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CHAPTER 2
METHODS
The Sample
Descriptive data were collected on a sample of 214 substance-abusing women on welfare. Procedures and selection criteria were designed to identify a sample of TANF eligible women who were detected on a substance abuse screening measure administered at the welfare office and upon further assessment were determined to be dependent on alcohol or other drugs, required drug free inpatient and/or outpatient substance abuse treatment, and were otherwise work eligible. This cohort would be the one most likely to be identified by screening and evaluation systems implemented or under consideration in welfare settings across the country. Women seeking methadone maintenance treatment were evaluated in a separate study.
Formal selection criteria were as follows: women were included in the study if they met criteria for a DSM-IV substance dependence diagnosis; were eligible or receiving Temporary Aid to Needy Families (TANF); were entering New Jersey's welfare-to-work program not deferred for a medical problem; and could speak English well enough to complete an interview. Women were excluded if they were currently psychotic; receiving or seeking methadone treatment; seeking long-term residential treatment; or currently in substance abuse treatment. In addition, descriptive data were collected on a sample of 69 women on welfare who did not have a substance abuse problem. Women in the non-affected sample were included if they did not meet DSM-IV criteria for a substance use disorder during the prior five years, were eligible or receiving Temporary Aid to Needy Families (TANF); could speak English well enough to complete an interview; were entering New Jersey's welfare-to-work program and were not deferred for a medical problem. Women were excluded if they were psychotic.
Procedures
Substance Abuse Sample. Women were screened for substance abuse problems by welfare workers in Essex County in accordance with New Jersey welfare regulations. Specifically, welfare workers were required to administer a brief screening measure, the CAGE-AID (Brown, 1992), to all individuals applying for or seeking redetermination of TANF benefits. The CAGE-AID is a nine-item measure designed to screen for alcohol and other drug use problems. Individuals responding positively to two or more questions were referred for further evaluation to trained addictions counselors who were co-located at the local welfare office. Welfare caseworkers received training on measure administration and referral. Specially trained addiction counselors screened clients for SARD eligibility and assessed those determined as eligible using a battery of standardized measures. Substance abuse and non-affected sample participants were recruited into the study between June 1999 and September 2000.
In order to determine representativeness of the sample, program records for a 12-month period (9/99-9/00) were reviewed. A total of 308 clients screened positive and were referred for SARD evaluation. About 53% (n=163) met eligibility criteria and 96% of those agreed to participate in the research study. The remaining 145 clients were not included for the following reasons: 29 did not meet current substance abuse or dependence; 70 did meet diagnostic criteria for a substance use disorder, but were excluded primarily because they were seeking methadone maintenance treatment; and 46 clients either did not complete the intake assessment or were ineligible for other reasons. Overall, the sample appears representative of the selection criteria. It is important to note that the sample may not be representative of substance abusers in the welfare populations. Rates of positive response to the screening measure were low (4-10%) suggesting that many substance abusers were not detected by the screening procedures (cf. Morgenstern et al., 2001).
Non-affected Sample. Women screening negative on the CAGE-AID were informed that they could participate in a research study and were referred to research staff located at the welfare setting. Research staff met with women and explained the nature of the study. Those interested were administered informed consent and then were escorted to a confidential interview space located several blocks from the welfare office where interviews were conducted. All comparison participants were required to provide a urine sample to verify self-report of substance use. A total of 203 comparison participants were contacted by research staff: 16% (n=32) were ineligible; of those eligible 40% (n=69) were enrolled; 32% (n=55) requested an interview, but did not complete the assessment; and 27% (n=47) refused.
The representativeness of the non-affected sample was further examined because 60% of eligible participants did not enroll in the study and not all women who screened negative met with research staff. Research staff actively approached a representative sample of women who screened negative and requested demographic characteristics of those women, whether or not they agreed to participate in the research study. Demographic data were collected on 84% (n=78) of women approached who refused study enrollment. A comparison of demographic data of eligible women who did or did not enroll in the study indicated no significant differences on age, ethnicity, education, or employment history. Anecdotal reports from staff indicated that the primary reason women refused participation was that they were too busy with other obligations that day to complete an interview. Overall, data suggest that the sample may be representative of TANF women in Essex County not affected by substance abuse problems.
Measurement
All participants were administered a battery of standardized measures by trained interviewers upon enrollment in the study. Measures were selected to assess: a) demographics, b) substance use problems, c) other barriers to employability, d) and child well-being. Constructs assessed for substance use problems included: DSM-IV diagnoses, current consumption and consequences, problem severity and chronicity, prior treatment history, and recommended level of intensity of treatment placement based on the American Society of Addiction Medicine Patient Placement Criteria (ASAM-PPC2; ASAM, 1996). Problems in eleven domains were assessed to determine the extent of other co-occurring barriers to employability: education, work skills, physical health, mental health, family, domestic violence, recent stressful events, legal, housing, childcare, and transportation. Need for services in the eight ASI problem domains was based on severity scores derived from both objective criteria related to the client's previous history and current needs, and from the client's perception of the severity of the problem and need for additional care. Need for service was scored on a 10-point likert scale with categories ranging from "no services needed" to "services required". These 10 categories were then collapsed into "no services needed", "services recommended", and "services required". To ensure standardization in scoring the need for services, staff received extensive training in evaluating the objective criteria consistently and applying appropriate weight to the client's perceptions. Child well-being was assessed via mother's self-report and included measures of home environment, parenting practices, child health, school engagement, and social and emotional health. A number of child well-being items were drawn from the National Survey of American Families (NSAF). For those items, findings from the substance abuse and non-affected samples are compared to the NSAF sample. Detailed information on measures, interviewer qualifications and training, and quality control procedures are available in Appendix 1.
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