While epidemiologic studies indicate the prevalence of recent alcohol disorder in rural America approaches that of urban America, the limited research to date suggests that rural problem drinkers may be less likely to use services for alcohol problems than their urban counterparts. The overall goal of this proposal is to investigate why rural drinkers may be less likely to use services for their alcohol problems and explore what consequences this limited use has on their subsequent drinking and drinking-related problems. To accomplish this goal we propose to pursue four specific aims. First, we will investigate differences between rural and urban problem drinkers in any use of formal and informal services for alcohol problems. Second, we will identify factors which explain the reduced treatment rates we expect to observe among rural problem drinkers, using a modified Aday and Anderson model to examine policy-relevant predictors which are particularly important in rural areas. Third, we will investigate differences between rural and urban problem drinkers in how drinking and drinking-related problems change during six months following baseline. Fourth, we will analyze both treatment and non-treatment variables to identify factors which explain the rural-urban differences in course of drinking we expect to observe. To accomplish these aims, we propose to conduct a two wave prospective study of an estimated 700 problem drinkers identified in a probability-based random telephone survey.of community residents in six Southern states. Problem drinkers include over 200 drinkers with a one year DSM-lV diagnosis of alcohol abuse or dependence, plus an estimated 500 drinkers who are at risk for meeting diagnostic criteria for alcohol disorder in the next year. The study will collect baseline measures of an extensive array of predictors of service use including the actual and perceived availability, accessibility and affordability of alcohol treatment services, use of services for alcohol problems in alcohol treatment programs, mental health settings, general medical settings and self-help groups like Alcoholics Anonymous will be measured at baseline and six months. Changes in drinking and drinking-related problems will also be measured at the same intervals. If the expected gap in treatment rates has negative consequences for rural problem drinkers, the study will provide practical insights about how policy makers can effectively increase use of services for alcohol problems in rural areas. For example, this study can provide evidence about the relative promise of interventions which increase the availability versus the affordability of alcohol treatment services. If the expected gap has no discernible effect because, for example, the lay network in rural areas provides greater support for sobriety, this investigation will provide important knowledge about how the social network helps individuals control their drinking problems. We elected to conduct this research in the South to provide targeted information on how to better serve an understudied and underserved population. The database we will develop during this study will allow us to conduct subsequent analyses beyond the hypotheses detailed in this proposal, including an examination of intra-rural variation in use of services for alcohol problems and a more extended analysis of service issues for women and minority problem drinkers.
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