The Role of Intrapersonal Factors on Alcohol and Drug Use Among Latinos With Physical Disabilities

Abstract

Persons with disabilities are disproportionately impacted by alcohol and drug use. Social work best practice approaches require an understanding of the effects of intrapersonal factors on alcohol and drug use, yet the theoretical and empirical literature remain underdeveloped, especially among ethnic minority populations. We sought to obtain a detailed description of the role of intrapersonal factors, including perceptions and life experiences, on alcohol and drug use among Latinos with physical disabilities. We employed community-based participatory research in conjunction with photovoice. A total of 17 focus group interviews were completed. Three rounds of photography and focus group interviews occurred with a total of 28 participants who participated in each round. Data analyses followed the tenets of descriptive phenomenology. Results highlight intrapersonal risk and protective factors to inform social work practice and work toward developing and evaluating alcohol and drug use preventive interventions for this overlooked and vulnerable population.

Persons with disabilities constitute the largest minority group in the United States (Brault, 2008). In fact, there are approximately 56.7 million people in the United States who report having a disability; they constitute 18.7% of the total U.S. population (Brault, 2012). For the purposes of this study, physical disability was defined as a physical impediment that limited the individuals’ ability to perform normal and daily activities, with a minimum duration of at least 3 months (Russell, Turner, & Joiner, 2009; Turner, Lloyd, & Taylor 2006). The onset and severity of disability can vary across the life span. For example, whereas some people might be born with a disability, others could become disabled at various times throughout their life span (Grant, Flynn, & Ramcharam, 2010). Age-adjusted prevalence rates of disability indicate that 17.8% of the Latino population (a total of 52 million) report having a disability, slightly higher than 17.6% among non-Hispanic whites and lower than the 23.2% reported by Blacks (Brault, 2012).

In spite of the fact that narrowing health inequities among persons with physical disabilities has received recognition as both a national and international public health priority, social work researchers and service providers have yet to fully take up this task (Institute of Medicine, 2007; O'Brien, 2011). Of particular concern with respect to health inequities among persons with disabilities refers to alcohol, including binge drinking, and drug use. A substantial amount of studies suggest that persons with physical disabilities are disproportionately impacted by alcohol and drug use, as compared to persons without physical disabilities (Hubbard, Everett, & Khan, 1996; Smedema & Ebener, 2010; West, Graham, & Cifu, 2009). Latinos with physical disabilities might be at even greater risk of alcohol and drug use. For example, when compared to their non-Latino White counterparts, Latinos with physical disabilities are more likely to report past-year alcohol abuse and dependence (Turner et al., 2006). Research has highlighted the ways in which intrapersonal factors play a key role in the etiology of alcohol and drug use (Abrantes, Brown, & Tomlinson, 2003; Chong & Lopez, 2008; Cordova et al., 2011; Witkiewitz, 2011). Although various lines of research have indicated increased risk for alcohol and drug use among persons with physical disabilities and intrapersonal factors as key antecedents to alcohol and drug use, this research remains underdeveloped among Latino populations. Therefore, the purpose of this study was to obtain a detailed description of the role of intrapersonal factors, including perceptions and life experiences, on alcohol and drug use among Latino adults with physical disabilities.

SUBSTANCE USE AND PHYSICAL DISABILITY AMONG LATINOS

Alcohol, including binge drinking, and drug use represent significant public health concerns facing adults in the United States. Latino adults with physical disabilities are disproportionately affected. For example, in an epidemiologic study conducted by Turner and colleagues (2006), Latino adults with physical disabilities were more likely to report drug abuse, relative to both non-Latino Whites and African Americans with and without disabilities. This is of concern given that alcohol and drug abuse have been associated with a myriad of adverse social, health, and mental health outcomes (Caetano, 2003; Mulia, Ye, Greenfield, & Zemore, 2009).

Developing meaningful social work preventive interventions requires a better understanding of the etiologic factors of alcohol and drug use in Latino adults with physical disabilities. Researchers have identified a number of risk and protective factors for alcohol and drug use behaviors in the general population. Essentially, these risk and protective factors can be grouped in two domains, namely intrapersonal (e.g., psychological, cognitive, emotional, beliefs, and attitudes) and ecodevelopmental (e.g., family, peers, school, community; Prado et al., in press). Because this study focuses on intrapersonal factors, we limit this discussion here to those risk and protective factors. Understanding intrapersonal risk and protective factors is important to ameliorate alcohol and drug use. For example, research has highlighted the ways in which intrapersonal factors, including disapproval of substance use (Chong & Lopez, 2008; Prado et al., in press; Vilamovska, Brown Taylor, & Bluthenthal, 2009), favorable attitudes toward substance use (Cordova et al., 2011; Tobler, Livingston, & Komro, 2011), and intrapersonal distress (e.g., depression, low ego integration; Brook, Ning, & Brook, 2006), have been shown to be risk or protective factors for alcohol and drug use among Latino populations. These studies, however, have not focused on Latino adults with physical disabilities (Chapman & Wu, 2012; Ebener & Smedema, 2011; Smedema & Ebener, 2010). Furthermore, in addition to intrapersonal factors, Latino adults with physical disabilities are also likely to experience social and cultural ecodevelopmental barriers that decrease their opportunities to engage in culturally responsive alcohol and drug use social work preventive interventions (Lezzoni, 2011). Therefore, we sought to answer this question: What is the role of intrapersonal factors, including perceptions and life experiences, on alcohol and drug use among a sample of Latino adults with physical disabilities residing in Los Angeles, California?

SETTING AND METHODS

Located in Los Angeles, California, we were successful at engaging as collaborators five community-based organizations (CBOs) serving Latinos and persons with disabilities. More specifically, we targeted CBOs located in Service Planning Area (SPA) 7, also referred to as East. SPA 7's population is approximately 1.38 million, of which 70.5% identify as Latino and 18.5% report having a disability. Thirty percent of people living in SPA 7 report not having graduated high school and 14% of the population report household incomes less than 100% of the federal poverty level (Office of Health Assessment and Epidemiology, 2009). This study was conducted from May 2008 through April 2010. It was approved by the Michigan State University Institutional Review Board and a certificate of confidentiality was obtained through the National Institutes of Health.

Recruitment and Sampling

A community-based participatory research design was used to ensure the collaborative nature of this study and included a community advisory board (CAB) consisting of stakeholders with strong ties to the Latino disability community (Isreal, Eng, Schultz, & Parker, 2005; Minkler & Wallerstein, 2003). The CAB participated in all aspects of the research, including the development of the interview guide; defining the inclusion and exclusion criteria; recruitment, engagement, and retention of participants; and data analytic procedures (Isreal et al., 2005; Minkler & Wallerstein, 2003).

Eligibility criteria were established in collaboration with the CAB. To be eligible for this study, participants had to (a) identify as Latino or Hispanic; (b) report having a disability, defined as a physical impediment that limited the individual's ability to perform normal and daily activities, with a minimum duration of at least 3 months; (c) report past year alcohol or drug use as indicated by the National Survey on Drug Use and Health past year substance use or past year binge drinking (Substance Abuse and Mental Health Services Administration [SAMHSA], 2007); and (d) be between the ages of 18 and 35. Therefore, only those participants who reported past year alcohol or drug use were included in the study. In collaboration with the CAB, we conducted community presentations and distributed fliers via face-to-face meetings at the CBOs and sites frequently attended by Latinos with disabilities, including churches, health care and community centers, fairs, and cultural events. Additionally, word-of-mouth and snowballing methods were employed. To work toward providing participants ownership of the project, we offered participants a $5 gift card for referrals of potential participants (Umaña-Taylor & Bámaca, 2004). Potential participants were screened either face to face at a location convenient for them or by phone. Eligible participants were then invited to an introduction and training session on the use of photovoice. Those potential participants who maintained interest were enrolled in the study.

The study sample consisted of 28 Latino adults with physical disabilities aged 19 to 35 years (M = 27.65, SD = 5.48). To ensure women (n = 14) and men (n = 14) were equally represented, participants were stratified by gender. The mean age of disability onset was 16.82 (SD = 6.72, range = 11–35). Eighty-two percent of participants reported being U.S.-born. Approximately 68% of participants identified as Mexican or Mexican American, followed by El Salvador (17.8%), Honduras (10.7%), and other (3.5%). Sixty-five percent of participants reported not having graduated from high school, 71% of participants reported being unemployed, and 61% of participants reported an annual household income of $25,000 or less. Although there are many approaches to categorizing disability, including medical models, social models, demographic categories, and federal programs (e.g., Social Security disability insurance), the International Classification of Functioning, Disability, and Health (ICF), used by the U.S. Census, attempts to bridge many of these definitions. Additionally, these categorizations aim to be more specific as to the type of disability, relative to more broad categories, and thereby “personalize” the type of disability (Waldman, Cannella, & Perlman, 2011; Waldman & Perlman, 2006). Employing the categories of disability established by the U.S. Census Bureau, 21% of participants reported difficulty lifting heavy objects, followed by difficulty bending (15%), using a wheelchair (14%), visual impairment (14%), hearing impairment (11%), limited leg movement (11%), and amputation and limited arm movement (7%), respectively. The most widely reported substance use was past year binge drinking (75%; defined as four or more drinks in one setting for women and five or more for men; Chen, Balan, & Price, 2012; SAMHSA, 2012). It is important to note that some research defines binge drinking as four or more drinks for females and five or more drinks for males within 2 hours (National Institute on Alcohol Abuse and Alcoholism [NIAAA], 2012). Therefore, it is possible that reports of binge drinking might be inflated when compared to the definition employed by the NIAAA.¹ Binge drinking was followed by marijuana (nonmedical; 34%), methamphetamine (32%), cocaine (29%), crack (11%), ecstasy (11%), heroin (7%), other hallucinogens (7%), and PCP or angel dust, LSD or acid, inhalants, benzodiazepine, and Vicodin (nonprescription; each at 4%), respectively.

Data Collection and Analysis

We employed photovoice methodology (Wang & Burris, 1994, 1997; Wang & Redwood-Jones, 2001) and focus group interviews in the collection of data. Photovoice has been employed with numerous minority populations, including Latinos (Jurkowski & Paul-Ward, 2007; Streng et al., 2004) and persons with disabilities (Hergenrather, Rhodes, & Bardhoshi, 2009; Newman, Maurer, Jackson, & Saxon, 2009). Grounded in Freire's pedagogy of the oppressed, feminist theory, and photographic imagery, the photovoice method constitutes an alternative to promote empowerment with disenfranchised populations. Feminist theory is also at the core of the photovoice methodology. From this perspective, research agendas can be influenced by patriarchal structures that tend to overlook or ignore the experiences of minority groups, including the disability community (Wang & Burris, 1997). Research on the impact of the photovoice method on participants indicates a process of empowerment as they gain awareness of their experiences and reflect about alternatives to promote social change (Carlson, Engebretson, & Chamberlain, 2006). Limitations of the photovoice method include the potential for high costs (e.g., cameras, film development) and a substantial time commitment from both the research team (tracking and matching photos to participants) and participants (e.g., taking photos, participating in multiple interviews; Wang & Burris, 1997). Additionally, a number of ethical considerations are warranted (e.g., consent to have picture taken, consent to publish pictures) as researchers have little control over participants when they are out in their community taking photos (Wang & Burris, 1997).

A semistructured interview guide was developed in collaboration with the CAB. To identify intrapersonal factors, participants were first asked an open-ended broad question: “Please describe your life experiences as a Latino/a with a disability particularly as it relates to substance use.” This approach aimed to privilege the voices of participants and minimize researcher bias. The interview guide was gradually modified in subsequent focus group interviews to include probes for themes that participants identified as most relevant that were not included in the original interview guide (Parra-Cardona, Cordova, Holtrop, Villarruel, & Wieling, 2008; Parra-Cardona et al., 2009). For example, additional probes included, “Wanting to escape: Some of you mentioned wanting to escape and how this increased your drug use. Can you tell me more about that experience? What did you want to escape from?,” or “Wanting to do something with myself: Some of you expressed your inner strength as a protective factor to overcome substance use. Can you tell me more about that?” Also aimed at minimizing researcher bias, all focus group interviews ended with the question, “Please talk about any issues that I did not address and that you consider important in describing your experiences as a Latino with a disability and substance use.”²

We implemented three rounds of photography and focus group interviews (Wang & Burris, 1994, 1997; Wang & Redwood-Jones, 2001). A total of 17 focus group interviews were conducted including 28 participants. Focus groups ranged in size from 2 to 7 participants. The same participants were interviewed in all three rounds and focus group interviews consisted of different members of the 28 participants from session to session. The first two rounds focused on promoting a process of reflexivity regarding the participants’ intrapersonal perceptions and experiences (Hussey, 2006; Killion & Wang, 2000; Porter, 1995; Stewart, Shamdasani, & Rook, 2007). The last round focused on ensuring trustworthiness of the data by sharing with participants our understanding and descriptions of intrapersonal factors, including perceptions and life experiences (Guba & Lincoln, 1989; Morrow, 2005). Although participants were given the option to participate in a predominately English- or Spanish-speaking focus group, all focus group interviews were conducted primarily in English. Data collection took place over the course of 20 weeks.

Prior to conducting the three rounds of photography and focus group interviews, we held an introductory, joining, and training session. The training session focused on discussing with participants the benefits of using a camera in this type of research, the specifics about handling a camera, and ethics associated with this method of data collection (Wang & Redwood-Jones, 2001). After completing a training session, participants were given a flash camera and instructed to take photos based on the grand tour question, “Please describe to me your life experiences as a Latino/a with a disability particularly as it relates to substance use.” Participants were given 2 weeks after the training session to take their pictures. At the end of this week, the cameras were collected and taken to a film-developing center for processing. All cameras and photos were numbered to ensure rigorous tracking and matching of photos to participants (Berkowitz & Nowell, 2003). Pictures were then returned to each participant, who was given a week to reflect on his or her pictures taken to prepare for the focus group interview. Each round was conducted approximately every 4 weeks to ensure adequate time for picture taking, film processing, and the implementation of the focus group interviews. These procedures were repeated in the second round of photography and focus group interviews. The third and final round was limited to only a focus group interview. The third focus group interview aimed to ensure that our descriptions of the most relevant intrapersonal factors were accurate, thereby establishing trustworthiness of the findings (Moustakas, 1994; Porter, 1995). All participants received a $30 honorarium for each of the three rounds of photography and focus group interviews.

The first author transcribed verbatim the digital audio recordings of the 17 focus group interviews. Once transcription was completed, the first author reviewed all of the transcripts and the second author reviewed 25% of the transcripts for accuracy. The analysis of transcribed data followed a sequential iterative process and was conducted according to the descriptive phenomenological approach because the purpose of phenomenology is to describe intrapersonal experience as it is lived and understood by people (Porter, 1995). The first and second authors were involved in the preliminary analysis and differences in codes were discussed until consensus was reached. Additionally, emerging themes were presented to the CBO and CAB during the collection of data. The CBO and CAB then provided minor revisions with respect to the emerging themes, and identified additional probes to ask during the subsequent focus group interviews. Once all of the focus group interviews were completed, the first author presented preliminary findings to the CBOs, CAB, and participants, and a detailed analysis was conducted that included revising findings according to their feedback. Given that the CAB was involved in the development of the interview guide, combined with the third round of focus group interviews consisting of member checks, minor revisions took place based on the CAB and participants’ feedback. Differences in themes were discussed until consensus was reached. We used NVivo 8 software to complete all qualitative data analyses (QSR International, 2008).

FINDINGS

The analytic process led to the identification of four phenomena out of 464 original intentions (see Table 1). We categorize these phenomena as intrapersonal risk and protective factors of alcohol and drug use. Because of space limitations, we do not describe all of the photographs that were shared in detail.

TABLE 1.

Analytic Process

Research questions	Features and phenomena	Descriptors and component phenomena	Intentions
What are the intrapersonal risk and protective factors of Latinos with disabilities who report substance abuse?	Experiencing the struggle of living with my disability	Experiencing pain and sadness	1. Crying about my life and wanting to die 2. Experiencing despair when feelings come back
		Trying to escape and forget about my disability	1. Trying to put aside and forget that I have a disability 2. Turning to drugs to escape from my disability and mental health problems 3. Losing my children to drugs
		Feeling inferior to others	1. Seeing myself as damaged goods 2. Having limitations
		Wishing I could be saved	1.Wanting family support 2. Wanting support from friends
	Not giving up and wanting to change	Not giving up	1.Getting up, fighting, and deciding to get my life back 2. Wanting to break the cycle
		Finding a motivation to change	1.My strength comes from within 2. Wanting to change for my kids 3. My job, giving me a reason to live
		Trying to define my new identity with a disability	1. Wanting to be comfortable with myself 2. Wanting to be normal just like you
	Accepting and embracing my disability	Getting a taste of being myself again	1.Being myself again 2.Accepting my limitations
		Learning to adapt	1.Adapting to my disability 2. No longer seeing my disability as a disadvantage 3. Learning to accept myself so others can accept me
		Wanting to be able to do things on my own	1. Not wanting people to feel sorry for me 2. Not wanting to completely depend on others 3.Me as a person first
	Wanting that bond and closeness from family and community	Wanting that bond and closeness with my family	1. Wanting my family to understand 2. Wanting a better relationship with my family 3. Wanting a bond and closeness
		Learning to understand that they don't understand	1. Wanting community to understand addiction and disabilities 2. Wanting mental health professionals to become accountable and “get it” 3. Wanting my community to become accountable

Intrapersonal Risk Factors

Experiencing the struggle of living with my disability

Participants reflected on photos highlighting intrapersonal perceptions and experiences that increased their risk for alcohol and drug use. Specifically, four aspects of experiencing the struggle of living with my disability emerged as common themes in participants’ reflections, including: (a) experiencing pain and sadness, (b) trying to escape and forget about my disability, (c) feeling inferior to others, and (d) wishing I could be saved.

Experiencing pain and sadness

Participants described in great detail photographs representing intense feelings of loss, sadness, and despair experienced in relation to their disability. Participants shared that such experiences increased their risk for alcohol and drug use. Some participants openly shared no longer wanting to live. One participant reflected on a photograph and expressed:

Being in a wheelchair, it's been really hard. I was really depressed . . . I wanted to die. I didn't want to face society. I didn't want to see the things that they would say about me . . . When I was in the hospital, I said, “God, please kill me!”

Trying to escape and forget about my disability

Participants reflected on photographs and shared the ways in which they wanted to escape and forget about the challenges resulting from having a disability. Given the intense emotions experienced with regard to disability, combined with the perceived shame and stigma of the larger societal context, mental health challenges were commonly reported. In an effort to cope with distressing experiences, participants expressed a desire to escape mental health challenges through alcohol and drug use. One participant shared a photograph and expressed, “My disability pushed me to use drugs and I made the situation worse . . . it was because of my depression though which pushed me to use.”

Participants explained alcohol and drug use as a means to numb the emotional pain and suffering. One participant reflected on a photograph and affirmed, “You want to get to that point where you're just numb. And you stay numb. You isolate, you stay numb.” Similarly, another participant explained, “That was like the best thing of using [drugs] because all that feeling would just go away.”

Participants reflected and shared in great detail the cycle of alcohol and drug use to cope with feelings of despair and profound sadness. One participant shared a photograph:

When I'm not using [drugs], that's when I really feel depressed. There are days that I wake up and I just feel like laying there and crying in bed all day. . . . All my feelings that I hate to feel, they just come right back.

Feeling inferior to others

Because of negative perceptions with respect to disability within their ecological context, participants indicated perceptions of inferiority relative to their nondisabled counterparts. Participants shared that these perceptions increased their risk for alcohol and drug use. One participant shared a photo: “There's going to be some type of repercussion from your injury period. There is nothing that will heal us where we are going to be 100%. We're going to have limitations.” Similarly, another participant shared, “We have physical scars that we can actually touch, not to mention feel. It's just that feeling of inadequacy.”

Wishing I could be saved

Having the support of family was extremely important for all participants in this study. Participants affirmed that having family support was paramount to facilitate change and work toward improving their health, particularly as it relates to alcohol and drug use. Unfortunately, some participants shared intrapersonal experiences of feeling misunderstood, which led to alcohol and drug use. One participant commented, “I would get high because they don't understand what I've been through.”

Participants reflected on how fast alcohol and drug use can develop, as well as their hopes that somebody had intervened to help prevent and reduce their alcohol and drug use. One participant described:

It's a shame to me, when I just wake up months later when I start feeling bad about my drug use and I just reflect. When I'm on drugs, I like it but then there's that part of me that wishes I could get some help from my family or I could be saved, or that things don't have to be this way.

Narratives such as these demonstrate the significant impact negative intrapersonal processes might have on alcohol and drug use among Latinos with physical disabilities. Participants reflected on experiences of feeling “less than” and not wanting to face society for the fear of shame and stigma. Research has demonstrated that Latinos in general experience significant ecodevelopmental challenges, including perceived discrimination, stigma, and social exclusion because of their ethnic background (Cordova & Cervantes, 2010; Dovidio, Gluszek, John, Ditlmann, & Lagunes, 2010). These experiences might be more pronounced when also identifying as a person with a disability. Thus, it is important to consider how identifying as a Latino and the ensuing ecodevelopmental challenges could impact intrapersonal factors.

Intrapersonal Protective Factors

Not Giving Up and Wanting to Change

Some participants shared photographs representing intrapersonal experiences aimed at overcoming negative perceptions and life experiences of disability, thereby reducing risk of alcohol and drug use, including (a) not giving up, and (b) finding a motivation to change.

Not giving up

Despite the numerous challenges they face, participants expressed a strong desire to overcome the adversity in their lives, including alcohol and drug use. One participant commented on a photograph:

Obviously it's in us to want better. The cry for help, we know that somebody believes in us and it just makes us not give up on ourselves. If we try, something good has to come out of all this badness. If we just try, one day everything is going to be better.

Finding a motivation to change

Participants described intrapersonal experiences of identifying motivational factors aimed at preventing and reducing alcohol and drug use. Obtaining and maintaining employment was a salient and central motivational factor among participants. They shared how their job constitutes a significant source of strength to their development and autonomy. Specifically, participants reflected on how having a job not only provided them with financial resources, but more important, gave them a reason “to wake up” and “live.” Additionally, participants shared intrapersonal experiences of how having formal employment constitutes a protective factor against alcohol and drug use. One participant mentioned:

And in this picture, this is where it all goes down for me 8 to 10 hours a day. I'm happier in this room than when I would isolate in my own room doing drugs. . . . And holding a job and being responsible with my coworkers to handle this office and manage this office is a strength that I'm going to be able to use and carry on with.

Participants also expressed how having a job provided them with the opportunity to no longer perceive their disability as a disadvantage. One participant affirmed:

I'm very fortunate to work ’cause I don't see my disability as a disability or a disadvantage. When I speak out to the kids here who might be going through things that I've gone through, I like to think that, “Hey, this guy has a disability. He's gone through something similar to what I've gone through. If he can do it and he's got a disability, why can't I?”

Through these photographs, participants reflected on how intrapersonal factors, including the experiences of having employment opportunities, facilitated them no longer perceiving their disability as a disadvantage and served to prevent and reduce alcohol and drug use. Unfortunately, as previously mentioned, 71% of participants in this study reported being unemployed. Thus, although this intrapersonal experience might help them combat alcohol and drug use, the majority of participants reported not having employment at the start of this study.

Accepting and embracing my disability

Some participants reflected on the ways in which positive intrapersonal perceptions and experiences decreased their risk for alcohol and drug use. These intrapersonal experiences included (a) getting a taste of being myself again, (b) learning to adapt, and (c) wanting to be able to do things on my own.

Getting a taste of being myself again

Participants described their efforts to define a new identity with a disability. Experiencing a sense of normalcy served as a strong motivational factor to continue to work toward accepting their new identity, inclusive of their level of ability, and prevent and reduce alcohol and drug use. One participant shared a photograph:

The more I get a taste of being myself again, being what I was before my disability, it makes me want to keep going. You feel so bad about not being you. And then when you do things that make you feel normal, it's like that endorphin rush. You forget all about that. I think for me, once I get a taste of being normal again.

Learning to adapt

Some participants reported intrapersonal experiences of learning to adapt and described perceiving their disability as a strength, which in turn prevented alcohol and drug use. Participants expressed that adapting to life challenges has been something that they have had to do all of their lives and adapting to their disability is just one more challenge for them to overcome. One participant described a photograph:

I have limitations, that's all. I have to learn to work with them. I have to deal with them. I have to adapt. Being a Latino that's been on drugs and alcohol, and made my life miserable . . . I've had to adapt always one way or another. I always had to adapt and this is just another thing that I adapted to.

In working toward adapting to their disability, participants shared the intrapersonal processes by which they no longer perceived their disability as a disadvantage, thereby embracing their disability. One participant stated, “And that's not the case today . . . I don't feel bad about my disability. The case is, I'm just like you . . . I'm cool right here where I am today.”

An important aspect of intrapersonal processes by which participants no longer perceived disability as a disadvantage refers to participants focusing on their level of ability in contrast to focusing on limitations. One participant described a picture of himself and another person with a disability accom plishing a task. He expressed, “So that's what that picture represents, that two friends can actually do things together having disabilities.”

Wanting to be able to do things on my own

Participants expressed that an important intrapersonal factor in working toward adapting to their disability is having a sense of autonomy and independence. To facilitate this process, participants stressed the importance of not wanting others to feel sorry for them because of their limitations, and wanting others to recognize them as a person first rather than focusing primarily on their disability. Additionally, participants indicated the importance of not wanting to completely depend on others to accomplish activities of daily living. By not depending on others, participants were able to experience a restored sense of independence, which in turn prevented and reduced alcohol and drug use. One participant reflected on a photograph:

I don't always want to depend on someone or someone to help me out. I want to be able to do things on my own as much as I can because one day, that person might not be there and I'm not going to be able to get that help. So that's why I want to learn how to do the things that I need to do.

One participant summarized the importance of not wanting to completely depend on others and how critical this is for his process of growth, “So now it's part of a growth process for me as a human being, as an individual, as a Latino, to be able to stand on my own two feet.”

Wanting closeness and better understanding

Participants described wanting a stronger bond and closeness with their family and community, as well as wishing that the community would develop a better understanding of disability and alcohol and drug use. Participants described the need for help in the community, including increased awareness, outreach, and engagement with regard to disabilities and alcohol and drug use.

Wanting that bond and closeness with family

Participants reflected on their desire and challenges to improve intimacy in their relationships, including bonding and closeness, aimed at facilitating open communication about difficult topics. Participants shared that critical issues, such as their disability and alcohol and drug use, were never openly discussed. One participant commented on a photograph:

I really think that our lack of communication and our lack of togetherness have been an underlying problem. It's not enough and I don't know how to express that and I don't want to bug her or make her feel bad for saying these things to her because I know that it will. We talk, but it's not like we get into a deep conversation. Not a lot of things get said and I don't know if they ever will. I really want that bond and closeness.

Reflections such as these show participants’ aspiration to openly communicate about challenges associated with disability and alcohol and drug use, as well as work toward improving family cohesion. Scholars have highlighted the important role family has in the lives of Latinos. For example, familismo is the Latino cultural value that refers to the value of close family relationships, interdependence, and family cohesion (Falicov, 1998). In fact, research has demonstrated that higher levels of family functioning, including communication and cohesion, have been shown to prevent and reduce alcohol and drug use in Latino populations (Cordova, Huang, Pantin, & Prado, 2012; Prado et al., 2012). Therefore, lacking family communication and cohesion might have an impact on intrapersonal processes and thereby increase the risk of alcohol and drug use in this Latino sample. Additionally, participants shared their reluctance to communicate their struggles as they perceived this to place a burden on others and “make others feel bad.” This highlights the nuances of familismo, which also stresses one's willingness to sacrifice for the importance of the family (Falicov, 1998).

Learning to understand that they don't understand

Participants reflected on their strong desire for the community to work toward a better understanding of both disability and alcohol and drug use issues. Participants also expressed the need for mental health professionals and service providers to become more accountable and responsive toward common challenges experienced by Latinos with disabilities. Finally, participants expressed a strong desire for their community to have accountability by promoting community-based alcohol and drug use preventive intervention programs tailored to meet the needs of Latinos with disabilities. For example, participants described the need for affordable alcohol and drug use programs, outreach to engage members of the community to participate in prevention services, an understanding of alcohol and drug use within the context of disability, and efforts aimed at reducing stigma associated with participating in interventions. One participant shared a photo: “I would really want more places out there so they could teach the community about people with disabilities.”

Participants highlighted intrapersonal processes demonstrating their ability to tolerate others’ lack of understanding with respect to disability and alcohol and drug use. In doing so, as described by participants, they were less likely to engage in alcohol and drug use and work toward health and mental health promotion. One participant reflected on this intrapersonal process:

Some people cannot relate to you . . . I found myself with mental health counselors that do not relate . . . And it takes a bigger person in me to understand that they don't understand . . . I have to catch myself and just take a moment of silence and just be, “Okay, well she doesn't understand.” . . . It's kind of complicated but that's how I see it . . . just patience with therapists . . . I wish they understood more.

Through stories such as these, participants shared their experiences with mental health service providers, including perceptions that mental health service providers lack understanding with respect to disability and alcohol and drug use. In spite of this perception, participants placed the burden on themselves of having “patience” and “understanding that they don't understand,” rather than addressing this with their therapist. The Latino cultural values of respeto and simpatia might influence intrapersonal processes and thus impact interpersonal relationships such that participants might be reluctant to confront their therapists’ lack of understanding. The Latino cultural value of respeto (respect) refers to having respect for authority figures, and simpatia refers to the avoidance of interpersonal conflict through being polite and friendly (Falicov, 1998). Thus, confronting their mental health service provider might be perceived as lacking respeto and simpatia.

DISCUSSION

Findings from this study highlight the complex role of intrapersonal factors, including perceptions and life experiences, on alcohol and drug use among Latinos with physical disabilities. Participants reflected on a multidimensional intrapersonal process characterized by both positive and negative perceptions and life experiences that might impact alcohol and drug use. Previous studies with Latino populations have highlighted the ways in which negative intrapersonal factors are associated with increased risk for alcohol and drug use (Brook et al., 2006; Cordova et al., 2011; Tobler et al., 2011) and positive intrapersonal factors act as a protective factor (Prado et al., in press; Vilamovska et al., 2009). Unfortunately, there is a dearth of studies examining intrapersonal factors for alcohol and drug use among Latinos with physical disabilities (Chapman & Wu, 2012; Ebener & Smedema, 2011; Smedema & Ebener, 2010). These findings contribute to the literature by highlighting intrapersonal risk and protective factors for alcohol and drug use among a sample of Latinos with physical disabilities. However, the question still remains: How does identifying as Latino shape intrapersonal risk and protective factors for alcohol and drug use? Study findings lend some support to suggest that identifying as Latino, and associated Latino cultural values, might shape intrapersonal risk and protective factors. For example, some participants shared their strong desire to improve family communication and cohesion but were reluctant to do so because of perceiving that openly communicating about difficult topics might place a burden on others. This highlights the importance familismo and the value of placing others’ needs ahead of your own (Falicov, 1998). Thus, identifying as Latino could influence the role intrapersonal factors have on alcohol and drug use among Latinos with physical disabilities. Some research has shown the impact of intrapersonal and ecodevelopmental, including cultural and familial, factors on alcohol and drug use in Latino populations (Prado et al., in press). However, there remains the need for research to examine whether and the extent to which there is a synergistic impact of intrapersonal and ecodevelopmental factors on alcohol and drug use among Latino populations in general and Latinos with physical disabilities in particular.

Understanding intrapersonal processes is essential to improving the health and mental health of this population. For example, participants described intrapersonal processes reflective of a strong desire to have better intimate relationships with their families, as well as the ways in which families could aid in the process of preventing and reducing alcohol and drug use in this population. Research has demonstrated that family-based drug use preventive interventions are among the most efficacious for Latino populations (Sandler, Schoenfelder, Wolchik, & MacKinnon, 2011; Szapocznik, Prado, Burlew, Williams, & Santisteban, 2007). Unfortunately, there currently are no efficacious family-based alcohol and drug use preventive interventions specifically tailored to meet the needs of Latinos with physical disabilities. In fact, participants in this study expressed not feeling understood with respect to the intrapersonal experiences associated with disability and alcohol and drug use by mental health service providers. Thus, future studies should work toward identifying core components to include in a culturally responsive, family-based, social work preventive intervention for this population.

Results highlight intrapersonal risk factors where prevention social workers might be most effective at intervening. For example, participants shared the ways in which they perceive and experience negative intrapersonal themes of disability characterized by pain, sadness, and inadequacy. Themes, including, “Trying to Escape and Forget About My Disability,” “Feeling Inferior to Others,” and “Wishing I Could Be Saved,” constitute critical periods where social workers could be most effective in preventing and reducing problem behaviors, including alcohol and drug use. At the root of these intrapersonal factors, it appears that participants strived for close intimate relationships and for social network support, including community and mental health services. Unfortunately, in spite of striving to achieve these close relationships, negative intrapersonal perceptions and experiences might in fact perpetuate unintended isolation, which in turn could increase risk for alcohol and drug use (Tate, Brown, Unrod, & Ramo, 2004). Thus, social work researchers and service providers should be cognizant when working with this population of the potential impact of negative intrapersonal perceptions and experiences on alcohol and drug use among Latinos with disabilities. Noteworthy is that the mean age of disability onset in this sample is 16.82, a developmental age at increased risk of engaging in substance use behaviors (Centers for Disease Control and Prevention, 2012; Johnston, O'Malley, Bachman, & Scholenberg, 2012). Therefore, research is needed to understand whether and to what extent the onset of a disability in adolescence has an impact on intrapersonal factors and increased risk for alcohol and drug use over time.

It is worth noting that persons reporting visual impairment also participated in this study. Initially, we thought of excluding these participants, as we assumed that their impairment would prevent them from fully participating in this study. However, contrary to what we expected, participants reporting visual impairment were eager and able to fully participate and share their stories. Therefore, as researchers, it is important to challenge the assumptions we carry, as having excluded these participants might have further marginalized them.

LIMITATIONS

This study is not without limitations. First, a purposive sample was used in this study design. Thus, the generalization of the findings is limited. For example, this sample is not representative of the U.S. Latinos with physical disabilities population, and hence the results might not generalize to all Latinos with physical disabilities. A second limitation is the reliance on self-report measures of alcohol and drug use, which are vulnerable to social desirability effects (Podsakoff, MacKenzie, Lee, & Podsakoff, 2003). Third, we did not control for the onset of alcohol and drug use. Therefore, we are not able to ascertain whether alcohol and drug use was a result of the onset of the participants’ disability, or vice versa. Thus, future studies should employ longitudinal methodologies to better elucidate some of these factors. Fourth, only two members of the research team participated in reviewing the focus group interview transcripts for accuracy. Future studies should include more reviewers to ensure accuracy of transcripts.

Finally, recent discourse has emerged with respect to the terms disability, (dis) ability, and ability challenges. Some scholars have argued that the disability paradigm is reductive pathology and places an emphasis on individual disability characteristics and deficits. In contrast, the ability paradigm aims to focus on a person's level of ability rather than his or her impairment (MacEachen et al., 2011). For the purposes of this study, we employed the term disability. It is important to note that the conceptualization of the research design, including defining disability, was conducted in collaboration with multiple stakeholders, including people with disabilities. During this time, we explored the most appropriate term to use in this community, including disability, disability culture, (dis) ability, and level of ability. Disability seemed to be the most appropriate as recommended by the stakeholders. However, this term might or might not be appropriate in other communities. Therefore, there remains the need for empirical research to determine the most appropriate terminology and work toward a more just society (Devlieger, 2000).

CONCLUSION

The results reported here highlight the role of intrapersonal risk and protective factors for alcohol and drug use among Latinos with physical disabilities. Understanding and identifying risk and protective factors might be helpful for social work research and practice to ameliorate alcohol and drug use health disparities experienced by Latinos with physical disabilities and work toward the development and evaluation of social work best practices for this overlooked and vulnerable population.

FIGURE 1.

Wanting that bond and closeness (color figure available online).

FIGURE 2.

Learning to adapt (color figure available online).

FIGURE 3.

Wanting to do things on my own (color figure available online).