Chapter 4

Outreach to and Identification of Women

Although there is growing awareness, understanding, and acceptance among health professionals and the public that alcoholism and other drug addictions are major public health issues, negative attitudes and misconceptions concerning women and substance abuse still abound. These attitudes and misconceptions often pose silent barriers to treatment for women. Women with substance abuse problems are often reluctant to admit their need for treatment. They may fear social rejection or loss of their children or they may have internalized the prevailing social attitudes toward addiction. Furthermore, for many women, poverty and related socioeconomic conditions, often compounded by discrimination based on race, psychiatric disorders, ethnicity, disability, sexual orientation, and/or age, create additional problems that may further inhibit them from seeking treatment.

        A woman who needs treatment for a substance abuse problem may be deterred by the relative lack of treatment services designed specifically for women. Women with children may be discouraged by the shortage of treatment services that include provisions for child care if they must leave their children in unreliable hands to enter treatment. A successful outreach program must recognize these factors as barriers to treatment and ensure that the treatment program addresses them.

        To develop an outreach program for women with substance abuse problems, it is important to acknowledge that substance abusing women are represented in all ages, races, cultures, ethnic groups, educational " levels, and socioeconomic status, as described in Chapter 2. To be successful, outreach efforts must recognize these differences and target specific populations.

This chapter addresses these issues by:

• describing barriers to outreach and treatment;

• describing barriers to outreach and treatment for specific population groups; and

• presenting general approaches to outreach.

4.1        Barriers to Outreach and Treatment

         Women often confront barriers to finding, entering, and completing substance abuse treatment programs. Society imposes some of the barriers. Others are internal within the woman herself. Some barriers are unique to special populations, but many are relevant to women of different ages, races, and socioeconomic status. There are generally three types of barriers:

• Generic, systemic barriers that are not gender-specific (e.g., racism, classism, aversion to behavior perceived as "deviant," lack of community-based social support services);

• Gender-specific barriers (e.g., lack of geographically accessible treatment services for women; lack of child care); and

• Internalized reaction to either the generic or gender-specific barriers, or other individual experiences or issues faced by an individual woman (e.g., the client's belief that she is indispensable and cannot leave home to seek treatment).

        In practice, specific barriers often cross these general types. Barriers that cut across different populations are in this section; those that are unique to special populations are presented in Section 4.3.

         Economic inequality. Women earn $0.70 for every $1.00 earned by men, are much more likely to be single heads of households, and are much more likely to live in poverty. The cost of treatment may be a significant obstacle for uninsured and low income women who need treatment for substance abuse and its related problems.

        By the end of 1993, nearly 40 million Americans had no health insurance. In 1989, the most recent year for which gender breakdowns of uninsured Americans are available, 15 percent of American women had no health insurance coverage (compared with 16 percent of men) and 7.6 percent of women were covered by Medicaid (compared with 5.2 percent of men).¹ Women who are insured by programs such as Medicaid often find it difficult to locate a program that will accept this type of payment.

        Furthermore, even if a woman has insurance, it may not cover alcohol or other drug treatment, or there may be limits to either the setting of care or the number and types of services (e.g., detoxification days or therapy sessions that may be covered in a lifetime). The coverage or entitlement program may also require a co-payment that the woman cannot afford. Because of the lower incomes of women in comparison to men, health insurance factors significantly affect financial access to care.

        Social Stigmatization. Women who have substance abuse problems are often perceived as less "socially acceptable" than their male counterparts. They are, therefore, less likely to disclose their need for treatment and more likely to have sustained periods during which substance abuse is not diagnosed or is misdiagnosed. In our society a substance-abusing woman is often considered a second-class citizen. She may also be seen as sexually promiscuous and weak- willed because of her alcohol and other drug abuse .² Social stigma exacerbates denial, a primary barrier to outreach. Outreach workers need to engage women in discussions that will overcome the psychological and emotional results of social stigma.

         In certain cultures, the fear of social stigmatization may be particularly strong. For example:

Women of color [who abuse alcohol] share a double stigma as alcoholics and as minority women. For a woman of color who is also lesbian, the stigma and isolation is further compounded. Women of color are usually alone or in a small minority in either minority programs dominated by men or women's programs dominated by Caucasian women. ³

         Thus, women of color experience many layers of stigmatization gender, race/ethnicity, culture, and substance abuse.

        Lack of Social and Emotional Support. Women generally encourage men who have substance abuse problems to enter treatment. However, women's partners, family members, and friends often enable women to continue their substance abuse by denying the existence of the problem or its seriousness rather than encouraging them to seek treatment. Women are more likely to bear the primary responsibility for care of their family members, in part because they are four times as likely as men to be the head of a single parent household with children. Therefore, women face practical considerations surrounding a decision to enter treatment, especially inpatient or residential care, that men do not confront as frequently.

         Lack of Institutional Mechanisms to Help the Substance-Abusing Woman. Institutional mechanisms that identify and sometimes help men with substance abuse problems are not as readily available as outreach vehicles to women. For example, women who need treatment are less likely than are men to be identified in the workplace because proportionally fewer are employed (63 percent of women were employed in 1990 in comparison to 75 percent of men).⁴ Although the number of adolescent girls and adult women in the criminal justice system is increasing (there has been a 200 percent increase in the women's prison population in the past 8 years), prisons for men are more likely to have medical services, substance abuse treatment, and other support services than are those for women. However, women have more contact with staff from social services (welfare), Head Start, shelters, hospitals (when giving birth), and emergency rooms (when battered). The personnel employed by these institutions need to be trained to identify substance- abusing women.

         Cultural Values and Norms. Until fairly recently, cultural differences have been largely ignored in addressing treatment issues. Today, it is understood that to treat women with substance abuse problems successfully a program must have a certain level of "cultural competency."

        Culture, as defined in Cultural Competence for Evaluators, is the shared values, norms, traditions, customs, arts, history, folklore, and institutions of a group of people. Within this perspective and from this definition, cultural competence is a set of academic and interpersonal skills that allow individuals to increase their understanding and appreciation of cultural differences and similarities within, among, and between groups. This requires a willingness and ability to draw on community-based values, traditions, and customs, and to work with knowledgeable persons of and from the community to develop focused interventions and other supports.⁵

        As Orlandi has noted,

Cultures do not remain the same indefinitely. Cultural subgroups exert an influence over and are influenced by individuals who are members of those groups as well as other cultural groups with whom these subgroups come into contact.⁶

        It is important to note that cultural competency is a key issue in attracting women of color into treatment programs:

Women of color fear not only outright racism but a treatment system insensitive to their cultural and ethnic values which may also have little sensitivity to the special needs of women ... ⁷ The culturally liberated caregiver acknowledges the reality of racism without allowing it to be an excuse for ⁸ the client's self- destructive behavior.

        This can apply to other populations as well, including lesbians, women with disabilities, and women who have been or are prostitutes.

         Family Responsibilities. Many women will not enroll in outpatient treatment programs unless they can arrange adequate supervision for their children. Women entering inpatient treatment who leave their children in someone else's care may fear losing custody of their children. This is particularly true for the following women:

• women already in the criminal justice system who believe disclosure of a substance abuse problem will be the "last straw" as far as custody is concerned;

• pregnant women who fear being called "unfit mothers" or facing legal sanctions for using drugs while pregnant;

• women subjected to domestic violence who fear that no one will protect their children;

• homeless women who fear that Child Protective Services will remove their children from their custody;

• lesbians who are concerned that disclosure of their lifestyle will result in losing custody of their children;

• women with disabilities who, even without the stigma of substance abuse, are often perceived as unable to fulfill the parenting role; and

• any woman with children who does not have a family or support system to care for her children while she is in treatment.

        The treatment program staff should be aware that the degree of fear experienced by these women (expressed or not) may depend on the cultural "value" placed on children and the role of children in the family.

        Thus if a program does not provide child care, neither inpatient nor outpatient treatment is truly available to women with children, who are the majority of substance abusing women. To attract women with children, the treatment program should do at least one of the following:

• investigate and evaluate the possibility of providing full or partial child care on the premises during the mother's treatment process and meet the necessary licensing requirements for providing such care;

• recruit volunteers among program staff, women in the final stages of treatment, family members, retired persons or senior citizens, interns from local schools and places of worship, and members of self-help groups to staff the child care program; and

• compile and distribute a directory of free or low-cost licensed day care service providers in the community and explore financial subsidies to improve access.

        Denial. Denial is a primary characteristic of addiction. Outreach programs may, in fact, be the first step in helping a woman break through denial. Reaching out to a woman and engaging her in a process of acknowledging a need for help is a prerequisite for effective treatment. A woman who acknowledges that she needs help is much more empowered to accept and remain in treatment.

        Women's Fears. Substance-abusing women have many fears that must be addressed in designing and implementing outreach strategies. These include the following:

        Fear of Rejection. Many women live in great fear of being rejected and abandoned by loved ones, friends, and by others, for example coworkers. They believe their loved ones may reject them if they learn that their mother, spouse, daughter, partner, friend, or sibling is addicted to alcohol and/or other drugs. Some adolescent girls and adult women also believe that a treatment program or its staff will reject them. They may fear rejection because they are "too bad," they engage in life styles not approved of by society.

        Fear of rejection may be particularly pronounced among adolescents, especially those in the criminal justice system, whose families may have already rejected them. Also, women with AIDS or women who are HIV-positive may fear rejection if they have already felt rejected by health care providers, employers, family, and friends once they revealed their medical status.

        Fear of Becoming Abstinent or Getting Well. For women who have developed few if any coping skills (e.g., assertiveness skills, stress management techniques), the idea of facing life without the temporary relief and/or escape that alcohol and other drugs offer at least in the early stages of use may be overwhelming. During the outreach phase, these women need assurance that it is possible not only to face life but to enjoy it without the "help" of mood-altering or mind-altering chemicals. Using recovering women as role models in the outreach program can provide this assurance, as will involvement in recreational programs related to stress management.

        Fear of Dealing with Authority Figures. This fear may be particularly pronounced for these types of women:

• women from economically or racially disadvantaged populations;

• women who have had negative experiences in trying to obtain social services (housing, medical care, food stamps, job training, etc.);

• women in the criminal justice system who see the system as punitive rather than rehabilitative, women with criminal records and/or outstanding warrants, and women who have engaged in illegal activities to support their addiction;

• female adolescents who have had behavioral problems;

• illegal aliens who fear deportation (and fear that registering anywhere will mean that the government will find them, whether a program is government-funded or not); and

• women who have been victims of incest or sexual abuse.

        To address these concerns, outreach programs should develop relationships with departments of education, local legal aid offices, law offices, and other relevant agencies to identify individuals who are sensitive to the needs of women who abuse alcohol and/or other substances. These individuals could then be "gatekeepers" for referrals to that agency and could also visit the program periodically to meet with women in treatment. By conducting training sessions for the staffs of these agencies, the outreach program would sensitize them to the needs of women in treatment. The program could then advertise the availability of these services in its outreach materials.

        Fear of Retaliation. Substance-abusing women may be involved in family and/or significant-other relationships with individuals who do not support their interest in treatment, and who often threaten to retaliate if they decide to enter treatment. Retaliation may take many forms, including "cutting the purse strings," threatening to report them as unfit mothers, abandoning them, putting them out of their homes, telling other people (such as employers and/or children) "all about them," and committing acts of physical violence against them, including the threat of death.

        Fear of Exposure. Women may fear being publicly "branded" as alcoholics and/or addicts if they enter treatment. In addition, concerns about confidentiality may be particularly acute for women fearing revelation of their status as pregnant and/or HIV-positive. Outreach materials should include statements that all client information is kept confidential (noting specifically what exceptions apply).

        Fear of Failure or Hopelessness. If women have already been in a treatment program and have relapsed or have had an unpleasant experience in a previous treatment program, they may feel hopeless about their ability to recover. Other factors may contribute to this sense of hopelessness:

• HIV-positive women/women with AIDS who believe that since they are going to die anyway, it is hopeless (or irrelevant ) to become alcohol and drug free;

• women who feel trapped in abusive relationships, who see no hope of getting out of them, who believe that only alcohol or other drugs make the situation tolerable; and

• young women who believe they have no future.

4.2        Barriers to Outreach Unique to Population Groups

        This section briefly describes barriers to outreach that are unique to specific groups of women, including the following:

• age groups (adolescents and older women);

• pregnant and postpartum women;

• ethnic and racial minority populations; and

• other specific groups of women.

4.2.1      Age Groups

         This section summarizes information about outreach strategies targeting adolescent girls (aged 12-18) and older women (65 and older).

Adolescent Girls

        The outreach information in this section addresses the concerns of both male and female adolescents because most of the available literature does not specifically address outreach to adolescent girls. It is important to note that this information may also apply to adolescents residing in programs with their mothers.

        Some obstacles to reaching high-risk teenagers, which apply to boys and girls, include the following:⁹

• a false sense of bravado and willingness to take risks, coupled with a fear of being branded as "sick." This can lead to a normalizing of substance abuse;

• feelings of ambivalence and confusion about alcohol because of conflicting messages about alcohol use in the home, in society and within peer groups;

• skepticism, distrust and fear of continued rejection based on the individual's history of treatment and of poor family relationships;

• hopelessness among young people in inner cities regarding the possibility of ever having a worthwhile future with a decent job; and

• the presence in some inner-city neighborhoods of an open, accessible drug culture without apparent social sanctions, and the easy way in which large sums of money can be obtained by those who deal in drugs.

        Many high-risk youth have had lifelong difficulties trying to "fit in" and to find a sense of belonging with their families, at school, and with peers. These youth may be harder to reach because they resist traditional authority. Some may have a low literacy level. If so, materials targeting this population are most effective if written on a third or fourth grade level.

        Before designing and implementing outreach programs for adolescent girls, it is important to assess the community and learn as much as possible about the particular environment in which the girls live. According to Resnick and Wojcicki:

understanding key adolescent issues is critical in planning intervention activities. Effective outreach programs make contact with high-risk youth in settings where they are most comfortable. Youth at high risk for use of alcohol and other drugs tend to be alienated from traditional institutions and, thus, difficult to reach through conventional approaches. ¹⁰

        Outreach to adolescents is often conducted through existing community youth organizations, such as places of worship, parent organizations, and schools. However, some adolescents at risk for or already involved in the use or abuse of alcohol and other drugs have dropped out of school or are not involved with community groups. In such cases, an effective outreach approach is to "hang out" and distribute literature in locations in which adolescents congregate, including fast food restaurants, street comers, and shopping malls. Outreach activities should focus on places where adolescent girls may seek services, such as family planning and STD clinics, general health care clinics, and welfare and other social agency offices. Networking with probation, parole, and correctional officers and with youth workers or community activists involved in outreach to gangs can help identify adolescent girls who need substance abuse treatment services.

        Beyond distribution of literature, more creative, youth-oriented strategies should be implemented. These strategies may include involvement in the following activities:

• street theater performed at locations frequented by youth;

• rap videos and music;

• distributing colorful, eye catching T-shirts; and

• special events at recreation centers or juvenile detention centers.

        Activities and services need to be appealing to young people to encourage their participation. The National Council on Alcoholism and Drug Dependence, the AIDS Clearinghouse, and other agencies have produced many informative brochures, posters, and other material for youth. These materials can be distributed with information from the treatment program.

        Outreach workers need to be specifically trained to identify youth at risk and to speak with them using their vocabulary; peer outreach can be utilized where feasible and appropriate. By knowing how to communicate with adolescents, outreach workers can encourage potential clients to seek help.

Older Women

        In general, neither the early- nor late-onset cases of alcohol and/or other drug abuse among older people come to the attention of the substance abuse treatment professional through the usual referral networks (courts, employers, spouses, families). Older women may be isolated from their community and family because they may no longer drive, may have retired from their jobs, and may be living alone because of separation or death. Widows may be a particularly vulnerable population for alcohol and prescription drug abuse.

        Therefore, the primary route of intervention may be through the health care system, including the health care provider(s) and the acute care setting where older women seek treatment for age-related health problems. However, physicians and other primary health care practitioners often do not diagnose substance abuse problems within the older female population, in part because of insufficient specialized training in addictions. Many physicians do not fully understand the potential consequences of alcohol and other drug interactions in this age group. Even when problems are recognized, many physicians, other health care workers, and family members are reluctant to intervene because of the mistaken notion that the woman's age precludes change or that withdrawal from the substance would cause her undue stress. Some family members even believe that the older woman is easier to deal with when she is numbed by alcohol and other drugs. Finally, family members and friends may have little knowledge about how alcohol, prescription drugs, and over-the-counter (OTC) preparations may affect their loved one's mood and physical condition.

        Many substance abuse treatment professionals are unfamiliar with the senior services network (and vice versa); thus, the network of senior services is underutilized in outreach and program development. Specific programming for older women has not, for the most part, become standard in substance abuse treatment programs. This is true partly because the proportion of substance-abusing women in older age groups is significantly lower than that of younger age groups. Also, because alcohol and other drug use patterns, lifestyles, and environments of older women are often different from those of many younger women, they may not readily fit into programs designed to treat younger substance-abusing women.

        Outreach and identification must be modified to attract the older woman with a substance abuse problem. Many women in this age range are socialized to believe that you do not "air your dirty laundry in public," and you do not to talk about problems. This makes outreach, access, treatment, and coordinating care more difficult. It also should be emphasized that women 65 and older have significantly varying physical and mental health states. Some "older" women of 75 or 80 may be in better health than women who are younger, although this is less likely to be true for women who abused alcohol or other drugs for long periods. As with other issues and populations, culture may play a role in outreach to this population.

        Specific outreach strategies for older women include the following:

• establish relationships with social service agencies and community organizations to work with older women. Arrange to distribute flyers through these agencies and conduct seminars about substance abuse among older women for their staff;

• arrange workshops and special events at adult day care centers and at meetings or activities sponsored by groups such as the American Association of Retired Persons, Gray Panthers, and the Older Women's League;

• meet with physicians who primarily serve older women to discuss substance abuse problems in this age group and to discuss drug interactions;

• train health aides who work with older women about alcohol and substance abuse;

• conduct seminars or workshops through state and local medical and nursing associations on substance abuse problems among older women;

• develop a list of signs and symptoms that are consistent with substance abuse in older women. The list of indicators should include the following: combined use of alcohol/ prescription/OTC medications; broken bones associated with falls or accidents; gaps in memory; cognitive impairment; trembling; weight loss; fatigue; insomnia; malnutrition; incontinence; aggression; depression; general debility; inadequate self-care/poor hygiene; lack of physical exercise; social isolation; and difficulty controlling such diseases as diabetes, gout, or angina. The list should be designed for use by primary care providers and should describe the possible array of indicators that may warrant further investigation of substance abuse or misuse; and

• maintain a list of older women in recovery who are willing to share their stories with other women in the program.

4.2.2      Pregnant and Postpartum Women

         It is important to reach out and enroll substance abusing women in treatment when they are pregnant. However, it is often difficult to do so because of complex societal and medical problems. Frequently, pregnant and postpartum women who use and abuse alcohol and other drugs are much more severely stigmatized than women who are not pregnant. Therefore, they may deny their drug use, its possible effects and their need for help. Pregnant and postpartum women, particularly young poor women, are often afraid of the medical and social welfare system and/or personnel within these systems because they have had negative experiences with them. A recent report by experts in the field and issued with support from CSAT, the Treatment Improvement Protocol (TIP) for pregnant substance abusing women, provides information about these issues. ¹¹

         Government agencies and the public are increasingly concerned about the use of both legal and illegal drugs by pregnant women. Some groups have taken or proposed punitive actions (including jail sentences) against substance-abusing women who are pregnant and women of childbearing age who are using cocaine and/or crack cocaine. Many states require hospitals to report pregnant women suspected of heavy alcohol and other drug use to local public health authorities or the criminal justice system when the women present for delivery. This reporting may cause women to be even more wary of acknowledging that they have a problem. In fact, it may result in some women avoiding prenatal care and hospital delivery, particularly if they have other children who are in the custody of Child Protective Services (CPS) or who are living with relatives. The women then fear the loss of their children. In many states, CPS, foster care placements, and review boards base their decisions on whether to return a child to his/her mother on the length of time the child is away from the mother. This serves as a deterrent to women -seeking effective long-term substance abuse treatment if child care is not available in such treatment programs.

        Strategies to encourage pregnant and postpartum women and adolescent girls to enter treatment include the following:

• develop and advertise specific services for pregnant and postpartum women. Materials should include information about the program's social services and child care provisions offered at or through the treatment program;

• conduct outreach activities in places such as WIC programs, ob/gyn clinics, family planning centers, well-baby clinics, departments of social services, Head Start offices, and Le Leche League chapters;

• develop and show videotaped stories of other pregnant women who have successfully completed substance abuse treatment;

• provide education on the relevance of seeking treatment before delivery; and

• educate physicians, midwives, and other health professionals about treatment resources and the importance of identifying substance- abusing women within their patient populations.

        Many women who seek treatment for substance abuse problems were teenagers when giving birth to their first children. Outreach to this population of mothers needs to co-occur with the development of specific programs for them. Intervening with the woman and the child(ren) she has at present, rather than waiting until subsequent children are born, is critical.

        The possibility of having their children reunited with them is often an incentive for mothers to enter treatment. Under supervision, mothers can learn effective parenting skills, become drug-free and experience improved relationships with their children. This not only provides further incentive for the mothers to enter treatment, it unburdens foster care systems by assuring the safety of the child in a therapeutic milieu. This reunification model is often not emphasized.

4.2.3      Ethnic and Racial Populations

         Successful identification and outreach to women with substance abuse problems requires racial, ethnic, and cultural knowledge, competency, and sensitivity. When staff members engage in outreach to women, they should understand the issues confronted by diverse ethnic and racial minority populations and recognize that there is diversity within racial and ethnic groups. For example, the culture and experience of an African American woman whose family has lived in an urban area in the Midwest for generations may be significantly different from an African American woman who lives in a rural community in the South. Their experiences will be different from a woman of primarily African descent who recently immigrated from Jamaica. The culture and experience of a Laotian woman who recently immigrated to the United States will differ significantly from a third generation woman of Japanese descent. Cultural values and norms vary across ethnic groups of Caucasian women as well, particularly among those who are recent immigrants or first-generation Americans.

        African American Women. Having survived a historical experience that demanded extraordinary courage and inner strength, traditionally African American women are seen as strong and as not needing anyone or anything to cope with life and its challenges. This perception is perpetuated by continuing socioeconomic conditions that require African American women to maintain a predominant role in caring for their families. If an African American woman believes she should be strong, regardless of her circumstances, she might feel that admitting she needs help is a sign of personal failure and that she has failed her family. This can result in low self-esteem and feelings of shame that could keep her from admitting to herself or others that she has a substance abuse problem.

        African American women are most likely to rely on other African American women or their place of worship for assistance with crises. For example, African American women often establish sisterhood relationships to help each other with proactive listening, counseling, and emotional support. Informal neighborhood groups (card playing groups), formal clubs (social and charity), church groups and to a lesser degree, sororities have been important sources of networking for African American women. Recently three of the largest sororities (Zeta Phi Beta, Delta Sigma Theta, and Alpha Kappa Alpha) have developed substance abuse prevention programs. These sororities differ from the mainstream sororities in that their dominant focus is on community action and social service.

        To facilitate the African American woman's acceptance of treatment, it is important for a program to establish relationships with respected African American individuals and organizations in the community. Religious institutions and community organizations that serve African American women can be vital resources for a successful outreach program.

         American Indian Women. American Indian populations consist of approximately 450 different tribes with varying customs and some 250 languages. For American Indian women, barriers to treatment include the following:

• the disproportionate number of unemployed American Indian women, which hinders early detection and referral in the workplace;

• the lack of education in cross-cultural issues among physicians, nurses, social workers, and other health care providers may result in a lack of sensitivity to the values, beliefs, and practices of American Indian women; the use of stereotypes, although unconsciously by health care providers, can be a basis for assessment and diagnosis;

• geographic isolation, which limits access to substance abuse treatment; the lack of funding in the Indian Health Service for needed programs; and the disproportionate poverty among American Indian women, further limiting financial access to treatment; and

• cultural differences among American Indian women in the relative value placed on the use of different substances (some of which they do not consider addictive), may preclude the women from accepting or seeking help for their abuse of other substances.

        Because of a long history of a lack of trust in the United States federal government (because of broken treaties, outlawing of American Indian languages and religious practices, and inadequate services provided through the government), American Indians often mistrust health care programs run by government agencies, including substance abuse programs. Developing a relationship of trust with American Indian women is, therefore, critical in the outreach phase.

        A simple, cost-effective strategy to identify high-risk American Indian women is for treatment programs to establish relationships with existing American Indian programs, such as cultural centers, Indian Health Boards, and Indian healers.

        However, it should be noted that a little less than half of all American Indians live in rural and/or reservation communities. The remaining population lives in urban locations scattered among other racial/cultural groups rather than in cohesive communities. This poses another barrier in identifying American Indian women who are at risk.

        Asian and Pacific Islander Women. To design an outreach program for Asian/Pacific Islander women, it is important to understand the complexity of the historical, social, economic, political, and cultural factors that underscore the Asian/Pacific Islander experience in the United States and the diversity of the population itself. Sue has suggested that for Asian American populations (as would be true for other recent immigrant populations), it is important to consider the specific ethnic group, place of birth, generational status, and degree of acculturation. ¹²

         Asian/Pacific Islander women who are immigrants and refugees confront many stressors that exacerbate already severe challenges in their daily ability to cope and function. These challenges may include language barriers (which can make it difficult to obtain basic resources such as health care), racism, social isolation, changes in traditional family roles, economic distress, and family disintegration. Mainstream services are often underutilized by Asian/Pacific Islander women because the services are inaccessible, too expensive, culturally irrelevant, and/or unavailable in their native language.

        Sun has suggested the following as useful strategies to intervene with Asian American women: ¹³

• have bilingual and bicultural professionals available who can engage and be involved in the treatment process for newly arrived immigrants - the program might gain access to volunteer professionals through Asian American organizations in their community;

• eliminate terms such as "mental illness" or "psychiatric dysfunction," which Asian Americans tend to be more sensitive to than Westerners; and

• include information that reflects cultural sensitivity, including recognition of the Asian woman's traditional role, ethnic, and cultural identity(ies) and the importance of intergenerational relationships in outreach material.

        Hispanic/Latina Women. The Hispanic population in the United States is heterogenous, representing different cultures and ethnic groups. Many communities are inhabited by multiple Hispanic groups where generational differences exist within each group. Treatment programs conducting outreach to Hispanic women should become familiar with the diversity, origins, dynamics, cultures, and problems of the different Hispanic groups living in the community. Treatment providers should not assume that one approach will work for all Hispanic groups or that all Hispanic women exhibit the same pattern or type of substance abuse problem.

        Many substance abuse treatment programs do not have staff who can communicate in Spanish. Hispanic women, therefore, tend to view these programs as less than "user-friendly." If possible, programs serving Spanish- speaking women should have treatment staff who can speak Spanish. Also, educational materials on substance abuse and treatment often assume high levels of reading ability. This presents an obstacle for those who are not proficient in the English language. Thus, materials should be available in Spanish.

        Outreach to Hispanic women requires a genuine respect for the women and their family culture. The families of Hispanic women can be important resources to help these women get treatment for substance abuse problems. However, if family members feel that a woman's participation in treatment threatens the status quo or legal standing of the family, they can work against a woman who is responding to outreach efforts. Disclosure may be a particular problem for undocumented Hispanic women who fear that this may result in their deportation; they may also fear that undocumented family members (and friends) will be discovered and deported if they enter the "system" in any way.

4.2.4      Other Specific Groups of Women

         Women with HIV/AIDS. During the second decade of the AIDS epidemic, the number of women with HIV/AIDS has increased dramatically. In recognition of the differences in disease progression and types of opportunistic infections of HIV/AIDS in women, the CDC recently revised the diagnostic categories used to define an individual as having AIDS. (Chapter 2 presented more detailed epidermiologic data on women and HIV/ AIDS.) The increase in the number of reported AIDS cases may, in part, be because of this expanded definition.

        Outreach and identification of HIV-infected women often occurs their point of need, such as through primary or acute health care, public assistance, or other social service agencies. However, it is important to note that many women are not aware of their HIV status until they are symptomatic with AIDS and/or have been diagnosed through the health care system, often through prenatal testing.

        HIV-positive women from lower socioeconomic groups often lack the resources to meet their most basic needs for food, housing, and transportation. As a result, they may delay seeking care for their substance abuse problems or for their HIV status until they become symptomatic or until their basic needs, or those of their children, have been met. HIV- positive women who are addicted to illicit drugs may fear interacting with the health care system, for fear of being placed in the criminal justice system. They may choose not to seek treatment until they have established a trusting relationship with a case worker or health care professional or until there is a medical crisis.

Specific outreach strategies include the following:

• work with local AIDS prevention and advocacy groups, including street outreach programs, to promote the program's services for women at high risk for or with HIV/ AIDS; and

• encourage staff members to appear on local radio and television talk shows to discuss the needs of substance using women with HIV/AIDS and how the treatment program tries to address those needs.

         Women Residing in Rural Areas. A shortage of primary care physicians exists in poor urban neighborhoods and in rural areas. Families who must travel from rural areas to urban clinics for health care may have no place to stay in the city. Few have the energy to make multiple visits to different institutions at different times (often waiting for a long time to receive services) to obtain care for themselves and their families. Because it may be difficult to find lodging when traveling long distances for services, many women delay seeking treatment until a crisis develops. Helping women from rural areas to use health and social services is important. This may require providing or helping the women to access transportation. Also important are methods of "getting the word out" about women-specific services across large, often sparsely-populated geographic areas.

Specific outreach strategies include the following:

• work with staff of rural hospitals and health clinics to identify women who need services and make home visits, where appropriate, with health care or social services personnel; and

• advertise program services on local radio stations and in local county newspapers.

        Homeless Women. Homeless women are vulnerable to a variety of risky behaviors, diseases, and disorders. Many homeless women are substance-abusing, psychiatrically impaired, and physically ill individuals. The stigma attached to being "homeless" impedes many women from seeking assistance. Some homeless women who have children fear that they will lose their children and/or their places in homeless shelters if they admit to having substance abuse problems. Homeless women may be frightened, distrustful, and/or unfamiliar with systems of care and treatment. Some women who are homeless and who have few dependents will move from one shelter to another. It is critical to note here that all homeless women are not in shelters: some may be in living arrangements with family or friends. Also, some women may be in a battering relationship and may be abusing alcohol or other drugs as a result of the stressors caused by this relationship. Such women may live temporarily with relatives or friends, and their residential status may be difficult to discern.

        Because homeless women are outside the mainstream networks of referrals and intervention, those who require acute medical attention or who are being detained for alleged civil or criminal violations often come to the attention of police and emergency room personnel more frequently than they do to substance abuse treatment professionals. The primary routes of intervention, therefore, must be through street outreach, medical clinics, law enforcement, emergency rooms, public housing communities (for those women still in housing), and jails or detention centers.

         Lesbians. Lesbians, unlike many other minority groups, cannot be readily identified based on appearance, language, or socioeconomic criteria. The lesbian category embraces women of all ages (including adolescents and older women), races, ethnicities, religions, socioeconomic groups, and physical abilities. Since determining the percentage of lesbians in our society depends on self-reporting, and knowing that many lesbians will not identify themselves because of society's stigmatization of homosexuality, the number of lesbians in any community is likely to be grossly underestimated. Adolescent lesbians (an extremely high-risk group with a very high suicide rate) and lesbians who are parents (approximately one-third of lesbians) are underserved by substance abuse treatment providers. Treatment programs may not have staff who are sensitive to the needs of lesbians, and in fact, the staff may even be hostile. These factors create barriers to outreach, treatment, and continuing care because a lesbian would not want to enter a program with an insensitive or hostile environment.

        Women of color who are lesbians face an even greater potential for discrimination than Caucasian women. Many of these women may be more difficult to identify and serve effectively than their Caucasian counterparts. Very few programs are designed for lesbians of color. Outreach strategies developed for this population must be detailed, consistent, and use appropriate language and events. Above all, the outreach strategies must be safe. As noted by Kanuha, lesbians of color face a variety of challenges because of the prejudices inherent in both the heterosexual and lesbian communities. Racism in the lesbian community is reinforced by the relative lack of presence of women of color in the mainstream lesbian culture. For lesbians of color to benefit from therapy, clinicians must understand the dynamics of being both a woman of color and a lesbian. ¹⁴

         The overriding emotion that drives almost all of the individual barriers to outreach for lesbians is fear. Lesbians fear losing anonymity or acknowledging homosexuality in a setting outside the lesbian community or an immediate circle of friends. A lesbian may fear that revealing her sexual orientation could result in losing a job or being separated from valuable relationships.

        Lesbians are cautious about obtaining help if they feel that their partners or significant others will not be treated with respect. Very often, programs are not willing or prepared to integrate same-sex partners into groups of couples or family therapy sessions. In addition, many lesbians who are mothers hesitate to seek services because they fear they will lose custody of their children.

        Outreach to lesbians must be specific to the population, must be community- based, and safe. Resources for lesbians in rural settings will, as a rule, be more difficult to develop because lesbians may be more difficult to reach (i.e., be less open about their sexual orientation) than those living in urban areas. Programs that seek to serve lesbians must be prepared to advocate on their behalf for health and social services, to anticipate the possibility of receiving criticism from the heterosexual population, and to invest time developing credibility within the lesbian community.

        Specific outreach strategies include the following:

• develop relationships with gay/lesbian bookstores, offering them, for example, space to sell books at program events in return for their distributing program materials at gay/lesbian bookstores;

• support lesbian-specific community events, and provide staff and/or assistance with advertising and distributing announcements;

• advertise programs and activities in publications created specifically for the lesbian community;

• have an information booth at lesbian and gay events;

• use language in program materials to indicate that services are available for partners of women, rather than for husbands or spouses only; and

• sponsor alcohol and drug-free social and sports events for lesbians.

         Women with Disabilities. Women with physical and mental health disabilities, who often face double discrimination based on disability and gender" and who have limited socially sanctioned roles, ¹⁶ are underrepresented in treatment programs for a variety of reasons. Barriers to women with disabilities receiving needed substance abuse treatment services include the following:

• social isolation because of transportation, architecture, and communication barriers as well as negative social attitudes toward people with disabilities;

• enabling behavior by physicians, family, and friends who feel frustrated by their inability to "fix" the woman's disability and unwittingly encourage the use of alcohol and other drugs; ¹⁷

• failure to identify substance abuse problems since abuse- related behaviors are mistakenly attributed to the disability;' ¹⁸ and

• lack of access to treatment services. Historic patterns of segregation have deprived women and men with disabilities access to the same range of substance abuse treatment services and programs available to their nondisabled peers. ¹⁹

         To reach women with disabilities, treatment programs must engage in an active, highly visible outreach campaign. One idea is to include women with disabilities or representatives from advocacy groups on the program's advisory board. Another idea is to work with representatives from local independent living centers, which are advocacy organizations governed and staffed by people with disabilities and located throughout the country. These representatives can help treatment programs become a presence in the disability community by serving as spokespersons at meetings and events, by serving as liaisons between programs and disability agencies, and by referring clients to the program.

        Advisory board members can also help design outreach materials in a range of formats that will be accessible to women with diverse disabilities. For example, brochures should be made available in braille, large print, and on audiotape to reach women with visual disabilities. They should also be available in simplified language to reach women with intellectual or learning disabilities. Public service announcements (PSAs) on television should be available with open or closed captions to reach women who are deaf. All materials should provide information on the accessibility of the facility and program to people with disabilities. Using images of women with disabilities in program publicity also sends a strong message of inclusion.

        Networking with disability and rehabilitation organizations is another useful outreach strategy. Such organizations often have limited awareness of the signs and symptoms of substance abuse and may benefit from training in the identification of substance abuse problems and referral strategies. Their staff, in turn, may serve as a resource to the organization on disability issues.

        Disability awareness training for all staff members is critical, not only to develop effective outreach strategies, but also to ensure that women with disabilities remain in treatment past the intake stage. Training should include an opportunity for staff to explore their own attitudes toward disability, since stereotypes and negative assumptions can be a major barrier to effective treatment.

        Staff members need to learn how disability relates to gender and the relationship of both disability and gender bias to substance abuse. Information on substance abuse issues for different types of disability groups is also useful." Ideally, the trainers should include women with disabilities. This is particularly important when staff members have had limited exposure to people with disabilities.

        Finally, programs should become familiar with the requirements of the Americans with Disabilities Act (ADA) which prohibits discrimination against people with disabilities. The ADA applies to all substance abuse treatment programs regardless of size as service providers .²¹ Privately-run treatment programs are covered under the public accommodations section of the law (Title III), and government-run programs are covered under state and local government provisions (Title II). Knowledge of the law is essential to ensure compliance as well as effective outreach. The law mandates that people with disabilities be served in the most integrated settings possible. To ensure nondiscrimination, the law establishes a series of specific requirements covering such areas as 1) eligibility criteria; 2) policies, practices, and procedures; 3) auxiliary aides and services for people with communication disabilities; and 4) architectural access. To obtain a full description of the law and its requirements, program administrators are advised to consult the growing body of available resources.²² Local disability advocacy groups are additional sources of information.

        Women and Adolescent Girls in the Criminal Justice System. Data show that most women in the criminal justice system are involved or have been involved in substance abuse. However, reaching these women for treatment requires overcoming many barriers, including their fear of self-disclosure, legal sanctions, and losing custody of their children. While many young women in particular fear self-disclosure (especially to adults, who may be judgmental about their behaviors), women in the criminal justice system generally fear that disclosing their need for substance abuse treatment will result in additional sanctions, including increased time on probation or parole, incarceration, a transfer to higher security or longer term facilities, or severance of their parental rights. Commonly, women who have lost or are in danger of losing custody of their children as a result of incarceration are cut off from the most potent motivation for them to enter treatment. Also, the laws on child abuse in many states require outreach workers to report women suspected of criminal negligence to local public health and/or criminal justice system authorities. When this occurs, the outreach worker becomes an adversary rather than an advocate for the woman, defeating the purpose of outreach. Moreover, a number of systemic factors in the criminal justice system impede the treatment process for women and should be considered as part of outreach. These include the fact that women are often given "flat time" in local jails, which frequently lack substance abuse treatment services (and general health and mental health services). The local jails also may not have adequate systems of referral for women to substance abuse treatment (and other support systems) following release.

        Often, by the time women are in the criminal justice system, traditional sources that might have supported their entry into substance abuse treatment have failed repeatedly. Treatment may also have failed, and these women are likely to believe that no other way of life is possible. The combination of fear and cynicism make it unlikely that they will voluntarily seek treatment. Criminal justice system personnel often view incarcerated women more negatively than incarcerated men. This further stigmatizes women, creates resistance among women to seek treatment, and creates resistance among treatment staff and the criminal justice system staff to provide women-specific services.

        Many of the criminal justice system personnel have little knowledge or training in the identification of substance abuse problems in women. Furthermore, they may not be aware of the daily realities of a substance-abusing woman's life and therefore may not be sensitive to her needs. They may also be unaware of the scope of women's issues as related to substance abuse and criminal behavior. These issues may include prostitution and rape, incest, or other sexual abuse.

        Although some level of treatment services is available either or indirectly through referrals in many jails and prisons, the services are generally considered inadequate. Referral to treatment as an alternative to incarceration is increasingly used in communities throughout the country, but these arrangements frequently do not have sufficient contact with other health and social service providers. In fact, there is a general lack of coordination among social service, substance abuse treatment, medical, and criminal justice agencies. This fragmentation and lack of coordination deters women with substance abuse problems from seeking treatment and has made it difficult to establish "user- friendly" support networks for women and adolescent girls in the system.

        Strategies to engage women in the criminal justice system include the following:

• establish relationships with parole, probation, third-party custody, advocacy, and other agencies and organizations from which clients can be referred; and

• hold meetings in detention centers for women of all ages. Provide them with written and audio visual materials.

        CSAT currently funds a few demonstration projects involving the treatment of women in the criminal justice. system. The evaluation of these projects will provide valuable information to plan and implement both outreach and treatment services.

4.3        General Approaches to Effective Outreach Programs

         Designing and implementing effective outreach programs for women requires an understanding of the basic principles of marketing social programs. These include defining the product, creating an effective message, and delivering the message to the target audiences. Trained outreach workers and strong community contacts are essential. Most importantly, comprehensive services that meet women's needs must be developed and made available. Finally, it is important to note that many alcoholic and drug-addicted individuals have brief moments when they show a willingness to acknowledge their problem and seek treatment for it. Outreach professionals must take advantage of these opportunities whenever they occur. For example, asking a woman seeking treatment to come back "tomorrow" or "next week" is dismissing an opportunity, and/or may actually place her in danger.

4.3.1      Staffing the Outreach Program

        Outreach workers who go into the community play a critical role in the success of the treatment program's outreach. Therefore, they need to be familiar with the community in which they work, both geographically and culturally. They must understand and be sensitive to the reality of women's lives and the many "pretreatment" issues women must face. In addition, they must understand the process of addiction and agree with their program's philosophy. Outreach workers must also convey respect and demonstrate support for women. They need to be able to describe to potential clients the problem of substance abuse and the opportunities offered by the treatment program in concise and understandable terms. Moreover, all program staff members should receive communication skills and outreach training because, in a sense, every contact outside the treatment program is a form of outreach.

Treatment programs have several options in staffing the outreach program:

• train existing program staff in outreach techniques;

• hire a former client or community resident who is a trained outreach worker with experience in or knowledge of substance abuse;

• contract with a community-based organization that has trained outreach workers in the community; or

• a combination of the above.

        Because different skills are needed for clinical work than for outreach, the latter three options may be preferable.

4.3.2       The Product: Designing a Program that Actually Meets the Needs of the Women in the Target Population

         To develop effective outreach strategies and identify women who need treatment, program directors and administrators must understand and accept the importance of customized outreach that uses gender-specific strategies based on existing knowledge and techniques. They must be willing to examine critically whether the current structure of the program helps or hinders outreach and to allocate the necessary staff and other resources to achieve outreach goals.

Before initiating outreach activities, the program staff and outreach workers must:

• identify the women to be reached within the community and understand their perspectives; and

• set specific program goals and objectives for treating women.

        Outreach may be conducted in many different ways. Each program should assess its own resources, both human and financial, before deciding which outreach strategies to employ. The strategies suggested below vary in terms of cost and complexity, but they can be applied or adapted for women of different ages, ethnic groups, and other specific populations.

Specifically, experts recommend that outreach personnel do the following:

• collect and analyze available demographic data to form an accurate and comprehensive picture of the extent and nature of substance abuse problems among population groups in the community;

• examine whether the structure of the program's advisory board, board of directors, and staff is appropriate for the client population, and whether those individuals understand the impact of substance abuse on women. Add women of color, older women, women in rural areas, women with disabilities, and women who are bilingual, bicultural, or lesbians as appropriate to ensure that the board and staff represent a cross-section of women in the community;

• solicit ideas from health, mental health, disability/rehabilitation, legal, and social service personnel in the community who are in contact with the target population. Also, solicit ideas from women in recovery who can share their own experiences and concerns about treatment, and from the program staff;

• form teams from these groups and have them develop common goals, shared values, and agreements on how to approach treatment for women and adolescent girls who have abused alcohol and other drugs; ensure that directions and guidelines are consistent and that they foster trust and interest in treatment; and

• examine the language that the program uses to ensure that it: helps women understand addiction as a health issue; does not reinforce low self-esteem or powerlessness; does not further stigmatize women by insinuating that addiction is a moral failing; and helps them to understand their anger and express it in healthy ways.

        Beyond recognizing the obstacles to treatment that women face, the program must be architecturally, economically, geographically, and culturally accessible. Strategies to accomplish this goal include the following:

• have a sliding-fee scale based on the woman's own ability to pay, if a fee is charged;

• arrange for safe, reliable, and low cost transportation to and from the facility. Provide bus or subway tokens for adolescents and low- income clients and, if necessary, request an extra bus stop by the facility or an extension of hours for bus service. If possible, have a donated vehicle available on-site or make arrangements to use a vehicle maintained by a local community organization or place of worship.

• for older women, work with the appropriate senior services agency to add bus routes that deliver passengers to the treatment facility; then schedule activities for seniors accordingly. Ensure that women with disabilities have accessible transportation. Explore a car-pool or other transportation for women who do not have access to public transportation;

• ensure that the individual program and facilities comply with the ADA requirements and that the staff is responsive to disability- related issues;

• ensure that the substance abuse services offered (or for which it makes referrals) are indeed available and responsive to the clients. A treatment program must develop a reputation for "keeping promises" in the community and to the women in its target population. It is important to ensure that this reputation is one that will attract women into treatment and that the program's success in this area is described in outreach efforts;

• recognize that providing treatment services to women is an evolutionary process that can be adapted based on the information gained from the program itself and from outside sources. In this regard, evaluation and feedback are extremely important aspects of treatment, but they have not been readily integrated into the treatment process or specifically into outreach. Part of the difficulty may be in misunderstanding these processes, which can be defined in two ways:

1. evaluate the degree to which the program is meeting its goals and objectives. The process usually involves a variety of methods, including review of client records and follow-up of clients after treatment;

2. obtain feedback as part of the formal or informal process of collecting subjective and objective information from clients and staff, and use these opinions in the treatment process and in program management.

        To ensure that evaluation and feedback support the outreach process, the program should hold regular staff discussions on perceptions of the program's strengths and weaknesses and solicit feedback from clients, community, and others. These discussions should include staff commentary on the program structure and various components of the program, including outreach. The program also should establish a policy that encourages women in the treatment program to provide input into the outreach program to learn what works and to build their self-esteem. Evaluation is further discussed in Chapter 7.

4.3.3      The Message: Make it Compelling and Appealing to the Targeted Women

        Materials should communicate an understanding of the stress that many women face in their everyday lives (e.g., poverty, discrimination, violence, unemployment, sexual or emotional abuse, problems with children) and acknowledge cultural or gender roles that contribute to or help lessen such stresses. Women often use alcohol or other drugs to "self-medicate" to deal with the effects of these stress factors. However, the lifestyle of substance abuse, particularly the use of illegal drugs, is itself a stressor. Outreach materials should inform women that there are ways to reduce and cope with stress, including understanding the factors over which they have no control.

        All written materials about the program, such as pamphlets, brochures, and posters, should be culturally sensitive, easy to read, and relevant to women targeted for services. Because some substance-abusing women may have learning deficits or reading difficulties, the language should be simple and illustrations should be frequently used. Large print should be used in materials directed at older women. Materials should be published in Spanish and in other languages as appropriate for the target populations. Describe the services and activities offered by the program, or through referral, that meet women's needs. These may include the following:

• information on the substance abuse treatment modalities used in the program. Be specific about whether the program is inpatient or outpatient, the duration of the program, and what child care services are available;

• a description of comprehensive health care and social services provided for women and children and special services for pregnant and postpartum women, such as assistance in obtaining entitlements for themselves and their children, infant care and developmental education, parenting training, pre- and postnatal health care for pregnant women, and nutrition education during pregnancy;

• counseling and support group options for women, by women;

• referral and resource information, including telephone numbers that women can call for food, shelter, medical care, and other forms of help in addition to treatment; and

• information on facility accessibility and referral resources to wheelchair users and women with other disabilities. Many programs have purchased telecommunication devices (TDDs) so that women who are deaf can contact the program.

        In addition to basic print materials, programs may develop and market public service announcements (PSAs) for radio and television. Collaborating with a local high school, community college, university, radio/television/cable station, or other businesses with a media center to produce professional quality audio and video PSAs that focus on substance abuse has been a highly successful approach. Success stories need to convey to women that they can confront addiction problems and begin their recovery process. If resources are available, develop a PSA targeted to women and adolescent girls in the criminal justice system that informs them about their rights and the services available. Produce a brochure and a PSA about the effects of alcohol and other drugs on an unborn child for distribution to pregnant women, mothers, and women of childbearing age. Advisory board members, advocacy groups (organized around the issues of women and substance abuse), alumnae association members, staff, and female clients can help develop and critique outreach materials.

        Programs can employ or request voluntary services from artists in the community to help design posters and flyers for the program. Many programs use art created by alumnae. Often, public relations and advertising firms may be willing to provide services to nonprofit organizations as a way of contributing to the community and reaping a tax benefit. The program can also conduct focus groups, formal or informal, with women who reflect the demographics of the target community to pretest the concepts and information developed for PSAs and print materials. This helps to ensure their relevance and effectiveness and create a sense of "ownership" among women in the community.

4.3.4      Delivering the Message: The Message Must Reach the Women Targeted for Services

         In most cases, one-on-one personal contact will be the most effective way to encourage substance-abusing women to enter treatment. These personal contacts may be formal (e.g., making a presentation at a club meeting or at a community-based women's health service organization) or informal (e.g., striking up conversations with women in the places where they gather in the community). Examples of strategies for delivering the message include the following:

Print Materials

• distribute materials in locations such as schools, grocery stores, malls, college campuses, places of worship, homeless shelters, food banks, runaway houses, battered women's shelters, senior citizen centers, day care facilities, welfare and public aid offices, detention centers, youth and recreation centers, major employers, the YWCA, health clubs, local police stations, probation and parole offices, soup kitchens, laundromats, beauty parlors, restaurants, bars, and gas stations;

• have local supermarkets print messages on grocery bags or insert flyers in the bags;

• display posters describing the program's services with phone numbers on telephone poles throughout the community, in compliance with local regulations regarding posters;

• post brochures and posters on bulletin boards in convenience stores;

• encourage local businesses to include flyers in salary envelopes;

• leave materials for distribution in doctors' offices (especially ob/gyn clinics, family practitioners and pediatricians), public health clinics, physical rehabilitation hospitals, emergency rooms, WIC offices, and other locations providing health care and social services for women;

• print buttons and t-shirts with the program's logo on them to advertise the program. Distribute them to women and girls involved in other programs and institutions through a social event arranged with the institutions, such as a movie and a discussion session with refreshments; and

• distribute materials at meetings of clubs, churches, and schools (e.g., Junior Leagues, Parent Teacher Associations).

Media

• write articles for the local newspaper on women, addiction, and health issues. Submit them to mainstream newspapers and periodicals as well as to publications for special population groups. Include information about the signs and symptoms of substance abuse and ways to get help;

• encourage local newspapers and radio and television (TV) stations to advertise the program free of charge. Using local media in rural areas can be a particularly effective outreach strategy because local newspapers and radio and TV stations reach women across large rural counties. Some newspapers may even provide free space;

• hand deliver the program's PSAs to TV and radio stations and try to meet with the person responsible for scheduling PSAs. Work with the station programmers to place the PSAs during programs that are most frequently viewed or listened to by the target populations;

• schedule the program's medical director or other staff members who are sensitive to women's issues as guests on local radio and television talk shows or call-in programs. This can be particularly effective in reaching older women, many of whom are devotees of talk shows; and

• use media outlets with specific target populations. For example, have program personnel fluent in Spanish speak on Spanish language radio and television programs to describe services for Hispanic women. Advertise program services in appropriate language on local radio stations that reach American Indian reservations.

Events

• hold information/education sessions in community settings, such as places of worship, community centers, schools, senior citizen centers, and other safe, familiar environments for potential clients;

• have a stand or booth at local health fairs, church gatherings, street fairs, and other community events. Answer questions and distribute information on women with substance abuse problems and the services that are available for them and their families;

• hold a potluck supper or an open house at a neighborhood center or public housing community and invite neighborhood women to attend. Arrange to have a recovering woman talk about her experience with substance abuse problems; and

• be sure events are held in locations that are accessible to persons in wheelchairs. Offer to provide sign language interpreters and other accommodations.

4.3.5      Professional and Community Contacts

        The success of program outreach efforts will depend in large part on the strength of relationships with community-based groups and local, state, and federal service agencies. These groups and agencies will serve as major referral and support sources for the treatment program. The types of agencies to be contacted include: 1) public health and social services; 2) community-based programs for women; 3) the criminal justice system (e.g. the local probation and parole agency, public defenders, detention centers, and jails); 4) major employers; 5) charitable institutions (e.g. the Salvation Army, YWCA, Girl Scouts); and 6) places of worship. To develop liaisons with these organizations it would be appropriate to: 1) send a letter requesting a meeting and enclosing program materials; 2) meet with the appropriate personnel and explain the services provided by the program; 3) arrange to give a presentation or hold an event at the organization; and 4) maintain contact with the organization.

        Other specific strategies include the following:

• invite health care providers working in the community to agency functions, community events, outdoor bazaars, and block parties;

• establish a relationship with child protection agencies to help identify women who need substance abuse treatment services and assist recovering women with family reintegration, if appropriate; and

• educate the housing authority about the importance of not evicting women with substance abuse problems, and promote the alternative of having women seek treatment and continuing care services.

4.3.6      Reaching Women's Support Groups

         The message must also reach and educate the substance-abusing woman's support group (family, significant others, friends, coworkers) and social systems (spiritual leaders, shelter personnel, law enforcement officials, physicians, pharmacists, visiting nurses, teachers, home health care aides, probation, and correctional officers, etc.). Specifically, an outreach program can reach support groups in the following ways:

• arrange for, facilitate, and/or recommend educational programs for physicians and other health care providers. Topics may include how to diagnose substance abuse and how to refrain from prescribing minor tranquilizers, benzodiazopines or sedative hypnotics for women who abuse alcohol and other drugs;

• encourage families, friends, and coworkers of substance-abusing women to contact the treatment program even if the women deny having a problem or resist help. These individuals may need counseling or other support for themselves. If the program does not have support available for the client's family or friends, the program can refer them to a support group for help (e.g. Al- Anon);

• develop a clear and specific list of symptoms of mental illness evidenced in women who abuse substances for physicians, psychiatrists, and psychologists. Delineate possible substance abuse connections in commonly misdiagnosed ailments such as depression, anxiety, and confusion. Share the list with other health care and treatment providers so they can refer women with dual disorders to substance abuse treatment programs;

• compile a roster of women program graduates and/or family members who can be organized into a community support network that will encourage women who need substance abuse treatment to enter a program; and

• collaborate with local hospitals and other service providers, including other treatment providers, and agencies to cosponsor events related to women's health, economic issues, parenting responsibilities, family health, and empowerment.

References

1. National Center for Health Statistics. (1993). Health United States: 1992. Rockville, MD: Department of Health and Human Services, Public Health Service, 291.

2. Finklestein, N., PhD, MSW, Duncan, S.A., MSW, Derman, L., MPH, MSW, and Smeltz, J., MEd, CAC. (1990). Getting Sober, Getting Well. Cambridge, MA.: The Women's Alcoholism Program of CASPAR.

3. ibid.

4. U.S. Department of Commerce, Bureau of the Census. (1992). Statistical Abstract of the United States: 1992. Washington, DC: Government Printing Office, 381.

5. Office of Substance Abuse Prevention Cultural Competence Series. (1992). Cultural Competence for Evaluators: A Guide for Alcohol and Other Drug Abuse Prevention Practitioners Working with Ethnic/Racial Communities. Orlandi, M., PhD, MPH, Ed. Rockville, MD: U.S. Department of Health and Human Service, Public Health Service.

6. ibid.

7. Getting Sober, Getting Well, 440.

8. Getting Sober, Getting Well, 44 1.

9. Arkin, E.B., and Funkhouser, J.E., Eds. (1990). Addendum to Chapter 1: High Risk Teenagers. Office of Substance Abuse Prevention Monograph (5): Communicating About Alcohol and Other Drugs; Strategies for Reaching Populations at Risk. U.S. Department of Health and Human Services, Public Health Service, 89.

10. Gopelrud, E.N., PhD, Ed. (1991). Office of Substance Abuse Prevention Monograph (8): Preventing Adolescent Drug Use; From Theory to Practice. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, 92-94.

11. The Center for Substance Abuse Treatment. (1992). Treatment Improvement Protocol (TIP) for Pregnant, Substance-Using Women. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service.

12. Sue, D. (1987). Use and Abuse of Alcohol by Asian Americans. J. Psychoactive Drugs 19(1) as cited in U.S. Department of Health and Human Services, Public Health Service. (1990). Seventh Special Report to the U.S. Congress on Alcohol and Health from the Secretary of Health and Human Services. January, 1990. Rockville, MD.

13. Sun, A. (199 1). Issues for Asian American Women. In Roth, P., Ed., Alcohol and Drugs are Women's Issues, Vol. 1. Metuchen, NJ: Scare crow Press, 127-128.

14. Kanuha, V. (1990). Compounding the Triple Jeopardy: Battering in Lesbian of Color Relationships. In Brown, Laura S., and Root, Maria P.P., Diversity and Complexity in Feminist Therapy. New York: Harrington Park/Hawthorne Press, 169-184.

15. Fine, M., and Asch, A. (1988). Introduction: Beyond Pedestals. In Fine, M., and Asch, A., Eds. Women with Disabilities: Essays in Psychology, Culture, and Politics. Philadelphia, PA: Temple University Press. 

16. Fine, M., and Ashe, A. (1981). Disabled Women: Sexism Without the Pedestal. Journal of Sociology and Social Welfare 8(2), 233-48.

17. Alcohol, Drugs, and Disability Project of the Pacific Research and Training Alliance. (1993). Disabled Women with Alcohol and Other Drug Problems. Berkeley, CA; (Unpublished Paper). 

18. ibid.

19. Getting Sober, Getting Well, 498.

20. For example, see Getting Sober, Getting Well, 508 -511.

21. Depending on the number of employees, treatment programs also may be covered by the employment sections of the Americans with Disabilities Act (Title I for private programs and Title 11 for public programs).

22. Eastern Paralyzed Veterans Association. (1993). The Americans with Disabilities Act: Resource Information. Jackson Heights, NY: Author. For additional free information pertaining to the ADA and produced by the U.S. Department of Justice and the Equal Employment Opportunity Commission, write the Public Access Section, Civil Rights Division, U.S. Department of Justice, P.O. Box #66738, Washington, DC 20035,  or call (202) 514-030 1.