A case study of the transformative effect of peer injection drug users in the Downtown Eastside of Vancouver, Canada.

• Author: Jozaghi, Ehsan

Introduction

The injection drug user population has a long and troubled history in Vancouver's Downtown Eastside community. In fact, despite the operation of North America's largest needle depot, between 1992 and 2000, an explosive outbreak of HIV forced the local health authority to declare a public emergency in 1997 (Wood and Kerr 2006). Kerr, Small, Buchner, Zhang, Li, Montaner, and Wood (2010) and the editors of the International Journal of Drug Policy (2006) attributed the outbreak of HIV to a number of factors, including a rigid one-for-one syringe exchange policy (i.e., only one sterile syringe is distributed for every used syringe returned) and the limited hours of the needle exchange operation. In the years following, a number of additional harm reduction strategies were put in place. In an effort to reduce rates of syringe sharing, maximize sterile syringe access, and slow the spread of HIV between 2000 and 2002, for example, the Vancouver health authority modified its needle exchange program policies by shifting from a focus on syringe exchange to a focus on syringe distribution (BC Harm Reduction Strategies and Services 2012). This shift included the opening of the Washington Needle Depot (WND)--an extension of the Portland Hotel Society's existing needle distribution services in an alley in the Downtown Eastside.

Another significant development in the realm of harm reduction was the establishment of North America's first and only supervised injection facility. Insite opened its doors on 22 September 2003 (Andresen and Jozaghi 2012; Jozaghi and Andresen 2013). Operating on a harm reduction model, Insite is a safe facility, where people may inject drugs and connect with a variety of health care services without fear of arrest (Vancouver Coastal Health 2013). To date, a considerable body of research has demonstrated the effectiveness of Insite and the other harm reduction programs in the community (for a concise summary of the research, see Small 2010). The policy change toward improving access to sterile syringes and the operation of Insite, for example, have been found to contribute to reductions in syringe sharing, drug overdose deaths, and HIV incidence in the Downtown Eastside (Kerr et al. 2010; Marshall, Milloy, Wood, Montaner, and Kerr 2011).

While such findings reveal health-related outcomes of the harm reduction programs, there has yet to be research that explores the specific impact of peer influence with respect to the injection drug user population. This, however, is an important area of inquiry. Because the Downtown Eastside is densely populated, the social networks of injection drug users and their peers--in addition to unique environmental conditions--create circumstances that allow peers to shape and influence risky injection practices, such as sharing and reusing needles and overdosing.

Such results have been found in similar studies where, for example, drug users have helped extend the reach and effectiveness of harm reduction programs (Broadhead, Heckathorn, Weakliem, Anthony, Madray, Mills, and Hughes 1998; Des Jarlais and Semaan 2008; Grund, Blanken, Adriaans, Kaplan, Barendregt, and Meeuwsen 1992). As a result, it is important not only to assess how peers intervene to shape social networks but to capture the transformative role of peer-led interventions in the lives of injection drug users. This marks the departure point of the current study. Adopting a qualitative methodology, the current work presents findings from an analysis of narratives that were collected through semi-structured interviews with peer injection drug users. The interviews were designed to solicit narrative accounts from participants on several themes related to their experiences in the Downtown Eastside community of Vancouver.

Methods

Participants

The sample of participants for the current study included peer injection drug users affiliated with Insite or the WND. Insite is located on East Hastings Street, in the heart of the Downtown Eastside (see Figure 1). Insite currently serves approximately 4,700 of Vancouver's estimated 8,000 injection drug users (Jozaghi 2012). The facility consists of a registration/waiting area, an injection room, and a "chill lounge." Inside the chill lounge, peer injection drug users are employed to provide coffee and juice. In addition, peers talk and socialize with users and watch for signs of overdose. Some peers also work as peer counsellors. Each pair of peers works an 8-hour shift and receives a small volunteer stipend. Peer injection drug users who work in the chill room must be current or former users themselves so that they are better able to understand, connect, and interact with clientele who may be homeless, be HIV positive, and/or suffer from drug psychosis.

[FIGURE 1 OMITTED]

The WND is also located on East Hastings Street, in close proximity to Insite (see Figure 1). It provides needles and ancillary equipment (e.g., insulin syringes with attached needles, bottles of sterile water for injection, latex condoms, alcohol swaps, disposal boxes, and spoons) 24 hours a day, seven days a week. The WND also conducts daily patrols in the alleys of the Downtown Eastside, which, historically, have proven to be difficult due to the displacement of homeless injection drug users during police crackdowns in the area (Wood, Kerr, Small, Li, Marsh, Montaner, and Tyndall 2004; Eby 2006). Each pair of peers works a 4-hour shift and receives a small volunteer stipend. Similar to Insite, all volunteers are current or former users.

Beginning in September 2012, peers living in the Downtown Eastside who had worked at Insite or the WND within the previous month were approached to participate in the study. Initial contact with potential participants was facilitated by two gatekeepers who had worked at the facilities and had direct knowledge about those who would meet the inclusion criteria for the study. The two gatekeepers were known by the ethnographer who had also worked at one of the facilities for a period of time. The recruitment of participants was completed through a non-probabilistic sampling method. Specifically, the sample was formed through introductions to potential participants via the gatekeepers (Biernacki and Waldorf 1981). The gatekeepers' knowledge of, and subsequent introductions to, volunteers were extremely effective in ensuring variation in facility membership within the sample. Participants were eligible for participation if they were 19 years or older and provided informed written consent. The consent statement (as well as the broader methodological approach) was designed based on the Wigmore criteria to protect the confidentiality of participants and to provide anonymity (Palys and Lowman 2002). (2) The study was approved by Simon Fraser University's Research Ethics Board (Study #2012s0457).

In total, 32 peer injection drug users were interviewed. Table 1 provides descriptive statistics of the sample. As is evident from the table, the sample included a mix of participant work experiences--some had worked at Insite, some at the WND, some at both, and some at these as well as other injection drug user groups such as the Vancouver Area Network of Drug Users (VANDU). (3) The sample was predominantly Caucasian, heterosexual males over the age of 40.

Interview process

The ethnographer who conducted the interviews adopted a semi-structured interview style to ensure that all of the interviews would be focused on the same general topics, while allowing the opportunity for participants to raise additional topics that they felt might be relevant. To ensure that all participants had the opportunity to respond to questions surrounding key topical areas, the ethnographer used an interview guide that was developed prior to data collection and modified throughout the collection process. Themes that were raised during the interviews included the following six dimensions: (1) experience as a peer worker, (2) injection of their clients, (3) overdose risk reductions, (4) drug use culture, (5) harm reduction education, and (6) an open discussion about anything raised during the interview.

To reduce distortion of data due to participants preferring socially desirable responses, interviews were conducted in a conversational format while peer injection drug users were involved in their routine work activities, such as foot patrols or needle distribution in the community. This strategy proved to be useful, as it allowed for conversational prompts as participants walked in the alleys and streets of their community (Bourgois, Martinez, Krai, Edlin, Schonberg, and Ciccarone 2006). Responses ranged from 20 to 70 minutes and all were audio recorded. As Palys and Atchison (2012) have suggested, a wireless microphone was used to facilitate this method of interviewing. Not having to worry about noticeable hardware that might draw third-party attention and not having the visual distraction of a recording device seemed to put participants at ease. This made it easy for the interviewer to establish a rapport and relation of trust with participants. In addition, the ethnographer took time to record field notes about his impressions of the interview immediately following each meeting. The interviewer also noted questions to ask in future interviews and interesting themes to consider during analysis. This strategy led to the documentation of rich detail for each interview and promoted reflexivity.

Data coding and analysis

To explore peer injection drug user perspectives, this study drew on data obtained from the semi-structured qualitative interviews. All interviews that were recorded were subsequently transcribed verbatim via Dragon Naturally Speaking software and analysed using qualitative content analysis methods. To ensure reliability and reduce bias, two different coding methods were used by two different analysts. The initial coding method involved an analyst identifying themes...