The aims of the proposed project are: 1) To compare the three primary systems of service delivery, the public, private indemnity, and health maintenance organization (HMO), investigating patient characteristics and patterns of service utilization among populations entering each type of treatment setting. 2) By expanding on a theoretical framework drawn from the medical literature on helpseeking, the study models the process of """"""""treatment entry,"""""""" testing hypotheses examining why some problem drinkers enter treatment while others do not. Sub-analyses focus on divergences from general patterns of help-seeking among important demographic groups, including women and ethnic minorities. Hypothesis testing focuses on representative samples of populations in public, private indemnity and HMO alcohol treatment programs in a single U.S. community. Relevant comparison groups are drawn from the general population of the same community, and include individuals who meet criteria for problem drinking and have not received treatment during the previous year, and who are also matched to the three clinical samples in terms of health coverage, including private indemnity or HMO coverage, and no coverage. Thus, repeated comparisons are conducted between each treatment service and its respective coverage pool of problem drinkers in the general population who have not received treatment during the previous year. Given the recent policy focus on privatization, decentralization, and cost containment, there are structural as well as individual level factors which increasingly affect the access of treatment and the types of care received. The literature is focused either at the micro level, i.e., examining individual-level factors or at the macro level of organizational and social policy influences on service utilization. The proposed research seeks to examine both sets of factors through a systematic comparison across populations of a theoretical model examining the mechanisms of treatment entry in each sector of services. In-person interviews will be conducted with 300 clients each from the county's public treatment programs, the largest HMO, and the largest private indemnity alcohol treatment programs in the county. In-person interviews will be conducted with problem drinkers in the general population of the same county matched for treatment sector eligibility with the respective programs. The theoretical model examines four domains: individual, need, enabling, and social predisposing variables. Clarifying our understanding of treatment entry is especially timely as policy decisions are now being made as part of the nation's health care reform effort. The study will provide information relevant to the reorganization of health services.
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