Availability: Are the services adequate?
Accessibility: Are they able to use those services?
Affordability: Are they able to pay the price?
to target areas with the greatest need. Given the limited delivery system, workforce and economic resources available in many rural communities, this is an essential part of the assessment to ensure the best use of scarce resources.81
Finally, it is critical to understand the level of support and resources available for the development of strategies to support rural communities in general and for the devel- opment of rural substance use strategies in particular:
• Who are the key stakeholders/champions at the
national, provincial and local levels that can influ- ence the allocation of resources and development of strategies to address rural substance use?
• Are there governmental agencies, academic pro-
grammes or NGOs that provide technical assis- tance and/or support to rural communities?
• Is there funding available to support these efforts? • How can these resources be accessed and
coordinated?
3.4.5 Role of law enforcement in
addressing substance use disorders
Law enforcement plays an important role in address- ing rural substance use issues from two perspectives. First, it plays a central role in intervening in drug sup- ply issues. Stemming the availability of drugs as well as local drug production is vital to reducing the drug use in rural communities. At the same time, the extent to which law enforcement works with health-care and social service systems to address substance use as a chronic disease (rather than a criminal activity) directly influences the willingness of rural residents to acknowledge substance use disorders and seek treat- ment. As such, it is important to assess the attitude and strategies of national, provincial and local law enforce- ment agencies on these issues and engage them as part- ners in efforts to address rural substance use disorders. One particularly important law enforcement strategy
81 Ibid.
is the ability to facilitate access to treatment as an alter- native to incarceration and other punitive sanctions. On the other hand, law enforcement agencies are often not well-positioned to be involved in prevention activ- ities, and, as such, should not be expected to play a sig- nificant role in prevention efforts.
3.4.6 Capacity and workforce issues
An essential element of efforts to enhance the response of rural substance use prevention and treat- ment systems of care involves the assessment of capac- ity and workforce supply issues. Any assessment should clearly identify the number, distribution and type of providers trained and credentialed to treat substance use disorders:
• What is the capacity of clinic training programmes
in the Member State to produce a sustainable substance use workforce? (e.g., How many pro- grammes exist? Where are they located? How many and what types of clinical providers are they able to produce? What are the costs? What is the state of current enrolment?)
• What are the licensing/credentialing requirements? • How do estimates of workforce production align
with estimates of workforce demands?
• Is it possible to estimate the number of providers in
training and willing to practice in rural settings? It is also essential to understand the issues that influ- ence the willingness of substance use treatment providers to practice in rural areas:
• Are compensation levels adequate to recruit and
retain substance use treatment providers in rural settings?
• What are the opportunities and resources to
support the development of viable substance use treatment practices?
• What are the employment and/or educational
opportunities for the provider’s spouse and family? Are they linked to other professional issues such as availability of peer engagement and support, pro- fessional development, supervisory resources, access to consultative support for complex cases, and/or the quality of the treatment facilities? One other workforce issue that must be assessed is the extent to which substance use treatment can be inte- grated with local primary care and mental health systems. People with substance use disorders are sub- stantially more likely to suffer from co-occurring mental health disorders and physical health problems. The ability to integrate these services is driven by factors that include supply issues for primary care and mental health services, reimbursement issues, pro- vider attitudes related to the treatment of substance use disorders, and the availability of resources to support integrated care.
Furthermore, in order to develop a comprehensive substance use response in rural settings, it is impor- tant to assess the available prevention workforce, including those with prevention-specific training as well as those with strong potential to deliver prevention-related programmes due to their profes- sional roles and capacities. This includes assessing the extent to which programmes exist to train prevention pro fessionals, the support for specific prevention programmes, and whether prevention-related tasks are included in the work descriptions of different professional groups.
3.4.7 The impact of stigma on
willingness to access substance
use treatment
Stigma remains a significant barrier to the willingness to access treatment by those suffering from substance use disorders. This stigma can be present within pro- fessional training programmes, political systems, health systems, law enforcement and criminal justice systems, and communities. It is important to adapt
and implement evidence-based stigma reduction pro- grammes developed by organizations such as the World Health Organization, the Substance and Mental Health Services Administration, the Addic- tion Technology Transfer Center, and the Canadian Centre for Addiction and Mental Health (see annex A for further information and links to these resources).
3.5 Local context for the
development of rural
prevention, treatment and
recovery strategies for
addressing drug and
substance use
The need to understand the prevalence of substance use in rural settings, the capacity of the existing pre- vention and treatment infrastructure, and the use of treatment services by rural residents has already been discussed in this chapter. To support the identifica- tion and adaptation of prevention, treatment and recovery strategies targeting rural settings, the local community context in which these services will be developed must be clearly understood. Issues that must be assessed include:
• Local cultural, religious and normative beliefs that
influence substance use and one’s willingness to seek treatment
• Availability of substance use treatment services as
well as physical, mental health, prevention and recovery resources
• The presence of local leaders to champion community- based strategies to address substance use
• The extent of community willingness to acknowl-
edge and address rural substance use issues
• The capacity and willingness to use telemedicine
and other technology-based treatment modalities to expand access to care
A local planning and action framework is needed to identify local priorities, goals and visions for address- ing substance use issues at the community level. Rural communities need evidence-based assessment and strategic planning models to identify, adapt and implement substance use prevention, treatment and recovery services. They also need technical assis- tance support to implement a local planning and action process.
3.6 Assessment framework,
and monitoring and
evaluation
3.6.1 Developing a national assessment
report framework
To support the strategic planning process and engage local stakeholders, it is essential that a report summa- rizing the findings and assessment data be prepared and disseminated to the stakeholders for review and comment. The key to the report is a clear summary that includes the following items:
• Quantitative and qualitative data collected during
the assessment process
• A discussion of the limitations of the data
• A list of key stakeholders involved in the assess-
ment process
• A discussion of how the report can be used in the
strategic planning process
• A list of priority substance use issues identified
by stakeholders to inform the strategic planning process
82 World Health Organization. Assessment Instrument for Mental Health Systems—WHO-AIMS, version 2.2. WHO Press: Geneva, Switzerland (2005).
83 Guidelines for the Development and Implementation of Drug Abuse Rapid Situation Assessments and Responses. ODCPP. 1999, Vienna.
• A discussion of next steps with measurable time
frames, process goals and outcomes for the strategic planning process
The goal is to develop a report framework that sum- marizes the results of the assessment process and reflects the needs of the stakeholders involved in the strategic planning process.
An example of a useful tool is the Assessment Instru- ment for Mental Health Systems, version 2.2, of WHO.82 Although not specific to substance use
prevention and treatment, the instrument provides a similar process for mental health systems of care and a useful report framework. Other examples include the Guidelines for the Development and Implementation of Drug Abuse Rapid Situation Assessments and Responses;83 the Strategic Prevention Framework for
the State Incentive Grant Program of SAMHSA and related strategic planning reports from state sub- stance use and mental health authorities; the System of Care programme of the National Technical Assis- tance Center for Children’s Mental Health; and stra- tegic plans developed by agencies such as WHO and EMCDDA, as well as by state substance use and mental health authorities in the United States and other United Nations Member States.
3.6.2 Ongoing monitoring
and evaluation
The goal of this assessment process is to collect and analyse data to improve rural substance use systems of care, to use that data to support a strategic planning process to identify and prioritize interventions at the provincial or community levels, and to provide baseline data to monitor the impact of those inter- ventions. As discussed earlier, data and findings from
Assessment Planning Baseline Implementation Evaluation of process Post- implementation
Data collection Evaluation of impact