Rural/Urban Residence, Access, and Perceived Need for Treatment Among African American Cocaine Users

Overall illicit drug use remains slightly higher in urban than rural counties, but it clearly is no longer an exclusively urban phenomenon,1 raising concerns about rural access to drug use treatment services. Many policy makers, researchers, and treatment providers presume that access to drug use treatment is worse in rural areas, but a review of the extant literature revealed that very little information exists on this issue.2 One study found that drug users residing in a single urban area were twice as likely to receive treatment as compared to those from a single rural area of Florida.3 A unique longitudinal study of at-risk rural and urban drinkers residing in 6 southern states found in bivariate analyses that rural at-risk drinkers had greater use of help for their drinking, more use of psychiatrists, and more use of inpatient, outpatient, and ER treatment than their urban counterparts.4 However, these differences did not remain when adjusting for demographic, social, and economic factors. The extant literature also offers very little information about rural or urban residents’ perceptions of the accessibility of substance use treatment. The longitudinal study of at-risk drinkers mentioned earlier found no significant rural vs urban differences in perceptions of waiting times, the acceptability of formal treatment for alcohol problems, and privacy concerns.4,5 Evidence from the broader mental health literature may lend some insight into potential rural/urban differences. For example, depressed persons living in rural areas have been found to have worse perceptions of the availability, accessibility, and acceptability of specialty mental health services than their urban counterparts.6 Related to actual treatment utilization is perceived need for treatment. Conceptually, perceiving a need for treatment reflects recognition of a drug use problem and a belief that treatment will help.7-11 Thus, it is arguably an essential “first step” in making the decision to seek treatment, at least among persons who are not mandated into treatment by the legal system.8,12 In fact, prior research suggests a strong association between perceived need and actual drug use treatment attendance.7,13,14 Perceived need has also been linked to remaining in substance use treatment and positive treatment outcomes.15,16 Despite the relevance of studying perceived need to advance our understanding of treatment-seeking decisions, few studies have examined the factors that promote or impede perceived need for drug, alcohol, or mental health services.7,10,12 Even less research has focused specifically on perceived need for drug use treatment, with the notable exception of a 3-state study of rural stimulant users which found that prior substance use treatment, family and social problems, and legal problems resulting from drug use were positively associated with perceived need.8 African American cocaine users residing in rural areas of the southern US may be at particularly high risk for low perceived need for treatment. According to data from the National Survey on Drug Use and Health (NSDUH), the lifetime prevalence of crack cocaine use is higher among African Americans age 18 years and older than among every other racial/ethnic group except persons reporting 2 or more races.17 The NSDUH also showed that only 2.8% of African Americans age 12 years and older who satisfy criteria for a drug use disorder think they need and actually attempt to seek treatment.18 Lastly, the multi-state study of rural stimulant users mentioned earlier found heavy cocaine use and low rates of treatment among mostly African American participants in the southern state of Arkansas.13,19,20 A better understanding of the factors associated with African American cocaine users’ perceived need for treatment could enable health policy makers, managers, and providers to make more informed decisions about the targeting and tailoring of programs aimed at increasing treatment uptake. Andersen's Behavioral Model of Health Services has been frequently used to identify the predisposing, enabling, and need/health status factors that explain health services utilization,21 including substance use treatment.13 Predisposing factors, such as demographics, are considered largely immutable but can be used to identify subgroups of persons at risk for inadequate utilization or, in the case of this study, perceived need for treatment. Enabling social and economic factors, such as health insurance and rural/urban residence, are thought to affect individuals’ ability to obtain services. Enabling access factors are sometimes distinguished from other enabling indicators because they are more modifiable by institutional or policy-level changes.22 Finally, health is typically assessed by self-reports or a clinical diagnosis and is theorized to have the strongest association with health services use. The study's primary purpose was to examine how rural/urban residence and other predisposing, enabling, and health status factors are associated with perceived need for drug use treatment. A secondary purpose was to compare and contrast rural and urban drug users’ perceived access to drug use treatment. Because prior research suggests that rural residents less frequently utilize substance use services,3,4 we hypothesized that they would have lower perceived need. To address these study questions, we conducted a population-based study of not-in-treatment African American cocaine users residing in rural and urban areas of Arkansas.