Relationships Between Social Network Characteristics and Behaviours of People Who Inject Drugs in Edmonton

1. Relationships Between Social Network Characteristics and Behaviours of People Who Inject Drugs in Edmonton Amanda Van Spronsen Jody Wolfe Marliss Taylor Cameron Wild 2 June 2011

2. Overview • The Big Picture • Background on IDU in Canada and Edmonton • A Community – University Research Partnership • Rationale for the Study • Social Networks of people who inject drugs in Edmonton • Conclusions

3. 1. The Big Picture

4. The Big Picture • Infectious disease transmission (HIV/HCV) • Associated health, social, and economic costs among people who inject drugs • Although IV drug use occurs throughout society, it is more visible – and more stigmatized – among marginalized, street-involved people • IV drug use is inherently an interdisciplinary (clinical, psychosocial, economic, social determinants) and multi-stakeholder public health issue

5. The Big Picture • Political mobilization: Unlike others with chronic disease issues (e.g., diabetes) IV drug users have little political influence and few advocates • Social response: Balancing appropriate social responses between • Enforcement (typically ~85%+ of health and social budgets) • Treatment (typically ~5-10% of budgets) • Prevention (typically ~5% of budgets) • Harm reduction (a pittance of budgets, but nevertheless the controversial black sheep, always questioned and always in danger of being eliminated)

6. The Big Picture • Policy makers and the public are often confused that people who inject drugs continue to do so, despite expressing awareness of the health and social risks involved • Such seemingly ‘irrational’ behaviour is understandable and even functional, however: • While ID use is associated with long term costs and few long term benefits, for a marginalized, addicted drug user, IDU is associated with many benefits and relatively few costs at the time of action (e.g., relief of aversive withdrawal, opportunity for social interaction and economic exchange)

7. 2. Background on IDU in Canada and Edmonton

8. Public Health Relevance of IDU Population health consequences of IDU are clear • 75 000 – 125 000 IDU in Canada • ~4000 – 10,000 IDU in CH region alone • Infectious disease transmission (HIV/HCV) • Premature and preventable mortality • Preventable morbidity • Socioeconomic impact

9. Public Health Relevance of IDU OPICAN study • CIHR-funded multi-site cohort study of street-involved untreated illicit opiate users • Data were collected in 2002 in Vancouver, Edmonton, Toronto, Montreal, and Quebec City • Snowball and outreach recruitment methods • N = 657 participants • Biological verification of recent opiate use • No addiction treatment in previous 6 months

10. Public Health Relevance of IDU

11. Public Health Relevance of IDU

12. Public Health Relevance of IDU Source: Wild et al. (2005). Cdn J Psychiatry, 50, 512-18

13. 3. A Community-University Research Partnership

14. The Promise Partnership research promises to: • allow academics and communities to become involved in new and broader health issues without taking sole responsibility; • help mobilize more talent than any one organization has; • demonstrate widespread support for issues and unmet needs; • maximize political impact through joint action; • minimize duplication of research activities.

15. Barriers Despite these desirable outcomes, partnership research is still relatively rare. A common pattern is that voluntary partnerships on research are difficult to start and maintain. Individual factors affecting participation • Social value orientation – are potential partners willing to work toward research of joint benefit? • Expected costs and benefits of participation • Interpersonal and technical skills in working across traditional sectoral boundaries

16. Barriers Partnership research is also difficult to initiate and sustain because of… Organizational factors affecting participation • Resource acquisition – acquired through academic or community channels? • Reward and punishment structures – what benefits and costs accrue to the partnership? • Organizational leadership and vision – how does this work in a multisector research partnership?

17. IDU and Partnership Research IDU provides an ideal opportunity for doing partnership research, because: • Academic researchers typically don’t have easy access to this hard-to-reach population • Community-based programs (e.g., harm reduction programs) cultivate relationships and provide opportunities for studying impact of interventions • IDU population is often marginalized – poverty, housing, and other health and social issues lend themselves to political action that can be enhanced via partnerships

18. Harm Reduction Programs These operate in a context, with historical baggage: • We’ve had positive and negative experiences with research and researchers • Nobody understands us! • We are suspicious by nature • Some groups would like to shut us down • Political support is somewhat nebulous – even adversarial in some sectors • We see ourselves in a ‘protective’ role

19. Some Rules of Engagement… Several processes were adopted from the beginning to ensure a successful partnership, including: • Streetworks Council consulted and formal approval sought for partnership research • Terms of the partnership were clarified and agreed upon • Joint advertisement for research candidates (RAs) • Joint interview policy adopted with questions targeting both the research role and the outreach/harm reduction role of RAs

20. Interorganizational Outcomes Processes resulted in a new social role for RAs • Employees of U of A, but • Integrated into Streetworks team • Located where harm reduction services are provided in the inner city • RAs provide outreach services, make contacts, build trusting relationships with service users • Up to 3 months of outreach/harm reduction services provided prior to introducing the research projects/studies. Cultural immersion essential to be effective and credible These processes also resulted in: • A code of conduct for partnership research designed to protect interests of both community program and the academics • Joint management and supervision of RAs

21. 4. Rationale for the Study

22. Why Do We Need Better Contextual Assessment for this Population? Rationale for the second phase of the research partnership… • There is an urgent need to understand social dynamics related to unsafe needle use. This is because: • Labelled needles remain in circulation among user networks more than a month after their distribution (Alcabes et al., 1999) • Suggests that intensive delivery of clean needles cannot guarantee low levels of disease transmission when social contexts discourage safe use • In Edmonton’s OPICAN site, 81% of ID users exchanged needles via Streetworks; however: • 53% reported reusing needles • 30% reported sharing injection paraphernalia • 16% reported sharing needles • Suggests that social dynamics are associated with risky IDU, even when clean equipment is available

23. Assumptions and Objectives Rationale for this study… • Assumption: provision of clean physical tools for IDU is necessary, but not sufficient, to eliminate transmission of HCV/HIV. • Scientific research objective: To describe contexts that enable unsafe needle use, even when clean physical tools are available. Specifically, we attempted to describe social, inter- and intra-personal contexts of IDU, with attention to personal and community beliefs, social comparison, and social networks • Community/practice objective: To develop brief tools to assess contextual aspects of IDU to facilitate targeted harm reduction activities and services.

24. A Mixed-Method Focus Instrument Development Overview (18 month process) • In-depth semistructured interviews (1-4 hours) were conducted with 31 drug injectors recruited through Streetworks and user networks • Data analyses derived a comprehensive pool of themes used to develop item pools assessing environmental, interpersonal, and attitudinal aspects of drug injection practices.

25. Assessment of Risk Contexts (ARC) Field tested version of ARC took about 1.5 hours to complete the full interview. But ARC can be disaggregated into focused contextual assessment in the following domains: • Part 1: Demographic information. In-depth coverage of living arrangements and housing issues. • Part 2: Drug use information. In-depth coverage of fixing contexts (drugs used, locations, others). • Part 3: Attitudes toward injecting • Part 4: Social network assessment • Respondents nominate up to 10 social network members and an extensive characterization of them is provided (resources, drugs, sharing, sexual relations, etc.)

26. Behavioural Risk Measures Blood-borne Virus Transmission Risk Questionnaire (BBV-TRAQ): Only content-valid instrument enabling assessment of injecting and other risk behaviours for HCV, HBV, and HIV. Has 34 items divided into 3 subscales. Respondents indicate the frequency with which they engaged in these risk practices in the last 30 days: • Injection practices (e.g., sharing needles, syringes, other equipment; second-person contamination in preparation and injecting) • Sexual practices (e.g., condom use, anal sex) • Skin penetration events (e.g., contact with others’ blood [fights, bloody nose, etc.], tattooing, piercing, using others’ razors, clippers)

27. 5. Social Networks of People Who Inject Drugs in Edmonton

28. Overview of Study • Recruited a convenience sample 91 people who inject drugs, using a combination of outreach and peer-referral techniques • Participants were paid for their participation ($20 gift certificate) • To be included in the study, participants had to: • be 18 years of age or older (or an emancipated minor) • be able to provide informed consent • report injecting drugs at least once in the last 30 days

29. Sample Characteristics (Demographics)

30. Sample Characteristics (Demographics)

31. Sample Characteristics (Demographics)

32. Sample Characteristics (Demographics)

33. Sample Characteristics (Drug Use)

34. Sample Characteristics (Drug Use)

35. Sample Characteristics (Drug Use)

36. What is Social Network Analysis? • A way to look at social structure and organization (a perspective) • Network analysis helps us understand influence • Network analysis helps us describe context • Networks can be evaluated and analyzed, by looking at structure and composition • There are many different types of Social Network Analysis, but this study focused on Ego Networks • Ego (Personal) Networks = Individuals (nodes) and their relationships (ties)

37. How are Social Networks Measured? • Think of all of the people that you have interacted with in the past 30 days • What is your relationship with them? • How long have you known them? • How frequently do you see them? • What types of activities do you do together? • What resources do you provide for one another? • What type of support do they give you? • If you were in trouble, could you ask them for help? • If you needed money, would they give it to you? • If you had something valuable, could you trust them with it? • If you needed advice on a health matter, would you ask them? • If you were in emotional distress, would you turn to them?

38. How Were Social Networks Measured in this Study? • We asked the respondents to think of the people that they were in contact with in the past 30 days. They could name up to 10 individuals. • We asked about their characteristics (gender, age, relationship role) • We asked about their support (trust, resource supply, help) • We asked about their activities with the respondent (drug use, drug sharing)

39. Network Size and Composition • Out of 91 respondents, 74 said that they had a personal network • Total size ranged from 1 to 6, average of 2.08 • Average age of members is 38.02 years • 66% of network members are male Other composition measures

40. Gender and Social Network Characteristics What do the networks like when we look at female and male respondents separately?

41. A Closer Look at Gender • What does the rest of the survey tell us? Statistically significant differences include: • More females are First Nations & Métis (79% vs. 36%) • More females have had children (84% vs 58%) • Females are younger (Average of 36 years old vs 41 years old) • Females have more relatives in their personal networks (19% vs 4%)

42. More on Gender • There are differences in drug use • Fewer females use Kadian (29% vs 51%) and Heroin (0% vs. 18%) • There are differences in risk behaviour • More females engage in unprotected vaginal sex (52% vs 18%), use other people’s hygiene equipment (56% vs 23%), and are injected by individuals who have performed multiple injections (56% vs 33%) • There are differences in attitude • More females agree with the statement “You have to be careful that someone you fix with doesn’t overdose you on purpose” and “I often fix beyond my normal limit”

43. Trust and Social Network Characteristics We asked: Do you trust this person to take care of your stuff if you had to leave it with them? • There was a significant difference in how males and females answered this question. What more would the survey reveal when we looked specifically at trust across social networks? • We defined the personal networks as follows: • Low trust networks = respondents said YES to the above question about FEWER than HALF of the people in their personal networks • High trust networks = respondents said YES to the above question about HALF or MORE of the people in their personal networks

44. Trust in Personal Networks

45. Trust and Risk Behaviours

46. People living in high-trust social networks… Were less likely to report using alcohol or speed/meth in the past month More likely to require their network to use safer practices More likely to be willing to delay use if feeling unsafe Only rarely feel that they aren’t always able to pay attention to everything that is going on when high Only rarely feel that worried about getting a disease because of being unable to maintain control over equipment

47. People living in high-trust social networks were… Less likely to say they never share a spoon or mixing container before using it More likely to say they never have licked leftover drugs from a shared spoon or mixing container More likely to say they have never been injected by someone who had injected another person first More likely to say they had never come into contact with a drug that had touched another person’s used needle More likely to say they have never had a needlestick injury More likely to say they had never used someone else’s hygiene equipment

48. 6. Conclusions

49. Conclusions (1): Gender matters a lot! In this sample of 91 people who inject drugs in Edmonton, females are… More likely than males to be First Nations/Metis More likely than males to have children Younger than the males More likely than males to report risky behaviours Less likely to report trust in their personal networks

50. Conclusions (2): Trust in personal networks is protective! In this sample of 91 people who inject drugs in Edmonton, people who report lots of trust in their personal networks… Use less alcohol and speed/meth than those who report low levels of trust in their networks Are more in control when injecting Engage in safer injection practices than those who report low levels of trust in their networks