Prejudice among health care workers toward injecting drug users with hepatitis C: Does greater contact lead to less prejudice?

The current research measured explicit (self-reported) and implicit (or unconscious) attitudes of health care workers and their drug injecting clients with hepatitis C virus (HCV) toward each other, and the association of these attitudes with contact. Sixty health care workers and 120 of their clients with HCV acquired from injecting drug use were administered attitude measures to determine whether greater contact with HCV positive clients would result in more favourable attitudes on the part of health care workers toward these clients, and also on the part of these clients towards their health care workers. Findings suggest that increased contact with clients with HCV is associated with more favourable explicit attitudes and more negative implicit attitudes among health care workers toward injecting drug users. Health care workers who had greater contact with HCV positive clients also had HCV positive clients who held more favourable explicit attitudes toward health care workers, but contact was uncorrelated with implicit attitudes of clients toward health care workers.     

Measuring attitudes toward injecting drug users and people with hepatitis C

Preexisting scales used to measure attitudes toward human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) and homosexuals were adapted to assess attitudes toward people with hepatitis C (HCV) and injecting drug users (IDUs). In 2005, 110 undergraduate psychology students completed these scales, and abbreviated versions of the IDU and HCV scales were then administered to 61 health care workers to establish their relevance in the field. Results indicated that the new scales have good reliability and validity with undergraduates and with health care workers in an applied setting.     

Measuring Attitudes Toward Injecting Drug Users and People with Hepatitis C

Preexisting scales used to measure attitudes toward human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) and homosexuals were adapted to assess attitudes toward people with hepatitis C (HCV) and injecting drug users (IDUs). In 2005, 110 undergraduate psychology students completed these scales, and abbreviated versions of the IDU and HCV scales were then administered to 61 health care workers to establish their relevance in the field. Results indicated that the new scales have good reliability and validity with undergraduates and with health care workers in an applied setting.     

Clients or colleagues? Reflections on the process of participatory action research with young injecting drug users

Few published reports have explored the potential for participatory action research (PAR) with injecting drug users (IDUs) that extends their role beyond consultation, facilitating recruitment or conducting peer-driven interventions. We reflect on the process of conducting a participatory needs assessment of young IDUs who do not access drug health services using qualitative methods. This report draws on formal feedback obtained from the research teams, which comprised both peer and health workers, and informal observations made by the university researchers, to describe the benefits and challenges inherent in implementing this approach. Results indicate that the privileged access of peer workers to hidden IDUs and sensitive information improved the quality of the data. The PAR approach was also instrumental in changing the negative attitudes of health workers towards IDU and peer involvement in service delivery, an important first step towards meaningful consumer participation. However, the success of peer involvement is dependent on the extent to which health workers are willing to accept IDUs as colleagues rather than clients. We suggest that the capacity of peer workers to undertake these roles needs to be judged according to performance-based criteria that regards their injecting drug use experience as a legitimate form of expertise.     

Access to health and social services for IDU: The impact of a medically supervised injection facility

Introduction and Aims. Injection drug users (IDU) often experience barriers to conventional health‐care services, and consequently might rely on acute and emergency services. This study sought to investigate IDU perspectives regarding the impact of supervised injection facility (SIF) use on access to health‐care services. Design and Methods. Semi‐structured qualitative interviews were conducted with 50 Vancouver‐based IDU participating in the Scientific Evaluation of Supervised Injecting cohort. Audio‐recorded interviews elicited IDU perspectives regarding the impact of SIF use on access to health and social services. Interviews were transcribed verbatim and a thematic analysis was conducted. Results. Fifty IDU, including 21 women, participated in this study. IDU narratives indicate that the SIF serves to facilitate access to health care by providing much‐needed care on‐site and connects IDU to external services through referrals. Participants’ perspectives suggest that the SIF has facilitated increased uptake of health and social services among IDU. Discussion and Conclusions. Although challenges related to access to care remain in many settings, SIF have potential to promote health by facilitating enhanced access to health‐care and social services through a model of care that is accessible to high‐risk IDU.[Small W, Van Borek N, Fairbairn N, Wood E, Kerr T. Access to health and social services for IDU: The impact of a medically supervised injection facility. Drug Alcohol Rev 2009;28:341–346]     

Perceptions of discriminatory treatment by staff as predictors of drug treatment completion: utility of a mixed methods approach

Introduction and Aims. Staff interactions with their clients are an important factor in the quality of care that is provided to people in drug treatment. Yet there is very little research that addresses staff attitudes or clients' perceptions of discrimination and prejudice by staff with regard to treatment outcomes. This research aimed to assess whether perceptions of discrimination by staff predict drug treatment completion. Design and Methods. The study used a mixed methods approach. Ninety‐two clients in residential rehabilitation facilities in Sydney were administered a series of quantitative measures assessing drug history, severity of drug use, treatment history, perceptions of staff discrimination and treatment motivation. Clients were followed up regularly until an outcome (dropout or completion) was obtained for the full sample. Results. Perceptions of discrimination were a significant predictor of treatment completion, with greater perceived discrimination associated with increased dropout. Qualitative interviews with 13 clients and eight health‐care workers from these treatment services were then conducted to gain insight into how perceived discrimination may impact on treatment experiences. Clients and staff discussed how they would address the issue of perceived discrimination during the current treatment experience. Discussion and Conclusions. Adopting a mixed methods approach facilitated exploration of the impact of perceived discrimination on treatment from both clients' and health‐care workers' perspectives. This methodology may also enhance interpretation and utilisation of these findings in drug treatment.[Brener L, von Hippel W, von Hippel C, Resnick I, Treloar C. Perceptions of discriminatory treatment by staff as predictors of drug treatment completion: Utility of a mixed methods approach. Drug Alcohol Rev 2010;29;491–497]     

Childhood misbehavior and the risk of injecting drug use

This investigation examined the association between misbehavior in early life and subsequent injecting drug use (IDU) among Baltimore participants in the NIMH Epidemiologic Catchment Area study. Information about early misbehavior was collected in 1981 and about IDU in 1994–1996. Conditional logistic regression models were used to estimate the degree of association between early misbehavior and IDU, with injecting drug users (n=38) and controls matched on census tract of residence (n=745), selected from within the same community survey sample, and assessed in a methodologically identical manner. Early misbehavior was associated with subsequent IDU, independent of the associations with sex, age, and race. The estimated risk of IDU increased with the number of reported conduct problems. Early misbehavior also discriminated between injecting drug users and non-injecting drug users. These results, which support and extend earlier findings, have public health implications for preventing and stopping the risk-laden practice of injecting drug use.     

Injecting drug user attitudes towards rules for supervised injecting rooms: implications for uptake

Supervised injecting rooms (SIRs) have been implemented in Europe to assist in reducing the health and public order problems from street-based injecting drug use. Since 1997, extensive debate around the feasibility of SIR trials has occurred in the Australian jurisdictions of Victoria, New South Wales and the Australian Capital Territory. A trial is currently underway in Sydney, NSW. An important issue for SIR feasibility and trial design is injecting drug user (IDU) attitudes about SIR rules and regulations. In this study, 215 IDU were surveyed about SIR knowledge, willingness to use SIRs and attitudes towards SIR rules. Participants were knowledgeable about SIR issues, were willing to use SIRs (89%) and undeterred from uptake by: mandatory hand-washing (96%); close supervision (82%); bans on pill injecting (87%) or client-to-client injecting (71%) and deal splitting (55%). Significant minorities said they would not use SIRs if prevented from splitting drug deals (34%) or assisting others to inject (18%) on-site. The high level of SIR rule acceptance suggests that SIRs will play an important role in reducing the public impact of street injecting and various injecting related health harms. However, that some IDU would avoid SIRs due to certain rules implies that additional strategies will be needed if the health and other concerns of this group (and that of the surrounding community) are to be adequately addressed. The design and implementation of SIRs must be informed by extensive IDU consultation to be target group appropriate.     

Effects of Screening,Brief Intervention,and Referral to Treatment (SBIRT) Education and Training on Nursing Students’ Attitudes Toward Working With Patients Who Use Alcohol and Drugs

ABSTRACT

Background: Screening, Brief Intervention, and Referral to Treatment (SBIRT) can reduce alcohol use and negative health outcomes in patients with risky substance use. However, negative attitudes that some health care professionals have toward patients who use substances are a barrier to implementing SBIRT. Methods: The University of Pittsburgh School of Nursing, in partnership with the Institute for Research, Education, and Training in Addictions (IRETA), developed a curriculum to train baccalaureate student nurses to deliver SBIRT. Results: Following SBIRT education and training, students’ perceived attitudes toward patients who use alcohol became more positive. Less robust changes were found for attitudes related to patients who use drugs. Conclusions: Nurses composing the largest group of healthcare workers are in key positions to screen, intervene, and provide education about substance use.     

Hepatitis C‐related discrimination among heroin users in Sydney: drug user or hepatitis C discrimination?

The hepatitis C virus (HCV) is a common infection among injecting drug users. There are currently few available data on the extent (or prevalence) of HCV-related discrimination. This study examined perceived discrimination among a sample of heroin users and sought to determine whether the discrimination was attributed to their drug user or HCV status. Heroin users were recruited through needle and syringe programmes and methadone clinics in Sydney and were asked about discrimination in the preceding 12 months. Four hundred and one heroin users were recruited, of whom 59% reported being HCV-positive. Discrimination was reported by 22% of the 237 IDUs who reported being HCV-positive, with 17% reporting that the discrimination occurred in the preceding 12 months. Sixty-seven incidents were reported, of which half were perceived to be due to their drug user status, 15% of these incidents were due to HCV status and 25% due to a combination of both. Twenty-five incidents occurred in a health-care setting, of which 13 resulted in the service being withheld. HCV is a serious public health concern, and if IDU are to be encouraged into drug treatment it is essential that service providers are perceived to be non-discriminatory. In managing IDU patients, health care workers need to be cognizant of the impact that their attitude has on treatment outcome.     

Access to Sterile Injecting Equipment is More Important Than Awareness of HCV Status for Injection Risk Behaviors Among Drug Users

Awareness of hepatitis C virus (HCV) infection status is expected to influence risk behaviors. In 2004–2005, injection drug users (IDUs) recruited from syringe exchange programs (SEPs) and methadone clinics in Montreal, Canada, were interviewed on drug use behaviors (past 6 months) and HCV testing. Subjects (n = 230) were classified as low/intermediate risk (20.4% borrowed drug preparation equipment only) and high risk (19.6% borrowed syringes), and 54.5% reported being HCV positive. Logistic regression modeling showed that compared to no risk (60% borrowed nothing), low/intermediate risk was associated with fewer noninjecting social network members, poor physical health, and problems obtaining sterile injecting equipment. High risk was associated with all of these factors except social networks. HCV status was not associated with any level of risk. Improved access to sterile injecting equipment may be more important than knowledge of HCV status in reducing injection risks among this IDU population. The study limitations are noted and recommendations discussed.     

Poor criterion validity of self‐reported hepatitis B infection and vaccination status among injecting drug users: A review

Issues. Limited resources may dictate the use of self‐reported hepatitis B virus (HBV) status to determine the need for testing and/or vaccination in resource‐poor settings, as well as in research and surveillance. Approach. A synthesis of the literature on the criterion validity of self‐reported HBV infection and vaccination history among injecting drug users (IDU) in order to determine the utility or otherwise of self‐reports in this area. Key Findings. The degree of agreement between self‐reported and serological HBV status is consistently poor among IDU. In previous research, 46–95% of IDU with serological evidence of exposure to HBV did not report a history of infection, and serological evidence of vaccine‐conferred immunity was not detected among 50–73% of IDU who reported being vaccinated. Implications. A lack of awareness or misapprehension about their HBV status may lead some IDU to inadvertently engage in behaviours which place their injecting and sexual partners at risk, contributing to the continued potential for high incidence of HBV infection among this population. Conclusion. Self‐reported histories should not be used in lieu of serological testing when assessing infection history or immunisation status. Poor criterion validity also indicates that self‐reports of HBV infection status should not be used to estimate the prevalence and incidence of this infection. Due to their low sensitivity, self‐reports of HBV infection should at best be considered only as a lower bound prevalence estimate.[Topp L, Day C, Dore GJ, Maher L. Poor criterion validity of self‐reported hepatitis B infection and vaccination status among injecting drug users: A review. Drug Alcohol Rev 2009]     

Severity of drug dependence, economic pressure and HIV-related risk behaviors among non-institutionalized female injecting drug users who are also sex workers in China

BACKGROUND: Female injecting drug users (IDUs) who are also sex workers (FSW-IDUs) is an important bridge population transmitting HIV from the IDU population to clients of FSWs. Little is known about the relationships between severity of drug dependence, economic pressure and relevant HIV-related risk behaviors. METHODS: 281 non-institutionalized participants were recruited using snowball sampling methods. Anonymous face-to-face interviews were administered by trained doctors. RESULTS: 64.1% of participants used condoms inconsistently with their clients in the past 6 months; 28.5% served at least 2 clients per day and 48.4% practiced at least one of the three studied needle sharing behaviors. Severity of drug dependence (adjusted OR=1.05, p<0.01) and economic pressure (adjusted OR=1.07 to 2.52, p<0.05) were significantly associated with inconsistent condom use with clients in the last 6 months. Severity of drug dependence (adjusted OR=1.15, p<0.01) and variables related to perceived economic pressure (adjusted OR=1.09-3.05, p<0.05) were significantly associated with higher frequency of commercial sex transaction. Severity of drug dependence (adjusted OR=1.07, p<0.01) were also associated with needle sharing behaviors. In summary models, severity of drug dependence (OR=1.17, p<0.001), economic pressure (OR=1.39, p<0.001) and their interaction term (OR=0.98, p<0.001) were all associated with inconsistent condom use with clients in the last 6 months. CONCLUSIONS: Prevalence of unprotected commercial sex was high and was independently associated with severity of drug dependence and economic pressure; severity of drug dependence was also associated with needle sharing behaviors. Such issues need to be fully considered when planning research studies and interventions.     

An examination of the quality of life among rural and outer metropolitan injecting drug users in NSW,Australia

This article aims to explore the relationship between quality of life (QOL) and health-related behaviours among rural and metropolitan injecting drug users (IDU) using a new scale developed specifically for use with IDU.One-hundred and sixty-four rural and 96 metropolitan IDU from seven different NSW Area Health Services were interviewed using a cross-sectional survey, including the Injection Drug Use Quality of Life (IDUQOL) scale. The mean domain-based IDUQOL score was 59.4 (SD 22.3). The life areas most commonly selected by participants as important in determining their QOL were family, health, money, housing and partnerships. Rural participants were less likely to choose “housing” compared to those from the metropolitan areas, but were more likely to select “independence”. Rural participants also gave a lower mean rating to “money” (33.1 vs. 47.0) and to “partnerships” (53.8 vs. 71.1), suggesting differences in the composition of QOL among rural and metropolitan IDU. Compared to metropolitan participants, rural participants had a lower domain-based QOL score (56.1 vs. 64.5). No association was found between QOL and health-related behaviours such as drug use or sexual and injecting practices. IDU subjective assessment of QOL is mediated by a range of factors. Disparity between rural and metropolitan IDU appears to be influenced by non-health related areas such as partnerships and money, highlighting the need for a more holistic approach to the management of substance use problems.     

The impact of injecting drug use status on hepatitis C-related referral and treatment

More than 160,000 people are living with chronic hepatitis C virus (HCV) infection in Australia, however, rates of medical treatment are low. The aim of this study is to examine uptake and predictors of HCV-related health care services among a community-based sample of people with HCV. A self-administered questionnaire was completed by a largely non-clinical sample of 362 women and 308 men with HCV living in the state of Victoria. Analyses were performed according to injecting drug use (IDU) status: no history of injecting (non-IDUs), previous history of injecting (past-IDUs) and current (within the last 12 months) history of injecting (current IDUs). Bivariate and multivariate predictors of referral to a specialist liver clinic were also assessed. Fifty-one percent of participants were current IDUs, 33% past-IDUs and 16% non-IDUs. Fifty-two percent of women and 37% of men reported ever being referred to a specialist liver clinic and 18% of women and 20% of men reported previous HCV antiviral therapy. Although there were many factors related to an increased likelihood of referral (e.g. being female, longer time since diagnosis, longer consultation time at diagnosis, experiencing HCV-related symptoms), multivariate analysis revealed that not being a current IDU and seeing a GP specifically for HCV were the most important independent predictors of referral. For those who had been referred to a liver clinic, a history of IDU was associated with a lower chance of receiving antiviral therapy. IDU status is associated with both referral and treatment. The extension of HCV treatment services to involve GPs and drug and alcohol practitioners should be explored as models to improve access to antiviral therapy.     

Unmet need for recommended preventive health services among clients of California syringe exchange programs: implications for quality improvement

BACKGROUND: Comprehensive preventive services are recommended for injection drug users (IDU), including screening tests, vaccinations, risk reduction counseling, and sterile syringes. Syringe exchange programs (SEP) may facilitate receipt of preventive services by IDUs, but whether SEP clients receive recommended preventive care is not known. We examined use of recommended preventive services by clients of 23 SEPs throughout California. METHODS: Five hundred and sixty SEP clients were recruited from 23 SEPs throughout California between March and September 2003. Receipt of 10 recommended preventive services and source of care (SEP versus non-SEP providers) was ascertained from client interviews. RESULTS: On average, SEP clients received only 13% of recommended preventive services and 49% of clients received none of the recommended services. Of services that were received, 76% were received from SEPs. In multivariate analysis, use of drug treatment and more frequent SEP visits were associated with receipt of recommended preventive services by clients. CONCLUSIONS: SEPs are often the only source of preventive care for their IDU clients. Still, SEP clients fail to receive most recommended preventive services. Interventions to increase use of preventive services and improve the quality of preventive care received by IDUs, such as increased access to drug treatment and SEPs, are needed.     

An evaluation of a heroin overdose prevention and education campaign

Introduction and Aims. Following detection of an upward trend in the frequency of fatal heroin overdoses in Victoria between 2001 and 2003, Victoria's Department of Human Services planned a campaign aimed at increasing injecting drug users' (IDU) awareness of overdose risks and prevention strategies. Stickers, wallet cards and posters featuring five key messages were distributed via needle and syringe programs (NSP) and other drug and alcohol services between November 2005 and April 2006. An evaluation of the campaign was commissioned to be conducted in late 2006. Design and Methods. The evaluation consisted of analysis of three independent data sets––quantitative data collected from IDU during the campaign period (n = 855 at baseline; and a range of 146–656 at follow up); qualitative interviews with IDU who were NSP clients during the campaign period (n = 16) and qualitative interviews with NSP staff and other key stakeholders (n = 9). Results. While key experts felt that the campaign messages had engendered lasting impact for at least some IDU, these positive impressions were not borne out by the NSP client data, with less than one quarter of all campaign messages being mentioned by a significantly higher proportion of clients during the post‐campaign period compared with baseline. Key experts perceived the greatest weakness of the campaign to be the delay between issue identification and the introduction of campaign materials. Discussion and Conclusions. While IDU are generally responsive to health promotion campaigns, future initiatives in this domain should be designed and implemented rapidly and in ways that are sufficiently flexible to cope with shifts in drug markets which could influence the reception of key messages.[Horyniak D, Higgs P, Lewis J, Winter R, Dietze P, Aitken C. An evaluation of a heroin overdose prevention and education campaign. Drug Alcohol Rev 2009]     

Hazardous alcohol consumption among young adult IDU and its association with high risk behaviors

BackgroundHeavy alcohol consumption has been associated with risk-taking behaviors in intravenous drug users (IDU). However, limited information exists on the relationship between alcohol use and injecting and sexual risk in young adult IDU (<30 years) who are at risk for hepatitis C virus (HCV) and HIV infection.MethodsWe conducted a cross-sectional study of young adult IDU in San Francisco (2006–2012) who had not previously tested positive for HCV. Participants completed a structured interview and HCV testing. We examined whether hazardous drinking (Alcohol Use Disorders Test-Consumption [AUDIT-C] 3–9 for women and 4–9 for men) and probable dependent drinking (AUDIT-C 10–12) levels were associated with injecting and sexual risk behaviors and HCV status, indicated by adjusted odds ratios (AOR) in separate models controlling for potential confounders.ResultsOf the 326 participants, 139 (42.6%) were hazardous drinkers and 82 (25.2%) were probable dependent drinkers; thus over two-thirds evidenced problem drinking. Being a hazardous drinker was significantly associated with injecting drug residue from another's drug preparation equipment (AOR 1.93). Probable dependent drinking was significantly associated with sharing non-sterile drug preparation equipment (AOR 2.59), and inversely, with daily/near daily injecting (AOR 0.42). Both heavy drinking levels were associated with having ≥2 sexual partners (AOR 2.43 and 2.14). Drinking category was not associated with HCV test results.ConclusionThe young adult IDU reported consuming alcohol at very high levels, which was associated with some unsafe sexual and injecting behaviors. Our study demonstrates the urgent need to intervene to reduce alcohol consumption in this population.     

Qualitative evaluation of a peer-based needle syringe programme in Vietnam

BackgroundHarm reduction has been identified as an important HIV prevention strategy for injecting drug users (IDUs) in Vietnam. However, to date only small geographically limited formal needle syringe programmes (NSPs) have been implemented; and little attention has been given to assessing the effectiveness of the piloted models. Using data from a qualitative evaluation of an NSP in northern Vietnam, this paper assesses the effectiveness of the intervention, examines barriers to the NSP, and documents lessons which can be applied to replicate and scale up interventions across Vietnam.MethodsData were gathered using key informant interviews, focus group discussions, in-depth interviews, observation and intercept interviews with IDUs and other project stakeholders. IDUs were introduced to the evaluation by peer educators (PEs).ResultsThe project contributed to a shift toward safe injecting practices and safe disposal of used needles and syringes (N&;S) among IDUs. Collection of used N&;S positively influenced community attitudes toward PEs and IDUs. Reduced community discrimination, achieved as a result of project advocacy activities, encouraged IDU to access free needle syringes and other project services provided by PEs. Resistance from the local government officials and community members was turned into support for the programme through intensive advocacy activities. The project highlighted the importance of involving law enforcement in the programme and promoted a public health approach toward working with IDU. However, periodic police campaigns against drug use continued to be an obstacle to successful programme implementation and demonstrated the need for continued efforts to address the issue.ConclusionProgramme success is dependent upon community support. Resistance to NSPs can be overcome through a programme of intensive advocacy with community stakeholders including; local government, mass organizations, local residents, IDUs and their families. Garnering the support of law enforcement officials requires a sustained effort.     

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.