Jpgrund bridging the streets and the institutions


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Jpgrund bridging the streets and the institutions

  1. 1. Bridging the Streets and the Institutions: The role of Ethnographic research in HIV prevention among people who use drugs Jean-Paul C. Grund CVO—Addiction Research Centre, Utrecht, The Netherlands
  2. 2. Presentation Overview       Research traditions Research on people who use drugs Injecting drug use and HIV infection Qualitative research of people who use drugs Case studies Conclusions
  3. 3. Research traditions    Quantitative VS. Qualitative approaches The science of numbers and the science of words, images and emotions Desk science or street science Importance of “Research Alliance” with community studied  Key informants, community field workers    Relevance in various policy areas Status and funding
  4. 4. How to lie with statistics… “Kurt and Vicki Oliver had great credit, long-term employment and excellent assets and income. So how did they almost come to lose their home to foreclosure? It was a bad mortgage from a fast-talking broker.”
  5. 5. Research on people who use drugs   Successful interventions require a thorough and multiangle social scientific understanding of the problem at hand, but… Mostly institution based research     Quantitative studies of treatment populations Limited relevance outside walls of institution: The “Clinician’s Bias” (Cf: Fiddle, 1967) Skewed epidemiology and perception of drug use and drug users Little interest in scientific community before onset of HIV among people who inject drugs (and are not in treatment)  Not much to gain in terms of status and funding
  6. 6. Qualitative research among injecting drug users and other hidden populations   “Good quantitative researchers go to Heaven. Good qualitative researchers go Everywhere” Hidden (out-of-treatment) populations      Vulnerable populations: people engaging in behaviors considered “deviant”—(injecting) drug users, sex workers, LGBT Stigma and discrimination; Criminalization Distrust of institutions and researchers Rationale for keeping ‘things’ covert and underground Case studies
  7. 7. And then there was HIV…  The onset of HIV among injection drug users (IDUs) in the early 1980s: Scientific Panic     Increasing number of IDUs presenting at medical clinics with symptoms of “GRID” HIV was seen as a “gay disease” The apparent link between HIV and injection drug use was not easily understood. What mechanisms were responsible for HIV transmission in this (at the time, atypical) population? Early ethnographic observations of people actually injecting drugs revealed the mechanisms behind the link between HIV and injection drug use.
  8. 8. Understanding the link between drug injecting and HIV, I. Equipment Sharing  Early ethnographic observations showed:       High levels of sharing many different types of injecting equipment. Scarcity of injecting equipment – how to change that? (Laws were a problem.) Social norms at work that encouraged sharing – how to change that? High levels of fear & concern among IDUs about HIV and (how to protect) their health. High levels of distrust among IDUs, as well as an eagerness to learn about HIV. The responses of IDUs in the community shattered the researchers’ own stereotypes about drug users in general.
  9. 9. The link between drug injecting and HIV, II. Syringe-Mediated-Drug-Sharing  Frontloading & Backloading  A serendipitous finding… Relevant to epidemiology     Subsequent research documented SMDS among IDUs around the globe Important driver of HIV epidemic in fSU countries Relevant to Prevention: Not the needles, but the drugs    Social context of sharing drugs and collective use of injecting equipment Social (ritual) meaning vs. instrumental utility and scarcity Existing mechanisms of social support and economic exchange
  10. 10. The link between drug injecting and HIV, III. “Other issues to consider” (AKA drug policy)         Drug, Set & Setting (Norman Zinberg) Rippin’ & Runnin’ (Michael Agar) Methadone, Wine and Welfare (Preble & Casey) A “hierarchy of risk” (Margaret Conners) Women on Heroin (Marsha Rosenbaum) Drug use and HIV risks among the Roma (Grund, et al.) The Risk Environment (Tim Rhodes) “Enemy Environment”   “Junkie Jogging”, Frankfurt aM, late 1980s; Carrying injecting equipment (USA, Russia) The “Blood Myth” — Debunking misinformation in Russia/fSU
  11. 11. Leading the response: Intervention development     Community based outreach: “Reach and Teach Bleach” Needle exchange (1981: Rotterdam Junkie Union; Gerry Stimson, UK) From 1-4-1 to “secondary” exchange and distribution From provider driven to peer driven  Example: the HADON NSP in Rotterdam, NL, mid 1980s.
  12. 12. The HADON NSP & Client Zero     First period (<1986): only needle exchange at the office and during street outreach: the clients highly appreciated the needle exchange, but we felt that we were only serving a small proportion of the IDUs in area. 1986: Client Zero (CZ) CZ was a relatively new, but regular client of the needle exchange; one day he came to exchange and told me that many other IDUs inject at his apartment. CZ and subsequent clients with similar stories made us realize that we had to find ways to get clean needles where these were needed most, at those places where IDUs meet to inject drugs. Serious reconsideration of needle exchange rules; from 1-4-1 exchange to distribution… …“Collective Exchange”
  13. 13. Introducing “Collective Exchange”    “Collective exchange” was experimentally initiated to determine if outreach component of the program could be extended and improved. Examined whether visitors could be motivated to both distribute new needles to their IDU friends and collect used needles. Turning them from service consumers into providers of services to their peers, stimulating them to take more responsibility for their own and their peers’ health.
  14. 14. Where have all the needles gone? Karel agrees to let Jerry take a shot at his place. Jerry wants to shoot up cocaine. He puts his syringe on the table and asks Karel for a spoon. Karel asks, "Is that an old spike you want to use?" Jerry replies, "Well, old, I've used it one time before, so it's still good for use." Karel says, "I've got some new ones left from HADON," and hands one over to Jerry, asking him, "Do you want some more for tonight or the weekend?" Jerry replies, "If you can spare them, I'll take some with me." Karel gives him four.  At present, secondary exchange is the primary mode of needle exchange in the US (Des Jarlais et al., 2009).
  15. 15. Drug Use Characteristics of Russian Syringe Exchange Participants N = 1,076 N. N. Pskov R-N-D St. Petersb. Volgograd N = 236 N = 201 N = 199 N = 221 N = 219 Age First IDU1 (Mean/SD) Total N = 1,076 19 (4) 21 (5) 21 (5) 18 (3) 19 (4) 20 (4) < 3 years 3+ – 6 years 6+ – 10 years >10 years 22 33 33 12 47 31 10 12 18 22 25 35 43 27 16 14 26 41 26 6 30 32 23 15 Drug Injected1,2 (%) Homemade opiates Powder Heroin Amphetamine 83 47 9 15 53 61 84 5 24 6 96 9 21 90 4 42 59 20 Reported Secondary Exchange (%) 40 46 40 43 48 44 Years Injecting1 (%) 1 N differs because results are derived from intake questionnaires that linked with risk assessment questionnaires, only, so that N for Nizhny Novgorod = 165; N for Pskov = 153; N for Rostov-na-Donu = 109; N for St. Petersburg = 56; N for Volgograd = 160; and the total N for the five programs = 643. 2 Percents may sum to > 100; more than one response may apply. Almost half of Russian Syringe Exchange Participants reported Secondary Exchange (4048%), whether the program encouraged it or not.
  16. 16. From “provider-client” outreach…   Qualitative studies documented successes but also limitations to traditional (professional) outreach model (e.g. Broadhead & Fox). The traditional outreach model:    Relies on hiring former or current drug users, or people with “street credentials” to serve as outreach workers Assumes a Provider-Client Relationship with IDUs: outreach workers become new “providers” who begin to work with their peers by turning them into “clients” OWs venture out into targeted areas, seek to identify IDUs, develop trusting relationships with them, educate them in the community, give out risk reduction materials, and recruit IDUs into services
  17. 17. Problems with traditional outreach  Qualitative study of traditional outreach (Broadhead & Fox) in San Francisco, USA    Observed outreach workers in different US cities Main findings: Traditional Outreach projects tend to stagnate and exhibit high levels of mal- and nonperformance by outreach workers They found: “Good Organizational Reasons For Bad Organizational Performance”
  18. 18. Why Traditional Outreach Projects Performed Poorly: Agency Problems          Low salaries Problematic supervision Adverse selection problems Occupational risks of outreach in drug scenes Black Market opportunities Work-related monotony and powerlessness Identity conflicts (e.g. harm reduction approaches vs. religious beliefs) High staff turnover all of the above in combination
  19. 19. But, IDUs responded positively to outreach projects!      Volunteered and helped outreach workers Introduced outreach workers to new IDUs, and eased IDUs distrust of them Revealed the drug scene to outreach workers Helped outreach workers distribute risk reduction materials (bleach, condoms) Responded to interviews and education sessions
  20. 20. Remarkable results and useful insights     These and other studies demonstrated dramatic decreases in risk behavior. Revealed that IDUs were far more capable and responsive to interventions than researchers previously thought. Demonstrated that IDUs could play active roles in helping themselves and others. Results dovetailed with research mentioned above: IDUs are not isolated individuals, but part of larger networks of users, within a(n underground) community with defined social rules and standards of conduct.  The “scene” — “secret societies” (Cf. MSM & sex work) (Howard Becker, Insiders)
  21. 21. … to peer driven prevention?  Researchers and community activists (in many places) started thinking about developing prevention models that rely on active drug users to carry out core outreach tasks “Why not develop a model that works with drug users as colleagues rather than as “sick” people, “criminals,” or “disabled” people, because IDUs demonstrated that they were more capable, responsive, and willing to work than previously recognized.” (Robert Broadhead)
  22. 22. Novel approaches relying on peer involvement  “Fellow network” approaches      Secondary needle exchange Overdose prevention & naloxone distribution Respondent driven sampling (RDS) Peer Driven Intervention (PDI) Peer support approaches are in line with the International Guidelines on HIV/AIDS and Human Rights (United Nations, 2006) “The most effective responses to the epidemic grow out of people’s action within their [own] community and national context” (UNAIDS/IPU 1999).
  23. 23. The Peer Driven Intervention (PDI)  Collaboration between ethnography and mathematical sociology (Broadhead & Heckathorn)   Strong fundament in both “the trenches” and theoretical sociology—Group mediated social control (GMSC) Chain-referral model based on a coupon system of referral      Relies on those with the best contacts to recruit and educate drug users: active drug users Relies on IDUs to carry out the core activities of outreach work Service recipients also get the opportunity to work as service providers—working with their “clients” as colleagues Offers nominal rewards for successfully completed prevention tasks (All IDUs are offered the same opportunity) In relying on “everyone,” the PDI is always potentially working: it relies on many to contribute a little and there are no holidays or take days off
  24. 24. Eight program factors that promote behavioral change  New Information Skills building Interaction Peer pressure Norms Rewards Repetition  In a PDI all of the above occur in combination        With IDUs accessing and educating their peers, a PDI is couched in terms that is always culturally appropriate to the population targeted
  25. 25. Discussion    Qualitative research in drugs/HIV policy and intervention development A bridge between the (research) institutions and the streets Methods developed by ethnographers, such as the PDI and other fellow network approaches towards HIV prevention target populations “sentinel” to succesful HIV prevention:    Out-of-treatment IDUs/those unreached by other health services Subpopulations with increased levels of risk behaviour and those avoiding regular service participation Need for capacity development on qualitative research in many countries
  26. 26. Thank you! Thanks to Robert Broadhead for some of the presented data.
  27. 27. Contact Jean-Paul Grund, PhD PI PROZE CVO—Addiction Research Centre T: +31 30 238 1495 F: +31 30 238 1496 E: W3: