldn’t even open the door for my kids. They finally took them from me, that’s what changed my life.

Substance Abuse Treatment-Related Needs. One participant shared, “[I] just [needed] to have somebody sit down and talk to me straight and give me some guidance. When you out there on dope, people think that nobody cares about you anymore. Just talk to them and give them some hope.”

Participants in all groups discussed substance abuse treatment-related needs. Assistance in accessing and/or becoming motivated to access services was most often cited as a primary need. Participants stated that people just needed someone to talk to about their substance use when they are actively using. A participant in another group stated that having providers conducting outreach on the streets was a need. Echoing a similar thought, one participant stated, “I think just being out there, don’t go into the dope house, but if you are working out there on the street word gets around.”

Harkening to the theme of a “safe place to rest” several groups expressed a need for a place to go while waiting for treatment center space.

As one woman stated, “A place to stay for a couple of days while you waitin’ for bed in treatment would be good. You have to have a made up mind when you go to treatment.”

Participants in other groups focused specifically on substance abuse treatment itself. Many of the participants had experiences in substance abuse treatment, often reporting several experiences. Many of the participants shared their own experiences of accessing services before they were ready to stop using crack cocaine, only to relapse again. The need for longer stays in treatment was a consistent theme, as was the need for treatment that is available on the day it is needed, that is, treatment on demand.

Several participants discussed the experiences of being motivated, but not being able to access treatment due to waitlists and/or childcare needs.

The need for shorter wait lists, and more programs that allow children to

Downloaded by [University of Tennessee, Knoxville] at 10:36 16 April 2015

170

JOURNAL OF HIV/AIDS & SOCIAL SERVICES

accompany their parents were expressed. Several groups discussed the need for insurance, “that will let people stay in treatment longer.” Almost all of the groups reported the need for substance abuse treatment to be sited in a place located in the community that they live.

Experiences with HIV/AIDS Services. Participants did not initially identify HIV/AIDS services as a specific need. Later in the interviews when asked about experiences related to receiving HIV/AIDS services, participants hadless toreportas comparedwithsubstancetreatmentservices,usually due to an expressed lack of interaction with HIV/AIDS services. Those who had accessed services usually remarked about the quality of the services and their experiences. In most of the groups, some of the participants reported that they had been tested for HIV/AIDS, usually while they were incarcerated, or pregnant. Participants in several groups reported that HIV tests often coincided with arrests for prostitution. Several participants also reported receiving prevention materials while incarcerated and/or in substance abuse treatment programs. A few participants felt that their were too many services, for instance a woman who stated, that she had “received more HIV services than [she] needed” and that “every time [she] turns around somebody’s giving out condoms, testing, whatever.”

When asked about experiences with barriers to the receipt of HIV/ AIDS services, the response in almost all focus groups was that many of the women stated that they had not used, or tried to access, these services.

Several groups discussed the relative easy access to educational pamphlets and condoms, but there was some concern about barriers to access to HIV testing. Several individuals cited the cost of HIV testing to be a prohibitive barrier. However, the more frequently discussed barrier was the fear of testing positive. Throughout all of the groups, the most frequently discussed barriers related to the stigma attached to HIV, either that the assumption that if one is using crack cocaine that he or she is HIV seropositive, and the assumption that if someone observes you visit an AIDS service organization that you are HIV seropositive. The other frequently cited barrier was continued use of substances, which lead to procrastination and/or apathy regarding HIV-related issues. A participant summed up how pervasive HIV is in the community, along with the paucity of services to address it: I only know of one program. Even when I was in college, there was nobody giving out condoms. It’s not just people on crack it’s everywhere. I have family members that have it. I’ve been educated about it so I know. You have to deal with it. There is global awareness, but not local awareness.

Lessons Learned

171

Downloaded by [University of Tennessee, Knoxville] at 10:36 16 April 2015

Preferences for the Provision of Services Once perceptions of service needs were established, participants in the focus groups were asked about their preferences and suggestions on how these services should be provided to women who actively use crack cocaine. When asked, issues such as hours, location, and availability arose in all groups. Almost all of the groups also developed new information related to the types of services that should be provided.

Types of Services. In terms of what specific services should be offered, participants, similar to the previous section, suggested focusing on the immediacy of very basic needs. As discussed in the previous section, participants stated that they were often so tired when using that all they wanted was place to rest. Suggested services included offering someone a place to go where they could get a bath, some food, and a place to sleep for a while. Other participants stated that providers should offer people food, cold drinks, and sweets, while they are still on the street.

Just pick us up and take us away from here. They a lot of people around, they wants help, but don’t know where to go to get help.

They think nobody cares. Get more information out there so people will know where to go, that will help.

Hours of Services. In terms of when the services should be offered, another participant suggested that, “There need to be services 24/7 because you don’t know when people are gonna reach out and want to get some help.” The most consistent time of the day that services should be offered that was specified was either very late at night or early in the morning, before dawn. One woman stated that, “services should be offered from 5:00 am until 9:00 am for people to access once dealers have gone home and the police have changed shifts.” Others stated that people need services at different times of the day during different seasons, depending on how cold it was outside as people tend to be out later in the warmer weather. Another participant related the experiences of many who need assistance, but who cannot utilize services due to the normal business hours of operation for many agencies stating, After 4 o’clock in the afternoon, you on your own. If you call crisis care, they just gonna talk to you on the phone, that ain’t gonna help me. Drugs ain’t no nine to five world. Sometimes you be needin’ help at four o’clock in the morning. If I can’t get help when I need it that ain’t no help if the place be closed when you need it.

Downloaded by [University of Tennessee, Knoxville] at 10:36 16 April 2015

172

JOURNAL OF HIV/AIDS & SOCIAL SERVICES

Location of Services. In terms of where services should be provided, participants almost uniformly suggested that services needed to be provided in areas where people use crack cocaine, and be a “constant presence in the neighborhoods,” or “there should be a program right here in the projects.” Another voice for creating local services stated, “Services need to be in the neighborhood where folks is hanging out, near the dope houses . . . they need a hope house near the dope house.”

Lack of transportation is also an issue in terms of where services should be offered, as one participant stated, “I think it should be like on site services likeinhousingdevelopments,‘causepeopledon’thavenotransportation.”

Participants also suggested that the program should be in an environment that provides all services in a clean and friendly atmosphere, “You need to have some type of facility open when people are ready to get help.

A nice place that is clean, and doesn’t smell like doo-doo, that has a shower and some clothes available, with a washing machine.”

Characteristics of Service Providers. In terms of who should provide services, it was suggested that service providers needed to be someone that individuals would be able to trust, and who could relate to participants in non-judgmental manners. Many participants used the term “experienced” in terms of their own personal substance use or understanding of it. Several participants suggested that service providers who have used crack cocaine in similar ways to their experiences may be especially able to provide services in non-judgmental manner, as one participant stated, “Folks [need] to know that the folks helping them have actually been out there and know about stuff, that’s really a good thing, if you been out there. It makes it easier to take to them if you know they have been through it.” Another participant echoed this stating, “If you ain’t been out there, how can you identify?” In yet another group, a third stated being a former user was not enough, “Make sure that there is someone available who is an addict and had kids. I want to have somebody that knows what my situation is and can relate to it.”

Another woman highlighted the stigma felt by women using crack cocaine and the need for a non-judgmental approach by service providers, “If people stop lookin’ down at you because of what drugs you do, treat people with dignity no matter how you look or where you been all night.

My brother is a thief and, my sister is a drunk, everybody’s cool but me because I smoke crack. I think that’s fucked up, at least I know what I am. All drugs is drugs.” The level of lack of trust was exemplified by another participant who stated, when she was using, she thought “everybody was the vice,” noting that she at first thought the facilitators were the police when she walked into the group. Another participant felt, “They need to be able

Downloaded by [University of Tennessee, Knoxville] at 10:36 16 April 2015

Lessons Learned

173

to trust the people who are providing the services. They need somewhere where they can go and not be judged.”

Approach to Service Delivery. In terms of how services are provided, many participants reiterated that services should be offered with no strings attached. One participant suggested that services should be provided, “when people are ready to use them.” She shared her own experiences of running from outreach vans when they tried to approach her because she was not ready to stop using. Another participant said, “When you want them, how you need them, where you need them. When you decide, you need to have something available to you.”

Several participants stated that there do need to be limits. One participant stated: No strings attached. It be like not so much 24/7, this ain’t they flop house. Early in the morning, late at night, a place to go to the bathroom and then leave and then go on about they business. A place where you can get in and get out in about 45 minutes, not a place where you can hang around all day, though. A place that ain’t there for you to be in all the time, people will take advantage if you let them hang around all the time.

Other Common Themes Related to Service and Service Delivery When asked about any additional thoughts they had regarding services and service delivery, participants offered many other considerations, suggestions, and observations that impact how services are received.

These include the (1) motivation of the women, (2) the need for agencies to make women at risk aware of their services, and (3) the long-term nature of these women’s service needs.

Motivation. The issue of motivation for change was present in many of the groups. A sign of motivation was identified by one participant: “If people start coming around regularly, that’s when you know they want some help.” Another stated, “I had to go to jail before I finally decided to go to rehab. It took me three months to decide. I was getting high in jail.”

Similarly, a third stated, “I can only speak from my experience, OK? I would have done anything, sold anything I had or didn’t have. When I got out of treatment,I didn’t go to meetings, so I didn’t get anything out of it.”

Awareness of Services. A consistent theme here included, “getting the word out.” One participant complained, “When people get ready to go they don’t know how to get the help they need, they don’t know where to

Downloaded by [University of Tennessee, Knoxville] at 10:36 16 April 2015

174

JOURNAL OF HIV/AIDS & SOCIAL SERVICES

go.” Participants suggested that all services should be well advertised in ways that even people who cannot read can understand. Other participants suggested that informing families and loved ones was also important, as one person stated that programs should “incorporate a family plan.” Another participant suggested that service providers should distribute “information to store owners where addicts hang out.”

Long-Term Nature of Service Needs. Substance abuse treatment alone isn’t enough for many of the women. This is expressed by one of the participants: Everybody talks about treatment, but some follow up three or four months later would give folks a sense of security. Help them with problems they be having later on and direct them to services they need later on, there’s not anything like that now. For me, people think they don’t need therapy or help, but they do. I didn’t know what services was out there until I got hooked up with Street Works.

(An outreach program) Other participants also reported that there are long-term service needs.

When asked if they had any additional thoughts, another woman in the group stated, “Once you get out the door, there needs to be something to pick up wherethetreatmentcenterleavesoff.”Connectionswith twelve-step groups were also suggested: “Having some meetings would be good, on any day.

They ain’t no meetings around here. A brown bag meeting would be the best; there’s a difference between AA [Alcoholics Anonymous] and NA [Narcotics Anonymous] and CA [Cocaine Anonymous] meetings.” Another woman in recovery stated, “Meetings 24/7, a brown bag meeting.

Where women could come and talk about they issues among themselves. It would be nice if they was some kinda way that they could be made to come.

You can see it, the children are hungry, they dirty. Nowadays they take longer to get help. Maybe the dope is different or something now.” However, twelve-step meetings alone were not sufficient, as one individual stated, “When I was using I used to like to shoot pool, bowl. Now that Iamin recovery I need activities, I like to do that same stuff but I like to do it with other people in recovery. Just talking all the time doesn’t do it for me.”

DISCUSSION The results of this study are a first step in documenting service needs and preferences of African American women who use crack cocaine.

Downloaded by [University of Tennessee, Knoxville] at 10:36 16 April 2015

Lessons Learned

175

While numerous studies have measured the HIV/AIDS risk behaviors of crack cocaine users, there are few that have looked at service needs from the perspectives of these women. The present analyses are only descriptive in nature and only report the theme of general perceptions of service needs of the peers of women who use crack cocaine. This study does not predict service needs, nor establish prevalence rates to better provide for HIV, substance abuse, or housing services for this HIV at-risk population. This study does provide a voice to these seldom-heard, hardto-reach, at-high-risk group. Their knowledge about the existence of services, the need for services provided in neighborhoods, and strategies to make them conducive to use by women at risk provides a basis for planning future research and implementing practice.

Research Implications The paucity of accessible services that directly respond to the needs of these women, who are at high risk for HIV transmission and the womenâ&#x20AC;&#x2122;s lack of a spontaneous perception of the need for specific HIV/AIDS services deserve further exploration in future studies. These womenâ&#x20AC;&#x2122;s focus groups indicated a definitive preference for outreach and transitional services at times and locations that are most convenient to women who use crack cocaine; as well as a preference for services, which meet more basic needs than either HIV prevention or substance abuse treatment. Of course, thesedataareonly suggestiveof theprevalenceof theseservicepreferences in this moderate sample, and cannot be generalized. However, these findings are consistent with the literature that indicates services for female African American women who use crack cocaine are not delivered in a manner that is culturally appropriate, gender specific, and/or provided at times and venues when they are most desired (Batki & Selwyn, 2002).

Given that crack cocaine use places women at particularly high risk for contracting HIV, the lack of appropriate HIV and substance abuse services appears to be fueling the epidemic. The present study does not allow formal testing of this notion, though further study is clearly warranted.

Practice Implications The demographic characteristics of respondents as well as their relationship to substance abuse treatment is in sharp contrast to assumptions often made about crack cocaine users, that they lack a willingness to consider stopping their drug use. The majority of the sample expressed a need for substance abuse treatment services; however, the lack of current

Downloaded by [University of Tennessee, Knoxville] at 10:36 16 April 2015

176

JOURNAL OF HIV/AIDS & SOCIAL SERVICES

involvementin such programs leads one to conjecture if this may be due to a lack of availability of appropriate drug treatment services or because of barriers to access to such programs. The theme of motivation described in this study by the women might be better understood through the prism of the “stages of change” or transtheoretical model (DiClemente, 2005; Miller & Rollnick, 2002; Prochaska & DiClemente, 1982; Prochaska, DiClemente, & Norcross, 1998; Prochaska, Norcross, & DiClemente, 1994), which might help conceptualize the women’s needs at what Prochaska and DiClemente refer to as the pre-contemplation or contemplation stage of change. If the women are or become ready for treatment at these early stages of treatment readiness, substance abuse treatment would need to be available. If treatment is not available, then a safe place to stay until treatment space is found would be one option to keeping a woman engaged in reducing risk and the change process.

Study Limitations Limitations to the data presented here include that the data are based on snowball sampling procedures in one urban area, not a random sample, so the respondents in this study are certainly not representative of all African American women who use crack cocaine. Second, the sample size (n = 89) clearly limits the ability to draw generalizable conclusions. However, given the descriptive focus of the analyses for the purpose of developing themes, the sample size was adequate in that it provided rich material, some of which was repeated to saturation and triangulated by having been repeated spontaneously in several independent groups.

Additionally, the reliability of self-report data from active drug users may be questioned, particularly with the study’s use of in-person group interviews. Given the social nature of group interviews the expressed interest in substance abuse treatment services may simply be a measure of the perceived social desirability of this response and not the true desire of the participants. There may also be significant differences between an expressed desire to access drug treatment services for others and taking the actions needed to facilitate that desire for the self.

CONCLUSION This descriptive qualitative study has sought to provide information about the preferences for social service delivery among African American women who use crack cocaine. The women expressed a need for a place to

Downloaded by [University of Tennessee, Knoxville] at 10:36 16 April 2015

Lessons Learned

177

stay and wanted substance abuse treatment services that were accessible and in which the people providing the service understood and respected them. They did not indicate a perceived need for HIV prevention services, however, it is recognized their insights about housing, substance abuse treatment, and childcare could be seen as effective forms of HIV prevention for this at-risk population. By not identifying immediately identifiable HIV prevention services, they both indicated either such servicesâ&#x20AC;&#x2122; lack of availability or their lack of relevance given their more immediate drug, poverty, childcare, and other concerns. In planning strategies to address those disparities, these womenâ&#x20AC;&#x2122;s voices, perceptions, and preferences need to be heard and taken into account if these initiatives are to be successful.

It appears from these results that women may be so focused on basic survival needs that HIV prevention is not perceived as a need that should be immediately addressed. While HIV prevention service providers may perceive HIV prevention services meeting a physiological need, or minimally to be a safety need; it appears that African American women who are using crack cocaine perceive other more pressing issues to be related to their day-to-day survival and security. In planning and developing services, it may therefore be important to include this perspective. HIV prevention services for African American women who use crack cocaine must include programming that is relevant to their lives and integrated into services that address their perceived immediate needs for survival and safety. Additionally, how these services are provided is equally important. It appears from the results of the focus groups that prevention services must also take into consideration hours, location, and availability when providing services. Without these perspectives, targeted audiences may only perceive HIV prevention services as not being relevant to them, despite their being disparately impacted by HIV/AIDS. REFERENCES Amaro, H. (1995). Love, sex, and power: Considering womenâ&#x20AC;&#x2122;s realities in HIV prevention. American Psychologist, 50(6), 437-447.

Aponte, J. F. & Barnes, J. M. (1995). Impact of acculturation and moderator variables on the intervention and treatment of ethnic groups. In J. F. Aponte, R. Y. River, & J. Wohl (Eds.), Psychological Interventions and Cultural Diversity, 19-39. Boston: Allyn & Bacon.

Batki, S. L. & Selwyn, P. A. (2002). Substance abuse treatment for persons with HIV/ AIDS: Treatment Improvement Protocol (TIP) series: 37. U.S. Department of Health and Human Services, Rockville, MD.

Downloaded by [University of Tennessee, Knoxville] at 10:36 16 April 2015

178

JOURNAL OF HIV/AIDS & SOCIAL SERVICES

Centers for Disease Control. (2004). HIV/AIDS Surveillance Report: 2002, 15(1).

Cochran, S. D. & Mays, V. M. (1993). Applying social psychological models to predicting HIV-related sexual risk behaviors among African-Americans. Journal of Black Psychology, 19, 142-154.

Copeland, J. (1997). A qualitative study of barriers to formal treatment among women who self-managed change in addictive behaviors. Journal of Substance Abuse Treatment, 110, 445-448.

Cottler, L. B., Leukefeld, C., Hoffman, J., Desmond, D., Wechsberg, W., Inciardi, J. et al. (1998). Effectiveness of HIV risk reduction initiatives among out-of-treatment non-injection drug users. Journal of Psychoactive Drugs, 30(3), 279-290.

DiClemente, C. C. (2005). A premature obituary for the transtheoretical model. Addiction, 100(8), 1046-8.

Friedman, S. R., Flom, P. L., Kottiri, B. J., Zenilman, J., Curtis, R., Neaigus, A. et al.

(2003). Drug use patterns and infection with sexually transmissible agents among young adults in a high-risk neighbourhood in New York City. Addiction, 98(2), 159-169.

Hoffman, J. A., Klein, H., Clark, D. C., & Boyd, F. T. (1998). The effect of entering drug treatment on involvement in HIV-related risk behaviors. American Journal of Drug and Alcohol Abuse, 24, 259-284.

Institute of Medicine (2003). Unequal Treatment: Confronting Racial & Ethnic Disparities in Health. Portland, OR: National Academy Press.

Longshore, D., Hsieh, S., & Anglin, M. D. (1993). Ethnic and gender differences in drug usersâ&#x20AC;&#x2122; perceived need for treatment. International Journal of the Addictions, 28(6), 539-558.

Marx, R., Aral, S., Rolfs, R., Sterk, C., & Kahn, J. (1991). Crack, sex and STD. Sexually Transmitted Diseases, 18, 92-101.

Miller, W. R. & Rollnick, S. (2002). Motivational Interviewing: Preparing People for Change. New York, NY: Guilford Press.

Morgan, D. (1998). The Focus Group Guidebook. Thousand Oaks, CA: Sage.

National Center for Health Statistics (2002). Health, United States, 2002. Hyattsville, Maryland: Public Health Service.

Prochaska, J. O. & DiClemente, C. C. (1982). Transtheoretical therapy: Toward a more integrated model of change. Psychotherapy Theory, Research and Practice, 19(3), 276-288.

Prochaska, J. O., DiClemente, C. C., & Norcross, J. C. (1998). Stages of change: Prescriptive guidelines for behavioral medicine and psychotherapy. In G. P. Koocher, J. C. Norcross, & S. S. Hill III (Eds.), Psychologistsâ&#x20AC;&#x2122; Desk Reference. New York, Oxford: Oxford University Press.

Prochaska, J. O., Norcross, J. C., & DiClemente, C. C. (1994). Changing for Good.

New York: William Morrow and Company, Inc. Ross, M., Ywang, L., Leonard, L., Teng, M., & Duncan, L. (1999). Sexual behaviour, STDs, and drug use in a crack house population. International Journal of STD and AIDS, 10, 224-230.

Tennessee Department of Health (2002). HIV/AIDS/STD Section Epidemiological Profile, 2001. Nashville: Tennessee Department of Health.

Downloaded by [University of Tennessee, Knoxville] at 10:36 16 April 2015

Lessons Learned

179

Wechsberg, W. M., Zule, W., Perritt, R., Roberts, A., Middlesteadt, R., & Burroughs, A. (2001). Women-focused HIV prevention for African-American crack users. In L. S. Harris (Ed.), Problems of drug dependence 2000: Proceedings of the 62nd Annual Scientific Meeting. The College on Problems of Drug Dependence, Inc. NIDA Research Monograph 181, 2000. Bethesda, MD: US DHHS, pp. 33-34.

Wechsberg, W. M., Lam, W. K., Zule, W., Hall, G., Middlesteadt, R., & Edwards, J. (2003). Violence, homelessness, and HIV risk among crack-using African-American women. Substance Use and Misuse, 38, 671-701.

Wechsberg, W.M., Lam, W. K., Zule, W. A., & Luseno, W. (2002, November). Barriers facing African-American crack-abusers in treatment. Presented at the 130th Annual Meeting of the American Public Health Association, Philadelphia.

Wechsberg, W. M., Lam, W. K., Zule, W. A., & Bobashev, G. (2004). Efficacy of a woman-focused intervention to reduce HIV risk and increase self-sufficiency among African-American crack abusers. American Journal of Public Health, 94(6), 11651173.

Zule, W. A., Lam, W. K., & Wechsberg, W. M. (2003). Treatment readiness among out-of-treatment African-American crack users. Journal of Psychoactive Drugs, 35(4), 503-510.

RECEIVED: 05/10/05 ACCEPTED: 02/24/06 doi:10.1300/J187v05n03_11