A scoping review of Aotearoa New Zealand women's experiences of substance use, alcohol and drug services

,


QUALITATIVE RESEARCH
Taonga will inform a doctoral research case study contributing to the limited evidence on experiences with healthcare services of women who use substances (WWUS), particularly when they are parenting.It is important to note that Te Whare Taonga is not a gender-inclusive service.Given this review examines historic literature, the language deployed around women who use substances and are pregnant and parenting for this article is similarly binary.However, it is important to flag that, as the landscape and language around motherhood shifts, social workers and service provider's framings must also be gender-inclusive (Polak et al., 2015).
Substance-use harm is a recognised problem in various social work settings and service user groups internationally.International research suggests that the number of women using drugs is increasing (Milligan et al., 2010;Seitz et al., 2019), with rates highest for those of reproductive age (Marcellus, 2017).Limited data are available on women's substance use in Aotearoa.However, problematic drinking affects one in five New Zealanders, with hazardous drinking highest among those aged 18-24 (35%) (Alcohol Healthwatch, 2020).Alcoholrelated harm in Aotearoa is estimated to cost up to $7 billion per year (Alcohol Healthwatch, 2020), while the total cost of loss of quality of life related to illicit drug use is estimated to be $328.6 million (McFadden et al., 2021).In addition, Māori are more likely to have problematic alcohol and drug use than non-Māori (New Zealand Drug Foundation [NZDF], 2020).Research has been conducted on substance and alcohol use in adolescence and throughout the lifespan in Aotearoa (Ball et al., 2022;Towers et al., 2018).However, there is a lack of research examining substance and alcohol use during different stages of the reproductive lifecourse.
Women with SUDs often have a unique set of risk factors, including histories of sexual and physical abuse, including intimate partner violence; coexisting mental health issues; eating disorders; and poverty (Brady & Randall, 1999;Milligan et al., 2010;Milligan, Usher et al., 2017).Pregnant women with SUDs face an increased risk of adverse health outcomes for themselves and their children, including complications during pregnancy, financial and legal consequences, and stigmatisation (Chou et al., 2018).Children whose mothers use substances when pregnant are at risk of neurodevelopmental and behavioural problems (Frazer et al., 2019).It is important to note that most pregnant women reduce or stop substance use when they know they are pregnant (Weber et al., 2021).However, some do not; in the UK, most women entering treatment are parents, and most women accessing treatment in the USA are either pregnant, parents, or both (Milligan et al., 2017).
While there are no statistics on pregnant women with SUDs entering AOD treatment in Aotearoa, a USA study in 2012 found that only 9% of pregnant individuals with SUDs accessed AOD treatment (Jansson & Velez, 2012).Furthermore, globally, only one in five women access AOD treatment despite comprising one in three individuals with SUD (United Nations Office on Drugs and Crime, 2015).As an example, in Australia, although half of regular methamphetamine users are women, they make up only a third of those seeking treatment (Clifford et al., 2023).Finally, women's perspectives on their substance-use experiences and preferences for residential AOD treatment are rarely included in the literature (Schamp et al., 2021;Shahram et al., 2017).Despite increased international research and practice to support pregnant and mothering women with SUDs, researchers acknowledge significant service gaps still exist (e.g., Heimdahl & Karlsson, 2016;Shahram et al., 2017;Suntai, 2021).Existing AOD and prenatal services for pregnant women fall short of providing specialist care for this population (Paris et al., 2020).

ORIGINAL ARTICLE
The motivation of WWUS to seek treatment for substance use when pregnant or parenting is complex.Mitchell et al. (2008) found that WWUS who are pregnant showed higher levels of motivation to change druguse behaviours than their non-pregnant counterparts.However, while WWUS may be motivated to change their behaviour, motherhood can act as a barrier to treatment due to concerns around child custody and limited services that can accommodate children (Adams et al., 2021).Additionally, some WWUS may lack the motivation to participate in formal AOD treatment programmes (Wilke et al., 2005).
Providing AOD treatment services for pregnant or parenting women is crucial as it can reduce substance use and improve parenting practices (Weber et al., 2021).Therefore, reducing the impacts of intergenerational trauma, increasing parental resilience, and providing pregnancy support to improve outcomes for parents and children (Weber et al., 2021).Social workers play a crucial role in service provision to people with SUDs.Gaining further insight into women's experiences of substance use and accessing health services can improve social work practice and health service provision (Wells et al., 2013).

Objectives
The researchers chose a scoping review to systematically map the research done in this area and identify gaps in knowledge (Pollock et al., 2021).The foci guiding this review were: 1) identifying literature that contains the voices (interviews/focus groups) of WWUS; 2) locating research that describes or evaluates AOD service provision for WWUS, including those who are pregnant or parenting; and 3) identifying the gaps within the knowledge.

Methods
We conducted a scoping review of the research literature published between 1992 and November 2022.The search criteria were broad due to the scarcity of literature found when searching within a 20-year date range.The Preferred Reporting Items for Systematic Reviews and Meta-Analyses: Extension for Scoping Reviews (PRISMA-ScR) methodological framework informed the design of this article (Tricco et al., 2018).
The scoping review includes: 1) establishing eligibility, inclusion, and exclusion criteria; 2) developing a search strategy and locating relevant studies; 3) selecting studies; 4) charting the data; 5) synthesising and reporting the results; and 6) discussing results and gaps within knowledge.The first author conducted the initial literature search and screening and then charted the sources by including titles, abstracts, executive summaries, and rationale for inclusion.This chart was then sent to the other two authors for screening and consensus on the final set of included articles and grey literature.The researchers used the PRISMA 2020 flow diagram to present the review process in a simplified manner (Figure 1).

Eligibility criteria
To be included in the review, literature needed to include first-hand accounts from WWUS, including those who were pregnant or parenting; and their experiences of substance use and health services in Aotearoa New Zealand.An appropriate  After the initial screening, full-text sources were evaluated according to inclusion and exclusion criteria.The reference list of each source was checked for other relevant studies, and an unpublished literature review which focused on AOD services for pregnant women or children was searched.

Information sources
The other authors were involved in the final selection of articles, especially in cases where there was uncertainty about the relevance of a source.Adapted from "The PRISMA 2020 statement: An updated guideline for reporting systematic reviews," by Page et al. (2021).).The fourth evaluated Te Ira Wāhine, an 8-week kaupapa Māori (Māori philosophy and principles) drugtreatment programme for women at the Auckland Regional Women's Correctional Facility (Morrison et al., 2021).
The four evaluation reports primarily had Māori participants, and one thesis specifically focused on Māori women's relationships and views on alcohol consumption during pregnancy.The other theses had mostly Pākehā participants, many of whom were tertiary educated.One journal article reported binge-drinking behaviour among New Zealand-born Niuean women (Gray & Nosa, 2009).The remaining sources did not report ethnicity due to small sample sizes and anonymity concerns.
All participants in the studies that reported on sexuality were identified as heterosexual, but one study included a trans man who had been treated as a woman while accessing services (Gibson & Hutton, 2021).Health workers were also interviewed in half of the sources.Many women had coexisting mental health and AOD issues and histories of abuse, neglect, violence, intergenerational alcohol and drug abuse, and disadvantage (Malatest International, 2022;Morrison et al., 2021;Parsonage, 2015;Vaughan, 1996).
After synthesising findings from the literature, four major themes were noted, along with significant sub-themes: 1. Aotearoa New Zealand Women's Experiences of Substance Use 2. Gendered Rules Shape Women's Substance Use 3. Pregnancy, Parenting and Substance Use 4. Experiences of Healthcare Providers and AOD Services

Aotearoa New Zealand women's experiences of substance use
Excessive alcohol use and binge drinking are common among women from Aotearoa, regardless of their ethnicity (Gray & Nosa, 2009;Pedersen, 2019;Stuart, 2009).Many women had their first experiences with AODs in their pre-teen or early-adolescent years, and some learned drinking and drug-use behaviour from their whānau at home, from partners, or from friends in social settings (Gibson & Hutton, 2021;Gray & Nosa, 2009;Handa, 2006;Morrison et al., 2021;Streatfield, 2022;Stuart, 2009;Vaughan, 1996).Women tend to use substances with similar groups of people at similar times and places, such as nightclubs, and parties (Gray & Nosa, 2009;Handa, 2006;Ramsay, 2014;Streatfield, 2022).The setting can also determine social pressures to drink, such as in the case of Māori women who may face isolation if they do not attend social gatherings like at sports clubs where they are pressured to drink (Stuart, 2009).

ORIGINAL ARTICLE
QUALITATIVE RESEARCH

ORIGINAL ARTICLE
Substance use can lead to increased risks such as arguments, fights, unsafe sexual behaviour, sexual harassment, rape and sexual abuse as well as blackouts and memory loss (Gray & Nosa, 2009;Pedersen, 2019).Consequently, some women reported drinking and drug taking with other women to minimise risks (Gray & Nosa, 2009;Ramsay, 2014;Streatfield, 2022).However, some women reported that methamphetamine use could lead to antisocial behaviour and isolation when they stopped sharing the drug with friends (Handa, 2006).

Gendered rules shape women's substance use
Societal views on gender and substance use was a theme of half of the studies.In several studies, women often tried to adhere to gendered norms around substance use to fit societal ideals of femininity and motherhood (Gibson & Hutton, 2021;Pedersen, 2019;Ramsay, 2014).For some, once children arrived, their drinking behaviour became more policed, publicly surveilled, and self-regulated (Pedersen, 2019).In contrast, fathers' drinking was seen as masculine and faced less scrutiny, benefiting from more social drinking opportunities due to the prevailing childcare responsibilities borne by mothers (Pedersen, 2019).
Women's adherence to "good mothering" ideology and acceptable feminine behaviour was found to be important in several studies, regardless of whether women were drinking, using illicit substances, on a methadone programme, or injecting drugs (Conroy, 2018;Gibson & Hutton, 2021;Pedersen, 2019;Ramsay, 2014;Spirrett, 1997).Women in Pedersen's (2019) study viewed deviating from good mothering ideology as lower class.Furthermore, Salmon's (2008) study showed that mothers of children with fetal alcohol syndrome disorder (FASD) experienced "mother blaming" when things went wrong in their child's life, with the mother being viewed as the cause of that behaviour (Salmon, 2008).
Four of the 16 studies highlighted women's attempts to challenge male-dominated conditions or societal norms (Gibson & Hutton, 2021;Pedersen, 2019;Streatfield, 2022;Vaughan, 1996).Women in one study engaged in recreational drug use, defying the expectation that only men engage in risk-taking behaviours or use illicit drugs (Streatfield, 2022).Some women in another study disregarded societal judgments and continued to take their tamariki to pubs and bars despite the judgement they faced for their mothering choices (Pedersen, 2019).
Gendered stereotypes of women who use substances as victims or sex workers were questioned in various studies (Gibson & Hutton, 2021;Handa, 2006).In one study, women reported self-injection, which provided a sense of empowerment and independence (Gibson & Hutton, 2021).None of the women in Handa's (2006) study were sex workers, countering the stereotype that sex work is often the only way women acquire drugs like methamphetamine (Handa, 2006).

Pregnancy, parenting and substance use
Substance use during pregnancy or parenting was a common theme across many studies.Half of the studies indicated that women continued to use substances in varying amounts while pregnant (Chan & Moriarty, 2010;Gray & Nosa, 2009;Handa, 2006;Malatest International, 2022;Parsonage, 2015;Pedersen, 2019;Salmon, 2008;Waitematā DHB, 2017).In Stuart (2009), Māori women followed certain unwritten Various factors motivated women and whānau to seek help with their problematic substance use.Pregnancy brought a sense of responsibility for children, whānau and future generations (Stuart, 2009).Once born, the pēpi (baby) was seen as a real person, which could bring about positive change (Stuart, 2009).Many tāngata whai ora and whānau were clients of Oranga Tamariki and had similar motivations for engagement with CADs Pregnancy and Parenting Service (PPS), such as retaining care of their tamariki or regaining custody (Malatest International, 2022;Parsonage, 2015;Waitematā DHB, 2017).

Experiences of healthcare providers and AOD services
Barriers and stigma within health services.Barriers to accessing healthcare services and maternity care were experienced by many women due to a lack of trust in services; communication difficulties; unclear or unhelpful information; and feeling misunderstood, stigmatised, and discriminated against (Chan & Moriarty, 2010;Gibson & Hutton, 2021;Handa, 2006;Malatest International, 2022;Salmon, 2008;Stuart, 2009).Institutional racism was identified as a significant obstacle for Māori accessing health and wellbeing services (Malatest International, 2022).Some Māori tāngata whai ora reported having felt "looked-down" upon and not engaging with other healthcare providers and community support groups before PPS engagement (Malatest International, 2022, p. 106).
According to several studies, stigma, whether perceived or actual, was found to reduce women's willingness and ability to engage with healthcare and pregnancy services and seek support from their social networks (Chan & Moriarty, 2010;Conroy, 2018;Gibson & Hutton, 2021;Handa, 2006;Spirrett, 1997;Vaughan, 1996).Some women reported experiencing discrimination when accessing services like methadone or needle-exchange services in pharmacies, which exacerbated feelings of shame and stigma (Conroy, 2018;Gibson & Hutton, 2021).Some women felt that pharmacy staff viewed them as more contaminated than male counterparts (Gibson & Hutton, 2021).
In contrast, most women in Conroy's (2018) research did not report experiencing stigma, but, for those who did, it significantly impacted their lives.Examples of stigma included being falsely accused of drug seeking or child abuse by hospital staff, leading to being reported to child protection services (Conroy, 2018).
Many women experienced barriers to accessing healthcare and maternity care due to lacking trust in services and communication.Vaughan's (1996) study found that some women viewed the label "alcoholic" as shameful and the most significant barrier to accessing treatment.This concern about disclosure led to difficulties with groups like Alcoholics Anonymous (AA) that required selfidentification as an alcoholic (Vaughan, 1996).

ORIGINAL ARTICLE
Negative experiences of healthcare workers.Several studies indicated that healthcare professionals, including general practitioners, lack practicespecific knowledge and information about problematic substance use, addiction services, harm reduction, FASD, and substance use during pregnancy (Chan & Moriarty, 2010;Conroy, 2018;Gibson & Hutton, 2021;Handa, 2006;Salmon, 2008;Stuart, 2009).For instance, Māori women did not perceive health professionals as a significant source of information about alcohol and pregnancy and some women experienced them as undermining (Stuart, 2009).Women in Salmon's (2008) study reported not being listened to, particularly by male doctors, and some felt insulted during consultations.
Some studies found that barriers to accessing appropriate healthcare services for women included receiving no information or conflicting messages about AOD use during pregnancy, such as neonatal withdrawal and breastfeeding (Chan & Moriarty, 2010;Handa, 2006).Handa (2006) found that women faced difficulties stopping methamphetamine use during pregnancy due to misinformation about its risks and lack of treatment facilities in Aotearoa.Additionally, Salmon's (2008) study showed that none of the women had heard of FASD when pregnant and would have stopped drinking had they known.After their child received a FASD diagnosis, these mothers sought help and knowledge from other mothers who also had children diagnosed with FASD (Salmon, 2008).
Strengths and weaknesses within AOD services.Conroy (2018) stated that an unexpected finding was that participants in her study reported generally positive experiences of AOD treatment in Aotearoa.
Several studies emphasised the need for holistic, wraparound services that address socioenvironmental factors and underlying mental health issues beyond substance use (Malatest International, 2022;Morrison et al., 2021;Spirrett, 1997).Women's diverse circumstances and needs highlighted the importance of individualised treatment, with tāngata whai ora involved in decisionmaking (Conroy, 2018;Spirrett, 1997).Women from two of the studies said building connections and feeling accountable to others on the same recovery pathway were crucial for positive programme experiences (Conroy, 2018;Morrison et al., 2021).
Women in multiple studies valued skilled and non-judgemental kaimahi (workers) who provided practical and unwavering support (Conroy, 2018;Malatest International, 2022;Morrison et al., 2021).Some women viewed Māori kaimahi as vital for programme engagement, while others emphasised the importance of service support and a nonjudgmental attitude over ethnicity (Morrison et al., 2021).Additionally, male kaimahi received positive feedback, and PPS sites in Northland and Hawkes Bay were trying to recruit male kaimahi (Malatest International, 2022; Morrison et al., 2021).Male kaimahi provided new perspectives on healthy relationships, which prompted some women to rethink their intimate relationships (Morrison et al., 2021).They also helped restore men's roles in pregnancy, birthing, and parenting, which was lost through colonising practices (Malatest International, 2022;Morrison et al., 2021).

QUALITATIVE RESEARCH
Four studies explored women's experiences accessing individual counselling or group work (Conroy, 2018;Morrison et al., 2021;Spirrett, 1997;Vaughan, 1996).Two studies found that women advocated for individual counselling to address core issues, sensitive topics, and historical trauma related to substance use (Morrison et al., 2021;Spirrett, 1997).Women receiving counselling reported positive benefits; some said it was the first time they recalled feeling heard and taken seriously (Morrison et al., 2021;Vaughan, 1996).However, some women expressed dissatisfaction with limited access to counsellors in critical moments (Vaughan, 1996).Women from two studies had mixed views on the 12-step philosophy of AA and Narcotics Anonymous (NA) but recognised the positive impact of women-only and selfesteem groups on their well-being (Conroy, 2018;Spirrett, 1997).
Conroy's (2018) study highlighted the need for treatment providers to address family violence and relationship issues.Tāngata whai ora engaged with PPS spoke positively about psycho-education on family violence, parenting, child exposure to substances, and safe sleeping, which could improve child outcomes (Malatest International, 2022;Parsonage, 2015;Waitematā DHB, 2017).Several studies highlighted the importance of continuing care and peer support after discharge to support tāngata whai ora's ongoing recovery (Malatest International, 2022;Morrison et al., 2021;Parsonage, 2015).
Social networks, relationships and cultural support.Numerous studies have examined the impact of social connections on women with SUDs during treatment.Findings suggest that relationships with friends, whānau, and partners have a positive influence during treatment (Chan & Moriarty, 2010;Conroy, 2018;Handa, 2006;Malatest International, 2022;Spirrett, 1997;Streatfield, 2022;Vaughan, 1996).However, some women hesitated to disclose their substance use or treatment status, even to family members (Conroy, 2018;Vaughan, 1996).The absence of significant others did not significantly affect treatment outcomes for some women (Conroy, 2018).However, for others, lack of support from loved ones led to isolation and hindrance in rehabilitation (Handa, 2006).Positive support from whānau was crucial for Māori women, particularly during pregnancy (Stuart, 2009).
Incorporating tikanga (traditional values and customs that have evolved over time) into their work was considered important across all sites (Malatest International, 2022;Parsonage, 2015;Waitematā DHB, 2017).While reconnecting with te ao Māori can be transformative for some tāngata whai ora, the impacts of colonisation resulted in others not wanting to reconnect (Malatest International, 2022).Tāngata whai ora from Te Ira Wāhine advocated for more cultural authenticity within mainstream rehabilitation programmes (Morrison et al., 2021).

Challenges for AOD service providers.
Several studies identified concerns about access to treatment, such as lengthy

ORIGINAL ARTICLE
wait times and a lack of follow-up when appointments were missed (Conroy, 2018;Handa, 2006;Malatest International, 2022;Parsonage, 2015).PPS tāngata whai ora disengaged from previous services due to these issues (Malatest International, 2022).Parsonage (2015) discovered that long wait times to access the Waitematā PPS meant that 10 of 17 women who were pregnant on referral had given birth at the time of assessment.Some women from Te Ira Wāhine wanted more programme content that dealt with grief and supported them to quit smoking and set goals before they transitioned back into the community (Morrison et al., 2021).
Several studies have found that negative influences and unhealthy relationships led some tāngata whai ora to cut ties with friends, acquaintances, partners, and whānau (Conroy, 2018;Malatest International, 2022;Spirrett, 1997;Vaughan, 1996).For instance, due to family dysfunction, some PPS tāngata whai ora had to cut contact and move away from whānau to progress (Malatest International, 2022).However, the shortage of housing, particularly social housing, made it difficult for tāngata whai ora to move away from unsafe partners and whānau (Malatest International, 2022).Women sometimes could not leave abusive relationships due to financial insecurity or children (Vaughan, 1996).
Women in several studies expressed concerns about the lack of AOD treatment providers tailored towards women, particularly those with children (Conroy, 2018;Handa, 2006;Malatest International, 2022;Spirrett, 1997).Some women felt unable to discuss sensitive topics such as sexual abuse at mixed-gender AA groups due to the presence of men (Vaughan, 1996).There was also a perceived lack of maternity services for pregnant methamphetamine users (Handa, 2006).Some women and a treatment provider said there was a need for live-in services for women and their children where they could reconnect and strengthen their bond (Conroy, 2018;Malatest International, 2022).

Discussion
Although substance use and its adverse effects are widely discussed in Aotearoa (see, for example, Handa, 2006;McCrone, 2008;NZDF, 2022b;Rankine et al., 2013;Reed, 2019), women's experiences and interactions with healthcare services are not widely known.This scoping review provides evidence to inform social workers and healthcare providers about women's experiences with substance use and their perceptions of AOD service provision in Aotearoa.
The studies showed that women have similar experiences with substance use and healthcare, but differences exist, such as the influence of male partners and experiences of stigma.Women's drinking behaviour changed at different stages and life transitions.Many spoke of drinking excessively in their younger years but reducing their drinking after children due to self-regulation, having less money, and societal monitoring and judgement.The cultural context plays a role in women's substance use.For example, Aotearoa New Zealand-born Niuean women found drinking with elders and men within the whānau disrespectful.Moreover, Māori women's drinking during pregnancy was influenced by factors such as people, places, and societal positions.
The studies provided insight into substance use among women in Aotearoa New Zealand and can be used to inform social workers on how to support this cohort.Some studies suggested that a holistic, long-term, strengths-based treatment that includes psycho-education and goes beyond treating problematic substance use is necessary to support women (Conroy, 2018;Spirrett, 1997).International research has also highlighted the importance of wraparound services and comprehensive care that are trauma informed and gender specific (Forray et al., 2015;Schamp et al., 2021).Discussions of patriarchy, gendered norms and rules, and the need for gender-specific or gender-

QUALITATIVE RESEARCH
sensitive treatment options featured in 12 of the 16 studies that focused on women in Aotearoa New Zealand (see Table 1).
According to international research, there is a considerable lack of outpatient and residential treatment services providing childcare or provision for children to enter the service with their mothers (Frazer et al., 2019;Proulx & Fantasia, 2020;Schamp et al., 2021).
Several studies have found that women reported not receiving credible information about substance-use harm and treatment options from healthcare providers, with some receiving conflicting information about substance-use risks during pregnancy (Chan & Moriarty, 2010;Conroy, 2018;Handa, 2006;Salmon, 2008;Stuart, 2009).These findings align with a systematic review that identified the lack of information and discussion about risks of substance use during pregnancy from healthcare professionals as a barrier to remaining substance-free (Escañuela Sánchez et al., 2022).
Mothers of children with FASD, in Salmon's (2008) Aotearoa New Zealand study, stated they would have stopped drinking if they had known the risks.Internationally, research suggests limited knowledge among the public and healthcare professionals about FASD (Mukherjee, 2019;Thomas & Mukherjee, 2019;Wood, 2010).Mothers from Thomas and Mukherjee's (2019) study reported a lack of advice from healthcare professionals about the dangers of drinking during pregnancy.Multiple studies suggested that increasing education on problematic substance use and the effects of alcohol and drugs on the fetus, available AOD resources and treatment options, and harm-reduction practices is necessary to address the issues of problematic substance use (Conroy, 2018;Salmon, 2008;Stuart, 2009;Waitematā DHB, 2017).This education should be provided to those delivering and accessing health services.Some studies recommended amending Aotearoa's education curriculum to include education on problematic substance use and harm-reduction practices instead of abstinenceonly messages (Conroy, 2018;Streatfield, 2022).
Women across several studies identified stigma, both real and perceived, as a significant barrier to engaging with healthcare providers and seeking social support (Chan & Moriarty, 2010;Conroy, 2018;Gibson & Hutton, 2021).Whether at an individual level, through perceived stigma, or a structural level, such as institutional racism, stigma was a significant block to accessing services.These experiences are consistent with international literature that suggested stigma from the public and healthcare professionals hinders women's access to AOD support (Proulx & Fantasia, 2020).Furthermore, stigmatising attitudes about substance use while pregnant or parenting increase the risk of being referred to child welfare services and having parental rights removed (Weber et al., 2021).
Several studies identified the need for political buy-in, policy changes, increased funding, and coordinated service implementation to improve substance-usetreatment provision at national, regional, and community levels (Conroy, 2018;Salmon, 2008;Streatfield, 2022).While changes were made to drug laws in Aotearoa to reduce court action, they have yet to result in significant improvements (NZDF, 2022a).
Several studies recommended that, to counter pro-drinking messages and promote available treatment options, mainstream health-promotion campaigns that are nuanced, culturally appropriate, designed for specific target audiences, and appear across various media platforms, are needed (Conroy, 2018;Gray & Nosa, 2009;Pedersen, 2019;Stuart, 2009).However, the recent actions the New Zealand government took contradict this approach.The government has deferred the second part of proposed alcohol reforms, which encompass issues such as sponsorship, advertising, and pricing (Hipkins, 2023).This decision seems to conflict with research conducted at the University of Otago, which demonstrated

ORIGINAL ARTICLE
that alcohol causes more widespread harm in Aotearoa New Zealand than illicit drugs like methamphetamine (Crossin et al., 2023).
Some authors advocated for better national coordination and delivery of AOD services, which would improve information sharing and networking between providers (Conroy, 2018;Salmon, 2008).Furthermore, to enhance kaimahi relationships and interactions with tāngata whai ora, AOD services need to ensure kaimahi are well trained, reflective, and empathetic (Chan & Moriarty, 2010;Conroy, 2018).Several studies recommended more services for those with coexisting mental health needs and problematic substance use (Conroy, 2018;Pedersen, 2019).
This scoping review reveals a concerning lack of diversity in research on women's substance and alcohol use, particularly concerning older adult women and sexual minorities.Older women encounter difficulties in accessing treatment and recovery for alcohol dependence, and research addressing alcohol abuse in this demographic is limited (Milic et al., 2018).Furthermore, most studies in the analysis focus on heterosexual women, leaving a significant gap in our understanding of substance use patterns and treatment needs for sexual minorities (Paschen-Wolff et al., 2023).This limitation hinders our comprehension of these groups' unique experiences and challenges.
Limited research exists on substance use experiences among Māori women and other ethnic minorities.Delivering appropriate services that meet the needs of Māori communities remains a significant challenge.Māori individuals seeking mental health and addiction support have reported experiencing racism in healthcare settings, leading to disengagement (Malatest International, 2022).The government's mental health and addiction inquiry reflects these concerns, as Māori describe the healthcare system as fundamentally racist, perpetuating marginalisation and recolonisation (Department of Internal Affairs, 2019).The report emphasises the need for transformative change in the healthcare system, valuing Māori customs (tikanga), adopting a holistic and whānaucentred approach, and working towards decolonisation.Existing literature indicates that substance abuse services aligned with these values have shown the most favourable outcomes for Māori (Malatest International, 2022;Morrison et al., 2021;Parsonage, 2015;Waitematā DHB, 2017).
Whether substance use was problematic or recreational, women discussed similar risks, including sexual abuse, rape, violence, and physical and mental health impacts.However, while the line between problematic and recreational substance use can be blurred, attempts to pigeonhole women into specific AOD-use categories are outdated and reinforce gender stereotypes.There were many examples of women determining how, what, where, and with whom their drinking and drug use occurred.
Through trial and error, women developed harm-minimisation strategies, including using drugs and alcohol with other women.The positive experiences of women who use drugs or alcohol cannot be overlooked and counter the idea that women do not use drugs, or, if they do, their use is always problematic.There is a need for harm reduction, safe substance-use practices, and more nuanced, women-centric treatment options with a broader focus than just abstinence (Conroy, 2018;Streatfield, 2022).

Conclusion
There is a lack of addiction-related content in social work education in Aotearoa New Zealand (Ballantyne et al., 2019;Nelson, 2022) VOLUME 35 • NUMBER 3 • 2023 AOTEAROA NEW ZEALAND SOCIAL WORK

Figure 1 :
Figure 1: Flowchart of the Search and Screening Process

Table 2 .
Selected Literature Information . However, it is essential to educate social workers about substance use and how to work with WWUS, especially those who are pregnant and parenting.Social workers should know AOD services exist for WWUS and advocate for service provision gaps to be filled.Maintaining a non-judgemental attitude and open mindedness in all interactions WWUS, regardless of whether they are pregnant or parenting, is critical.Additionally, the field requires a scaling up of research on WWUS and their experiences of substance use, healthcare, and AOD services.At the time of writing, there were no Aotearoa New Zealand research studies on WWUS who are pregnant and parenting accessing AOD residential services.This significant gap is undoubtedly due to the lack of AOD treatment to accommodate this population.Findings from the scoping review are valuable for AOD treatment services for women.They will be beneficial when analysing the viability of the new Te Whare Taonga, especially when evaluating similar residential-treatment centres. with