Measuring Met and Unmet Need of Drug Misusers: Integration of Quantitative and Qualitative Data
Jane Fountain John Strang Paul Griffiths Beverly Powis Michael Gossop
National Addiction Centre, The Maudsley, Institute of Psychiatry, London, UK
Key Words Service evaluation • Combination methodology
This paper reports on the combination of qualitative and quantitative methods which were used to record the atti- tudes to, and perceptions of, drug treatment services by current, ex-, and potential clients in south-east London. Three research instruments were employed: a structured current client satisfaction survey (n = 333); a question- naire which included open-ended questions, adminis- tered to drug users not currently in treatment (n = 88), and focus groups for young drug users not in treatment
= 14), women in treatment (n = 7) and men in treat- ment (n = 11). The data thus collected were used to con- struct a picture of local met and unmet need and obsta- cles to the uptake of health care, which is supported by more than one perspective, and which can reasonably be used as the basis for the planning of local health care purchase. Three major concerns were revealed by the data: the inadequacy of existing GP drug services; the deterrent effect of long waiting lists for methadone treat- ment, and the role of treatment services in relation to those drug users who acknowledge that their drug use is problematic, but believe that treatment services have nothing to offer them.
Need has been defined, in the health care needs assess- ment literature, as 'ability to benefit.' The health care needs of a population in a locality can then be considered as 'met' or 'unmet' . Substance misusers constitute a group who are frequently out of contact with treatment service and who are often considered poor utilisers of existing available treatment services . Furthermore, they may themselves be unaware of their health care needs . Addressing the unmet needs of drug misusers poses a particular challenge to public health planners. Dif- ferent perspectives are required in our attempt to under- stand these drug-taking behaviours and the associated met and unmet health needs, which are complex and mul- ti-faceted. Triangulation, a combination of quantitative and qualitative research methods which gathers data from subjects with differing experiences [4, 5], offers the best prospects for improving our grasp on the shapes and opportunities before us. There is undoubted benefit from study of current clients of a drug service, as in the approach of a consumer audit recently described by Me- trebian et al. . However, if the service is examined only from the standpoint of those who are current con- sumers, then there is a danger that only one dimension of the service will be seen. For a fuller picture, as shown by figure 1, if those who have never had contact with the service and those who are not current attenders are also asked, via interviews and discussions, a multi-dimen- sional picture of local need can be constructed, following which the suitability of the local provider line-up can be gauged.
The Context for the Local Study
The local health authority responsible for commission- ing and funding drug services in south-east London was conscious of probable gaps in the provision of these ser- vices and consequently commissioned a review. The re- search team had pre-existing awareness of the local drug- using community and service responses through previous studies of clients both in treatment [7-10] and out of treatment [11-13]. The research team worked with the local health authority, local agencies and drug users to explore need (met and unmet) amongst more than 450 clients and potential clients.
The research project consisted of three parts: (1) a cur- rent drug client satisfaction survey; (2) interviews with drug users not currently receiving treatment, and (3) dis- cussion groups (focus groups) of drug users both in and out of treatment. Whilst the level of need for drug services in other parts of the UK is likely to be different, the approach used in this project could readily be adapted for use elsewhere.
It should be noted that data are presented here only to illustrate the results from using a combination of research methodologies: the paper is not intended to be a report of research findings.
Client Satisfaction Survey
A self-completion questionnaire was administered to all clients who had attended a drug agency in the locality during a 1-week peri- od. A total of 16 agencies were surveyed, including needle exchanges, drop-in advice centres, drug treatment clinics and residential rehabil- itation units. The questionnaire was designed to be completed in no more than 10-15 min. It was worded simply, and most responses required only a tick. Clients were assured of their anonymity and asked not to put their names on the questionnaire. Agencies were identified by a code number.
The focus of the questionnaire was on clients' satisfaction with different aspects of service delivery and the range of services they received, and was developed in consultation with the local health authority. Clients were asked for basic demographic information; how they knew about the agency; what kind of help they wanted; what kind of help they received, and how satisfied they were with various aspects of the agency and its services. They were also asked about help-seeking experiences with a drug problem from a GP; if they had used any other agency, and if they had tried to get a place in a residential rehabilitation unit.
In order to maximise the number of questionnaires completed and returned, the following procedure was adopted. Each agency was sent the appropriate number of questionnaires, with instructions for distribution. An explanation was given to clients that no-one at the agency would see their answers, and it was stressed that clients should be allowed to complete them in private whilst they were at the agency (if a client asked for help to understand a question, staff were asked to explain it to them, but not suggest any answers). Clients were asked to put the questionnaire in a stamped, addressed envelope, seal it, then hand it in at the agency or post it themselves. Three hundred and thirty-three completed questionnaires were returned at the end of the 1-week survey.
Client Satisfaction Survey: Results
Responses were received from 230 males and 103 females, with a mean age of 31. Two hundred and thirty- four of them (70%) had injected drugs during the last year.
Self-Identified Problem Drugs
Heroin was identified by the majority of current clients (84%) as their main problem drug. The benzodiazepines temazepam and/or diazepam were seen as a problem by 44% of clients, methadone by 43% and crack cocaine by 41%. Thirty-eight percent of clients agreed they had a problem with drug use in general. Figure 2 provides a full overview of clients' main problem drugs.
Were Current Clients Satisfied with the Services They Were Receiving from the Agencies?
Eighty-three percent agreed that 'Coming to the agency has been very helpful', and 81% thought that the staff 'al- ways' or 'usually' understood their problems. When asked if they would return to the same agency if they had the same problem again, 92% said they would.
Which Services had Clients Received?
Clients were asked which services they had received in addition to those specific to the agency they were attend- ing (such as clean injecting equipment from needle ex- changes and methadone from methadone clinics). Two hundred and ninety-five (90%) clients were registered with a GP and 138 (41%) said the agency had given them help to register. Clients were asked 'Has the agency dis- cussed HIV/AIDS with you?' Thirty-one percent of clients said they had not. Twenty-five percent of those who had been given advice on HIV/AIDS agreed they knew 'a lot' more about it now. Thirty-eight percent had been given general health advice.
Sixty-seven (20%) clients said they had to look after children, and 27 of them (40%) said that this 'usually' or 'sometimes' made it difficult for them to go to the agency. This was more of a problem for women than for men.
Eighty-nine clients (27%) had been seeking referral to, and linked funding for, a place in a residential rehabilita-
Eighty-eight drug users not currently in contact with a drug or alcohol agency were interviewed in the community by a team of nine interviewers, using a structured questionnaire adapted for the pur- poses of this study. The focus of the interview was on knowledge, attitudes and beliefs about services, and satisfaction with previous service contact.
Interviewers and Interviewees
The use of special interviewers who have established access into networks of drug users is ideal for collecting structured data outside treatment settings, and has previously been described by Griffiths et al. . Whilst not designed for maximum scientific yield, and whilst further pockets of drug users may still exist, the method nevertheless provides an invaluable mixed quantitative/qualitative insight into the beliefs and behaviours of a large proportion of the 'hidden' drug misusing population. A range of interviewers with different back- grounds and links with the local drug-using community was used. The key selection criteria were that the interviewer had access to the study population and could successfully conduct interviews. The team included ex-drug users, occasional users and 'streetwise' members of the local community who were on good terms with local drug users.
The sample interviewed were: (1) not currently using any type of treatment service, and (2) currently using at least three times a week an opiate (e.g. heroin) or a stimulant (e.g. cocaine). They could there- fore be defined as potential clients of drug treatment services. The interviews were carried out over a 3-week period and, whilst anony- mous, they were all tape recorded (with the respondents' consent). Each lasted about half an hour.
Initial enquiry covered basic demographic questions, drug use and injecting and sharing behaviour. There followed six sections in which structured questions were asked about attitudes to, and experi- ences of, six types of drug service: needle exchanges, drop-in drug services, structured care services (that is, where respondents had been taken on as a formal client by, for example, a Community Drug Team or a street agency), hospital in-patient drug units (DDUs), resi- dential rehabilitation units and GP drugs services.
Each of the six sections contained two sets of questions. One set was for respondents who had attended the specified agency in the last year, and included questions on the services they had received and how satisfied they were with them. The second set was for those who had not attended this type of agency in the last year, and asked why they had not and what they thought the agency would be like. Finally, there were questions on respondents' perceived likelihood of wanting help with a drug problem over the next year, and from whom they would ask for such help.
Non-Treatment Survey: Results
The sample comprised 47 men and 41 women, with a mean age of 28 years. In the last year, 65% had used heroin, 56% methadone, 40% crack cocaine, 40% am- phetamine sulphate and 35% had used cocaine powder. Equivalent figures for use in the last month were 61, 21, 9, 28 and 23%. Thirty-five (40%) respondents had injected drugs in the last month, and 8 of them had shared a nee- dle/syringe during this period.
Forty-eight (55% of the sample) had approached a drug treatment agency or a GP for help with a drug problem in the last year, although none was currently receiving help. During the last year, 28(80%) of the current injectors had attended a needle exchange, and of the whole sample, 33 (38%) had asked a GP for help with a drug problem; 29 (33%) had attended a drop-in centre; 10 (11%) had been taken on as a client by a structured care service, and 2 had been residents in a rehabilitation unit. Thirty-one (35%) had attended more than one agency in the past year.
Those who had attended an agency in the last year were asked how satisfied they were with the services provided. (Not enough respondents had been admitted to residen- tial rehabilitation units and hospital in-patient units for any meaningful statistics to be presented).
Of the 28 injectors who had attended a needle ex- change in the last year, 79% were satisfied or very satis- fied; of the 29 respondents who had attended a drop-in centre, 79% were satisfied or very satisfied, and of the 10 who had attended a structured care service, 60% were sat- isfied or very satisfied. However, of those who had attended a GP for help with a drug problem, the degree of satisfaction was far lower: only 5(15%) of the 33 who had been to a GP were satisfied or very satisfied with the ser- vice they received. A greater proportion of women than men were satisfied with all services, except needle ex- changes.
Respondents who were not currently in treatment, but had attended one or more of the six types of drug agencies in the past were then asked for their views on the services' best and worst features. The most frequently reported best features were: for needle exchanges — the provision of nee- dles and swabs (54%); for drop-in centres and structured care services — they were helpful and gave good advice (63 and 50%, respectively), and for GPs, the answer most often given to the question 'What was the best thing about going to a GP for help with a drug problem?' was 'nothing' (55%). There was no consensus on the worst features. although 21% of those who had attended a needle ex- change and 26% of those who had attended a drop-in centre complained about the opening hours.
Why Had Drug Users not Attended an Agency?
When those respondents who had not attended any agency in the last year were asked why not, by far the most frequent response (other than for needle exchanges) was that they did not need the services offered: for drop-in centres, 38% gave this reason; for structured care services —44%; residential rehabilitation units —39%; in-patient units —42%; GPs-4l%.
Respondents were also asked what each service could do to make them more likely to attend. For drop-in centres, structured care services, residential rehabilitation units and for in-patient units the most frequently given answer was 'nothing'. For GPs, the commonest response (37%) was that attendance would be more likely if GPs were more sympathetic, welcoming and supportive.
How Likely Were Users to Ask a Treatment Service for Help over the Next Year?
Figure 3 displays the non-treatment sample's reports of the likelihood that they would seek help with a drug problem over the next year from each type of agency. The most likely was a drop-in centre (48%), and the service the respondents thought they were least likely to use was an in-patient drug dependency unit (92%). Figure 3 also clearly illustrates that there were more respondents who thought they would not ask for help from each type of service than those who thought they would. Nevertheless, elsewhere in the interview, 68% reported that they thought it was 'very likely' or 'likely' that they would need some type of help with their drug use over the next year.
All respondents were given a list of potential sources of help with a drug problem and asked how likely they thought it was that they would approach each in the next year. More reported that they would seek help from friends (59%) and partners (49%) than from any agency.
The rationale behind the scheduling of focus groups  was to provide an unstructured forum for both current and potential service consumers to raise and explore the issues which they saw as impor- tant.
Three focus groups were held to cover pre-selected areas of recog- nised special local concern or interest, One group consisted of 14 young opiate and/or stimulant users (4 females and 10 males, age range 17-23) not currently in contact with any service, and the other two groups looked at special gender issues with 7 women (age range 19-40) and 11 men (age range 18-54) in treatment. The groups were recruited from the community using the research team's network of privileged access interviewers and from several local treatment agen- cies. To ensure that group members would arrive punctually, taxis were provided for some of them, and they were all reimbursed for their time (£ 20 in cash). Nevertheless, too many turned up for the young persons' and the mens' groups, and some had to be turned away, and less than expected arrived for the women's group.
Each group was guided by a moderator who was experienced in the drugs field, and a member of the research team was also present. With each group's permission after assurances of confidentiality, all the meetings were audio taped.
The groups were not intended to be representative of all the types of client groups in the locality, but were chosen to represent those who were likely to have differing concerns about, and attitudes to, service provision so as to provide an insight into how the participants saw their own drug use and the possible relevance of services.
Measuring Met and Unmet Need
Focus Groups: Results
The ideal service was seen by the young drug users as one which provided 50 mg methadone mixture daily, on demand, with no bureaucratic delays, whilst the women and the men in treatment looked further than this short- term solution to their problems. The women wanted emo- tional support in order to be able to live their lives drug free, or with an individually tailored methadone prescrip- tion, whereas the men favoured self-help and/or a metha- done prescription. The majority of the young people and the men rejected counselling as a treatment option, seeing it as an unnecessary intrusion into their 'private lives'.
Women-only services did not appear to be a major objective for the young people, nor for the men. However, the women wanted more women-only provision within existing services, and, most definitely, better child care provision.
For all three groups, information about treatment ser- vices had been obtained mostly from other drug users. It was clear that more attention should be paid to the drug users' grapevine to ensure that the information passed on is accurate.
The young people thought the best service was that offered by needle exchanges. This can be seen as reflecting their rationale to service provision — easy access and prac- tical help. The women thought that methadone prescrip- tions and counselling were the services most likely to meet their needs. The men's preferences reflected the diversity of the group, and there was no clear favourite service, although both self-help and methadone maintenance pro- grammes were rated highly.
Overall, the drug service which received the most criti- cism was that offered by GPs. Most of the focus group participants had not even attempted to ask a GP for help: they considered GPs unsympathetic and unlikely to be responsive to repeat episodes of help seeking. The clearest failing of services, and one clearly articulated by all the groups, was that of waiting lists for methadone prescrip- tions, which were seen as a major hurdle to help seeking, especially by the younger group.
Many of the participants expressed a preference for contact with service workers who were themselves ex- drug users. Further enquiry is required to clarify whether this relates specifically to the ex-user status, or may alter- natively be shorthand for staff who have similar back- grounds across a range of dimensions (such as class, age, ethnicity), not just drug use.
The sample of this study was not randomly selected, and caution should be applied when generalising the find- ings to other populations. However, the major advantage of a project which uses three different research instru- ments and three different groups of subjects is that it is possible to cross-check opinions. For example, a finding from the non-treatment survey was that clients were far from satisfied with GP drug services: only 15% of respon- dents were satisfied or very satisfied — a figure far lower than those relating to the other drug treatment services. The client satisfaction survey reinforced this finding: whilst 91% of the clients said they would go back to the same agency if they had the same problem again, only 23°k said they would go to their GP. These two findings were confirmed in the focus group discussions.
The findings raised a special concern about the inade- quacy of existing GP services in view of the central posi- tion of the UK government's strategy for treatment re- sponse  and high local activity . The data also revealed the inadequacy of methadone maintenance ser- vices with deterring long waiting lists, even though south London is one of the most extensively covered parts of the UK, with approximately one methadone treatment slot per 1,000 catchment population. The study also identified barriers to the take-up of treatment and raises the ques- tion of health services' reaction to those drug users who agree their drug use is problematic, but believe that treat- ment services have nothing to offer them.
In today's new health care marketplace, efficient pur- chasing requires judicious investment in market research. This should cover the extent and nature of unmet need  and the extent to which current methods of delivery are acceptable to the target populations. In the addictions field, this is particularly difficult, as many of the target population carefully preserve their 'hidden' status . However, by simultaneous recourse to different ap- proaches, we have been able to construct a local picture of unmet need and obstacles to the uptake of health care which is supported by more than one perspective, and which can reasonably be used as the basis for the planning of local health care purchase. The issues revealed by the study can be explored further in other studies, and whilst the specific findings from this local investigation may not be universally applicable, the general approach could be re-applied elsewhere — with an overall improvement in the effective identification and tackling of such important unmet health care need.
We are grateful to Lambeth, Southwark and Lewisham (LSL) Health Authority for funding support for this project, and to Mark Gilman and Robert Power for acting as moderators for the focus groups.
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