"New Choices" for women with addictions: perceptions of program participants

Background Substance use in pregnancy is a major public health problem. It can have profound effects on pregnancy outcomes, and childhood health and development. Additionally, women who use substances have their own health-related issues. Although intervention is important, these women often have difficulty using traditional systems of care. The New Choices program is a centralized, multi-sector approach to service delivery that has attempted to overcome barriers to care by offering one-stop shopping in a supportive environment. As part of an evaluation of this program designed for women who are pregnant and/or parenting young children, interviews were conducted with participants to gain insight into their experiences in New Choices and perceptions of any changes attributed to program involvement. Methods A qualitative, exploratory design was used to guide data collection and analysis. Four women participated in a focus group interview and seven women agreed to individual interviews over the course of the program evaluation (N = 11). A semi-structured interview guide was used to explore women's experiences in New Choices and their perceptions of the program and its impact. The interview data were analyzed using NVivo software and an inductive approach to data analysis. Results The emergent themes captured women's motivations for attending New Choices, benefits of participation, and overall quality of the program. Children were the primary motivating factor for program enrollment. Perceived benefits included decreased substance use, improved maternal health, enhanced opportunity for employment, increased access to other resources, enhanced parenting skills, and improved child behaviour and development. Women highly valued the comprehensive and centralized approach to service delivery that provided a range of informal and formal supports. Conclusions Interview findings endorse the appropriateness and potential efficacy of a collaborative, centralized approach to service provision for women with substance use issues. Although the findings provide insight into an alternative model of service delivery for women with addictions, future research is needed to evaluate the effectiveness of the intervention. Research also is needed to determine which program components or constellation of components contribute to desired outcomes, and to learn more about processes that underlie changes in behaviour.


Background
Substance use in pregnancy is a major public health problem. Measuring prevalence of substance abuse in pregnant women is problematic because it can involve single or multiple substances, including alcohol, prescription and over-the-counter medications, and illegal drugs such as cocaine, marijuana, heroin, and barbiturates [1][2][3]. Additionally, self-reported substance use underestimates the extent of the problem and urine toxicology screens are only selectively administered [4]. Estimates of the percentage of women who use substances or have substance dependency during pregnancy vary, but are in the range of 5 to 20% [2,5].
Maternal use of alcohol and other drugs can have profound effects on pregnancy outcomes as well as on childhood health and development. Although the findings are inconclusive, substance use has been found to be associated with low birth weight and premature delivery [3,5]. It also can lead to neonatal abstinence syndrome or withdrawal syndrome, with 55 to 94% of neonates exposed to opiates in utero developing signs of withdrawal [6]. Other negative health consequences of maternal substance use during pregnancy include respiratory distress or depression in the newborn infant, infection, physical deformities, and compromised neurobehavioral progress after birth [7,8]. Children born to women who used substances during pregnancy are at greater risk for impaired physical growth and development, behavioural problems, and learning disabilities [9][10][11][12][13][14][15].
Women who use substances have their own health-related issues. Frequently substance abuse coexists with mental health problems and a history of physical and/or sexual abuse [2,3,16,17]. Moreover, these women commonly have special medical needs, poor nutrition, inadequate housing, relationship problems, and lack meaningful social support, education, and employment skills [7,[18][19][20]. Substance abusing women also are likely to be involved with the court system and child protection services [19]. Women who continue to use substances after childbirth often have limited capacity for parenting and are unable to provide a stable, nurturing environment for their children [21,22]. Substance abuse has been associated with child neglect and abuse [23,24].
Although intervention can benefit women, their offspring, families, communities, and society as a whole, women with substance use issues have difficulty using traditional systems of care [2]. Services are not accessed for a number of reasons: fear of losing custody of children; fear of forced treatment or criminal prosecution; lack of treatment readiness; coexisting mental illness; guilt, denial and/or embarrassment regarding their substance use; and lack of transportation and/or child care [2,18,25]. System-related issues also present barriers to care. Negative attitudes of health care providers and responses that stigmatize women can deter them from receiving prenatal care [20,26,27]. In addition, traditionally there have been separate service delivery systems for prenatal care and substance abuse treatment rather than a collaborative approach that offers a continuum of care to meet women's complex needs. Health care workers might lack not only the knowledge and skill to identify substance abuse, but also familiarity with available resources and therapeutic management; workers in substance abuse treatment are unlikely to have the capacity to adequately address needs specific to pregnant women [2,25].
The importance of comprehensive, coordinated, and individualized service provided by an interdisciplinary team of professional who are supportive, nonjudgmental, and nurturing has been widely acknowledged [2,3,7]. The New Choices program is an example of a centralized, multi-sector approach to service delivery in a large urban centre in Ontario, Canada, that offers one-stop shopping for women with substance use issues who are pregnant and/or parenting young children. The program components include addiction groups and counselling, nutrition counselling and skill development, parenting education, peer support, and an enriched children's program. In addition, it provides linkages with prenatal services, a family physician, a perinatal home visiting program, and other services as appropriate. The program is individualized in that women are assisted in defining their needs and goals as well as in designing their own program for change. Therefore the program is not set in terms of a specific structure or length of time. Attendance at New Choices has ranged from 1 to 12 months, with the average length of involvement being 4 months. Sometimes clients will be involved for a few months, leave, and then return to the program at a later date. The long-term objective of New Choices is to improve the health and well being of women and their children by providing a flexible program that offers information, support, treatment, and advocacy services in a safe, welcoming environment. This latter feature has been deemed essential to the process of change for women with addictions [7].
An evaluation of the New Choices program used valid and reliable measurement tools to assess substance use, social support, mental health, nutrition, parenting ability, and child development upon entry into the program, and at 3 months and 6 months thereafter. Interviews also were conducted with women to obtain a more in-depth account of their experiences in New Choices and their perceptions of any changes that could be attributed to program involvement. The findings of these interviews are reported in this article.

Methods
A qualitative, exploratory design was used to guide data collection and analysis. All women who participated in New Choices for a minimum of 3 months during the program evaluation period were invited to participate in interviews. Four women participated in a focus group interview and seven women agreed to individual interviews (N = 11). The focus group was conducted with women who had attended New Choices during the previous year. The intent then was to individually interview all seven women who were new to the program at 3 months, 6 months, and 12 months post program entry. However, it was not always possible to reach women for the followup interviews. Two participants were interviewed three times, four participants were interviewed twice, and one participant was interviewed once. Therefore, a total of 15 individual interviews were conducted.
A research assistant conducted the interviews, which were audio taped and later transcribed. A semi-structured interview guide was used to explore women's experiences in the New Choices program. The researchers discussed and identified the most important issues to be included in this guide given the objectives of the program. In the focus group and in the initial individual interviews, women were asked to comment on: personal goals upon entering the program and progress towards achievement of these goals; impact of the program on the women's lives, their children's lives, and access to services; and, general perceptions of New Choices including service delivery characteristics. The research assistant used follow-up questions or probes that were conversational in nature to encourage the provision of rich information within each of these broad areas of exploration [28]. With the exception of personal goals upon program entry, the same issues were explored in all subsequent individual interviews. The interview guide allowed for similar and comprehensive data to be gathered from all participants [28]. It also allowed for issues most relevant or significant to a particular participant to be pursued in greater depth.
The interview data were analyzed using NVivo software and an inductive approach to data analysis. Two members of the research team independently coded the interviews. Initially open coding was done in which each meaningful segment of the interview transcripts was coded using the exact words of the participants or a term that connoted those words [29]. These open codes were descriptive in nature (e.g., child "came out of his shell", learned to share). The researchers looked for similarities in the data and assigned the same code to data that had some common characteristic [29]. The analysis proceeded to pattern or thematic coding in which the descriptive codes were clustered into groups of related conceptual codes or themes (e.g., positive effect on child's social develop-ment). Finally, the researchers met to compare and discuss coding schemes and reached consensus on the emergent themes.

Participants
Participants ranged in age from 21 to 36 years when they entered New Choices. Fifty-four percent of the women were married or living common-law, 85% were receiving social assistance, and 25% were involved with the criminal court system. About two-thirds (69%) had children who were not living with them, 58% were involved in the family court system, and 69% were involved with a child protection agency. Reported substance use upon program entry was as follows: nicotine 92%, alcohol 67%, marijuana 50%, crack 33%, cocaine 25%, tranquillisers 17%, and barbiturates 17%. The children in the program ranged in age from newborn to 6 years. The women, on average, attended New Choices 20 out of the 24 days the program was offered in each 3-month period.

Findings
The themes captured women's motivations for attending New Choices, the ways in which participation in New Choices had changed their lives and their children's lives, and their perceptions about the quality of the program.

Motivation to participate in New Choices
Almost all of the women interviewed acknowledged that their children were the primary motivation to participate in New Choices. Many women with addiction issues lose custody of their children or do not have their children living with them. When asked about her reasons for attending New Choices, one woman said, "It was the point of staying clean from cocaine, getting my children back." Another participant remarked, "The biggest motivation is that I'm going to keep my kids and I'm going to keep my sanity. Those two good things and then I can just pretty much conquer the world."

Impact on women
All of the women interviewed noted the positive impact New Choices had had on their lives. These effects were consistently described as decreased substance use; enhanced mental, social and physical health; improved parenting skills and knowledge; increased opportunity for employment; and increased awareness of and access to other services in the community.

Substance use
Almost all women commented that coming to New Choices helped them to stop or decrease use of drugs and/ or alcohol and to resist the urge to relapse. One woman remarked:

I'm a bit smarter now because when I see people who are walking around high on crack, I won't bullshit, I do itch for it especially when I get upset. It makes me smarter because I can see it now. Before I couldn't. I couldn't identify. Now I can. It's just a matter of staying at that point when I'm strong enough not to do it anymore.
Change in substance use was attributed, in part, to "selfdiscovery" and learning strategies to reduce use: ... substance abuse has been around my whole life. We have to try and have an understanding and to know why you're doing things that you're doing and maybe it gives you a chance to rethink it and maybe something else that would help to deal with the situation. Like you can cover it up but it's not going to solve your underlying problem. So like there's a lot of self-discovery, things that I really like.

Well, I don't think it's a problem that you can just solve, it's an ongoing thing, but it [New Choices] gives you much ... you're much better prepared to deal with it and you can understand yourself a lot better. So I think once you have those tools you have a much better chance of not falling into the same trap.
Hearing other women's stories in the addictions group sometimes served as a reminder of the impact of addiction:

Yeah, just go in and see what happens to people when they don't [stop] is reason enough to. You see the problems that it causes in people's lives ... So you can just see how damaging it can be if you let it get out of hand, that it can really be devastating to the family.
Listening to others also gave women encouragement and a sense of hope because "you see the other girls step-by-step improving their lives." One participant stated, "The one that's talking, going through the exact same thing. Seeing her put her life back together and achieve so much, yeah, it just gives you the willpower knowing that it can be done." Women valued the peer support they received in the addiction group: Most of the girls like it when they're going to the group and they're going for the addiction group and they're sitting with a bunch of other women. They need the support of the other women, not just the counsellors. They want the support of other people. They want to see someone that's going through it, they want to see how they're advancing, they want to get that motivation to advance themselves as well.
And coming here on that Tuesday, it just made me realize hearing other people say to me that that wasn't healthy, that I had to change something. And when I told them I knew that I had to change something, they came out and said, "If you're sure you need to change something this is how you can get help." Other than that I would've gone home and just taken it, dealt with my day.

Mental, social and physical health
During the interviews, participants explained how New Choices had impacted positively on their health. One of the goals of the program is to empower individuals to make healthy choices, and many of the women commented on their increased sense of control: "And that's the main thing of becoming clean is getting control of your life, and I have control and that's all that matters to me. I control my future and my destiny." Another participant vividly described her sense of control as follows: I used to have anxiety attacks, but I've worked through those by just convincing myself that nothing is going to overpower me, no drugs, no man, no nothing is going to overpower me but me.

So only I can control me and my thoughts and my feelings. Me doesn't want to do those drugs anymore.
The validation and positive reinforcement women received through New Choices raised self-esteem: "It's almost embarrassing, I feel too important sometimes. They make you feel really good about yourself. That's good." Another woman remarked, "I don't feel like a low-life when I come in here and that's what I meant before is that they treat me like a real person in here. They don't treat me like, oh, you're a drug addict." The following comment illustrates the process of self-esteem enhancement experienced by some women: In addition to improving emotional well being, New Choices provided opportunities for enhanced social health. Women commented favourably on the support they received through the program. For example, a participant stated: Actually, most of the girls get along really, really good. I was actually surprised. I thought they were all going to be some evil women but no, they were really nice, they were really helpful, they listened great. They were always there to hand out their advice. They're always sharing their stories. All  New Choices also contributed to enhanced physical health in that participants concurred that the program provided useful information on nutrition and highlighted its importance. Women commented, "They teach you how to do cooking or meal ideas, things like that" and "I liked the nutrition and I liked the budgeting. I found that to be probably the most practical information that I was getting." Another woman noted, "Nutrition is the key for me, it's definitely key for getting healthy myself so that I could overcome my addictions."

Parenting
Women who were interviewed agreed that they gained knowledge about parenting and learned new parenting skills. Some women were more resistant to the parenting program than others: "About the fact of the parenting thing, that's the one thing I had a problem with is people telling me how to be a parent ... and I don't believe in textbook parenting." However, most of the comments about the program were positive. One woman said:

Access to other services
Many participants reflected on their increased access to other services through involvement in New Choices. One woman reported that this enhanced access was one of the things that attracted her to New Choices:

Another participant said:
They helped me with a lot of other services as well, like I was given an opportunity to speak to many different professionals from all different agencies and stuff like that, and psychiatrists. That was a good experience to be able to talk to him. And just provided me with a lot of different services here like CPR, you know.
Women identified a number of other services made accessible to them:

Impact on children
The women observed that New Choices had had a positive effect on their children's behaviour and development, including improvements in motor skills, social skills, and language skills. In discussing changes she had noted in her child's behaviour, one woman said, "Like before, well, yeah, it was a discipline because before he was having problems hitting everyone, and now he's totally out of that where he ... I don't have to get mad at him. He's just been so good." Another participant commented, "It's given [

child's name] an opportunity to express his feelings in different ways to cope when he's angry. And to be around with other children who have been through similar things like he has."
When asked about how her child benefited from participation in the children's program, one woman reported, "His fine motor skills, definitely." Another participant remarked, "Oh I love it. I think it's great. I think it teaches a lot of kids motor skills which [child's name] was really lacking of." Comments on children's social skills development included the following: "Oh she's very social. Like before she would shy from people" and: My kids enjoy it. They like the playtime. They like the people that are involved around them. They've learned how to share more being here because there's a lot of kids here. I think it's a growing experience for them as well.
Some women noticed improvements in their children's language and speech: "I think he can express himself more which is good" and "Like I said she uses her words a lot more now ... She's more expressive." Enhanced language and speech development was sometimes attributed to linkages with appropriate services:

Quality of the program
Every woman who was interviewed commented that participating in New Choices had been a positive and meaningful experience. One participant remarked, "Well, it was a positive, like you said, it was a positive experience for me while I was here and I'm ready to move on now." Another woman said,

Staff
Most respondents agreed that staff members in New Choices were very supportive. One woman described how she was assisted through a difficult period in her life:

Another comment was, "They've been very supportive of all of the choices and the decisions that I've made."
Although women generally felt supported, some participants were concerned about confidentiality in relation to reporting harm or the potential for harm to a child to child protection services. One women said, "I don't tell them [staff] too much about that. They'll call the Children's Aid and stuff like that." Another participant stated:

The one thing that I would probably say could be improved was the confidentiality between what people disclose and what the counsellors need to report to the Children's Aid. I feel if they report everything no one is going to be able to say what's really going on and then really they're not going to benefit from the program if they're afraid to open up and say what they're really thinking. So I think that could be kind of harmful.
Some women were not in agreement with the obligation to report, as suggested by the following comment: Well, I was told that if anybody reports any drug or alcohol, you must report it to Children's Aid immediately and I don't think that's good because it's an addictions group, so if you think you want to have some you should be able to talk through it with somebody and maybe they can give you some support instead of being worried about saying, "What's really going on?" and have to deal with it on your own.

Program components
The comprehensive nature of the program was an important feature to clients: The thing I like about New Choices is it doesn't just focus around the person who has the addiction, but you also focus around, ok, what's going on in your life to make you do this, how is your family reacting to this, do you have children, who's taking care of your children during this time. All of these things come up. And they also help them focus on dealing with your children because they're growing up with an addictive lifestyle. So they help you to deal with them and learn how to take care of them throughout this period.
One of the features of New Choices is the provision of bus tickets, food vouchers, and clothing. Women expressed appreciation for these items as follows: "Well, yeah, they also give you bus tickets and food vouchers. I find it helpful. If you're down and out and you need to buy the milk, you've got your food voucher, you can get a bag of milk" and "Yeah, donations, I found that very helpful. I got a lot of good clothes for the kids and myself. So it is resourceful, and I mean I bring things in myself for the donations program." In spite of the generally positive comments about the addictions group, there were differing opinions about the group size and structure. Some women expressed preference for a smaller group of "three or four, then that leaves enough room for you to discuss things and get feedback, to have your space for validity because a lot of the time you need to be validated." It also was mentioned that women's different stages of recovery sometimes made it difficult to relate to and share with others: "...on the negative side, everybody has a different stage. There are some people who are just coming off the street and then there's somebody that's been clean for a year." The women highly valued the children's program and described how their children enjoyed participating in it: The first couple of times she was like not very sure of it [the children's group]. She didn't know and maybe some of the kids were a bit rough or whatever. But she got a good grip of it and went with it. Yeah, she loves it. She looks forward to group. She asks me almost every day, mommy, is today group day? "Not today, Tuesday." When's Tuesday? "Tuesday is coming." When?
Women remarked favourably on the staff's interaction with their children. One woman said: Although women were positive in their comments about the impact of New Choices on their children's life, a few women mentioned that they would have liked more of a focus on education in the children's program. One participant said, "You've got to have some educational force in there somewhere, especially for the children getting older and getting ready to go to school and stuff. I think that would be a benefit." Women who did not have custody of their children appreciated the additional opportunity for supervised visitation available through New Choices. The importance of this feature to one individual was expressed as follows:

Oh, if I didn't have this place to visit I think I'd go nuts because to see, like I can see my two older babies whenever I want but [child's name], I'd have to see her like only in that visitation for that and I can't stand it.
New Choices played a role in helping some women regain custody of their children. As one participant said: The urine samples proof helped [ Another woman commented on the importance of location especially for women with addictions: And when you're dealing with addiction and you're dealing with children and you're dealing with life and you're trying to cope, you throw some screwed up bus schedule that you have to take this bus to this place and this bus to this place and then get off and walk two blocks and walk up one, I mean you're literally screwed. ... I'm making myself nuts. I'm going to go use just because I'm coming here. It's stressful.

Discussion
The finding that children were a primary motivating factor for participation in the New Choices program is congruent with others' suggestions that pregnancy and childrearing are main incentives for engagement in treatment for addictions [7,30,31]. Many of the women were involved in child protection services. Regaining custody or not losing custody of their children was a goal for some participants, a finding consistent with that of Howell and Chasnoff [19]. At the same time, some women in New Choices were cautious about what they told staff for fear of being reported to child protection services. In Ontario, Canada, members of the public and professionals have an obligation to report suspicion, based on "reasonable grounds," that a child is in need of protection [32]. There is no mandated drug testing or reporting of maternal alcohol or drug use as there is in some jurisdictions in the United States [33]. Women should be aware of professionals' legal obligation to report, but be assured that child protection agencies will not undermine their well being and that of their children by terminating parental rights, except in situations where it is clear that the child is in an unsafe environment [33].
Participation in New Choices reportedly contributed to decreased substance use. Other programs that provide a wide range of services for women with addictions have noted improvements in substance use [e.g., [2,25,34]]. As suggested by Rosenbaum and Irwin [20], diminished use is more realistic for many women than complete abstinence. Women need to be supported in their "harm reduction" strategies, which include not only decreasing substance use but also making other lifestyle changes and seeking prenatal care [20]. One specific lifestyle change supported by New Choices was improved nutrition. Because women who use drugs generally maintain poorer nutritional status than non-drug-users, nutrition education is regarded as a critical element of programs for pregnant or parenting women with substance use issues [35,36].
Participants' accounts of how New Choices affected their mental and social health are relevant in the context of women's recovery process. As noted by Kearney [37], awareness of choice and enhanced sense of control are empowering to women and contribute to recovery efforts. Identity revision, which involves taking on a new personal and social self, is a sustaining factor in health behaviour change [38]. Having the opportunity to share experiences, obtain advice, and receive positive reinforcement from peers might be especially important. Many women with substance use issues are isolated and lack close ties with family and friends, yet constructive social support can foster recovery and maintain gains made in treatment [4,36].
Women with addictions face barriers to employment, including limited education, work history and skills training [4,40]. It, therefore, is not surprising that New Choices participants valued the employment component of the program that offers them pre-employment counselling and job skill training. If programs are to be successful in reducing substance use, attention to the social problems encountered by women (e.g., lack of job skills and economic self-sufficiency) is important [41,42].
Participants remarked that New Choices enhanced their capacity to parent effectively. McMurtrie et al. [43] attested to the importance of parenting education as a component of addictions treatment. They suggested that women need to be exposed to positive parenting models, be assisted in responding to their children's needs and in developing a positive parental self-concept, and be provided hands-on opportunity to improve parenting skills. Other studies similarly have reported that parenting education for women with substance use issues is perceived to be beneficial by participants, and can improve selfesteem, parenting knowledge and attitudes, and parenting satisfaction [44,45].
Women in New Choices commented on improvements in their children's behaviour and development that could be attributed, in part, to the enriched children's program. Early child development interventions are effective in preventing developmental delay in children at risk [46]. Given that the period of child development from birth to 5 years of age is critical and substance use is associated with lower quality of parental stimulation [46,47], it is important that programs for parents with addictions include opportunities for enhanced development in early childhood.
A comprehensive, coordinated and centralized approach to service delivery was valued by the women interviewed in this study. The collaboration and cooperation of multiple community-based services enhanced access to a range of services for women and their children. There is consen-sus that treatment programs should address women's social and mental health needs as well as children's needs through parental interaction and child care [3]. Transportation services and childcare might be important components of programs because women who have substance use issues often lack adequate transportation and babysitting options [3,7,43]. The findings of this study suggest that even with the provision of bus tickets, transportation can be problematic for women. Thus careful selection of program location to minimize the burden for women is important. Because fear of stigma is a barrier to seeking care [18], it is essential that programs for pregnant and parenting women with substance use issues be staffed by professionals who provide service in a nonjudgmental, non-punitive, and culturally and linguistically appropriate manner [3,27].
Although the findings provide insight into an alternative model of service delivery for women with addictions, the study is limited in a number of ways. The findings represent the views and experiences of a small sample of women with addictions who were served by one particular program. Participants were at varying stages in their treatment process at the time of interview, which could have influenced perceptions about the program. However, the sample was not large enough to address differences in perceptions given the stage of treatment and recovery. The interview data presented in this article are limited because they are based on participants' perceptions and perspectives that are subject to distortion due to personal bias, emotional state, self-serving responses, and selective recounting of positive aspects [28]. Moreover, the responses of focus group participants might have been influenced by the presence of others. Nonetheless, the qualitative findings are consistent with the results of quantitative measures of substance use, social support, mental health, nutrition, parenting ability, and child development [48].

Conclusions
Women with substance use issues present with complex biopsychosocial needs, which become even more complicated if they are pregnant or parenting [40]. Findings from the interviews with women support the appropriateness and potential efficacy of a collaborative, centralized approach to service provision to meet their multiple needs. Women commented on the benefits of participation in New Choices for both themselves and their children. These benefits included decreased use of substances, improved maternal health, enhanced opportunity for employment, increased awareness of and access to other resources, enhanced parenting skills, and improved child behaviour and development. Program participants, in general, spoke very favourably about New Choices, acknowledging the importance of a coordinated approach to service delivery that enabled them to access multiple formal and informal supports in one location.
Future research is needed to evaluate outcomes objectively to determine that the intervention has a positive impact on both women and their children. A variety of outcome measures, including substance use, birth outcomes, parent-child interaction, and health and social services utilization, should be examined using an experimental or quasi-experimental design and a larger sample. Research also is needed to determine which program components or constellation of components contribute to desired outcomes. Furthermore, there is a need to learn more about processes that underlie changes in behaviour. Triangulated study designs using both quantitative and qualitative methods allow for comprehensive understanding, and also provide meaningful direction for program development.