Research PaperBack to the core: A network approach to bolster harm reduction among persons who inject drugs
Introduction
Injecting drugs safely almost always involves the presence of others, especially for the prevention of overdose. Intervention efforts are most effective when we treat the networks of persons who inject drugs (PWIDs) as mechanisms for delivering services, education, and strategies to members embedded in their own social injection networks. Yet, while injection networks serve as a mechanism for support, they may also facilitate at-risk behaviors that are a source of health-related risks. Network methods provide opportunities to understand the flow of infectious diseases, insights into the at-risk behaviors of drug users, and a means to map the transmission of practices of safe behavior amongst drug users (Curtis et al., 1995; Friedman et al., 1997; Klovdahl et al., 1994; Latkin, Mandell, Oziemkowska, Vlahov, & Celentano, 1993; Suh, Mandell, Latkin, & Kim, 1997; Weeks, Clair, Borgatti, Radda, & Schensul, 2002). Harm reduction behaviors are not independent of the types of social exchange and interpersonal relationships that surround PWIDs. The use of harm reduction behaviors is associated with both the perceived acceptance, as well as the use of such practices by other injectors in one’s social network (Andía, Deren, Robles, Kang, & Colón, 2008; Hawkins, Latkin, Mandel, & Oziemkowska, 1999 Unger et al., 2006).
This study draws from 200 interviews with PWIDs in Vancouver’s Downtown Eastside (DTES) from a supervised injection facility and a drug users’ advocacy group. Respondents were asked about the individuals they personally considered as facilitators of harm reduction, and the connections between them. The research design allowed us to map an important slice of the harm reduction amongst PWIDs in the DTES. Mapping the network of a relatively hidden phenomenon provides a unique opportunity to uncover its social structure. For example, are some PWIDs well supported and part of a harm reduction “core”? Alternatively, are some users isolated from others, situated on the periphery of the network and insulated from providing and receiving harm reduction services? The aim is to identify individuals that could help bring peripheral users back to the core of the harm reduction network.
Section snippets
Background
In 2003, InSite, North America’s first sanctioned supervised injection facility was opened in the DTES, operating under a constitutional exemption. InSite has been subjected to dozens of peer-reviewed studies (Potier, Laprévotec, Dubois-Arbere, Cottencina, & Rollanda, 2014). The results of these studies have been overwhelmingly positive: Reduction in the human immunodeficiency (HIV) and hepatitis C (HCV) viruses in the DTES population, overdoses, public drug use, publicly discarded syringes and
Data collection sites and peer recruitment
InSite opened in 2003. It is North America’s first legally sanctioned supervised injection facility located in Vancouver, B.C. VANDU was founded in 1998. It brings together drug users from an adjacent area, and encourages practices of safe behaviors by providing users the opportunity to design and implement harm reduction interventions through peer-based models. VANDU has historically operated through peer-based unsanctioned syringe exchange services, supervised injections and smoking rooms (
Analytic strategy
The analysis proceeds in three steps. First, we provide descriptive measures for the network structure. Second, we apply a core-periphery algorithm to the data. A network is said to have a core-periphery structure when a relatively small (relative to network size) group of nodes have a high density of links, highly connected to each other (and in general), and connected to the periphery, though the latter are not highly connected to the core or to one another (Borgatti & Everett, 1999; Rombach,
Results
Fig. 1 provides a visual representation of the main component of the network.6 There emerges a dense center, which comprises many of our respondents, especially the 75 respondents who had the dual role of respondent, and contact. Towards the periphery of the network are contacts, generally
Discussion and conclusions
The DTES, Canada, is home to a host of individuals actively involved in diffusing harm reduction practices. In many ways, it follows a network principle to diffuse the message of safe behaviors to as many PWIDs as possible through InSite (Jozaghi, 2015, McNeil et al., 2014, Small et al., 2012) and VANDU, an informal peer-based network of safe injection practices (Kerr et al., 2006), and several peer engagement programs (Greer et al., 2016). Peer-driven research have been used to effectively
Conflict of interest statement
Co-authors Bouchard, Hashimi, Tsai, and Jozaghi have no conflicts of interest to declare.
Co-author Lampkin is on the executive board of the Vancouver Area Network of Drug Users (VANDU), one of the two sites used for data collection. The study, however, does not impact VANDU in any positive, or negative way.
Acknowledgements
This work was supported by a grant from the Simon Fraser University’s Steel Endowment Fund (2014s0441) and the Canadian Institute of Health Research Postdoctoral Fellowship(201511MFE-358449-223266). The authors would like to thank the PHS Community Services Society, VANDU who provided access to their peers, clients and resources and the individuals who directly or indirectly contributed to this research project, in particular, we would like to thank Marion Allart, Aiyanas Ormond, Darwin Fisher,
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