Published on January 7, 2008
Intrinsic and Extrinsic Barriers to Health Care:Implications for Problem Gambling: Intrinsic and Extrinsic Barriers to Health Care: Implications for Problem Gambling Dave Clarke School of Psychology Massey University Albany Campus, NZ Overview: Overview Intrinsic and extrinsic barriers defined Models of health care change and access Specific research questions for problem gambling derived from literature on barriers for substance abuse and mental illness. Definitions: Definitions Intrinsic barriers: personal emotions, cognitions and behaviour, including shame, fears of stigma and treatment; attitudes: self-reliance, handle problem on own, not serious, like feeling Extrinsic barriers: diagnostic criteria and practical limitations such as accessibility; also the attitudes, values and beliefs of social/cultural groups and of treatment providers Transtheoretical Model (TTM)(Prochaska, 1992) Intrinsic: Transtheoretical Model (TTM) (Prochaska, 1992) Intrinsic Precontemplation – no intention to change Contemplation – weighing costs and benefits of changing Preparation – intend to take or have taken some action Action – modify behaviour, experiences, or environment Maintenance - prevent relapse and consolidate the gains attained Social Behavioral Model (SBM)(Andersen, 1995)Extrinsic: Social Behavioral Model (SBM) (Andersen, 1995) Extrinsic Predisposing factors – demographics Enabling / access factors availability accessibility affordability acceptability (and appropriateness) Need factors - severity of a disorder, diagnoses, co-morbidity, treatment history, negative consequences such as work-related and financial difficulties Network-Episode Model (NEM)(Pescosolido, 1998)Intrinsic x Extrinsic: Network-Episode Model (NEM) (Pescosolido, 1998) Intrinsic x Extrinsic social networks and events, with a focus on coercion in the decision-making process pressures from family members, friends, employers or the legal system shame, fears of stigma and isolation are affected by social/cultural attitudes, values and beliefs Specific Research Questions - Intrinsic Barriers : Specific Research Questions - Intrinsic Barriers Are there discrete stages of change in the decision-making process of problem gamblers, and do longitudinal and experimental studies of problem gamblers support these changes, as predicted by the Transtheoretical Model? In the TTM contemplation and preparation decision stages, are women quicker than men to seek help? Are problem gamblers more likely to enter treatment if they are pressured to get help than if they rely on individual decision making or on lower extrinsic barriers to access (SEM)? Specific Research Questions - Intrinsic Barriers : Specific Research Questions - Intrinsic Barriers Are problem gamblers more likely to handle problems on their own than alcohol and substance abusers? Is the male gender role of self-efficacy, success, power and competition negatively related to seeking help for problem gambling? Are problem gamblers who report that their lives are out of control and they want to stop gambling less likely to complete treatment programmes than problem gamblers who are not as strongly motivated? Specific Research Questions - Intrinsic Barriers : Specific Research Questions - Intrinsic Barriers To what extent do attitudinal barriers and fears of stigma, shame and treatment present barriers to help for problem gambling among the following groups: (a) mothers, (b) men who define their gender role in terms of success, power and competition, (c) young people, and (d) ethnic minorities? Before seeking help, do problem gamblers follow the same temporal sequence of events as substance abusers: (1) early recognition of the problem, (2) relationship, employment, financial and legal problems, (3) severe physical and emotional symptoms? Are problem gamblers more likely to consider professional knowledge and training more salient than trust in treatment providers? Specific Research Questions - Intrinsic Barriers : Specific Research Questions - Intrinsic Barriers Are attitudinal barriers and fears of stigma, shame and treatment for problem gambling greater barriers to treatment than the extrinsic enabling factors of availability, accessibility, affordability, acceptability and appropriateness? Specific Research Questions - Extrinsic Barriers : Specific Research Questions - Extrinsic Barriers Is the stigma associated with female substance abuse greater than the stigma associated with female problem gambling? Is the stigma of problem gambling greater for women than for men, and what gender differences are there for different ethnic groups? Are men more likely than women to seek treatment for problem gambling? Are youth, low education, employment difficulties and low socioeconomic status negatively associated with beginning and completing treatment for problem gambling? Specific Research Questions - Extrinsic Barriers : Specific Research Questions - Extrinsic Barriers Are high socioeconomic status, employed, male problem gamblers less likely to seek treatment than low socioeconomic status, unemployed, male problem gamblers? Do women and ethnic minority groups have more economic and childcare barriers than men in seeking treatment for problem gambling? Are young women more likely to gamble than older women, but less likely to perceive a need for treatment? Specific Research Questions - Extrinsic Barriers : Specific Research Questions - Extrinsic Barriers Are rural problem gamblers more likely than urban ones to have difficulties with availability, accessibility, affordability, acceptability and appropriateness of some treatment services, especially for indigenous groups such as Maori? Are primary health care services such as general practitioners and public health emergency services usually the first contacts for problem gamblers? Are there culturally appropriate interventions for Maori, Pacific Island and Asian problem gamblers in New Zealand? Are Asian families in New Zealand more likely to seek help from mainstream agencies for problem gamblers in their families than Pakeha, Maori or Pacific Island families? Specific Research Questions - Extrinsic Barriers : Specific Research Questions - Extrinsic Barriers Do immigrants have more language difficulties and less knowledge of problem gambling services and entitlements than residents in a country? What proportions of different clinicians believe that female problem gamblers have different needs than male problem gamblers, such as assistance with parenting difficulties? What proportions of different clinicians working with problem gamblers and their families take some form of culturally appropriate interventions? Are women more likely than men to seek help for problem gambling from other sources such as the Internet rather than mutual self-help groups such as Gamblers Anonymous? Specific Research Questions - Extrinsic Barriers : Specific Research Questions - Extrinsic Barriers Are social pressures and social consequences more influential than severity of behavioural symptoms in getting problem gamblers into treatment? Do problem gamblers with comorbid substance dependence or mental health disorders encounter systems barriers, including fragmentation of services, poor communication between agencies, inconsistency of care, and clinicians’ judgmental attitudes, lack of knowledge and skills in assessment, treatment planning and interventions for comorbid disorders? For comorbid problem gambling with substance abuse, are women less likely than men to enter treatment and have more severe symptoms of the disorders? Specific Research Questions - Extrinsic Barriers : Specific Research Questions - Extrinsic Barriers For problem gambling and substance abuse, are comorbid cases more likely than single-disordered cases to have a history of chronic mental and physical health problems, fewer social networks and greater frequency of use of treatments? Are changing public attitudes and policies towards problem gambling encouraging problem gamblers to seek help? Conclusions: Conclusions The Social Behavioral Model and the Network-Episode Model seem to explain barriers to health care access and utilisation for addictive disorders and mental health problems better than the Transtheoretical Model. This review of literature on barriers to health care access and utilisation for substance abuse and mental health problems may have some relevance to similar barriers for problem gamblers and their families.