Poverty and deprivation are more likely to encourage than discourage drug use (Combat Poverty Agency, 2001), and substance misuse can be both a cause and an effect of social exclusion. Problematic use of alcohol, tobacco, prescription medicines and illegal drugs has serious consequences for public health, and it is already known that lower socio-economic groups have a lower health status overall.
It is clear some people turn to addictive substances when living in difficult circumstances and without the supports, incentives and opportunities available to them to live a healthy life. There is a social gradient to most aspects of substance use, with people from lower socio-economic groups using more tobacco and illegal drugs, and having lower rates of successfully quitting.
( Public Health Alliance Ireland, 2004:45 )
Low level of educational attainment is associated with problem drug use, and educational disadvantage sustains and exacerbates social exclusion: "some school communities . are characterised by high levels of unemployment, single-parent families, low levels of parental education, lack of pre-school facilities, substance abuse, poor diet, absenteeism and a lack of parental involvement", yet such schools are often seriously under-resourced (Flynn, 2005). Failure to tackle the root causes of such problems in a coherent way at an early stage ends up costing society much more in the long run. The ongoing and ultimate costs of childhood antisocial behaviour, juvenile offending and consequent social exclusion, for example, are very high and fall on many different agencies; proper resources, deployed in a rational and coordinated manner, could therefore result in large cost savings (Scott et al ., 2001).
It is essential therefore to recognise the needs of groups that are often marginalised in society and target them for priority inclusion. Given the opportunities and imperatives provided by national and regional development strategies, the Task Force must play its part in concerted efforts to tackle social exclusion, as "the importance of achieving coordination and integration of social inclusion measures under the National Development Plan cannot be overstated" (NDP/CSF Evaluation Unit, 2003:67). If these opportunities are not grasped, "social exclusion will continue and . street violence, crime, drug and alcohol abuse will increase" (Galway City Development Board, 2002:22). It is important that efforts are made to tailor service developments to fit the needs of groups that are marginalised, disadvantaged or isolated. For example, assertive outreach initiatives can be an essential service provision for some populations.
4.1 The significance of rurality and underdevelopment
The GMR area is a "double peripheral area" within the Border Midlands West (BMW) region, hence the particular designation of the three counties of the West as an area eligible for continuing aid from EU Structural Funds (Sprenger, 2004). The historical depopulation of large tracts of marginal land has resulted in the "desertification" of many areas in the GMR region, a phenomenon characterised by weakening of demographic structures, loss of funding and investment, increasing marginalisation, and closure or absence of rural services and facilities (Heanue, 2002).
A large land area, historical depopulation, significant pockets of deprivation and poor social and physical infrastructure may have implications for patterns of substance misuse and for service responses to such patterns. For example, a chronic lack of social and civic amenities, along with inadequate public transport, has led to a situation where in many localities the rural pub functions as a community centre. This is not without risk: for instance, 70% of fatal traffic accidents occur on rural roads (those in non-built-up areas with higher speed limits, including national routes) and alcohol is involved in 30-40% of such accidents (National Roads Authority, 2002; National Safety Council, 2004).
A decade ago, the prevalence of alcohol and illicit drug use was higher in urban areas of the GMR, especially Galway City , than in rural areas (Kiernan, 1995). In recent years there has been a "growing recognition that illegal drugs, particularly cannabis and ecstasy, are readily accessible in towns and rural areas throughout [Ireland] and, along with alcohol, are becoming an increasing aspect of recreational activity amongst categories of youth in particular" (Moran et al ., 2000:21). However, little or no data are available in Ireland or elsewhere to systematically compare the current nature and extent of substance use in urban and rural areas. Nonetheless, it appears that while variations in the geographical distribution of drug use are known to occur (heroin being the most obvious example), other differences are not as great as might be hoped for, although problem drug use is in general more likely to occur in deprived urban areas (Forsyth & Barnard, 1999).
In this context, it is important to acknowledge that whilst disadvantage occurs in both urban and rural areas, it is necessary to distinguish between the two: "special emphasis must be placed on the causes of disadvantage in rural areas . [taking] careful recognition of the need to have decentralised mechanisms that reach out into the heart of rural areas and which are specifically targeted at those who need them the most" (Mayo County Development Board, 2002).
Although many people expect and enjoy a good quality of life in the countryside, rurality and isolation are not intrinsically protective, and a lack of diversionary leisure and recreational facilities could increase the vulnerability of rural young people to the misuse of alcohol and illegal drugs (Countryside Agency, 2004). The problems of boredom, nothing to do and lack of positive alternatives also occur in towns, but may be particularly acute in rural areas: "young people who find themselves living in rural areas have fundamentally the same needs as young people living anywhere else. It is the variability of access to provision to meet those needs which creates disadvantage" (Henderson, 1998:10).
Where drug dependence and associated difficulties do occur, lack of treatment facilities, or lack of access to such services, increases the prevalence of problems in the community (Hutchinson & Blakely, 2003). Research conducted in the UK and other countries has demonstrated the extra costs and barriers associated with rurality and remoteness (Asthana et al ., 2003). Problems include: economies of scale; additional travel costs and high levels of unproductive time; additional communications costs; poorer access to training, consultancy and other support services; difficulties of networking; and the slow pace of development work. Distance from services has a direct negative impact on utilisation rates and health-seeking behaviour (the 'distance-decay effect'). Social features of rurality also affect service utilisation rates. For example, a culture of self-reliance and a fear of stigma have been cited as key factors in the low utilisation of mental health services. In Ireland , the counties with the highest suicide rates are predominantly rural, with the rates in all areas being much higher among males, who are less likely to access health services (Kelleher et al ., 1997). There are also inequities in the geographical distribution of health services, including primary care and mental health services, which typically have been developed in areas of greatest affluence rather than greatest need (Public Health Alliance Ireland , 2004). All of these barriers point to the need for "rural proofing" of service provision (Mayo County Development Board, 2002).
Unfortunately, many disadvantaged areas have been caught in a "Catch 22" situation: without development there has been a lack of infrastructure, while the deficiencies in infrastructure have impeded development (Roscommon County Development Board, 2002). Development efforts over the years by a range of local, regional and national organisations, both statutory and voluntary, have sought to address these and other deficits. More recently, under the terms of the National Development Plan, prioritised state investment programmes such as CLÁR and RAPID have been introduced with the aim of revitalising disadvantaged rural and urban areas in a coherent, targeted and accelerated way.
It is essential that these programmes and related initiatives are fully resourced and continued as long as is necessary in order to resolve the significant deficiencies in social, community and service infrastructure and investment that exist in the region (Western Development Commission, 2003; BMW Regional Assembly, 2004). It is a matter of considerable concern that, as Minister for Finance Brian Cowen has stated, "investment in the BMW region at mid-2004 in the key area of economic and social infrastructure was some €660 million below the target set [while] Exchequer-funded investment in the infrastructure in the region was only €240 million below profile" (Seanad Éireann, 2005).
4.2 Tackling social disadvantage
Ireland has become a very prosperous country in the last decade, and the benefits of this prosperity are evident. The number of people employed in is now around 45 per cent of the population, a record level in recent history. Some areas of the West, particularly Galway , have experienced rapid jobs growth. Jobs mean disposable income of course, and it needs to be considered what effect this may have on patterns of alcohol and illicit drug use. Despite the enormous progress made, significant pockets of unemployment, socio-economic disadvantage, deprivation and infrastructural deficit still remain (whether in terms of geography or social groups) and these must be given due consideration also. The key risk factors for poverty and social exclusion are many and varied, with substance misuse often playing a role as both origin and outcome:
[Factors] include discrimination, poor quality public services, unemployment (especially long-term), low income, low quality employment, poor health, low qualifications, disability, old age, migration, family break-up, drug addiction and alcohol abuse, as well as living in disadvantaged areas. These social risk factors often interact and accumulate over time.
(European Foundation for the Improvement of Living and Working Conditions, 2003:5)
The Programme for Prosperity and Fairness committed the Government to providing, under the National Development Plan, targeted investment in disadvantaged areas. Initiatives include the Local Development Social Inclusion Programme operated by the Area-Based Partnerships, and the Community Development Programme. In 2001 the CLÁR and RAPID programmes were introduced for rural and urban areas respectively (see Annex 3 for maps). Both programmes are coordinated by the Department of Community, Rural and Gaeltacht Affairs (a relatively new ministry that was established in 2002 and which now also has responsibility for the National Drugs Strategy). The principle of "additionality" is central to both CLÁR and RAPID, which means that approved projects are meant to obtain matching funding from other Government departments, state agencies and Local Authorities. Public/Private Partnerships are also encouraged. The measures covered by the programmes include "physical, social and community infrastructure", which obviously gives scope for a wide range of initiatives broadly or specifically relevant to alcohol and drug issues.
4.2.1 Revitalising disadvantaged areas
CLÁR areas (Ceantair Laga Árd-Riachtanais) were selected on the basis of population decline between 1926 and 1996, and the programme is intended to combat the negative effects of this depopulation, such as withdrawal of services and loss of development funding. Following an analysis of the 2002 Census data, the CLÁR areas were reviewed and extended. Substantial sections of the GMR region are now included: North-West, North-East and South-East County Galway, most of County Mayo , and the Northern half of County Roscommon (plus a strip adjoining the North-East Galway CLÁR).
RAPID ( Revitalising Areas by Planning, Investment and Development ) is a focused Government initiative targeting the most concentrated urban areas of disadvantage in the country. Strand 1 was confined to the major urban areas, and Strand 2 focuses on certain provincial towns. There are several RAPID areas within the GMR region: Ballinasloe, Tuam, designated neighbourhoods of Galway City (Ballybane, Ballinfoile, Bohermore, New Mervue and Westside), and the Monksland area west of Athlone. Although each RAPID area may have its own particular concerns, the broad priorities typically include health, education, childcare, community facilities, sport & recreation, youth development, substance misuse and community policing. Problems such as lack of recreational and diversionary activities for youth, sale of alcohol to minors, underage and "bush" drinking, illicit drug use, antisocial behaviour, vandalism, crime and lack of community policing are recurring themes in RAPID areas, and are being addressed in the Local Action Plans of the Area Implementation Teams (Doherty, 2003). The Task Force needs to work in close collaboration with these initiatives going forward.
4.2.2 Social Inclusion Measures Working Groups
The Social Inclusion Measures Working Groups of the County Development Boards "have proved successful in providing a networking forum where social inclusion stakeholders can meet, discuss issues and share information [and have] increased awareness of social inclusion issues and assisted in breaking down traditional organisational barriers" (NDP/CSF Evaluation Unit, 2003:ii). Nevertheless, given that the SIM Groups' function is to coordinate at local level the delivery of the social inclusion measures of the National Development Plan, much greater progress needs to be made in terms of collaboration not just between all the relevant services but also between the relevant government departments. The NDP/CSF Evaluation Unit, evaluating the social inclusion coordination mechanisms, found that the coordination process has faced major constraints at national as well as at local level. These included
- The vertical nature of departmental organisational cultures
- Lack of flexibility to adjust spending programmes to local circumstances
- Lack of authority underpinning the local coordination function
- Absence of incentives to encourage organisations to eliminate duplication
- A general lack of priority attached to the objectives and work of SIM Groups by government departments and local delivery agencies.
At national level, "no cross-departmental framework agreements have been drawn up setting out clear principles for inter-departmental cooperation . nor has any specific department been appointed to lead on [this]" (NDP/CSF Evaluation Unit, 2003:iii). At local level, representatives on the SIMS groups reported that "no guidance from their parent departments and agencies had been received nor had any formal mandate or direction been provided" (p56).
Partnerships have improved the ways society collectively solves its problems and meets its needs (OECD, 2001). Local partnerships contribute positively to both the processes and the outcomes of social inclusion initiatives. Their potential benefits include better policy coordination and integration, as well as cost-effective, innovative and multi-dimensional approaches to social inclusion (European Foundation for the Improvement of Living and Working Conditions, 2003). However, these potential benefits will not be realised through purely local effort:
Governments have created networks of partnerships and given them goals to achieve, but without ensuring that the prospective partners could take an active and consistent part in the activities to reach these goals. Public services have rarely been required to integrate in their mission the policy objectives assigned to the partnerships in which they were expected to participate.
(OECD, 2001:125)
It would appear therefore that authorities and agencies at national level have experienced the same coordination difficulties that local partnerships are expected to overcome. The Western Region Drugs Task Force will suffer from the same problems if these fundamental issues are not dealt with. Many of the Social Inclusion Measures and Target Groups are highly relevant to Task Force objectives. It is important therefore that the work of the Task Force closely interconnects with the implementation of SIMs and other programmes, and that the necessary steps (including and especially those relating to resource allocation) are taken at appropriate level in government departments as well as in the various stakeholder organisations to ensure that strategies and operations are coherent, coordinated and complementary.
Social exclusion in the region involves multiple disadvantages which can only be addressed in an integrated way (Fitzpatrick Associates, 1999). One route to tackling coordination problems at local level would be to focus on outcomes for socially excluded target groups and to work towards a problem-solving agenda where a common problem is identified and a strategy to address this jointly agreed (NDP/CSF Evaluation Unit, 2003) .
4.2.3 Travellers
The Traveller Health Strategy (Dept. of Health & Children, 2002) states that not enough is known about the pattern and use of drugs and alcohol in the Traveller community and recommends that more research be conducted in this area. This lack of information applies to Travellers themselves as well as to service providers. However, drinking, smoking and related illnesses were among the most common issues identified by Travellers themselves when consulted on their health needs (Western Health Board, 2003).
The national Traveller Health Strategy seeks to promote awareness among the Regional Drugs Task Forces of the issues for Travellers in relation to drug use and to ensure that there is recognition and inclusion of Travellers in the development of strategies and plans.
The Traveller Health Strategy proposed a number of actions including the following:
- Any research into Traveller health and lifestyles to include research into the pattern of use of alcohol and drugs.
- Service providers in the area of substance misuse to be made aware of the results of research and of the importance of including Travellers in the planning and delivery of services.
- Ensure access to services is improved.
- Travellers will be involved in the design of targeted substance misuse prevention.
- Training of Traveller Community Health Workers around education and prevention approaches to substance misuse.
The Task Force has identified a need for research into substance use and related issues in the Traveller community, and recognises the importance of assertive outreach in meeting the service needs of this client group. Substance misuse initiatives in the Traveller community should be culturally appropriate and peer-led, "to enable Travellers to respond to misuse issues on their own terms" (Western Health Board, 2003:78).
4.2.4 Homelessness
A study of the health status of homeless people in the West (Hourigan & Evans, 2003) found that homeless people experience significant inequalities in health and are in particular need of health promotion interventions. Referring to substance use in this population group, the report stated that "addiction makes it difficult for those affected to break the cycle of homelessness". The main pathways to homelessness were a range of inter-related factors including addictions, mental health problems, relationship difficulties and poverty. 80% of the study participants were current smokers and 60% were current drinkers. Over half of current drinkers scored 2 or more on the CAGE alcoholism screening instrument, indicating alcohol problems. A quarter of those who used drugs had drug problems warranting further investigation, as indicated by the Drug Abuse Screening Test, while over a third had substantial problems requiring intensive assessment. The report recommended that "alcohol counselling and treatment services, including outreach facilities, should be reviewed with a view to increasing the uptake of services by homeless people".
A comprehensive study of substance use and homelessness in the country's four main urban centres (including Galway) was carried out in 2003, the first of its kind in Ireland (Lawless & Corr, 2005). The prevalence of substance misuse in the homeless population was substantially higher than in the general population. 70% of the study participants were drinkers, and half of this group had a high level of alcohol problems. 52% overall had used an illegal drug (mainly cannabis) in the last month, and of these almost two thirds were assessed as having a drug dependence problem. Nearly one in five of the total study population were engaged in concurrent problematic alcohol and drug use. Substance misuse was cited as both a significant cause of first becoming homeless and as a major factor in remaining homeless. 30% overall had ever been admitted to a psychiatric hospital and over half had been imprisoned. Although the prevalence of heroin use in the West was very much lower than in the Dublin area, its impact was still felt by homeless services. A need was identified by homeless service workers for low threshold facilities with a harm reduction orientation, including needle disposal and exchange facilities, that would help to engage and retain the more chaotic and high-risk drug users in the services generally.
These and other related issues are under active consideration by the Homeless Forum in Galway , who are at present assessing the needs of homeless persons with substance misuse problems and the possible services responses. Options being considered include a 'wet house' (where alcohol is permitted in the building) or 'low threshold facility' (where there is a greater tolerance of people staying in the building having consumed alcohol or drugs). There is no 'dry' hostel at this time, nor is there any street outreach. Meanwhile, there are few places available in community treatment programmes, and waiting lists are lengthy. Homeless services have called for a more client-centred approach to service provision that facilitates access and responds to the particular needs of homeless people with drug and alcohol problems. To respond to these issues, the Task Force has identified a need for a Community Substance Misuse Worker to provide specialist services for the homeless agencies. The Task Force also now has a representative on the Homeless Forum and will therefore be closely involved in future developments.
4.2.5 Prisoners
There is one prison in the GMR area, Castlerea, which caters for male offenders aged 17 and over. The prison's committal region comprises all of Connacht , plus the counties of Longford, Donegal, Cavan and Monaghan, but prisoners may also be transferred to Castlerea from other prisons around the country. The total number of committals (convicted and remand) to the prison during 2003 was 1431, the daily average number in custody being 195, or 102% of bed capacity (Irish Prison Service, 2004). In 2004, 54% of prisoners were from within the GMR area - 35% from County Galway (84% of these from Galway City ), 15% from Mayo, and 4% from Roscommon - and 75% of prisoners were unemployed (Roscommon Partnership, 2005).
The Task Force must be cognisant of issues relating to prisoners' drug and alcohol problems that may become apparent not just during their incarceration in Castlerea but also pre-sentencing and post-release. Anecdotal reports from service providers familiar with the prison suggest that substance misuse is very prevalent. " There is little doubt but that much crime leading to imprisonment results from substance (including alcohol) misuse", therefore tackling drug addiction should be "a central part of any crime prevention strategy and measures to tackle [drug and alcohol] addiction in the prison system should be intensified and given greater priority" (National Economic & Social Forum, 2002:44).
A wide range of individual and group programmes is provided by Castlerea Prison to assist prisoners with addiction and other problems. Harristown House, situated beside the prison, was established in 1998 and is funded by the Department of Justice, Equality & Law Reform through the Probation & Welfare Service (National Economic & Social Forum, 2002). It offers a six-week residential programme providing addiction treatment for up to 12 men at a time. This is followed by a two-year aftercare support programme, involving the participants and their families. An addiction counsellor from the HSE Western Area Drugs Service attends the prison one day per week. Voluntary agencies, such as Alcoholics Anonymous, also visit the prison and "engage with a large number of prisoners" (Irish Prison Service, 2004:41). A new initiative, the You Are Equal project, is working on developing the employability of former prisoners (Roscommon Partnership, 2005) . This project is a network of statutory bodies and community/voluntary groups that work with serving and former prisoners, and focuses on both securing and maintaining employment by addressing issues such as homelessness, addiction and personal development.
It is evident, however, that need outweighs the services currently available and that more and better coordinated services are required within the prison. There is also a need for well-coordinated follow-up services to assist prisoners and their families in resettlement and re-integration and to prevent relapse and re-offending. Waiting lists are too long, and sometimes this may result in a prisoner being transferred to another institution before receiving treatment or counselling, only to end up back at the end of another waiting list elsewhere. Protocols regulating access to treatment may vary from one prison, agency or administrative region to another, which complicates referrals both within the prison system and after release. Barriers such as these only serve to obstruct and discourage prisoners who are trying to seek help.
In addition to the need for a comprehensive response to problems with treatment service provision, significant institutional reform is also required. The National Economic & Social Forum (NESF, 2002:48) recommended that, with prisoner re-integration as a key goal, "all prisoners under sentence should have a comprehensive Sentence Management Plan developed on committal by a multi-disciplinary team with the cooperation of the prisoner and in consultation with other stakeholders". Prisoners' addiction treatment needs should be put in place as part of their Sentence Management Plan, and the health services should ensure that all prisoners on treatment programmes in custody have their treatment continued on release. However, two years later the NESF, while acknowledging the positive developments that have taken place in the Prison Service, stated that it was "concerned at the pace of change in some instances, such as the system of Positive Sentence Management which has not yet come on stream" (National Economic & Social Forum, 2004:9). Difficulties with implementing cost-cutting measures initiated by the Department of Justice, Equality & Law Reform are also having a detrimental effect on some promising and effective rehabilitative programmes for prisoners (Lally, 2005). It is important that Castlerea prison should not be adversely affected by these difficulties and that existing programmes and initiatives are supported and strengthened. |
