Structural interventions and social suffering: Responding to amphetamine-type stimulant use among female entertainment and sex workers in Cambodia

BackgroundIn Cambodia, HIV infection remains high among female entertainment and sex workers (FESW) and the use of amphetamine-type stimulants (ATS) is an independent risk factor for unprotected sex and sexually transmitted infections among this group. For decades public health approaches to HIV prevention in low and middle income countries (LMIC) have attempted to target the macro-power relations that shape risk behaviour with structural interventions. Recent research has highlighted that interventions that combine ATS risk reduction, in the form of financial incentives for abstinence, with existing HIV prevention programmes, may also play an important role. However, whether this approach goes far enough as a response to structural drivers of risk requires further examination.MethodsSemi-structured in-depth interviews were conducted with 30 FESW (mean age 25 years) from five provinces in Cambodia, as part of formative research for the implementation of the Cambodia Integrated HIV and Drug Prevention (CIPI) trial. The aim was to explore the contexts and drivers of ATS use. Data were analysed using grounded theory.ResultsIn addition to increasing occupational functionality, ATS were used to control pervasive feelings of ‘sadness’ in relation to the lived experience of poverty, family and relationship problems. Feeling sad could be viewed as an expression of social suffering, in response to competing priorities and seemingly inescapable constraints imposed by a lack of options for income generation, gender inequalities and stigma. Participants expressed interest in microenterprise (ME) opportunities, particularly vocational training, that could create new work opportunities beyond sex work and ATS use.ConclusionIn addition to reducing ATS use, HIV prevention interventions need to target sources of sadness and social suffering as drivers of risk among FESW in this context. The inclusion of ME opportunities in HIV prevention, to alleviate social suffering, warrants further investigation through qualitative and ethnographic research.     

Patient perceptions of acute infectious disease point-of-care tests and treatment within community pharmacy settings

BackgroundCommunity pharmacies are well-positioned to help patients overcome many health care barriers they experience when trying to receive care. Community pharmacists are ready and equipped to provide patient care interventions like the test-and-treat model for acute infectious diseases.ObjectivesThe objective of this study was to determine patients’ experiences with rapid strep and influenza tests administered at community pharmacies, focusing on what impacted patients’ decisions to receive care, their perception of the care received, and if offering these tests in community pharmacies expanded their access to care.MethodsSeven independently owned pharmacies in Tennessee and Kentucky from November 2020 to April 2021 recruited study participants. Qualitative semi-structured key informant interviews were conducted using the theory of planned behavior as a theoretical framework. Participant interviews were audio recorded, transcribed, and independently coded by 2 investigators and reviewed by a third investigator. A qualitative analysis was completed, with a selection of supporting quotations for each theme. Qualitative analysis identified participant perceptions of rapid strep and flu POCT and treatments provided in community pharmacies, consistency and quality of patient care, and if these interventions expanded their access to care.ResultsA total of 11 patients participated in the interviews; of which, 9 (81.8%) participants were female, and participants ages ranged from 22 to 64 years (median, 40 years). Of 11, 7 participants received a strep test, 3 participants received a flu test, and 1 participant received both the tests. The analysis uncovered 10 major themes within the following 4 different categories: (1) convenience to patients, (2) quality of care received, (3) improved access to care, and (4) additional interventions for which patients want expanded access to care.ConclusionPharmacies offering services like rapid strep and flu tests provide convenience and quality care that can help expand patient access to health care and could help provide expanded access for underserved populations.     

Environmental risk,social cognition,and drug use among young men who have sex with men: Longitudinal effects of minority status on health processes and outcomes

BackgroundYoung men who have sex with men (YMSM) continue to be at elevated risk for substance use; however, models explaining this phenomenon have often focused on a limited array of explanatory constructs. This study examined the longitudinal relationship of contextual risk factors, social cognitive processes, mental health, and health protective behavior to identify key mechanisms of illicit drug use of YMSM as they aged through emerging adulthood.MethodsOur sample included an ethnically diverse cohort of 487 YMSM recruited through venue based probability sampling in Los Angeles. We used latent growth curve modeling to understand relationships between environmental risk factors, changing individual and social process variables, health protective behavior, psychological distress, and illicit drug use outcomes among YMSM.ResultsAge, ethnicity, violence and discrimination, depression, and previous histories of illicit drug use were key elements of risk for future illicit drug use among YMSM. During this theoretically distinct time period, health as a value, self-efficacy, and social support are vital social cognitive processes for promoting self-change among YMSM, and YMSM have independent growth within each process. Health as a value, self-efficacy, and social support were dynamic social cognitive processes, which served as key mechanisms by which risk factors were converted into health promotion strategies or psychological distress, and ultimately illicit drug use.ConclusionsThe efficacy of prevention interventions aimed at reducing illicit drug use among YMSM can be enhanced by addressing social cognitive processes for this underserved portion of the male population.     

Psychiatric and Physiological Reactions Produced by Over-the-Counter Medications

Abstract

Injecting practices of illicit drug users in San Antonio, Texas, were studied by means of informal field interviews and participant observation. The methods injection drug users (IDUs) employed to obtain drugs seemed to affect their HIV risk behaviors. Many of the methods involve reciprocal exchanges between a person who has drugs and a person who wants drugs. The exchanges frequently occur in the context of asymmetrical social interactions. The person with the drugs usually occupies the dominant role in the interaction and determines the needle hygiene for both parties. Analysis of the decision-making process of IDUs indicates that the party in the dominant role may choose not to disinfect a syringe for a variety of reasons. An understanding of the subcultural rules that govern these interactions may provide valuable clues to researchers or educators who are designing interventions aimed at reducing HIV risk behaviors among IDUs. This research suggests that for IDUs in subordinate roles, education alone may be insufficient to produce behavior changes necessary to eliminate risk of HIV infection.     

Intervention research to enhance community pharmacists' cognitive services: A systematic review

BackgroundPositive impact of community pharmacists' cognitive pharmaceutical services (CPS) is well documented. However, community pharmacists have been slow to expand CPS roles. This systematic review explores how community pharmacy intervention research can help inform efforts to expand cognitive pharmaceutical service delivery.ObjectivesTo: 1) identify community pharmacy CPS intervention studies that report data on pharmacist behaviors, either as a final study outcome itself or as a fidelity measure in patient outcome studies, and 2) describe the state of this research to help frame future research agendas.MethodsEmpirical articles examining improvement or expansion of community pharmacist cognitive services published through December 2010 were searched using various search engines, bibliography searches and authors' libraries. Studies were included if they: 1) reported findings on pharmacist behaviors during cognitive service delivery, 2) employed a minimum of pre-post design or two study arms for pharmacists/pharmacies, and 3) were in community-based pharmacies.ResultsA total of 50 studies evaluated impact of community pharmacy based CPS delivery; however, only 21 included a pharmacist behavior outcome measure as a final outcome or as a fidelity measure. The majority (14 out of 21) of studies used a randomized controlled trial design. Nearly half (10 of 21) addressed asthma or tobacco cessation. Limited details were provided about interventions to prepare pharmacists for CPS delivery. The most frequent measures of pharmacist behavior were patient surveys and observation of pharmacists' behavior by secret shoppers; electronic data sets were rarely used.ConclusionsThere is a need for well-designed intervention research that evaluates how interventions impact on pharmacist cognitive service behavior. Positive findings from this review reinforce that planned interventions have the potential to improve and expand pharmacist cognitive service delivery; however, more detail is needed in study publications for this potential to be fully realized.     

Short-term effects of a brief intervention to reduce alcohol use and sexual risk among homeless young adults: results from a randomized controlled trial

Background: Homeless young adults are more likely than their never-homeless counterparts to abuse alcohol and engage in risky sexual behaviors, yet no interventions to simultaneously reduce both these behaviors among this vulnerable population have been systematically designed and evaluated. We therefore developed a brief intervention (BI) to reduce both alcohol use and sexual risk behaviors among homeless young adults. The results of a randomized trial testing the BI against an education comparison (EC) are presented.

Method: Young adults (N?=?61; age 17–22 years) from an urban, Northeastern crisis shelter were randomly assigned to either the two-session, individual-level BI or a time-matched, two-session, individual-level EC. Generalized linear mixed models for repeated measures determined effects of treatment condition on outcomes.

Results: The BI significantly increased participant readiness to change alcohol use. However, it did not significantly decrease primary alcohol or HIV sexual risk outcomes, independently or relative to EC (all ps > 0.05). Participants in the EC reduced times engaged in unprotected sex between baseline and post-intervention to a significantly greater extent (p?Conclusions: Findings suggest that the BI was acceptable and successful in getting participants to consider changing their drinking. However, lack of change in alcohol and sexual behavior outcomes indicates the need for further research to determine how to translate readiness to change into actual behavioral change among homeless young adults.     

Reducing sexual risk behaviors: secondary analyses from a randomized controlled trial of a brief web-based alcohol intervention for underage,heavy episodic drinking college women

Background: Alcohol use and sexual risk behaviors (SRBs) are significant problems on college campuses. College women are at particularly high risk for negative consequences associated with sexually transmitted infections (STIs) and unwanted pregnancy.

Methods: The current study (n?=?160) examined the effect of a brief, web-based alcohol intervention (n?=?53) for college women on reducing SRBs compared to an assessment only control (n?=?107) with a randomized controlled trial. Outcome measures included condom use assertiveness and number of vaginal sex partners and data were collected at baseline and three-month follow-up.

Results: Regression analyses revealed that the alcohol intervention was associated with higher levels of condom use assertiveness at a three-month follow-up. Additionally, more alcohol use was associated with less condom use assertiveness for those with more significant sexual assault histories.

Conclusions: These findings suggest that alcohol interventions may impact college women’s beliefs but not behavior, and future interventions should more explicitly target both alcohol and sexual risk to decrease risky behaviors.     

Use of the job demands-resource model to understand community pharmacists’ burnout during the COVID-19 pandemic

BackgroundCommunity pharmacists are one of the most accessible healthcare providers during the COVID-19 pandemic. Whilst playing a vital role in medication supply and patient education, exposure to the pandemic demands and prolonged stressors increase their risk of burnout.ObjectivesUsing the Job Demands-Resources model, this study aims to understand the factors that led to community pharmacists’ burnout and to identify their coping strategies and perceived recommendations on interventions to mitigate burnout during the COVID-19 pandemic.MethodsA qualitative phenomenological approach was used with focus groups and interviews of community pharmacists in Qatar who were recruited using purposeful, convenience, and snowballing sampling methods. Interviews were conducted between February and April 2021, were audio-recorded and transcribed verbatim. Using thematic analysis methodology, manual inductive and deductive (based on the model) codes from the interviews were used for synthesis of themes. 11 themes emerged from six focus groups, six dyadic interviews and mini focus groups, and four individual interviews with community pharmacists.ResultsThe contributing factors to community pharmacists’ burnout have been identified as practical job demands, and emotional demands including fear of infection. On the other hand, government and workplace-specific resources, personal characteristics such as resiliency and optimism, as well as the implementation of coping strategies, have reduced their stress and burnout.ConclusionsThe use of the Job Demands-Resources model was appropriate to identify the contributing factors to community pharmacists’ burnout during the COVID-19 pandemic. Based on these factors, individual, organizational, and national strategies can be implemented to mitigate burnout in community pharmacists during the pandemic and future emergencies.     

A micro-environmental intervention to reduce the harms associated with drug-related overdose: evidence from the evaluation of Vancouver's safer injection facility

BackgroundConventional drug overdose prevention strategies have been criticised for failing to address the macro- and micro-environmental factors that shape drug injecting practices and compromise individual ability to reduce the risks associated with drug-related overdose. This in turn has led to calls for interventions that address overdose risks by modifying the drug-using environment, including the social dynamics within them. Safer injection facilities (SIFs) constitute one such intervention, although little is known about the impact of such facilities on factors that mediate risk for overdose.MethodsSemi-structured qualitative interviews were conducted with fifty individuals recruited from a cohort of SIF users in Vancouver, the Scientific Evaluation Of Supervised Injecting (SEOSI). Audio recorded interviews elicited injection drug users’ (IDU) accounts of overdoses as well as perspectives regarding the impact of SIF use on overdose risk and experiences of overdose. Interviews were transcribed verbatim and a thematic analysis was conducted.ResultsFifty IDU, including 21 women, participated in this study. The perspectives of participants suggest that the Vancouver SIF plays an important role in mediating various risks associated with overdose. In particular, the SIF addresses many of the unique contextual risks associated with injection in public spaces, including the need to rush injections due to fear of arrest. Further, SIF use appears to enable overdose prevention by simultaneously offsetting potential social risks associated with injecting alone and injecting in the presence of strangers. The immediate emergency response offered by nurses at the SIF was also valued highly, especially when injecting adulterated drugs and drugs of unknown purity and composition.ConclusionThe perspectives of IDU participating in this study suggest that SIFs can address many of the micro-environmental factors that drive overdose risk and limit individual ability to employ overdose prevention practices. Although challenges related to coverage remain in many settings, SIFs may play a unique role in managing overdoses, particularly those occurring within street-based drug scenes.     

Perceptions and concerns of hepatitis C reinfection following prison-wide treatment scale-up: Counterpublic health amid hepatitis C treatment as prevention efforts in the prison setting

BackgroundHepatitis C (HCV) infection is highly prevalent within the prison setting. Direct-acting antiviral (DAA) therapies have changed the HCV treatment landscape, offering simple treatment (with minimal side-effects) and high efficacy. These advances have enabled the first real-world study of HCV treatment as prevention (TasP), the Surveillance and Treatment of Prisoners with hepatitis C (SToP-C) study. This paper draws on data from qualitative interviews completed with SToP-C participants following prison-wide DAA treatment scale-up.MethodsSemi-structured interviews were undertaken with 23 men in prison following HCV treatment completion to identify ongoing risk practices, perceptions of strategies for HCV prevention within the prison setting, experiences of HCV treatment (as prevention), and perceptions of reinfection following cure. Analysis was undertaken using a counterpublic health lens to identify risks and perceptions of reinfection among people treated for HCV within the prison setting.ResultsParticipants identified a number of challenges of meaningful HCV ‘cure’ in the absence of increased access to prevention strategies (e.g., opioid agonist therapy and prison needle syringe programs) along with concerns that ‘cure’ was only temporary whilst incarcerated. ‘Cure’ status included self-perceptions of being “clean”, while also imposing responsibility on the individual to maintain their ‘cure’ status.ConclusionHCV DAA treatment is provided somewhat under the guise of ‘cure is easy’, but fails to address the ongoing risk factors experienced by people who inject drugs in prisons, as well as other people in prison who may be at risk of blood-to-blood exposure. Health messaging regarding HCV treatment and treatment for reinfection should be tailored to ensure patient-centred care. Health interventions in prison must address the whole person and the circumstances in which they live, not just the illness.     

Characteristics of Female Sexual Partners of Injection Drug Users in Southern Arizona: Implications for Effective HIV Risk Reduction Interventions

SUMMARY

Epidemiological data suggest that women who are sexual partners of injection drug users (IDUs) are at increasing risk for HIV (CDC, 1992). This study describes characteristics of 180 female sexual partners (FSPs) living in southern Arizona. These characteristics include ethnicity, age, income source, living arrangement, sexual risk behavior, reasons for sexual risk, and knowledge of AIDS risk and transmission. Data from this study indicate that FSPs vary a great deal on all of these characteristics and thus a single “profile” of FSPs is difficult to conceptualize. Implications of the data suggest that effective interventions for HIV risk reduction for FSPs should be personalized to fit the specific characteristics and needs of the individual.     

Perceptions of network based recruitment for hepatitis C testing and treatment among persons who inject drugs: a qualitative exploration

BackgroundSocial network interventions that take advantage of existing individual and group relationships may help overcome the significant patient, provider, and system level barriers that contribute to low hepatitis C Virus (HCV) treatment uptake among people who inject drugs (PWID).MethodsWe conducted semi-structured interviews with 20 HCV antibody positive PWID (15 male, 5 female) in Baltimore, Maryland, USA. We utilized thematic analysis and employed both inductive and deductive coding techniques to assess perceptions of barriers and facilitators of social network interventions for HCV testing, linkage to care, and treatment among PWID.ResultsPWID perceived a high prevalence of HCV within their social networks, especially within injection drug use networks. Overwhelmingly, participants reported a willingness to discuss HCV and provide informational, instrumental, and emotional support to their network members. Support included sharing knowledge, such as where and how to access HCV care, as well as sharing lived experiences about HCV treatment that could help peers build trust within networks. Participants who were already linked into HCV care had an increased understanding of using social network interventions to provide peer navigation, by accompanying network members to HCV related appointments. Across interviews, drug use related stigma and feeling undeserving of HCV treatment due to previous negative experiences accessing the health care system emerged as a major barrier to linkage to HCV treatment and cure. Undeservingness was often internalized and projected onto network members. To overcome this, participants supported access to low-barrier HCV treatment in alternative locations such as community-based or mobile clinics and drug treatment centers.ConclusionSocial network based interventions have potential to increase HCV treatment uptake among PWID. To be successful, these interventions will need to train peers to share accurate information and personal experiences with HCV testing and treatment and enhance their ability to provide support to network members who face significant stigma related to both HCV and drug use.     

Boltushka: a homemade amphetamine-type stimulant and HIV risk in Odessa, Ukraine

BackgroundHomemade amphetamine-type stimulants (ATSs) have been reported in Russia and Eastern Europe for decades. Recipes differ geographically and over time producing differing active ingredients. Vint and jeff (active ingredients methamphetamine and methcathinone, respectively) are two such homemade ATSs originally produced from over-the-counter cold medications and household chemicals.MethodsDuring a Rapid Policy Assessment and Responses (RPAR) project in Odessa, Ukraine, researchers found use of boltushka, a novel homemade ATS. Fourteen supplemental qualitative interviews were conducted, including ten interviews with boltushka injectors and four interviews with pharmacists. We report patterns of boltushka use among local injection drug users (IDUs) as well as the role of laws, regulations, and current pharmacy practices.ResultsLegal restrictions on over-the-counter cold medicines in Ukraine led to products containing phenylpropanolamine (PPA), which oxidised with KMnO₄ (potassium permanganate), produces a weak ATS, cathinone, called boltushka. Boltushka’s ingredients are easily available in pharmacies or on the black market. IDUs reported a mean age at first use of 16 years old (range 12–21). While published data are scant, anecdotal evidence reported here include amphetamine-like effects on energy and appetite, binging patterns of use, and some reports of shaking and other neurological damage consistent with earlier reports from exposure to KMnO₄. Users reported sharing syringes and other non-sterile injection practices. No users reported specific treatment or prevention programs for boltushka users.ConclusionsAlthough Ukrainian government regulations have limited access to precursor chemicals, IDUs have continued to make and use boltushka. The actual extent and demographics of boltushka use are unknown. Besides risk of bloodborne disease, the health effects of injected homemade ATSs and their constituent chemicals are poorly documented. Interventions beyond available harm reduction efforts may be required. Education/treatment specific to boltushka users and screening for other physical harms are critical interventions.     

Virola: A Promising Genus for Enthnopharmacological Investigation

Abstract

This article presents findings from a qualitative study concerning drug injectors' constructs of human immunodeficiency virus (HIV) risk behavior. Analysis of data obtained from in-depth interviews (some with a vignette) of drug injectors found that when individuals needed an injection of drugs and were experiencing drug withdrawal they were more likely to take drug injecting risks. This was often discussed within an overall preoccupation with drug use. The substantive focus of the analysis goes on to explore drug injectors' desire to think about the consequences of HIV risk behavior at a later point in time. These exploratory findings highlight how further research needs to be undertaken in order to improve understanding of the temporal issues concerning drug injecting HIV risk behavior.     

Development of Risk Perception and Substance Use of Tobacco,Alcohol and Cannabis Among Adolescents and Emerging Adults: Evidence of Directional Influences

Background: While several studies have investigated the relationship between risk perception and substance use, surprisingly little is known about mutual influences between both variables over time. Objectives: The present study aimed to explore two different hypotheses separately for tobacco, alcohol and cannabis: influences from risk perception on behavior (motivational hypothesis) and influences from behavior on risk perception (risk reappraisal hypothesis). Methods: A prospective and longitudinal cross-lagged panel design was used with substance use and risk perception measured five times over the course of 10 years. Participants were 318 German youths aged 14–15 at the beginning of the study. Risk perception and substance use frequency were measured using self-reports. Results: Structural equation modeling indicated significant influences of risk perception on substance use behavior for all substances, which supports the motivational hypothesis. Changes in risk perception predict changes in future substance use of tobacco, alcohol and cannabis. Specifically for cannabis, influences of substance use on risk perception can also be shown, thus, supporting the risk reappraisal hypothesis. Conclusions: While there is support for the rationale behind adequate risk perception as a goal of preventive interventions, the possibility of risk reappraisal should not be neglected, especially regarding illicit substances.     

Behavioural interventions for preventing hepatitis C infection in people who inject drugs: a global systematic review

BackgroundA systematic review was conducted to determine whether behavioural interventions are effective in preventing transmission of hepatitis C virus (HCV) amongst people who inject drugs.MethodsMedline, EMBASE, the Cochrane Clinical Trial Database, PSYCHINFO and hand-searching of bibliographies were used to identify controlled trials of behavioural interventions for reducing HCV transmission amongst people who inject drugs. Behavioural interventions were defined as non-pharmacological interventions that aimed to change individual behaviours without explicitly attempting to change population norms.ResultsSix trials evaluating peer-education training and counselling interventions were included in the review. There was considerable variation between trials with respect to intervention duration, control and study population. Trials evaluated the impact of interventions on HCV incidence (three studies, 1041 participants) and frequency of injecting risk behaviours (six studies, 2472 participants). Amongst the three studies which measured the impact of the intervention on HCV incidence, none found a statistically significant difference between intervention and control groups. Measures of frequency of injecting risk behaviours varied greatly and could not be pooled. Only two studies (n = 418, 854) showed significantly greater reductions in injecting risk behaviours in the intervention group compared with the control group.ConclusionsThere was considerable variation in study design, outcome measures and magnitude, direction and statistical significance of findings between studies. Nonetheless, it is unlikely that behavioural interventions can have a considerable effect on HCV transmission. It is likely that multi-component interventions are required.     

A blended model to support brief interventions in primary care: A qualitative study of usability and acceptability of HealthEir in community pharmacy

BackgroundBrief interventions for lifestyle behaviour change are effective health promotion interventions. Primary care settings, including pharmacies, are the most frequently visited healthcare facilities and are well placed to provide brief health interventions. However, despite the evidence-based and policy guidance, barriers to brief interventions have limited their implementation.ObjectivesThis study aimed to explore the usability and acceptability of HealthEir, a blended model with digital, print, and communication elements designed to support the delivery of brief health-promoting interventions in pharmacy practice.MethodsUsability tests using a think aloud protocol and set tasks (to assess usability) and semi-structured interviews (to assess acceptability) were conducted with fifteen patients and twelve pharmacists. Usability data were analysed deductively using Nielsen's five quality components of usability as a framework. Acceptability data were analysed using inductive thematic analysis.FindingsAll participants found HealthEir straightforward to use and completed the required tasks without assistance. A small number of patient and pharmacist participants identified opportunity for improvement of the digital element. Acceptability was also high, with individual comments from participants identifying opportunity for improvements to HealthEir, and two patients identifying privacy or safety concerns. The majority of comments regarding acceptability reflected wider social and cultural challenges such as perceptions of the roles of pharmacists and pharmacies and the low priority of preventative health interventions.ConclusionHealthEir has been demonstrated to be a usable and acceptable support that has the potential to overcome barriers to delivery of brief interventions in pharmacies. Usability and acceptability testing identified minor changes that may further improve its design prior to piloting and implementation.