Group Title: Substance Abuse Treatment, Prevention, and Policy 2006, 1:21
Title: Insights from a national survey into why substance abuse treatment units add prevention and outreach services
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Title: Insights from a national survey into why substance abuse treatment units add prevention and outreach services
Series Title: Substance Abuse Treatment, Prevention, and Policy 2006, 1:21
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Creator: Wells R
Lemak CH
D'Aunno TA
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Substance Abuse Treatment,

Prevention, and Policy BioMedc


Insights from a national survey into why substance abuse treatment
units add prevention and outreach services
Rebecca Wells*1, Christy Harris Lemak2 and Thomas A D'Aunno3

Address: 'Department of Health Policy and Administration, School of Public Health, University of North Carolina, Chapel Hill, North Carolina,
USA, 2Department of Health Services Research, Management and Policy, College of Public Health and Health Professions, University of Florida,
Gainesville, Florida, USA and 3INSEAD, Fontainebleu Cedex, France
Email: Rebecca Wells*; Christy Harris Lemak;
Thomas A D'Aunno
* Corresponding author

Published: 03 August 2006
Substance Abuse Treatment, Prevention, and Policy 2006, 1:21 doi: 10.1 186/I747-597X- I -

Received: 12 April 2006
Accepted: 03 August 2006

This article is available from:
2006 Wells et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background: Previous studies have found that even limited prevention-related interventions can affect health
behaviors such as substance use and risky sex. Substance abuse treatment providers are ideal candidates to
provide these services, but typically have little or no financial incentive to do so. The purpose of this study was
therefore to explore why some substance abuse treatment units have added new prevention and outreach
services. Based on an ecological framework of organizational strategy, three categories of predictors were tested:
(I) environmental, (2) unit-level, and (3) unit leadership.
Results: A lagged cross-sectional logistic model of 450 outpatient substance abuse treatment units revealed that
local per capital income, mental health center affiliation, and clinical supervisors' graduate degrees were positively
associated with likelihood of adding prevention-related education and outreach services. Managed care contracts
and methadone treatment were negatively associated with addition of these services. No hospital-affiliated
agencies added prevention and outreach services during the study period.
Conclusion: Findings supported the study's ecological perspective on organizational strategy, with factors at
environmental, unit, and unit leadership levels associated with additions of prevention and outreach services.
Among the significant predictors, ties to managed care payers and unit leadership graduate education emerge as
potential leverage points for public policy. In the current sample, units with managed care contracts were less
likely to add prevention and outreach services. This is not surprising, given managed care's emphasis on cost
control. However, the association with this payment source suggests that public managed care programs might
affects prevention and outreach differently through revised incentives. Specifically, government payers could
explicitly compensate substance abuse treatment units in managed care contracts for prevention and outreach.
The effects of supervisor graduate education on likelihood of adding new prevention and outreach programs
suggests that leaders' education can affect organizational strategy. Foundation and government officials may
encourage prevention and outreach by funding curricular enhancements to graduate degree programs
demonstrating the importance of public goods.
Overall, these findings suggest that both money and professional education affect substance abuse treatment unit
additions of prevention and outreach services, as well as other factors less amenable to policy intervention.

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Substance Abuse Treatment, Prevention, and Policy 2006, 1:21

As policy makers grapple with the persistent social and
economic costs of substance abuse and other risky behav-
iors, the need for prevention remains starkly evident.
Studies have found that even brief, informational inter-
ventions can lead to significant reductions in risky behav-
iors [1-4]. Given the enormous human and financial costs
involved, the need for such preventive efforts is obvious.
A critical question is who will provide them.

The current study addresses this question in the context of
substance abuse prevention, specifically asking: "What
factors make it more likely that substance abuse treatment
units will add new community prevention, education,
and outreach services?" The current inquiry focuses on
outpatient substance abuse treatment providers, which
provide the majority of substance abuse treatment in the
United States [5]. These units may be self standing or
based in hospitals, mental health centers, or other facili-
ties. Thus, like many health and human service providers,
substance abuse treatment units are often organizations
embedded in larger organizations.

This study employs The Washington Circle's definition of
"prevention/education" as "delivery system activities
designed to raise the general awareness of substance abuse
as a major debilitating disorder affecting individuals, fam-
ilies, and the greater society... [and] ... those activities
designed to target high-risk individuals and groups for
more focused interventions" [[6], p. 638]. The Washing-
ton Circle thus highlights prevention/education as a
domain within the continuum of substance abuse treat-

The focus here is on decisions by substance abuse treat-
ment units to add new prevention-related education and
outreach services. These included programs related to sub-
stance abuse as well as HIV/AIDS, a continuing epidemic
whose spread is closely linked to substance use. The vast
majority of outpatient substance abuse treatment centers
already provide some type of community outreach or pre-
vention services [7]. The current investigation therefore
focused on factors related to whether units extended
themselves in this vital, yet under-reimbursed, area.

This inquiry was premised on two key assumptions. The
first was that substance abuse treatment units were ideal
candidates to provide prevention-related education and
outreach because they had staff members who were
knowledgeable about how to help people avoid risky
behaviors as well as about local human service resources.
The second was that prevention and outreach were "pub-
lic goods" in that society clearly benefited from these
efforts. In the United States, however, third party reim-
bursement for prevention services was generally low or

nonexistent [8,9]. Thus, what was good for society could
be financially risky for organizations. It was therefore not
sufficient to use financial incentives alone when examin-
ing why substance abuse treatment units would add new
prevention and outreach services.

Conceptual model and predictions
In addition to the assumptions noted above, the investi-
gation outlined here builds on two conceptual perspec-
tives. First, the outcome is viewed as part of organizational
strategy. That is, whether the additions of prevention and
outreach emerge from formal, top-down planning or
result from incremental operational decisions, such diver-
sifications entail resource commitments and affect the
ways providers serve their markets [10].

Second, building on previous analyses from the same
national survey utilized here, the authors employ an eco-
logical perspective on factors potentially affecting organi-
zational strategy. Previous analyses of these data have
revealed environmental, organizational, and facility lead-
ership factors to be associated with the likelihood of form-
ing cooperative relationships with other agencies [11] as
well as with facility survival [12]. The current investigation
extends this research program, this time with respect to a
societally vital type of service diversification.

Traditionally, different "schools" of strategic thought have
emphasized environmental, organizational, and leader-
ship factors respectively [13]. There is utility to focusing
deeply on one level of any given organizational phenom-
enon at a time. This study, however, seeks to reveal how
well different levels of units' ecologies affect the establish-
ment of new prevention and outreach services. Previous
research indicates that factors that may affect strategic
change include market conditions [14] and relationships
with other actors [15], organizational capabilities and
norms [16], and those of the individuals leading them
[17]. Thus, the current inquiry included local market con-
ditions and relationships with other organizations at the
environmental level; attributes of the units themselves;
and, finally, the attributes of administrative and clinical

Predictions about environmental factors
At the environmental level, two market and three inter-
organizational factors appeared potentially relevant to
additions of prevention and outreach services. The first
market factor expected to facilitate such additions was
local affluence, as resource availability often supports
more generous public goods (e.g., affluent areas have bet-
ter municipal services). The second potentially relevant
market factor was competition. Previous evidence from
hospitals indicates that competition encourages broader
service offerings [18,19]. This is consistent with the ten-

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Substance Abuse Treatment, Prevention, and Policy 2006, 1:21

dency for organizations to respond to environmental
pressures with strategies intended to reduce reliance on
any one source of income [20]. The question was whether
this would apply to service that generally cost money but
did not generate revenue. If organizations generally add
services to respond to competition in ways to diversify
their revenue base, treatment units facing greater compe-
tition might refrain from adding prevention and outreach.

Relationships with other organizations are another vital
element of unit environments. Two key types of external
partners are payers and parent organizations. For behavio-
ral health care providers, an increasingly important type
of payer is managed care. There is evidence that substance
abuse units involved with managed care reduce some
services [21], although there have not been similar find-
ings from other health care sectors [22,23]. Thus, no spe-
cific prediction was appropriate about the effect of
managed care on likelihood of adding prevention or out-
reach. Because of the now salient role of managed care in
behavioral health [24], however, this factor was included
in the predictive model.

Organizations may also be based in parent organizations
that affect their decisions about services. One major moti-
vation for diversification is to complement existing serv-
ices. Hospitals have generally not historically emphasized
prevention and outreach. Faced with increasing pressure
to become more prevention and community-oriented,
they may have encouraged units to add such services.
Conversely, units based in mental health centers might be
less likely to add prevention and outreach because these
services are generally part of the parent organizations'
existing portfolios.

The catch is that strategic theory assumes profit motiva-
tion, which does not apply to public goods such as pre-
vention and outreach services. Another potentially
applicable perspective is institutional theory [25]. Institu-
tional theory predicts that belief systems affect strategic
decisions, irrespective of their financial implications. The
result is an opposite set of predictions. In other words,
because hospitals are culturally oriented toward remedia-
tion rather than prevention, institutional theory implies
that their leadership would not emphasize prevention-
related outreach. Conversely, mental health center admin-
istrators, having a more public health ethos, would be
more supportive of adding prevention and outreach serv-

The evidence to date does not suggest such differential
predictions. Instead, it appears that inter-organizational
relationships are generally conducive to prevention activ-
ities. Previous research has found agency relationships
with other human service organizations to be positively

related to AIDS education for current clients [26] and hos-
pitals' network and alliance participation to be positively
associated with more prevention services [23]. On bal-
ance, however, because of limitations to the relevance of
strategic theory to public goods, the authors relied on
institutional theory rather than on empirical findings to
date. Thus, based on the assumption that key partners'
belief systems affect strategic decisions, the expectation
was that units based in hospitals would be less likely to
add prevention and outreach services and those based in
mental health clinics would be more likely to add these

These predictions can be summarized as follows:

H1. Substance abuse treatment units in higher income
areas will be more likely to add prevention and outreach

H2. Units whose directors perceive more competition will
be less likely to add prevention and outreach services.

[No prediction made about managed care, but included in
model due to relevance of payment mechanisms.]

H3. Hospital-based units will be less likely to add preven-
tion and outreach services.

H4. Units based in mental health centers will be more
likely to add prevention and outreach services.

Predictions about substance abuse treatment unit-level
The predictions outlined above have drawn on manage-
ment theories emphasizing organizations' relationships
with their environments. At the same time, however,
attributes of organizations themselves may affect what
strategies they pursue and how. In the context of decisions
about new service offerings, the financial structures, exist-
ing services, and community interfaces of the units them-
selves may also be relevant. Previous studies indicated
that for-profits would be less likely than other facilities to
add prevention or outreach [23], but did not support any
predictions about significantly different likelihood
between public and nonprofit facilities [27]. Previous
findings indicated that methadone units would be more
likely than others to add these services [27]. All the units
in the current study were outpatient, and thus drew on
local clientele. However, methadone units differ from
other treatment facilities in having more functional (phys-
iologically stabilized) clients who come in for longer peri-
ods of time. Thus, methadone units may have more
ongoing connections to their local communities through
their clientele and be more aware of prevention needs.

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Substance Abuse Treatment, Prevention, and Policy 2006, 1:21

Another unit-level factor expected to increase the likeli-
hood of new prevention and outreach services was partic-
ipation by volunteers, whose presence could both reflect
and enhance community orientation [28]. Finally, larger
and older units may be more likely to add prevention and
outreach services because they have more slack resources
to pursue public service [29] and more established com-
munity ties, although a previous study in substance abuse
treatment did not find age of unit to be associated with
more innovative treatment methods [30].

Predictions about unit-level factors may be summarized
as follows:

H5. For-profit units will be less likely than non-profit
units to add prevention and outreach services.

H6. Units providing methadone maintenance services
will be more likely than other units to provide prevention
and outreach services.

H7. The number of volunteer hours reported by units will
be positively associated with addition of prevention and
outreach services.

H8. Larger units will be more likely to add prevention and
outreach services.

H9. Older units will be more likely to add prevention and
outreach services.

Predictions about unit leadership factors
Organizations may face compelling environmental forces
and have distinctive collective features, but they are also
managed by individuals. The current study therefore also
sought to incorporate the attributes of unit leaders that
might affect decisions about prevention and outreach
services. Previous research indicates that individuals'
licensing has less of an effect than their university-based
education [30,31]. Perhaps there is a greater exposure to
distinct treatment philosophies in university programs.
People may also tend to earn degrees during a more
impressionable phase of their professional socialization
than non-university based training. Whichever the rea-
sons, this implies that formal education, but not licens-
ing, would predict additions of prevention-related
outreach as well. Because service decisions may emerge
from either the top administrator or front line supervisors,
these associations were tested for both unit directors and
clinical supervisors.

This leads to the last hypothesis:

H10. Unit-level leaders' advanced education, but not
licensing, will be associated with increased likelihood of
adding prevention and outreach services.

Thus, previous theory and evidence suggest that factors at
a variety of levels might affect the likelihood that sub-
stance abuse treatment units would add prevention and
outreach services. Given the prevalence of at least mini-
mal such programming, however, the question driving the
current inquiry was: What factors make it more likely that
units will add new community prevention, education, and
outreach services? These analyses were conducted in the
context of a longitudinal survey of outpatient substance
abuse treatment units throughout the United States.

The data used for this study were from a national sample
of outpatient substance abuse treatment units surveyed in
1995 and again in 1999/2000 as part of the National Drug
Abuse Treatment System Survey [32]. The National Drug
Abuse Treatment System Survey is a longitudinal program
of research into the organizational structure, operating
characteristics, and treatment modalities of outpatient
substance abuse treatment units in the United States [33],
defined in this survey as physical facilities devoting at least
50% of their resources to treating individuals with sub-
stance abuse problems (including alcohol and other
drugs) on a non-residential basis. As incorporated in these
analyses, a treatment unit could be either self-standing or
part of a larger organization, such as a mental health
center or hospital. The sampling frame is the Institute for
Social Research's well-maintained list of the nation's out-
patient substance abuse treatment units [32,34]. The Uni-
versity of Michigan's institutional review board has
approved all processes involved in this research program.
This survey has been conducted again after 2000, but due
to respondent burden concerns did not include questions
about new services. Thus, the data used here are the most
recent available.

Sample stratification by public/private status, treatment
modality (methadone or non-methadone) and organiza-
tional affiliations yielded generality to all major types of
outpatient substance abuse treatment units in the US in
1995, with the exception of hospital-based units; these
were excluded because none added prevention or out-
reach services during the study period (thus, hospital affil-
iation perfectly predicted the outcome and could not be
retained in the multiple regression model). Research staff
pilot tested instruments and built probes and follow-up
questions into the interview protocols to enhance validity
and reliability of the data. Survey staff interviewed the
director and clinical supervisor of each participating unit
separately, asking each about his or her areas of greatest

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Substance Abuse Treatment, Prevention, and Policy 2006, 1:21

expertise (for instance, they asked directors about new
service additions and asked clinical supervisors about cur-
rent services).

After screening and non-response, the total number of
organizations completing interviews in 1995 was 618, for
a combined response rate of 86%. A similar sampling
process in 1999/2000 resulted in 745 organizations com-
pleting interviews for a response rate of 89%. 489 organi-
zations were present in both 1995 and 1999/2000. After
listwise deletion, the final sample size was 450. Because
only those organizations that completed surveys in both
1995 and 1999/2000 were included, the analysis sample
is not nationally representative to the extent that changes
in the population of treatment providers that occurred
after 1995 are not reflected in the data. However, the
lagged panel design allows stronger attribution about
causal relationships.

The dependent variable identifies those units that added
general or AIDS-related education, prevention, or out-
reach to the community between 1995 and 1999/2000.
Each organization's director provided this information in
response to forced choice prompts specifically concerning
additions of: (1) "community education prevention, and
outreach," classified as substance-abuse related (n = 19);
(2) "community: AIDS education, information," classi-
fled as substance-abuse related (n = 3); (3) "community
service: education, prevention, or outreach," classified as
non-substance abuse related (n = 18); and (4) "commu-
nity service: AIDS education, information," classified as
non- substance abuse related (n = 5). For purposes of the
current analysis, a composite variable for community pre-
vention and outreach = 1 if the director responded affirm-
atively concerning the addition of any one of these four
options. Conceptually, this made it possible to examine a
set of prevention and outreach activities addressing highly
inter-related risky behaviors. Empirically, because addi-
tions of HIV-AIDS prevention activities were so rare, it was
necessary to combine responses about that domain with a
broader response category to have sufficient statistical
power to detect associations with possible predictors.

The initial multiple regression model included two meas-
ures of the unit's local market (per capital income and
overall perceived competition [alpha = .83 for a five item
scale]); three measures reflecting ties to other organiza-
tions (the presence of managed care contracts, being
based in a hospital, and being based in a mental health
center); and six organizational attributes (private for-
profit or public ownership versus private not-for-profit
status; methadone status; number of volunteer hours;
number of clients; and facility age). All the units in the
sample already provided some level of community educa-

tion, outreach, or prevention services in 1995. Thus,
although previous related programming would have been
a relevant predictor, because there was no variation it was
excluded from the model. Finally, four measures reflected
characteristics of the unit's leadership (substance abuse
treatment licenses held by director and clinical supervisor,
director graduate degree, and clinical supervisor graduate
degree). Each measure is described in greater detail in
Table 1.

A multiple logistic model estimated associations between
each predictive factor and the likelihood of adding general
or AIDS education, prevention or outreach services to the
community between 1995 and 1999/2000. Stratification
variables (methadone status, hospital affiliation, mental
health center affiliation, and for-profit ownership)
accounted for probability of entry into the study and for
non-response [32,34].

Descriptive results
Table 2 lists summary descriptive statistics for new preven-
tion, education, and outreach services between 1995 and
1999/2000 as well as predictors from 1995. In 1999/2000
7% of facility directors reported having added new pre-
vention-related services during the previous 5 years.

Environmental factors
Results of the final regression model are shown in Table 3.
All else being equal, for every $1,000 increase in county
per capital income, treatment units had 5% higher odds of
adding prevention and outreach services, relative to not
adding such services. Given an $8,900 difference between
per capital incomes at the 25th and 75th percentiles, respec-
tively ($19,170 vs. $27,070) during the study period, this
translated into 44% greater odds of prevention-related
service additions for units in counties at the higher level of
income. Relationships with both payers and parent organ-
izations were associated with prevention-related educa-
tion and outreach services. Units with managed care
contracts had only 42% of the odds of adding these serv-
ices as units without managed care contracts. No hospital-
affiliated treatment units added prevention or outreach
services during the study period. This factor was thus
omitted from the final model due to perfect prediction. In
contrast, units affiliated with mental health centers were
more likely as other units to add these services.

Unit-level factors
Two of the six unit-level factors examined were associated
with the likelihood of adding prevention-related educa-
tion and outreach. The type of facility ownership was
unrelated to the service additions examined. Contrary to
expectations, methadone units had on average only about

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Table I: Description of study measures


Source/Response Options

New education, prevention or outreach

Per capital income


Managed care contracts)
Hospital affiliation

Mental health center affiliation

Private for-profit ownership

Public ownership


Previous community education or outreach
Volunteer hours (log transformed)

Number of clients (log transformed)

Unit age

Director substance abuse treatment license
Supervisor substance abuse treatment license

Director graduate degree
Supervisor graduate degree

Units adding general or AIDS education,
prevention, or community outreach services
between 1995 and 1999/2000
Per capital income of county where unit is
Degree of competition as perceived by the
director (a = .83)
Unit has one or managed care arrangements
Unit is part of a hospital

Unit is part of a mental health center

Unit ownership or control status is private, for-
Unit ownership or control status is public

Unit provides methadone treatment services to
Unit provided community education, outreach,
or prevention services in 1995
Number of volunteer hours in the most recent
complete fiscal year
Total number of clients in most recent
complete fiscal year
Years of unit substance abuse treatment
Director holds at least one professional license
Clinical supervisor holds at least one
professional license
Director has a degree beyond a bachelors
Director has a degree beyond a bachelors

Director (Yes= I)

Area Resource File


Director (Yes = I)
Director (Yes = I, referent group includes
freestanding units or those with "other"
Director (Yes = I, referent group includes
freestanding units or those with "other"
Director (Yes = I, referent group is private
nonprofit units)
Director (Yes = I, referent group private for-
profit units)
Director (Yes= I)

Clinical Supervisor (Yes = I)

Clinical Supervisor



Director (Yes = I)
Clinical supervisor (Yes = I)

Director (Yes = I)
Clinical supervisor (Yes = I)

one-fifth the odds of adding prevention-related education
and outreach as non-methadone units. The number of
volunteer hours was unrelated to likelihood of adding
prevention and outreach services.

Unit leadership
Previous research had suggested that leaders' licences
would be unrelated to the likelihood of adding new serv-
ices, but that university degrees would predict these addi-
tions. In keeping with the first expectation, there was no
association between director or supervisor substance
abuse treatment licenses and additions of prevention and
outreach. Although, contrary to second prediction, units
whose directors had graduate degrees were on average had
only about a third the odds of other units of adding new
prevention and outreach, this was not statistically signifi-
cant at alpha = 0.05. In keeping with this latter prediction,
however, units whose clinical supervisors had graduate
degrees had odds over four times greater than those of
otherwise comparable units to add these services.

This investigation began with an interest in what factors
might prompt substance abuse treatment units to add pre-
vention and outreach services. Such facilities are logical
players in the prevention of risky behaviors. In keeping
with an ecological perspective on organizational strategy,
the overall expectation was that factors across multiple
levels would affect the likelihood that units would offer
new outreach and prevention services. Findings supported
this expectation, with support for one or more predictors
for each level (environmental, unit level, and unit leader-

As predicted, findings indicate that substance abuse treat-
ment units in more affluent communities were more
likely to add prevention-related education and outreach
during the study period. Risky substance use and sexual
behaviors know no class boundaries. There is arguably no
community that does not need prevention-related educa-
tion. However, behavioral health problems often affect
low income areas even more than high income areas [35-
38]. Thus, it is unfortunate, if unsurprising, to find an

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Substance Abuse Treatment, Prevention, and Policy 2006, 1:21

Table 2: Descriptive Statistics

Variable Mean Minimum Maximum SD

New education, prevention, or outreach services initiated 0.07 0.00 1.00 0.26
Per capital income (in $000) 24.12 11.49 58.10 7.86
Competition 25.09 5.00 46.00 8.42
Managed care (2) 0.71 0.00 1.00 0.45
Hospital-based (3) 0.15 0.00 1.00 0.36
Mental health center-based (3) 0.23 0.00 1.00 0.42
Private for-profit (4) 0.12 0.00 1.00 0.32
Public (4) 0.27 0.00 1.00 0.44
Methadone facility (2) 0.24 0.00 1.00 0.42
Prior education/outreach (2) 1.00 1.00 1.00 0.00
Volunteer hours (log transformed) 2.32 0.00 9.21 3.02
Number of clients (log transformed) 6.08 3.26 9.21 1.02
Unit age 16.54 0.00 40.00 8.00
Director license (2) 0.51 0.00 1.00 0.50
Supervisor license (2) 0.59 0.00 1.00 0.49
Director graduate degree (2) 0.70 0.00 1.00 0.46
Supervisor graduate degree (2) 0.69 0.00 1.00 0.46

(1) N = 450 treatment units
(2) Yes = I
(3) Yes = I; other or no affiliation is referent category
(4) Yes = I; private not-for-profit is referent category

Table 3: Results of Logistic Regression: Factors Predicting Substance Abuse Treatment Units' Additions of New Outreach and
Prevention Services (I)

Odds Ratio Std Err P > Z 95% Confidence Interval


Per capital income 1.050 0.024 0.032 1.004 1.099
Competition 0.961 0.024 0.112 0.916- 1.009
Managed care (2) 0.421 0.178 0.041 0.183 -0.965
Mental health center affiliation (3) 3.131 1.430 0.012 1.279 7.664

Private for-profit ownership (4) 0.280 0.303 0.240 0.034 2.335
Public ownership (4) 0.477 0.237 0.137 0.180 1.265
Methadone (2) 0.179 0.129 0.017 0.044 0.733
Volunteer hours 1.040 0.070 0.557 0.912 1.186
Number of clients 0.767 0.161 0.206 0.508 1.158
Unit age 1.015 0.026 0.571 0.964 1.068

Unit leadership
Sub abuse treatment license (director) (2) 0.895 0.430 0.818 0.349 2.295
Sub abuse treatment license (supervisor) (2) 0.830 0.401 0.700 0.322 2.138
Director advanced education (2) 0.347 0.188 0.051 0.120 1.006
Supervisor advanced education (2) 4.476 2.845 0.018 1.288 15.559
Pseudo R-squared statistic: 0.158

(1) N = 450 treatment units
(2) Yes = I
(3) Yes = I; other or no affiliation is referent category
(4) Yes = I; private not-for-profit is referent category
p < 0.05

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Substance Abuse Treatment, Prevention, and Policy 2006, 1:21

association between community resource abundance and
service additions in this vital area. Those funding preven-
tion-related outreach and education may want to specifi-
cally focus on lower income populations.

The fact that managed care contracts were negatively asso-
ciated with the likelihood of adding prevention and out-
reach services may indicate that this type of financing
discourages prevention-related programs. This suggests
that regions with very high managed care penetration may
be particularly likely to have inadequate prevention and
outreach, although future research may reveal that differ-
ent types of managed care arrangements have varying
effects. To the extent that substance abuse treatment is
publicly funded, however, legislators may be able to
change this effect by requiring that payment for health
education and outreach be included in managed care con-
tracts. For instance, the majority of states now use man-
aged care to pay for Medicaid-funded substance abuse
treatment [24]. Medicaid managed care contracts may
therefore be a logical mechanism for supporting increased
prevention and outreach programming. Altering Medicaid
managed care contracts would also address the recom-
mendation made above to focus prevention-related fund-
ing on lower income populations.

Institutional theory had suggested that substance abuse
treatment units based in hospitals would be less likely to
add prevention and outreach because such additions
would be inconsistent with hospitals' remediative and
individual patient orientation. The same perspective sug-
gested that mental health center-based units would be
more likely to add new prevention and outreach because
prevention has traditionally been salient in mental health
care. Findings from the current study supported these pre-
dictions. No hospital-based units added prevention or
outreach services during the study period. In contrast,
mental health center-based units were more likely than
other facilities to add these services. These findings are
congruent institutional theory's emphasis on culture and
belief systems. Another possibility, however, is that some
hospitals are not set up to receive grants supporting pre-
vention and outreach. To the extent that such financial
structures rather than hospital cultures are the main bar-
rier, units may be able to increase prevention and out-
reach if funds are earmarked through managed care

Hospital leaders may benefit their communities by con-
sidering local needs for prevention services and looking
for new ways to address those. If institutional theory does
apply, this case will need to be made in a manner consist-
ent with the more business oriented culture of hospitals.
A business case could be made for prevention and out-
reach on the basis that they improve the hospital's visibil-

ity in its local market and/or because philanthropic or
public funding could support their costs.

Previous evidence indicated that methadone units would
be more likely to add prevention-related services. Instead,
in this sample they were less likely than other types of
units to add these services. The a priori logic was that
methadone units' higher functioning, long-term clients
might foster greater awareness of local prevention needs.
Although data available for this study do permit in-depth
examination of this issue, methadone units differ from
other types of substance abuse treatment facilities in a
range of factors that may affect prevention programming.
Methadone units have distinct types of services, clients,
payment mechanisms [39], and legal oversight [40]. It is
possible, for instance, that their revenue streams are
restricted in ways that preclude prevention-related pro-
gram additions.

The facts that all units in the sample were already offering
some kind of community services, yet only 7% added any
new services in this area during the study period, are
themselves worth noting. It is possible that substance
abuse treatment units feel a normative pressure to do
something about community outreach but not too
much. Future research should investigate the extent and
impact of community outreach and education services by
a variety of health care providers as well as what factors
prompt varying levels of such services.

Regardless of environmental and organizational factors,
leaders exercise discretion about what services to offer.
This is particularly applicable to public goods that typi-
cally enhance mission accomplishment but may under-
mine financial margin. Directors may decide to launch
new prevention and outreach initiatives; supervisors may
tacitly expand unit strategy by sending staff to community
health fairs and similar events to promote healthy behav-
iors. This study acknowledged the possibility that such
service additions could therefore reflect both director and
supervisor influence.

As expected on the basis of previous literature, facility
director and supervisor licensing in substance abuse treat-
ment were unrelated to additions of new prevention-
related services during the study period. The mixed effects
of graduate degrees in the current sample suggest that
facility leadership's university education may affect their
inclination to provide public goods. In the current sam-
ple, the majority of both directors and clinical supervisors
had graduate degrees in counselling, education, or social
work (44% of directors and 48% of supervisors) and the
most common single type of degree was in psychology
(35% of directors and 38% of supervisors). However,
unsurprisingly, directors were 50% more likely to have

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Substance Abuse Treatment, Prevention, and Policy 2006, 1:21

administrative degrees than supervisors (12% versus 8%)
and twice as likely to have earned those degrees in busi-
ness administrative programs (8% versus 4%). Supervi-
sors were slightly more likely than directors to have
graduate degrees in counselling (19% versus 16%) and
psychology (38% versus 35%).

It is possible that business administration programs
emphasize financial efficiency norms while other types of
graduate degree programs (e.g., counselling and psychol-
ogy) promote a more holistic perspective on organiza-
tional performance including more emphasis on societal
goals. Public funding may be used to encourage graduate
education that supports a more holistic view of agencies
within their broader social contexts. This may become
increasingly important if more leaders in health and
human service earn business administration degrees.

Limitations and future research
The current study had limitations that suggest the need for
complementary research on this under-examined topic.
Empirically, the large number of associations tested
makes it very likely that at least one of the findings from
this study would not be replicated in another similar sam-
ple (i.e., was a Type I error). This suggests treating results
from these analyses with caution and looking at patterns
across studies before drawing strong conclusions. In gen-
eral, benefits of breadth of necessity occurred at the
expense of depth (due primarily to concerns about
respondent burden from director and supervisor inter-
views). Future research should probe more fully the
potential leverage points identified in this study. For
instance, what kinds of payment structures, if any, are pos-
itively associated with more additions of prevention and
outreach services? What kinds of graduate training
enhancements affect attitudes toward public goods such
as prevention, and do such attitudes actually translate into
strategic behavior? Both questions suggest pre-post exper-
imental studies with longitudinal follow-up. For instance,
some states could add a prevention component to Medic-
aid managed care payments for substance abuse treatment
(potentially with varying levels, to identify the thresholds
at which impact increases), allowing for comparison with
units in non-intervention states over time. Similarly, a
foundation could enroll management graduate programs
in a matched study design tracing effects of specific mod-
ules on student attitudes. It could even be feasible to track
differences in subsequent actions of program graduates
using self-report data.

These or other studies might also address another limita-
tion of the current investigation, which was the dichoto-
mous nature of both some key predictors (i.e., the pre-
existence of prevention-related services and presence of
managed care contracts) and the outcome measure in the

current study. Better measures of existing commitment to
prevention services could include the number of staff
members and annual expenditures devoted to these activ-
ities. Measures of new prevention and outreach should
include not only levels of resource commitment but also
whether or not they are truly evidence based. Use of such
measures, combined with longitudinal designs, could
facilitate identification of causal sequences that would
inform more operationally specific policy recommenda-
tions. The authors do not, however, believe that such
investigations would yield policy recommendations dif-
fering from those from this study's. For instance, it is pos-
sible that units that are more reliant on managed care
have lower pre-existing commitments to prevention and
outreach than other units, but it is not likely that the asso-
ciation found here between managed care and new pre-
vention-related services was causally attributable to the
(unmeasured) level of current services. Concerning the
other major policy lever identified in this study, leader-
ship graduate education, it is not plausible that levels of
prevention programming affected leaders' education.
Thus, more refined measurement is likely to complement
rather than contradict conclusions presented here.

The personal, social, and economic effects of substance
abuse are staggering. There are compelling moral and eco-
nomic reasons to make a far greater public investment in
prevention-related education and outreach than currently
exists. At this point, however, investment lags far behind
rhetoric, and current US fiscal trends bode badly for the
immediate future of this field. It is thus important to
understand what encourages health care providers to add
such vital services in the absence of adequate reimburse-
ment. The current analyses indicate that there are leverage
points for encouragement of additional prevention and
outreach services. Most notably, the structure of managed
care contracts and some types of graduate degree pro-
grams for facility leadership may encourage more such
services. In all of these cases, relatively modest invest-
ments of public funds may facilitate services with great
importance to individual and societal health.

Competing interests
The authors) declare that they have no competing inter-

Authors' contributions
RW conceived and conducted the analyses and drafted the
background section. CHL provided input into the analy-
ses and drafted the methods and results sections. TD
designed the study from which the data derive, provided
input into the analyses, and contributed to the discussion
section. All authors read and approved the final manu-

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Substance Abuse Treatment, Prevention, and Policy 2006, 1:21

This research was supported by grants 5R01-DA03272 and 5R01-
DA087231 from The National Institute on Drug Abuse. The authors would
also like to thank the SATPP peer reviewers for their very thoughtful and
constructive comments.

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