Alcohol And Other Drug Abuse Research Articles

"It just took something from me": A mixed-methods examination of intimate partner violence victimization and perpetration among U.S. Indigenous peoples.

Indigenous peoples of the United States experience disproportionate rates of intimate partner violence (IPV). The framework of historical oppression, resilience, and transcendence (FHORT) was used to understand risk factors for IPV victimization and perpetration. In this exploratory sequential mixed-methods study, data were collected with 436 participants in the qualitative portion and 127 participants in the quantitative portion. After listwise deletion of missing variables, 117 participants were included in the main analyses. Thematic reconstructive analysis was used to qualitatively investigate how Indigenous peoples describe IPV victimization. T-test and regression analyses examined the following risk factors for IPV victimization and perpetration: (a) perceived oppression, (b) adverse childhood experiences (ACEs), (c) alcohol and other drug (AOD) abuse, (d) posttraumatic stress disorder (PTSD), (e) anxiety, (f) younger age, and (g) female gender. Qualitative results revealed ACE, infidelity, and AOD abuse were frequently mentioned among IPV victimization for participants, with women experiencing more severe violence. Quantitative results indicated PTSD and IPV victimization were higher among women. Oppression, ACE, AOD abuse, PTSD, and female gender were risk factors for victimization, whereas younger age, anxiety, and alcohol use were risk factors for perpetration. Indigenous peoples in these samples experienced rampant IPV, which was exacerbated and triggered by alcohol, drug use, and infidelity. To prevent IPV for adults, it is germane to prevent exposure to violence and substance abuse across the life course. Family-focused and culturally grounded interventions that focus both on AOD abuse, emotional regulation, and violence prevention are recommended. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Is conditional welfare an effective means for reducing alcohol and drug abuse? An exploration of compulsory income management across four Australian trial sites

ABSTRACT Conditional welfare has become a prominent policy tool in recent years. One of the harshest forms of conditional welfare in Australia is arguably compulsory income management (CIM) which involves the quarantining of between 50 and 90 per cent of a participant’s benefit payment for spending on food, rent and other essential items. A leading aim of all Australian income management (IM) programs since 2007 has been the reduction of alcohol and other drug (AOD) abuse by participants, which is expected to reduce associated social and community harms. Building on the mixed findings of official evaluations of IM, this qualitative study examines the views of both compulsory and voluntary IM participants and community stakeholders concerning AOD abuse in four IM sites. It concludes that there is little evidence to support the view that IM per se contributes to a significant reduction in AOD abuse.

Building cooperative learning to address alcohol and other drug abuse in Mpumalanga, South Africa: a participatory action research process

ABSTRACT Background: Alcohol and other drug (AOD) abuse is a major public health challenge disproportionately affecting marginalised communities. Involving communities in the development of responses can contribute to acceptable solutions. Objectives: To: (1) document forms, processes, and contexts of engaging communities to nominate health concerns and generate new knowledge for action; (2) further build participation in the local health system by reflecting on and adapting the process. Methods: PAR was progressed with 48 community stakeholders across three rural villages in the MRC/Wits Agincourt Health and Socio Demographic Surveillance System (HDSS) in Mpumalanga, South Africa. A series of workshops explored community-nominated topics, systematised lived experience into shared accounts and considered actions to address problems identified. Photovoice was also used to generate visual evidence. Narrative and visual data were thematically analysed, situated within practice frameworks, and learning and adaption elicited. Results: AOD abuse was identified as a topic of high priority. It was understood as an entrenched social problem with destructive effects. Biopsychosocial impacts were mapped and related to unemployment, poverty, stress, peer pressure, criminal activity, corruption, and a proliferating number of taverns. Integrated action agendas were developed focussed on demand, supply, and harm reduction underpinned by shared responsibility among community, state, and non-state actors. Community stakeholders appreciated systematising and sharing knowledge, taking active roles, developing new skills in planning and public speaking, and progressing shared accountability processes. Expectations required sensitive management, however. Conclusion: There is significant willingness and capacity among community stakeholders to work in partnership with authorities to address priority health concerns. As a process, participation can help to raise and frame issues, which may help to better inform action and encourage shared responsibility. Broader understandings of participation require reference to, and ultimately transfer of power towards, those most directly affected, developing community voice as continuous processes within social and political environments.

Risk and Protective Factors for Alcohol and Other Drug Use (AOD) Among Adolescents in Rubavu District, Rwanda

Background: Despite ongoing prevention efforts, alcohol and other drug (AOD) abuse among adolescents remain public health concerns. Rural adolescents, many of whom are underserved, are disproportionately affected. AOD bring a major challenge for affected families and communities and places an enormous burden on mental health and other health service providers in Rwanda as well as the country’s economy. To our knowledge no study has been done to address AOD in Rwanda. Objectives: The purpose of this study was to explore perspectives on risk and protective factors influencing AOD of parents and their adolescents attending parent-adolescent communication (PAC) program in Rubavu district, Rwanda. Methods: This study employed qualitative methods and community-based participatory research (CBPR) guided in large part by community members, in partnership with research and health practitioners from Imbuto Foundation and Rubavu Youth Friendly Center (RYFC). CBPR principles are aimed at improving the effectiveness of research by addressing locally relevant health issues and involve communities in every aspects of the research process. Through a systematic process, community participants and researchers work to achieve a shared understanding of the important influences on AOD in the community and suggestions for how to take action in addressing AOD. Purposive sampling procedure was used to select participants for the study. A total of 20 families (17 fathers, 20 mothers and 20 adolescents aged 14 to 24 years) were participants in PAC program from Rubavu Youth Friendly Center (RYFC) in rural sector of Rubavu district. Focus groups and in-depth interviews in Kinyarwanda language were conducted with all study participants. The interview guide was semi structured, nondirective and informal process to elicit rich information regarding risk and protective factors of AOD abuse among adolescents. Each interview and focus group session were written in narrative format and were analysed using grounded theory approach. Results: This Individual risk and protective factors for AOD, environmental risk and protective factors for AOD and suggestion to AOD among the adolescents were the main themes that emerged from this study. Parents and their children adolescents’ participants in PAC program perceived poor communication as a leading risk factor of alcohol and drugs abuse; other risks included poor family support, stressful life events and availability of drugs. Family support, communication about drugs, employment and religion were viewed as protective factors. Participants suggested strengthening parent-adolescent communication about drugs through parenting and drugs education sessions and community home visit and integration the program in village. Other suggestions included strengthening the parent-adolescent relationship in prevention or reduce AOD. Conclusions: Participants believe that parents and families have the ultimate responsibilities to protect and educate their own children about alcohol and drugs. This study calls for the governments to equip families in performing this task. Establishing a family-based drug prevention intervention that aims to produce competent parents would improve parenting practice in prevention of adolescent risk health behavior including alcohol and other drugs.

Heterogeneous Costs of Alcohol and Drug Problems Across Cities and Counties in California.

Estimates of economic and social costs related to alcohol and other drug (AOD) use and abuse are usually made at state and national levels. Ecological analyses demonstrate, however, that substantial variations exist in the incidence and prevalence of AOD use and problems including impaired driving, violence, and chronic disease between smaller geopolitical units like counties and cities. This study examines the ranges of these costs across counties and cities in California. We used estimates of the incidence and prevalence of AOD use, abuse, and related problems to calculate costs in 2010 dollars for all 58 counties and an ecological sample of 50 cities with populations between 50,000 and 500,000 persons in California. The estimates were built from archival and public-use survey data collected at state, county, and city levels over the years from 2009 to 2010. Costs related to alcohol use and related problems exceeded those related to illegal drugs across all counties and most cities in the study. Substantial heterogeneities in costs were observed between cities within counties. AOD costs are heterogeneously distributed across counties and cities, reflecting the degree to which different populations are engaged in use and abuse across the state. These findings provide a strong argument for the distribution of treatment and prevention resources proportional to need.

Improving Service Utilization for Parents with Substance Abuse Problems: Experimenting with Recovery Coaches in Child Welfare

Substance abusers often face substantial systematic and personal barriers to receiving required substance abuse treatment services as well as other services; hence, various linkage mechanisms have been proposed for drug abuse treatment programs to overcome such barriers. Although there is a growing interest in the use of case management with a substance abuse background, its effectiveness in child welfare has yet to be explored. In this study the author attempts to investigate the effectiveness of case management in service utilization by systematically evaluating the five-year Alcohol and Other Drug Abuse (AODA) waiver demonstration project with Recovery Coaches in Illinois. A classic experimental design with a control group was used. Random assignment occurs at the agency level. Parents in the experimental group (N = 1562) received recovery coaches in addition to traditional child welfare services while parents in the control group (N = 598) only received traditional child welfare services. Bivariate and multivariate analyses (Ordinary Last Square regressions) were used. Compared to parents in the control group, parents in the experimental group were more likely to utilize substance abuse treatment. The results suggest that gender, education level, employment status, and the number of service needs were significantly associated with service utilization. Controlling other factors, recovery coaches improved overall service utilization. Because the outcome of child welfare often depends on the improvement of risks or resolution, it is important for parents to utilize the needed services. Future studies need to address what aspects of recovery coaches facilitate the services utilization.

Substance abuse prevention in Cape Town's peri-urban settlements: local health trainers' perspectives

South Africa currently experiences high levels of alcohol and other drug (AOD) abuse. As a result there is a need for the initiation of regional AOD abuse prevention programmes with a specific focus on youth prevention strategies. The Medical Knowledge Institute (MKI) is a non-profit organisation which develops and facilitates health information workshops to members of disadvantaged peri-urban communities in South Africa. This research investigated the views of eight local MKI health trainers on factors contributing to AOD abuse in their communities. Although the expected focus of the discussion was on prevention strategies and effective interventions, the trainers placed more emphasis on the individual and community factors influencing AOD abuse. The themes which emerged through the research included: status, government, (di)stress, gender, recreation, consequences and community. This research holds significance as it has the potential to assist further development of community-based AOD prevention workshops and to guide public health policy and service development for AOD abuse.

The effect of recovery coaches for substance-involved mothers in child welfare: Impact on juvenile delinquency

Despite the documented relationship between parental substance abuse and youth delinquency, the effects of parental interventions on delinquency outcomes are unknown. Such interventions are particularly vital for families in the child welfare system who are at heightened risk for both parental substance involvement and youth delinquency. The current study tested the impact of intensive case management in the form of a recovery coach for substance-involved mothers on youth delinquency outcomes among a randomized sample of 453 families involved in a Title IV-E experimental waiver demonstration in Cook County, Illinois. In comparison to control group participants, families enrolled in the Alcohol and Other Drug Abuse (AODA) waiver demonstration experienced a lower rate of juvenile arrest, net of factors such as demographic characteristics, primary drug of choice, and time spent in substitute care. Findings support efforts to curb delinquency among child-welfare involved youth by providing recovery coaches to their substance abusing or dependent parents.

Counselor Trainee Attitudes Toward Alcohol and Other Drug Abuse

Using the Counselor Trainee Attitudes Measure (CTAM) to assess student attitudes toward alcohol and other drug abuse (AODA), results indicated that students had more positive attitudes toward AODA when they were in recovery or had a family member in recovery. Furthermore, completion of AODA related courses predicted more positive attitudes toward AODA. Undergraduate versus graduate standing also appear to play a role in model adherence.

AODA Training Experiences of Blindness and Visual Impairment Professionals

Co-existing alcohol and other drug abuse (AODA) and blindness or visually impairment may complicate the delivery of rehabilitation services. Professionals working with individuals who are blind or visually impaired need to be aware of unique issues facing those with co-existing disabilities. This study sought to examine the AODA training needs, attitudes, and knowledge of blindness and visual impairment professionals. Twenty participants agreed to participate in a co-existing disabilities training session. During the training, each participant was asked to complete a questionnaire measuring his or her previous AODA training and knowledge and attitudes toward people with co-existing disabilities. Results revealed negative attitudes toward people with AODA and highlighted training needs of professionals who serve people with co-existing AODA and blindness or visual impairment.

A Critical Review of Adolescent Substance Abuse Group Treatments

Objective: Evidence-based social work requires the use of interventions that are supported by good research evidence. This article reviews the empirical research on adolescent alcohol and other drug (AOD) abuse group treatments. Despite the popularity of group work, searches of the academic literature yielded only 13 adolescent group treatments for which AOD use outcomes have been reported. These treatments and the studies that evaluated them are systematically reviewed. Method: Methodological, efficacy rating, and treatment factor criteria are applied to these studies. Results: Statistically significant reductions in pre-, post-, and/or follow-up use rates of one or more substances were reported for 10 of the 13 reviewed treatments, but only two met Chambless and Hollon's (1998) criteria for “possible efficacy.” Similarities between the two possibly efficacious treatments, as well as among the three treatments with no indication of positive outcomes are described. A major limitation of the studies overall was the lack of group treatment factor descriptions and analyses. Conclusion: If the state of the science is to advance, adolescent AOD group treatment researchers must improve study designs and reporting on group-related treatment factors. Based on the limited information provided, treatment factors and/or active ingredients that may distinguish effective vs. ineffective group work are discussed. Finally, the evidence suggests that group work is a viable modality for treating adolescent AOD abuse despite recent concerns to the contrary. Recommendations for advancing the state of the science are made.

Competency Issues for Alcohol/Other Drug Abuse Counselors

Coexisting disabilities involve persons with physical, cognitive, and psychiatric disabilities together with alcohol and other drug (AOD) abuse concerns. Prevalence rates of coexisting disabilities are high and access to treatment is limited. This study examined the attitudes of AOD abuse counselors as well as their perceptions of competency in working with people with coexisting disabilities. A significant negative relationship was found between counselor competence and their knowledge of the impact of coexisting disabilities (r = −.519). A significant relationship was also found between counselor attitude toward the problems associated with coexisting disabilities in treatment and both their accurate responses (r = .784) and their inaccurate responses on the impact of coexisting disabilities (r = .726).

Alcohol and other drug related deaths among young people in CIS countries: Proximal and distal causes and implications for policy

Background Although the mortality crisis that followed the break-up of the Soviet Union in 1992 has been well researched, most attention has been paid to mortality among middle-aged men. There has been relatively little analysis of death rates among young people, many of which appear related to alcohol and other drug (AOD) use. Death rates ranged from exceedingly high in some countries (e.g. Russia) to very low in others (e.g. Armenia). This divergence among Commonwealth of Independent States (CIS) countries increased considerably over the 1990s. What caused this divergence in youth deaths and what policy response is needed? Method An ecological study of country-level data was used to explore the relationships between risk factors, AOD use and youth deaths across time and between countries. Qualitative research literature was used to supplement the statistical data. Results AOD abuse risk factors were divided into ‘proximal causes’ (e.g. AOD availability) and ‘distal causes’ (e.g. social cohesion, welfare, culture). Proximal risk factors appeared to explain some of the AOD use and death data, but they did not explain all of the country differences. Analysis of distal risk factors suggested that family and community strength are important factors in the trends in AOD abuse and youth mortality. Conclusions The policy response to AOD abuse and mortality among young people needs to attend to both proximal and distal factors. An exclusive focus on proximal risk factors is unlikely to provide a satisfactory solution. Rather, the social determinants of child and youth development need to be considered. More research is needed on the relationship between AOD abuse and youth mortality, and on the influence of family and community strength on both these outcomes in the region. Useful lessons may be learned from countries such as Armenia, where both AOD abuse and youth mortality have remained low.

Evaluating the Effects of Comprehensive Substance Abuse Intervention on Successful Reunification

Objective: This study examines permanency outcomes of families with children in foster care who participated in a comprehensive service-delivery program designed to assist families and communities in dealing with alcohol and other drug (AOD) problems. Method: Survival analysis is used to measure the impact of program participation on family reunification and re-entry of children into foster care. Results: The results of this study are that, contrary to initial expectations, participants move more slowly to reunification, although the group differences are not statistically significantly different, and re-entry rates are significantly higher among those children whose parents participate in this service. Conclusions: AOD abuse recovery is a long-term process. More intensive service interventions may not automatically produce better permanency outcomes.

Co-occurring problems for substance abusing mothers in child welfare: Matching services to improve family reunification

Substance abusing families often experience multiple problems simultaneously. Prior substance abuse research suggests that attention to these co-occurring problems is essential to achieving desirable outcomes. Yet no prior study attempts to determine whether tailoring services to meet clients' co-occurring problems improve key child welfare outcomes such as family reunification. This study addresses this gap by investigating the relationship between matching mothers' needs to service and family reunification for substance abusing families in public child welfare using the Illinois Alcohol and Other Drug Abuse (AODA) waiver demonstration project. The sample consists of a total of 354 substance abusing mothers and their 602 children enrolled in the Illinois AODA waiver demonstration. Hierarchical non-linear modeling is used to understand the role of both child level and family level characteristics. Matched services in mental health, housing, family counseling and substance abuse treatment significantly improved the likelihood of family reunification. The analyses also reveal that child welfare systems continue to struggle with low rates of service utilization and low rates of family reunification. Thus, it remains important for researchers, practitioners and policy makers to continue identifying the barriers to the provision of matched services, and to develop strategies for improving the provision of matched services.

Is cigarette smoking related to alcohol use during the 8 years following treatment for adolescent alcohol and other drug abuse?

The present study examined the relationship between cigarette smoking and alcohol use outcomes over an 8-year period following treatment for adolescent alcohol and other drug (AOD) use disorders. The present study was based on a sample of 166 adolescents recruited during inpatient AOD abuse treatment. Included in this study were 123 (74% of the full sample) participants, of whom 41% were female, 81% identified themselves as White and who averaged 15.9 years of age (SD = 1.3) when entering treatment. Data for the present study were drawn from interviews conducted at the time of treatment and 2-, 4-, 6- and 8-years post-treatment. Twenty six percent of participants had quit smoking for > 1 year at the 8-year assessment, while 44% reported persistent smoking over time. Overall smoking rates decreased significantly over time. Subjects associated with the highest alcohol involvement trajectory reported significantly greater likelihood of persistent smoking as well as higher current smoking and cigarette consumption across time points. The significant declines observed in smoking from adolescence into young adulthood were contrary to expectations, indicating that this behaviour may be less stable than previously thought among adolescent AOD abusers. Smoking involvement over time was greater within the highest alcohol use trajectory, consistent with previous evidence for a positive relationship between these behaviours. However, when compared with the general population smoking rates remained very high regardless of alcohol involvement. Thus, individuals treated for AOD abuse as adolescents remained at elevated risk for tobacco related disease regardless of post-treatment AOD use outcomes.

Integrating Substance Abuse Treatment and Child Welfare Services: Findings from the Illinois Alcohol and Other Drug Abuse Waiver Demonstration

Alcohol and other drug abuse is a major problem for children and families involved with public child welfare. Substance abuse compromises appropriate parenting practices and increases the risk of child maltreatment. A substantial proportion of substantiated child abuse and neglect reports involve parental substance abuse. Once in the system, children of substance-abusing families experience significantly longer stays in foster care and significantly lower rates of reunification. To address these problems, child welfare systems are developing service integration models that incorporate both substance abuse and child welfare services. This study provides an initial examination of the effectiveness of one service integration model that emphasizes the provision of intensive case management to link substance abuse and child welfare services. The authors used an experimental design and focused particular attention on two outcomes: access to substance abuse services and family reunification. The findings indicate that the families assigned to the experimental group used substance abuse services at a significantly higher rate and were more likely to achieve family reunification than were families in the control group. KEY WORDS: case management; families; reunification; substance abuse ********** The effective collaboration of multiple service systems to deal with parental alcohol and other drug abuse (AODA) continues to challenge government efforts to ensure family permanence and the safety and well-being of neglected and abused children. Research has documented the heavy toll that parental drug addiction exacts on families and children who come to the attention of state child protection authorities. According to Young and colleagues (1998), at least 50% of the nearly 1 million children indicated for child abuse and neglect in 1995 had caregivers who abused alcohol or other drugs. A 1994 report issued by the U.S. General Accounting Office (GAO) estimated that the percentage of foster home placements resulting in part from parental drug use rose from 52% to 78% between 1986 and 1991 in the cities of Los Angeles, New York, and Philadelphia (GAO, 1994). A 1998 GAO study of child protection systems in Los Angeles and Cook County, Illinois, documented that substance use was a problem in more than 70% of active foster care cases (GAO, 1998). If child welfare systems are to achieve desirable permanency and safety outcomes, the development of innovative service strategies and agency partnerships are necessary. Parental substance abuse often compromises appropriate parenting practices, creates problems in the parent--child relationship, and significantly increases the risk of child maltreatment (Famularo, Kincherff, & Fenton, 1992; Jaudes, Ekwo, & Van Voorhis, 1995; Kelleher, Chaffin, Hollenberg, & Fisher, 1994; Nurco, Blatchley, Hanlon, O'Grady, & McCarren, 1998). Once involved in the child welfare system, substance-abusing parents are more likely to experience subsequent allegations of maltreatment compared with non-substance-abusing parents (Smith & Testa, 2002). In addition to the increased risk of maltreatment, access to and engagement with treatment providers is often limited (Maluccio & Ainsworth, 2003). Consequently, children of substance-abusing parents remain in substitute care for significantly longer periods of time and experience significantly lower rates of family reunification relative to almost every other subgroup of families in the child welfare system (GAO, 1998). Access and Engagement Access to substance abuse treatment is limited for substance-abusing parents. Overall, in the United States approximately one-third of all individuals who need treatment receive it (Substance Abuse and Mental Health Services Administration [SAMHSA], 1997). The supply of treatment services for women with children is especially inadequate (Price, 1997). …

Integrated services for families with multiple problems: Obstacles to family reunification

Child welfare clients with co-occurring problems are recognized as clients who have difficulty achieving positive child welfare outcomes. The current study focuses on families in the child welfare system with co-occurring problems and the impact of such problems on the likelihood of reunification. The current study contributes to the literature on service integration by examining whether it is necessary to go beyond assessment and service access to insure families make progress in each co-occurring problem area to achieve reunification. The sample is comprised of 724 substance-abusing families enrolled in the Illinois Title IV-E Alcohol and Other Drug Abuse (AODA) Waiver Demonstration. Data on client progress consisted of provider ratings completed quarterly to track progress related to problems of substance abuse, domestic violence, housing and mental health. The findings indicate that progress in resolving co-occurring problem areas does increase the likelihood of achieving family reunification. Thus, the provision of the child welfare service model alone is insufficient. In order for child welfare systems to increase reunification rates, services must target the specific needs of individual families and assist them in achieving progress within co-occurring problem areas. Successful integrated service programs must identify the range of specific problems that clients are dealing with and insure that they address and resolve these problems in order to increase the likelihood of family reunification.

Service Delivery for Persons with Blindness or Visual Impairment and Addiction as Coexisting Disabilities: Implications for Addiction Science Education

ABSTRACT Although research strongly suggests that individuals who are blind or visually impaired (BVI) experience alcohol and other drug abuse (AODA) disorders at rates higher than those expected within the general population (NAADD, 1999), less is known about specific barriers that influence AODA treatment for these consumers (Koch & Nelipovich, 1999). Accurately describing these barriers presents an extremely complex challenge due to the fact that problems may arise (a) directly as a result of the BVI (blind or visually impaired) disabilities; (b) directly as a result of the AODA disorders; or (c) only in circumstances where both disabilities co-occur or co-exist. Although some preliminary research on this problem exists (Koch, 2000; Moore, Greer, & Li, 1994; NAADD, 1999), few researchers have collected data describing these barriers from rehabilitation and AODA counselors who are actively working with the population of persons with visual impairment and blindness. The purpose of this study was to condu...

The Portal Project

SUMMARY Palladia, Inc. is a not-for-profit, multi-service agency, located in New York City, serving primarily African-American and Latino communities. Palladia's Portal Project, in collaboration with the evaluation team from Hunter College School of Social Work (HCSSW), participated in the national Women, Co-Occurring Disorders and Violence study. We studied 270 women with co-occurring issues of alcohol and other drug (AOD) problems and mental illness, who had histories of violence, and were high end users of service. Palladia built an integrated system of care and implemented a comprehensive trauma-informed intervention that is designed to put trauma and safety first to assist women in remaining in treatment. Primacy of trauma in the early stages of treatment constitutes a major philosophical shift within the traditional residential drug treatment setting. The focus of the engagement and treatment process is on the role of trauma in the woman's life and its relationship to patterns of AOD abuse and mental illness. Another key feature of the Portal model is the emphasis on normalizing the adaptations which the women have made in response to interpersonal traumatic life events. The women feel less stigmatized and isolated. They are encouraged to see their former coping and adaptive behaviors as strengths rather than maladaptive weaknesses, deficiencies or character flaws. Support for the women in their parenting and family roles and attention to their individual perceptions of culture are also part of the intervention. Portal blends service intervention, policy development, research, and evaluation for effective service delivery. The collaborative work of this project has produced a replicable model that configures specific direct service enhancements and service system improvements, using the active involvement of consumers, practitioners, service providers and policy makers.