Perceived consequences of refusing to share injection equipment: A qualitative study

Transcription

1 Perceived consequences of refusing to share injection equipment: A qualitative study Karla D. Wagner,* Stephen E. Lankenau, Lawrence A. Palinkas, Jean L. Richardson, Chih-Ping Chou, Jennifer B. Unger *Division of Global Public Health, Department of Medicine, University of California San Diego NIDA R36 DA & T32 DA

2 Injection drug users continue to be at risk for HIV and HCV infection SEPs have increased availability of injection supplies in many areas of the US HIV risk behaviors, incidence & prevalence have decreased But... residual injection risk behavior persists 1,2 Receptive syringe sharing: 23%-53% 3 Paraphernalia sharing: 37% - 62% 3 1 Van Ameijden et al., Des Jarlais et al., Bluthenthal et al., 2007, Cox et al., 2008, Thiede et al., 2007

3 Rationale for Current Study Why do people continue to engage in risk behavior? Risk behavior is contextualized within the broader social and environmental setting (Rhodes 2002, 2005; Latkin & Knowlton 2005)

4 If HIV is the biggest consequence or risk to be avoided, then sharing syringes doesn t make sense But there are often other (social, political, economic, physical) consequences that compete with the priority of HIV infection......the perceived consequences of refusing to to share injection equipment

5 Methods Qualitative interviews with 26 IDUs recruited from large urban SEP in Skid Row area of Los Angeles, California Conducted during a variety of days/times in order to generate diverse sample 50% female to allow for gender comparisons in larger study Eligibility: > 18 years old any IDU in past 30 days shared any injection equipment in past 30 days

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8 Results: Perceived Consequences Organize results into five primary domains: (1) Individual Factors: Withdrawal and forgoing drug use (2) Social Factors: Trust, IDU social norms, non-idu social norms (3) Physical Factors: Syringe access/inconvenience (4) Economic Factors: Threats to housing, economic consequences (5) Policy Factors: Policing, drug-free shelter policies

9 Individual Factors: Withdrawal (+homelessness and policing) I got up that morning and I was sick. And I didn t have my own equipment. And after [my injecting partners] had used it, I asked them if I could - God! - I asked them if I could use theirs. And that s sad, you know? and then it didn t dawn on me until after What the hell am I doing? It s just...i was sick. -Chloe, 47 years old

10 Social Factors: Trust, social norms [My partner] would probably feel a little sad because I don t trust her. We re so close. It would kind of hurt her a little bit, you know? Because if somebody don t want to fix after me, I m like, you know, there s nothing wrong with me, you know? Or You re scared of me. That s why you won t fix behind me. It s weird, you know? -Sarah, 48 years old

11 Physical Factors: Syringe access (+homelessness and policing) Oh, wow. I would have had to walk...it takes 10 minutes to walk waaay to the other side of the park. Then, you got to look around, see if it s safe. Because they have those, ah, like some type of cops that patrol the area. And then you ve got to walk all the way back to the other side, and it s hot, and I m sick. -Jose, 47 years old

12 Economic Factors: Threats to housing (+ social norms) When I went back with him, he goes, You haven t fixed yet, huh? I go, No. He goes, OK, where s your syringe? I go, I don t have a syringe, you know that. I already tell you, I never carry nothing. You know that. He usually has new ones for me when I go down there. He says, Well, I don t have a new one today. What do you want to do? You want to snort it? Or you want to use my needle? I go, Do you have anything? Are you sick? You don t look sick, but are you? He goes, No. C mon, man. If I was sick, I would tell you. We ve known each other too long. I go, Yeah, that s what they all say. But just do what you got to do. I ll rinse it out. Give me some bleach. -Beth, 42 years old

13 Discussion 5 broad domains of perceived consequences of refusing to share injection equipment: Individual Social Policy Economic Physical Few people reported a single consequence- most described interactions between domains and multiple consequences

14 Withdrawal was a highly significant consequence that trumped most other concerns (Mateu-Gelabert et al. 2010) Difficult to act on intentions to inject safely in the presence of withdrawal symptoms (especially in the presence of other structural forces such as the threat from police) Lowering thresholds for methadone or other drug treatment could assist with risk reduction efforts Social consequences are embedded in social, economic, and instrumental resources that are at risk if friends/partners are alienated Many narratives were characterized by a fear of legal consequences This concern often resulted in rushed injections and situations were people did not carry their syringes

15 Limitations Limited generalizability - purposeful sample, only SEP participants Social desirability and recall bias Last event method may have yielded descriptions of atypical events

16 Conclusion Continued syringe sharing may seem irrational at first glance but social, political, economic, physical conditions make it difficult to act on knowledge, attitudes, intentions Considering the situated rationality (Kowalewski et al., 1987, March & Simon, 1959) of injection risk behavior might help make sense out of seemingly irrational behavior

17 Acknowledgements The participants who shared their stories for this report NIDA R36 DA & T32 DA Brett Mendenhall, Mark Casanova, James Hundley