Journal of Substance Abuse Treatment 47 (2014) 307–313

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Journal of Substance Abuse Treatment

Regular articles

Predicting substance-abuse treatment providers’ communication with

clients about medication assisted treatment: A test of the theories of reasoned action and planned behavior☆ 

Anthony J. Roberto, Ph.D. a,⁎, Michael S. Shafer, Ph.D. b, Jennifer Marmo, Ph.D. c

a Hugh Downs School of Human Communication at Arizona State University b School of Social Work and Center for Applied Behavioral Health Policy at Arizona State University c Department of Education, Arizona State University

a b s t r a c ta r t i c l e i n f o

☆ This paper was made possible by Cooperative Agree from the Department of Health and Human Services, Health Services Administration. The opinions expressed those of the authors and no endorsement of the HHS or ⁎ Corresponding author. Tel.: +1 11 480 9654 111.

E-mail address: anthony.roberto@asu.edu (A.J. Rober

http://dx.doi.org/10.1016/j.jsat.2014.06.002 0740-5472/© 2014 Elsevier Inc. All rights reserved.

Article history: Received 13 August 2013 Received in revised form 3 June 2014 Accepted 8 June 2014

Keywords: Medicated assisted treatment (MAT) Substance-abuse treatment providers Theory of reasoned action Theory of planned behavior

The purpose of this investigation is to determine if the theory of reasoned action (TRA) and theory of planned behavior (TPB) can retrospectively predict whether substance-abuse treatment providers encourage their clients to use medicated-assisted treatment (MAT) as part of their treatment plan. Two-hundred and ten substance-abuse treatment providers completed a survey measuring attitudes, subjective norms, perceived behavioral control, intentions, and behavior. Results indicate that substance-abuse treatment providers have very positive attitudes, neutral subjective norms, somewhat positive perceived behavioral control, somewhat positive intentions toward recommending MAT as part of their clients’ treatment plan, and were somewhat likely to engage in the actual behavior. Further, the data fit both the TRA and TPB, but with the TPB model having better fit and predictive power for this target audience and behavior. The theoretical and practical implications for the developing messages for substance-abuse treatment providers and other health-care professionals who provide treatment to patients with substance use disorders are discussed.

ment Number 1UR1TI024242 Substance Abuse and Menta in this manuscript are strictly SAMHSA is to be inferred.

to).

© 2014 Elsevier Inc. All rights reserved.

Great strides have been made in the past decade in the efficacious application of pharmacological intervention in the detoxification, treatment, and long-term sobriety of patients experiencing alcohol and illicit drug abuse. Medication-Assisted Treatment (MAT) is a form of pharmacotherapy and refers to the treatment for a substance use disorder that includes a pharmacologic intervention as part of a comprehensive substance abuse treatment plan. Pharmacotherapeutic interventions have been demonstrated efficacious in the treatment of opioid abuse (Knudsen, Ducharme, & Roman, 2007; Weiss et al., 2011), alcohol dependence (Chandreakekaran, Sivaprekash, & Chitraleka, 2001), and cocaine dependence (Carroll et al., 2000). In spite of the growing evidence base, adoption and widespread implementation of MAT has lagged, hampered by a combination of structural, financial, and workforce related issues (Knudsen et al., 2007).

In contrast to other chronic health conditions, treatment of substance use disorders remains largely a disease treated by counselors, social workers and therapists through a network of community based, non-medically-based treatment agencies. Among surveyed substance abuse treatment facilities, only one-third report

l

provision of MAT (National Survey of Substance Abuse Treatment Services, 2008), while the vast majority of primary care physicians report little knowledge of, or attendance to, the treatment of substance use disorders among their patients (Mark et al.; 2003). Confounding this situation are long held social beliefs and attitudes regarding the use of medication to treat substance use disorders, with such beliefs often present among a sizeable group of the professionals serving as addiction providers who are themselves in recovery (Institute of Medicine, 1995, 1997). As evidence of the efficacy of MAT continues to accumulate (Friedmann & Schwartz, 2012), so does the research related to providers’ and clients’ attitudes beliefs, and behaviors, regarding MAT (Forman, Bovassdo, & Woody, 2001; Reickmann, Daley, Fuller, Thomas, & McCarty, 2007). In general, these studies report rather powerful social normative influences mediating what might best be described as neutral to negative attitudes toward MAT.

Little research exists that explores effective strategies for impacting these attitudes and the corresponding behavioral intentions that providers might have about discussing MAT with their clients. Evidence-based targeted communications and information for pro- viders are needed to facilitate improved openness to MAT efficacy, along with their own professional efficacy in promoting and integrating MAT as part of the treatment and recovery services they provide to their patients. Given the potentially important role previous research seems to assign to attitudes, norms, and efficacy in this area, the theories of

308 A.J. Roberto et al. / Journal of Substance Abuse Treatment 47 (2014) 307–313

reasoned action and planned behavior were selected to guide this inquiry. A discussion of each of these theories follows.

1. The theory of reasoned action and the theory of planned behavior

According to the theory of reasoned action (TRA; Ajzen & Fishbein, 1980; Fishbein & Ajzen, 1975), the best predictor of a person’s behavior is their intention to perform or not perform the behavior, and the best predictors of intention are a person’s attitude toward the behavior (i.e., do they feel positively or negatively toward the behavior) and subjective norms (i.e., how they think significant others think they should behave). The theory of planned behavior (TPB; Ajzen, 1985) adds a direct link from perceived behavioral control (i.e., how much influence the person has over the behavior) to both intention and behavior. Notably, the TPB “was made necessary by the original model’s limitations in dealing with behaviors over which people have incomplete volitional control” (Ajzen, p. 181). Thus, Ajzen predicts there should be less difference between the TRA and TPB when the behavior in question is under volitional control. Many factors affect whether someone perceives a behavior under their volitional control, such as time, money, skills, cooperation of others, etc. A visual representation of the TPB is included in Fig. 1. Meta- analyses by Albarracin, Johnson, Fishbein, and Muellerleile (2001) and Downs and Hausenblas (2005) offer consistent support for the ability of these theories to predict behavior.

While the TRA and TPB are typically used to predict how likely an individual is to engage in a given healthy behavior themselves, research also suggests that they can be used to explain recommendations made to patients by medical practitioners (Millstein, 1996; Perkins et al., 2007; Roberto, Goodall, West, & Mahan, 2010; Taylor, Montano, & Koepsell, 1994; Walker, Grimshaw, & Armstrong, 2001). For example, Millstein (1996) found that both the TRA and TPB accurately predicted primary care physicians’ intentions and behavior to provide STI education to adolescents. However, it should be noted that most of these studies took place more than a decade ago, focused on physicians, and did not include any sort of behavioral measure (i.e., the majority focused on intentions rather than actual behavior). Further, the question remains if the TPB is generalizable to other health professionals such as substance-abuse treatmentproviders. So, it seemsthere is still a need for more current research in this area using different participants, an additional topic, and a behavioral measure.

Among other things, Reickmann et al. (2007) used the TRA to predict substance abuse treatment counselor’s intentions to tell their patients to use each of four different types of MAT (methadone, buprenorphine, clonidine, and ibogaine). Results indicate that attitudes and norms explained between 40 and 71% in intentions in

Attitudes: Positive or negative evaluation of the behavior.

Beha What

Perceived Behavioral Control: Perceived ease or difficulty of adopting behavior.

Subjective Norms: What you think others think you should do.

Fig. 1. The theory of reasoned action (Ajzen & Fishbein, 1980; Fishbein & Ajzen, 1975) and th reasoned action. The entire figure with shaded box shows the theory of planned behavior.

these instances. Similarly, Kelly, Deane, and Lovett (2012) looked at whether the TPB accurately predicted if residential substance abuse workers would make an effort to employ evidence-based practices (EBP) into their treatment of clients. In this study, EPB were defined as, “an approach which integrates the most appropriate clinical information and scientific evidence, with a view to improving psychological interventions and therapeutic relationships, and pro- ducing the best treatment outcomes for clients” (p. 662). Results indicate that attitude, norms, and perceived behavioral control explained 41% of the variance in intentions to use EBP. Notably, neither of these studies included a behavioral measure.

In sum, though previous applications of the TRA and TPB in the health arena have focused primarily on predicting whether individuals engage in healthy behaviors, work by Perkins et al. (2007) suggests that they should provide a solid theoretical framework for health professionals behavior in general, and Millstein (1996), Reickmann et al. (2007), and Kelly, Thompson, and Waters (2006) suggest they might also predict health professionals communication with patients in particular. Thus, the following research questions and hypothesis are advanced:

RQ1: What are substance-abuse treatment providers’ attitudes, subjective norms, perceived behavioral control, intentions, and behavior regarding recommending medication-assisted treatment as part of their clients’ treatment plan? H1A-B: The (A) TRA and the (B) TPB will accurately predict whether or not substance-abuse treatment providers encouraged their clients to use medication-assisted treatment as part of their treatment plan. RQ2: Does the TPB add to the predictive power of the TRA for this target audience and behavior?

2. Method

2.1. Response rate and research participants

2.1.1. Response rate A link to the survey was sent via email to all 510 individuals who

were (1) subscribers to an e-newsletter distributed by the Addiction Technology Transfer Center(s) (ATTC), and (2) who identified them- selves as serving in a clinical/direct service role in the provision of substance abuse treatment as counselors, clinical supervisors, or peer recovery specialists. Twenty-eight of these surveys were returned as undeliverable. Response rate was calculated as the number of surveys returned (n = 210) divided by the number of surveys that were sent out and not returned asundeliverable (n = 510 − 28 = 482). Thus, the final response rate is 43.57%.

vioral Intention: you plan to do.

Behavior: What you actually do.

e theory of planned behavior (Azjen, 1991). Note: Non-shaded boxes show the theory of

309A.J. Roberto et al. / Journal of Substance Abuse Treatment 47 (2014) 307–313

2.1.2. Research participants Participants were 210 substance-abuse treatment providers

reporting an average age of 48 (range = 26 to 76; SD = 11.11) and 14 years of substance abuse treatment experience (M = 13.84, SD = 9.37). In the 30 days immediately preceding the survey, these respondents reported seeing a median of 39 clients (M = 64.34; SD = 104.90). Additional descriptive statistics are provided in Table 1. Taken together, these descriptive statistics suggest that respondents had regular, frequent, and intensive interaction with substance abusing clients. Finally, using the first digit from the ZIP code from the agency for which the participants worked, it was possible to determine that participants from all 10 of the U.S. Postal Service’s general regions of the country completed a survey (range = 5 to 18% per region, M = 10.9% per region).

2.2. Instrumentation

All TRA and TPB measures were developed using procedures outlined by Ajzen and Fishbein (1980) and Madden, Ellen, and Ajzen (1992); and are similar to items developed by Reickmann et al. (2007) and Kelly et al. (2006). Participants were provided with instructions and a definition of MAT adapted from SAMHSA (2010) before being

Table 1 Participant demographics.

Variable %

Sex Male 35.8 Female 64.2

Ethnicity Hispanic or Latino/a 9.0 European-American 81.9 African-American 7.8 Native American 5.4 Asian 0.5 Other 4.2

In recovery Yes 46.0 No 54.0

Location of work Outpatient treatment facility 63.7 Residential treatment facility 19.6 Correction/criminal justice program 15.2 Hospital/medical facility program 7.4 Other 20.6

Core work functions Assessing clients 79.4 Developing treatment plans 74.0 Providing individual counseling 77.5 Providing group counseling 66.7 Provide case management 63.2

Medication-assisted treatment offered Yes, MAT is provided on-site 30.9 Yes, but in partnership with a physician/group 16.2 No 50.5

MAT organizational support level Very unsupportive 12.3 Unsupportive 10.9 Neutral 26.7 Supportive 29.2 Very supportive 20.8

Workshops/training about use of MAT to treat substance abuse Yes 88.2 No 11.8

Self-rating knowledge level of MAT Very low 2.0 Low 20.1 Moderate 37.7 High 27.5 Very high 12.7

Interest in participation in training using MAT Yes 79.9 No 17.2

prompted to complete a series of forced-choice questions. The definition read, “This survey asks questions about medication-assisted treatment (sometimes referred to as MAT). For the purposes of this survey, medication-assisted treatment is defined as the use of medications such as suboxone, clonidine, and methadone in combi- nation with counseling and behavioral therapies to provide treatment of substance-use disorders.”