ETHNO-EPIDEMIOLOGICAL APPROACHES TO UNDERSTANDING DRUG-RELATED RELATED HARM

Transcription

1 ETHNO-EPIDEMIOLOGICAL APPROACHES TO UNDERSTANDING DRUG-RELATED RELATED HARM Combining Social Epidemiology and Ethnography to Study Health among Injection Drug Users in Vancouver Will Small 1,2 Evan Wood 1,3 Thomas Kerr 1,3 1. British Columbia Centre for Excellence in HIV/AIDS. St. Paul s Hospital, Vancouver, Canada 2. Interdisciplinary Studies Graduate Program, University of British Columbia 3. Dept. of Medicine, University of British Columbia

2 Background Commentators have increasingly pointed to the potential of ethno-epidemiological epidemiological studies of specific problems among people who inject drugs (IDU) However, relatively l few studies involve direct collaboration between ethnographers and epidemiologists

3 Objective To illustrate how methodological approaches have been combined within an ongoing program of research among injection drug users in Vancouver We review published research findings regarding: The impact of intensive street level policing upon IDU Incarceration and high risk syringe sharing

4 Methods The BC Centre for Excellence in HIV/AIDS operates large prospective cohort studies following over 2000 IDU Vancouver Injection Drug User Study (VIDUS) follows over 1500 IDU 6 month follow-up behavioral questionnaire i and blood testing ti This program of research also includes an ongoing, long-term ethnographic component utilizing: participant-observation in Vancouver s Downtown Eastside in-depth interviews with IDU

5 Direct Collaboration The use of both epidemiological and ethnographic methods has enabled the examination of specific research questions through multiple lines of inquiry The combination of disciplinary perspectives has been accomplished through a problem-oriented oriented approach to specific policy-relevant issues Epidemiological analyses of cohort data have identified important environmental influences shaping injection-related risk behavior among IDU in Vancouver Ethnographic research efforts have documented the local risk environment and focused upon injection-related risks among local IDU

6 The Impact of Street-Based Policing upon IDU In 2003, ethnographic investigation of Vancouver s public injecting scene indicated that a street-based policing initiative was precipitating negative impacts: Heightened police presence displaced drug users away from locations where health services were located Difficulty connecting with health services negatively influenced access to syringes among IDU Police presence also reduced drug users willingness to carry syringes fostering increases in unsafe disposal Small et al. Impacts of intensified police activity on injection drug users: Evidence from an ethnographic investigation. International Journal of Drug Policy 2006

7 The Impact of Street-Based Policing upon IDU Epidemiological analysis of cohort and syringe discard data documented: large-scale displacement of IDU occurring during the police initiative increased unsafe syringe disposal during the police initiative Previous epidemiological analysis documented that individuals who reported difficulty accessing sterile syringes were more than 3 times more likely to engage in high risk needle sharing Barriers to syringe access are a significant issue at the community level Wood et al. CMAJ 2004 ; Wood et al. AIDS. 2002

8 Incarceration and High Risk Syringe Sharing A qualitative study conducted in 2002 examined injection drug use within British Columbia prisons participants were recruited through VIDUS 26 in-depth interviews with individuals recently released from provincial i and federal institutions Injection drug use in prisons routinely involves syringe sharing among large networks composed of numerous individuals Syringe scarcity drives syringe sharing among inmates, increasing risks for HIV and HCV infection Small et al. Incarceration, addiction, and harm reduction: Inmates experience injecting drugs in prison. Substance Use and Misuse 2005

9 Incarceration and High Risk Syringe Sharing In 2005, longitudinal analyses using data from the VIDUS cohort were conducted to examine syringe sharing in prisons 1123 individuals reported a history of incarceration 351 (31%) reported that they had injected drugs while incarcerated Among 318 HIV+ individuals recent incarceration was significantly associated with syringe lending Among 1157 HIV- individuals recent incarceration was significantly associated with syringe borrowing This supports ethnographic work indicating that HIV may be spreading among injection drug users within the prison setting Wood et al. Public Health Reports 2005

10 Discussion The depth of measurement possible with ethnographic methods and the breadth of measurement achieved through epidemiological methods complement each other: Ethnographic work produces in-depth descriptions and understandings of particular groups of drug users and social contexts Sampling techniques and statistical analyses utilized in epidemiological research identify significant relationships at the population level The strengths of one approach offset particular limitations of the other

11 Discussion The ability of ethnographic research to identify and illustrate social processes implicated in risk and health is well recognized However, the potential for epidemiology to inform, strengthen and invigorate ethnographic research merits greater attention These studies illustrate the ability of epidemiology to: direct t ethnographic hi inquiry i by identifying i patterned relationships requiring further investigation and analysis complement or confirm the findings of small-scale scale ethnographic and qualitative studies

12 Conclusions Direct collaboration between researchers from different disciplinary backgrounds has influenced the focus of our research Although ethnographic and epidemiological research are based on different theoretical and methodological foundations, combining perspectives to focus on specific problems has generated: greater understanding of environmental forces that influence risk, risk reduction and health research findings which are of significance and relevance for policy makers and policy decisions

13 The authors thank Acknowledgements The people who use drugs who have taken the time to participate in these studies The study staff of the ACCESS, VIDUS, & SEOSI Projects Administrative staff at the B.C. Centre for Excellence in HIV/AIDS Will Small acknowledges the support of Doctoral Research Awards from CIHR and the Michael Smith Foundation for Health Research Support to conduct ethnographic and qualitative research in conjunction with the cohort studies is provided by the CIHR operating grant, Exploring the Natural History of Injection Drug Use: Social & Environmental Influences

14 Articles Discussed Small et al. Impacts of intensified police activity on injection drug users: Evidence from an ethnographic investigation. International Journal of Drug Policy 2006, 7(2): Wood et al. Displacement of Canada's largest public illicit drug market in response to a police crackdown. Canadian Medical Association Journal 2004, 170(10): Small et al. Incarceration, addiction, and harm reduction: Inmates experience injecting drugs in prison. Substance Use and Misuse 2005, 40(6): Wood et al. Recent incarceration independently predicts syringe sharing among injection drug users. Public Health Reports 2005, 120(2),