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Reorienting risk to resilience : street-involved youth perspectives on preventing the transition to injection… Tozer, Kira; Tzemis, Despina; Amlani, Ashraf; Coser, Larissa; Taylor, Darlene; Van Borek, Natasha; Saewyc, Elizabeth Marie; Buxton, Jane Aug 19, 2015

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RESEARCH ARTICLE Open AccessReorienting risk to resilience: street-involvedyouth perspectives on preventing the transitionto injection drug useKira Tozer1, Despina Tzemis1, Ashraf Amlani1, Larissa Coser2, Darlene Taylor1,3, Natasha Van Borek1,Elizabeth Saewyc4 and Jane A. Buxton1,3*AbstractBackground: The Youth Injection Prevention (YIP) project aimed to identify factors associated with the preventionof transitioning to injection drug use (IDU) among street-involved youth (youth who had spent at least 3 consecutivenights without a fixed address or without their parents/caregivers in the previous six months) aged 16–24 years inMetro Vancouver, British Columbia.Methods: Ten focus groups were conducted by youth collaborators (peer-researchers) with street-involvedyouth (n = 47) from November 2009-April 2010. Audio recordings and focus group observational notes weretranscribed verbatim and emergent themes identified by open coding and categorizing.Results: Through ongoing data analysis we identified that youth produced risk and deficiency rather thanresiliency-based answers. This enabled the questioning guide to be reframed into a strengths-based guide ina timely manner. Factors youth identified that prevented them from IDU initiation were grouped into threedomains loosely derived from the risk environment framework: Individual (fear and self-worth), Social Environment(stigma and group norms – including street-entrenched adults who actively discouraged youth from IDU, support/inclusion, family/friend drug use and responsibilities), and Physical/Economic Environment (safe/engaging spaces).Engaging youth collaborators in the research ensured relevance and validity of the study.Conclusion: Participants emphasized having personal goals and ties to social networks, supportive family and rolemodels, and the need for safe and stable housing as key to resiliency. Gaining the perspectives of street-involvedyouth on factors that prevent IDU provides a complementary perspective to risk-based studies and encouragesstrength-based approaches for coaching and care of at-risk youth and upon which prevention programs shouldbe built.BackgroundThe United Nations defines street-involved youth as “anyboy or girl… for whom the street in the widest sense ofthe word… has become his or her habitual abode and/orsource of livelihood, and who is inadequately protected,supervised, or directed by responsible adults”[1]. InCanada, youth aged 16–24 years make up 20 % ofCanada’s homeless population [2]. The homeless countin Metro Vancouver in 2011 identified 321 homelessyouth under 25 years, 80 % of whom had been homelessfor more than one month [3]. However, one Vancouveragency reported providing services to almost 1,500 street-involved youth aged 16–24 years each year [4], which maybetter reflect the hidden nature of this population.Street-involved youth are more likely than youth instable housing to use drugs and to initiate drug use earl-ier in life [5, 6]. They are also more likely to use drugsintravenously, which puts them at greater risk of adversehealth outcomes, such as addiction and communicable* Correspondence: Jane.Buxton@bccdc.ca1British Columbia Centre for Disease Control, 655 West 12th Avenue,Vancouver, BC V5Z4R4, Canada3School of Population and Public Health, University of British Columbia, 2206East Mall, Vancouver, BC V6T1Z3, CanadaFull list of author information is available at the end of the article© 2015 Tozer et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide alink to the Creative Commons license, and indicate if changes were made. The Creative Commons Public DomainDedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in thisarticle, unless otherwise stated.Tozer et al. BMC Public Health  (2015) 15:800 DOI 10.1186/s12889-015-2153-zinfections including hepatitis C virus and HIV [7, 8].Further, street youth are 11 times more likely to die of drugoverdose and suicide than youth in the general population[9]. Recent estimates suggest that 20‐50 % of street‐involvedyouth inject drugs [10–12]. In a Vancouver-based study, in-jection drug use (IDU) was reported by 41 % of street-involved youth who used illicit drugs other than marijuana[13]. Studies from Montreal, Canada calculated an inci-dence rate of 6.8 - 8.2 per 100 person-years for street youthinitiating IDU; in other words, 7 - 8 % of street youth startinjecting drugs each year [14, 15]. Previous research sug-gests that street-involved youth make the transition fromnon-injection drug use to IDU for various reasons includ-ing exposure to IDU and social influence from street-involved peers [16] and sexual/intimate partners [17, 18]self-medicating for depression, childhood trauma, or othermental illnesses [19]; coping with homelessness [6]; and dif-ficulties accessing treatment for drug use [20].However, despite the plethora of risk factors mountedagainst street youth that make them vulnerable to tran-sitioning to IDU, many do not. An important step inaddressing and preventing IDU by street youth is rec-ognizing that the transition to IDU is not inevitable forall “at‐risk” youth [21].At-risk youth who avoid IDU, are often referred to as“resilient”. Resiliency is perhaps best understood as aperson’s ability to navigate and negotiate psychological,social, cultural, and physical resources that sustain theirwell-being in the context of exposure to significant adver-sity [22]. Resilience research with marginalized adolescentsin Canada identified seven key factors that youth mustbe able to access in order to experience resilience: thedevelopment of a desirable personal identity, experiencesof power and control, experiences of social justice, accessto supportive relationships, experiences of a sense of cohe-sion with others, adherence of cultural traditions andaccess to material resources [23].A review of the literature found that the majority ofresilience studies with street-involved youth focus onhow youth survive on the streets without a specific focuson IDU prevention. Further, much of the research exam-ining IDU among street‐involved youth focuses on riskfactors for IDU initiation, and few studies examine thefactors that may prevent youth from IDU initiation [7].Therefore, the Youth Injection Prevention (YIP) projectset out to investigate IDU prevention from a uniqueangle, namely resilience. The project framed its inquiryto identify protective (rather than risk) factors that youthperceive as preventing them from using IV drugs, andmoreover foster resiliency. It is anticipated that findingsfrom this study will help service providers working withstreet-involved youth to identify, encourage and provideaccess to factors that enable resiliency with an eye topreventing IDU initiation among this at-risk population.MethodsThis was a qualitative descriptive study [24] to identifyyouth’s views of protective factors that prevent the tran-sition to IDU. Qualitative description provides a com-prehensive summary of events. “Researchers conductingqualitative descriptive studies stay close to their dataand to the surface of words and events” [24]. The studywas conducted between November 2009 and April 2010in Metro Vancouver in British Columbia, Canada.The YIP project employed six youth to work as re-search collaborators throughout the project. The youthcollaborators were recruited from partner organizationsand selected through an interview process; they wereaged 18–24 years and most had personal experience ofstreet involvement and/or illicit drug use [25]. The youthcollaborators received qualitative research methods train-ing from research team members including how to lead afocus group, sensitivity training and performed mockfocus groups [25]. Inclusion of youth collaborators on theresearch team added a participatory spin to the projectand resulted in benefits to both the project and the youthcollaborators themselves. The youth collaborators helpeddevelop the questioning guide, facilitated focus groups,took focus group observation notes, participated in opencoding exercises and discussed key themes [25, 26].Participants & samplingYouth were eligible to participate in the study, if agedbetween 16 and 24, were clients of organizations thatprovided services to street-involved youth and had spentat least three consecutive nights in the past six monthswithout a fixed address or not with their parents or caregiver. Although our participants included young adults(ages 19–24) the term youth has been selected to beconsistent with other research.Youth participants were recruited via purposive andsnowball sampling techniques by partner organizationsthat provided services to street-involved youth. Each part-ner organization advertised the focus groups to clientsusing posters. Detailed recruitment invitations and consentforms were given to interested youth and to youth that theorganizations thought would ensure diversity of age, ethni-city and gender of the participants at each site. If the youthwere interested they signed up at the agency front desk fora prescreening interview and if eligible were invited toparticipate in the focus group. The partner organizationsincluded those providing services specifically to Aboriginaland to lesbian, gay, transgender and queer youth, thus en-suring we heard the perspectives of the most vulnerableand marginalized youth. As this study was focused on fac-tors that dissuade street youth from IDU, we invited youthwho had never used drugs intravenously to share their per-spectives. Written consent was obtained by the researchersprior to commencing the focus group.Tozer et al. BMC Public Health  (2015) 15:800 Page 2 of 11Ethical approval was obtained from the BehavioralResearch Ethics Board at the University of British Columbia;the ethics committee was aware that for youth under theage of 19 years consent was sought from a parent orcare giver; however where this was not possible youthwere considered emancipated and able to give informedconsent.Data collectionFocus groups (FGs) were used to obtain a broad rangeof information and stimulate discussion and dialogue[24]. To create a safe environment with room for anonym-ity, FGs occurred at partner organizations which were fa-miliar to the participants and youth were encouraged toshare examples regarding their peers as well as their ownlives. Each FG lasted approximately 90 min. Participantswere provided with a $25.00 (CAD) honorarium, returnbus transportation tickets and food.A semi-structured questioning guide was developed bythe research team including the youth collaborators. FGswere conducted by a youth collaborator, a second youthcollaborator was assigned to be the note taker, and a se-nior researcher was also present. A debriefing occurredbetween the youth collaborators and senior researcherfollowing each FG.Despite the study’s intention to identify resiliency fac-tors, a review of transcripts of the first few FGs notedthat the questioning guide and scripted prompts wereeliciting ‘risk and deficiency’ rather than ‘resilience andstrength-based’ answers. Further, the focus group facilita-tors reported that some participants appeared frustratedand somewhat uncooperative, and eager to leave the FGs.Being mindful of participant safety as well as the aim ofthe study to identify protective factors and examples ofresiliency, the research team including the youth col-laborators revised the questioning guide.The questioning guide changes included the additionof an opening question “What are some supportive andhelpful things in your life”, and reframing of promptssuch as: “Why do you think some youth decide to in-ject?” to “What are some positive things in a youth’s lifethat help them not to inject?” and “Why did you orothers decide not to inject (when offered)?” to “Whatwere the positive things in your life that influenced youor others to decline (when offered)?” These revisionswere successful in both eliciting the kinds of protectivefactor information the research team was interested in,and keeping participants more positively engaged in theFGs. The original and revised FG guide can be found inthe YIP project Final Report [27].Data analysisAll focus groups were audio recorded and transcribedverbatim. Identifying information was removed from thedata to protect participant confidentiality. Thematicanalyses of focus group data was conducted accordingto four steps [28]: immersion, coding, categorizing andgeneration of themes. Data analysis began during datacollection; two researchers immersed themselves inthe data by reviewing audio recordings and re-readingtranscripts on an ongoing basis so that issues thatwere not clear could be re-examined in a subsequentfocus group. Data were entered in QSR NVivo 8 to as-sist organization of the data. Through open coding, anew category is created for each meaning unit thatdoesn’t fit with a previously created category. Categoriesare kept as distinct and mutually exclusive as possible.Coding was conducted independently and then the tworesearchers met to discuss findings and reach consensus.When the focus groups were complete, i.e. saturationoccurred and no new concepts emerged from the focusgroups despite the diverse sample of participants, theresearch team held a ‘coding workshop’ with the youthcollaborators through a paper-based exercise. This codingworkshop provided the youth collaborators a new researchskill and experience, informed the revision of the categor-ical scheme developed by the two researchers and contrib-uted to the validation of the data [26].Following two knowledge translation events with ser-vice providers and youth collaborators where prelimin-ary data were shared and discussed, the research teamrevisited the categories identified as protecting againstthe transition to IDU. The categories were then groupedinto conceptually related domains based loosely on therisk environment framework, which examines the inter-play of various types of environments (social, physical,economic and political) and levels of risk (micro, meso,macro) in the prevention of HIV and reduction of drug-related harms [29–32]. In the context of harm reduction,the risk environment framework is helpful as it redistrib-utes the focus of interventions and responsibility fordrug harms from individuals to “something shared be-tween individuals and social-economic structures” [32].However as Sandelowski articulates, qualitative contentanalysis based on preexisting coding systems are alwaysmodified in the course of analysis to ensure the best fitof the data [33].ResultsA total of 47 street involved youth participated in tenFGs. Participants were between the ages of 16 and24 years with an average age of 21 years; 87 % were aged19 years and older. Of the participants, 27 (57.4 %) weremale, 19 (40.4 %) were female and 1 (2.1 %) identified astransgendered. Of those who reported their sexual orien-tation, 70.5 % reported being heterosexual, 9.1 % as gayor lesbian and 20.5 % as bisexual. Forty-five percent self-identified as Aboriginal, 34 % as Caucasian, 9 % multiethnicTozer et al. BMC Public Health  (2015) 15:800 Page 3 of 11and 10 % as other ethnic groups. The drugs study partici-pants reported using in the past month are shown in Table 1and indicate poly-substance use; 62 % were using illegalsubstances other than marijuana.Seven categories of factors that protect against thetransition to IDU were identified through the codingand grouped into three domains loosely derived fromthe risk environment framework: fear and self-worth(Individual), stigma, support/inclusion, family/friend druguse and responsibilities (Social Environment), and safe/en-gaging spaces (Physical/Economic Environment). Table 2denotes the final categories and codes within each domain.Individual level factorsMany of the reasons offered as to why youth choose notto inject drugs fell within an individual’s own locus ofcontrol, feelings, personal observations and preferences.FearThe notion of fear, aversion to needles and concerns re-garding consequences of injecting were commonly notedas a major deterrent to IDU:“I’ve used the majority of the drugs out there. I’venever injected… I know I’m scared shitless of needlesand I don’t think I ever will” – FG7, #3“I don’t like injection drugs because of the way, like,you have to, like, suck the blood out then and push itback in. That really grosses me out.” – FG1#1In addition to a fear of needles and injection practiceitself, the youth mentioned a further fear of addictionwhich they saw as a down-hill trajectory, which almostinevitably followed the transition into IDU:“I just wouldn’t do that [IDU] cause that’s how peopleget really bad…I don’t want to end up on East Hastings…I want better for myself than that.” – FG4#1A few youth demonstrated considerable insight byciting their ‘addictive personalities’ as a reason to avoidinjection drug use:“I personally wouldn’t do injection drugs ‘cause I havean extremely addictive personality so I’d mostly likelylike it and continue to do it so that’s why I won’t doit.” – FG4#1Further to the broad fear of addiction, many youthdemonstrated an understanding of the adverse healthoutcomes associated with IDU including transmission ofviral infections, overdose and the physical appearance ofthose who inject. These concerns contributed to theirdecision to not use drugs intravenously:“I don’t inject because I don’t want to catch anything…If I was to fix I would be worried about catching HIV,Hep C, all that kind of stuff. ” – FG1#4Table 1 Drugs participants reported used in the past monthNumber PercentTobacco 40 85.1Alcohol 37 78.7Marijuana 34 72.3Ecstasy 17 36.2Cocaine 16 34Crack 13 27.7Acid 13 27.7Mushrooms 12 25.5Heroin 10 21.3Crystal methamphetamine 9 19.1Speed 7 14.9Other drugs 5 10.6Table 2 Factors reported by street-involved youth to protectagainst the transition to injection drug useDomain Category CodesIndividual Fear Fear of NeedlesFear of AddictionFear/Awareness of IDU HealthConsequences: e.g. HIV, hepatitis C,overdose, physical appearanceSelf-Worth Desire for Better Life/GoalsSelf EsteemSocialEnvironmentStigma&Group NormsSociety’s negative views of IDUPeer Group negative view of IDUAdults who inject drugs deterring youthfrom IDUSupport &InclusionSupport from/Involved FamiliesMembership to Peer Group/CommunityPositive Role ModelsFear of Losing Peer Group/FamilyConnection with Culture/CommunitiesFamily/FriendDrug UseFamily Drug UseObserving OthersResponsibilities Responsibility for another Person e.g.child, or for a PetPhysicalEnvironmentSafe &EngagingSpacesOpportunities for Recreation &EmploymentHousing (affordable/accessible)IDU Injection drug useTozer et al. BMC Public Health  (2015) 15:800 Page 4 of 11“A friend of mine asked me if I want to inject… I was,like, wait a second. I’ve never done this before and Idon’t want to because I don’t know what the effectsare, the outcome of this drug is… Or overdosing on thefirst time, you never know, you don’t know that you’regoing to overdose on the first time” – FG5#2“They have, like, holes in their face and they’re alwaysscratching at themselves and there’s chunks of skinmissing on their backs and on their necks and theyjust look dead.” – FG3#5Self-worthIt was evident that some of the youth in this study had astrong sense of self-worth and a desire for a better futurewhich they perceived could be jeopardized by engagingin IDU. This is consistent with previous studies whichsuggest that youth with high levels of self-confidence,positive self-image and desire for a positive personalidentity are less likely to engage in high-risk behaviours[34]. Many of the YIP participants credited their abilityto avoid IDU with personal strength and satisfactionwith their current lives:“I got scared and I realized, you know, I’m worth somuch more than that. Like, I’m here on this earth fora reason and it’s not, you know, to be down theredoing the Hastings shuffle…” – FG8#6“I have lots of goals so I just work towards the goals.Education and a career” – FG6#1“I just like my life how it is and I don’t want to throwit away for drugs.” – FG6#2One focus group participant's reflection on where hissame-age mainstream peers were in their lives comparedto him was motivation to avoid the transition to IDU:“I was thinking about all my friends that aresuccessful and don’t do drugs and have jobs and just–they’ve already made it in life and I’m just downthere. I wouldn’t want to go any further down thatbumpy road.” – FG7#1Social environment factorsIn addition to individual level protective factors, partici-pants discussed in depth the ways that social environmentscan influence youths’ decisions to navigate away from IDU.Social environmental factors reported included negativeperceptions such as stigma from society and their peergroup, and observing the hardships of others who injectedespecially family and friends. However, the majority ofthe participants identified many positive factors such assupportive relationships, cultural connection and re-sponsibility, which prevented the transition to IDU.Stigma & group normsSociety’s negative views towards individuals who use in-jection drugs is generally problematic as it contributesto their marginalization and isolation; however, youths’awareness of this stigma appeared to serve as a protectivefactor against the transition to IDU for youth who did notinject drugs.“A lot of people look down on, like, society big timelooks down on injection drug use…I have a lot offriends who aren’t from this lifestyle at all and whenthey see one of my friends that use IV it’s almost likelooking at a gremlin or something, you know. ” – FG5#1Peer group norms play a crucial role in shaping indi-vidual attitudes and behaviors [16]. Studies of street-involved youth in Vancouver and Montreal found thatyouth were more likely to inject drugs when their peersinjected drugs, particularly because their peers who werenewer to injection had yet to experience many adverseoutcomes [35, 16]. Within the YIP study, in addition tonoting societal stigma, the participants commented thatIDU was looked down upon by their peer groups or thatthey simply preferred other forms of drug use:“Down here when people offer to doctor you or to injectyou, it’s a real sign of disrespect.” –FG1#1In addition to society and peer groups, a few partici-pants noted that social pressure to avoid IDU came fromyet another group, adults who inject drugs. Exampleswere shared of street-entrenched adults actively discour-aging youth from IDU and were viewed as protectingyouth and concerned about their welfare:“Most people down there, when they see someoneunder 18, they’ll usually kick their ass or somethingand tell them to get lost, yeah… I see it daily all thetime… kids coming down, they’re trying to get high andyeah, it doesn’t fly, man. They usually end up gettingslapped around or fucking’ you know, they’ll grab acop and say, listen, this kid’s fucking under 18, get himout of here, right?” – FG5#1This “code” of experienced adults who use drugs inVancouver’s downtown eastside discouraging youth frominitiating IDU has previously been reported [16]; al-though as noted by Small et al., it is likely a “convention[that] is routinely ignored”[16].Tozer et al. BMC Public Health  (2015) 15:800 Page 5 of 11Support & inclusionParticipants commonly noted supportive and involvedfamilies as a protective factor against injection drug use:“I had a bad drug problem and she [my sister] mademe go to detox as soon as I got out of the hospital.And then as soon as I got out of the detox she got mein to get [treatment] back home. And I went home toclean up for awhile, got a job right away and cameback down here and been clean ever since.” – FG7#1“I think the biggest part of it is when family andfriends step in. ‘Cause then that’s when you realizethat your friends and family actually do care aboutyou. You’re not just a big shit that no one caresabout.” – FG7#3Previous studies have shown that supportive relation-ships, in or outside the family, foster resiliency amongat-risk youth; feeling loved, trusted, and having a senseof belonging can cultivate resiliency [36]. For manyyouth, the protective ‘sense of belonging’ came from peergroups with shared experiences and values:“Having, like, a sense of the family again and even ifit’s just a fake family, you know, like, it’s not your realblood family, that helps a lot.” - FG10#1“Like I said, mud- mud is thicker than blood. Thestreet family’s definitely the greatest support. Some ofthem might be, you know, not the best but they’ll helpyou out whatever way they can.” – FG8#3The street family has previously been found to play asupportive role [37], although this may not be seen asfostering positive relationships by mainstream society. Inaddition to the support found in group affiliation, partic-ipants talked about the value of positive role models andmentors in preventing transition into IDU:“I have a mentor that I have a really good relationwith who’s also, like, one of my best friends and she’sbeen there– it’s really awesome. She’s helped introduceme to services around Vancouver to help me throughwhatever I’m going through. Also introduced me to mymartial arts school and to various artists.” – FG7#1The support and sense of belonging to families, peergroups and communities was so valued that fear or ex-perience of losing those relationships was also frequentlymentioned as a reason not to initiate IDU:“Social factors, losing your friends and family…youmight get to the point where you’re so addicted thatthe drug becomes your #1 priority and then you’reneglecting your family and your friends and thenfinally just drift apart…That’s a concern, yeah. Not avery positive thing.” – FG6#1Some youth also reported assessing the drug use be-haviors of peer groups and actively seeking the companyof people who did not inject.“Find something to do, go hang out with somebodywho’s not in the wrong crowd. And find a good crowdto hang with.” FG9#2A number of Aboriginal youth also credited connec-tions with their culture and communities as a protectivefactor:“Being sort of part of my culture, I– not only do Idance, I also sing and I play a big role in– throughoutthe community… We’ve developed a sense of other.And if you’re needing help, you could just go and talkto them.” - FG8#3“I kind of grew up in foster care so I wasn’t, like,introduced to that stuff at all. And I thought it wasreally awesome and kind of like coming home, like, Iwas finally home and I knew who I was once I got intouch with that…I don’t think I’ll ever let it go.” - FG8#6Family/friend drug useSome of the participants shared that IDU was commonin their families and that they had been around the life-style for their whole lives. Further, many youth citedfamily deaths due to overdose or IDU related illness asreasons not to start using injection drugs."If you’re going to grow up with it you want to bebetter than what you’ve grown up with or you’veexperienced.” – FG8#2“Personally for me, like, my mom she died two yearsago. She was an intravenous drug user for, like,30 years – pretty young but, like, when I see people herage and they look so young, like, healthy and young,like, my mom just looked, like, so haggard and old.” –FG1#3”In contrast to previous literature that largely reportsfamily drug use as a risk factor for youth initiation[38, 39], the youth in our study were motivated toavoid IDU because of witnessing the challenges andconsequences faced by family members with addiction.This illustrates well that resilience may not be determinedsolely by the presence or absence of certain risk factors,Tozer et al. BMC Public Health  (2015) 15:800 Page 6 of 11but rather determined by an individual’s ability to navi-gate life’s circumstances in a way that leads to optimaloutcomes.Other participants shared ‘cautionary tales’ based ontheir observations of friends, acquaintances or peopleon the street changing as a result of using drugsintravenously:“‘I’ve had about five friends lost to the DowntownEastside. Like, they’re not dead or gone but their spiritis, like, they’re- they’re not the person that I used toknow.” – FG2#6“Just seeing the effects it has on other people. Like,Hastings and other areas, even going by on the bus, Imean, it’s only for a few seconds and you just, like, sortof glance over, it’s, like, hmm, it’s just for half a secondyou’re bound to see somebody that’s, like, doing theHastings shuffle down the street. And it doesn’t looktoo appealing.” – FG8#4ResponsibilitiesThe duty to protect and a moral responsibility to lookafter another life - be it child or relative was a factorcited by many youth participants that discouraged theinitiation of IDU:“His kids are more important than him. He’s, like,either I get high or I feed my kids, what’s better? ” –FG7#4“They’ll be drinking, drinking, drinking, party, party,party, oh, shit, I’m having a kid. Okay, now I gottaclean up, you know, and sometimes it lasts, sometimesit doesn’t and sometimes it bounces back“ – FG7#5“Her mom’s sick and she’s going to die, like, next twoor three years of something like that. And her momjust got back in contact with her and she just decided,like, for her mom’s sake that she doesn’t need to seeher all sick and, you know.” – FG9#3Physical & economic environment factorsSafe & engaging spaceSafe spaces to hangout, skill building and job placementprograms, and youth drop-in centres were commonlyreferenced as positive persuasions away from street lifeand injection drug use:“You need incentive to stay clean, like, stuff to do thatthey’re interested and, like, art programs, like, justanything that they could be there doing and not outgetting high.” – FG1#3“The only way that- that, like, Vancouver or evenCanada, has a chance for young people, is places like< name of drop-in centre > where you can offer lifeskills. You can offer uhm..job placements, like, <nameof program > because you get your money from notsucking dick or prostituting or whatever.” – FG3#2Before street-involved youth can benefit from the re-sponsibility and meaningful engagement that employ-ment and recreation opportunities provide, they mustfirst encounter such opportunities. It is interesting tonote that 25 % of the youth surveyed in the MetroVancouver Homeless count indicated that they hadbeen affected by the withdraw of youth services by oneor more government agency [3]. Unsurprisingly, many YIPparticipants commented on the need for more or ex-panded youth programming:“There’s really not much to do in this city and it– untilyou’re already hooked on drugs then people will comeup and help you out, right. You know, so we do need,like, youth programming.” – FG8#5Youth, both with and without adequate, accessible andaffordable housing commented on the crucial role thatshelter plays in ones decision to use or avoid drugs.Many participants provided examples of using drugs as ameans to keep warm during inclement weather, or tokeep awake through the night to protect themselves andtheir belongings from harm on the streets.“I think in general most people do drugs because they’reon the streets and it makes it easier to stay on thefreezing cold sidewalks at night, especially heroin.” –FG3#2Others commented that having a safe space to live wasexceedingly helpful to avoid temptation or pressure toparticipate:“You know, if you’re in a shitty living situation, say onthe street, where your stress level’s raised a lot morethan what it would be if you had a nice place to live,you’re going to be more susceptible to doing things youwouldn’t normally do… making shitty decisions likepicking up a needle or whatever.” – FG5#1The youth participants’ frequent mention of the valuein safe, engaging spaces and opportunities for recreationaland employment activities underscores the role that com-munities can play in providing avenues for resiliency forat-risk youth. Increasingly, youth programming and lifeskills programs have been shown to prevent youth druguse [34, 40]. Recreational and employment opportunitiesTozer et al. BMC Public Health  (2015) 15:800 Page 7 of 11may also provide youth with skills that prevent IDU andfoster resiliency such as how to cope with stress, solveproblems effectively, build social support and connect withothers [40, 41].DiscussionYouth perspectivesAs others have argued [42], it is important for serviceproviders and policy makers to understand street youth’sperspectives on drug use in order to address the chal-lenges in their lives. This study offered street-youth anopportunity to voice their concerns and assurances abouttheir own health and wellbeing, as well as that of theirpeers. Study participants were keen to share their storiesand experiences with the research team and provided manyinsights into how to prevent the transition of street‐in-volved youth to IDU and/or reduce drug‐related harms.Further, the involvement of youth collaborators as group fa-cilitators enhanced the opportunity for rich data collectionas our study population shared experiences with peers.Risk to resiliencyThe intentional shift away from a risk framework to oneof resilience in this study necessitated an early revisionFG questioning guides to ensure that prompts and ques-tions were eliciting information on resiliency and pro-tective factors, rather than negative risk-based dialogues.Interestingly, youth in the first focus groups that elicitedrisk-based information were somewhat uncooperativeand eager to leave the room, where as those in the laterfocus groups were more willing to stay and participate,some commenting that the experience of participatinghad been in many ways, therapeutic.Through regular post FG debriefing and performingongoing data analysis we were able to identify that par-ticipants were eliciting risk rather than resiliency basedanswers which enabled us to identify the need to revisethe questioning guide in a timely manner. Despite thesuccess in revising the questioning guides to elicit dia-logue around factors that prevent IDU rather than causeit, the research team noted that many of the participants’answers were still framed as negatives. For example,many participants discussed negative life events or expe-riences of friends and family as reasons to avoid IDU.We postulate that this is in part a result of these youth,like society at large, being accustomed to identifyingrisks, problems and deficits in their lives, rather thanstrengths and protective factors.The observation that youth appeared primed to giverisk-based and negative answers when asked about theirdrug use patterns and decisions, might prompt serviceproviders to re-examine their own word choices andphrasing when asking youth questions. People who workwith at-risk youth should be mindful to not only highlightrisks and problems when conversing with the youth butwhere possible, ask questions that encourage strength-identification and positive possibilities.Rhodes’ risk environmentAs mentioned, the “risk environment” framework hasbeen increasingly used as a way to organize risk informa-tion in relation to the prevention of HIV and reduction ofdrug-related harms [29–32]. Discussing factors in terms ofsocial and physical influences introduces a helpful shift ofblame/credit, responsibility and opportunity from individ-uals to families, communities and society. Yet to date, fewstudies have taken an environmental approach to studyingresilience in relation to drug use behavior. Therefore, ac-knowledging that risk and protective factors are often theinverse of each other, the risk environment frameworkwas selected as a helpful starting point for categorizing theYIP data and contextualizing the reasons that youth pro-vided that enable them to navigate away from IDU.To better fit the YIP data, our categorical scheme tooka slight departure from Rhode’s four ideal types of envi-ronments: physical, social, economic, and policy [31], aswe added an “Individual” tier to account for the manyinternalized and personal factors that youth discussed,we merged the Economic and Physical environmentsand interestingly, did not find any content within ourdata that aligned with what Rhodes would consider thePolitical Environment. This is perhaps not surprising asour data was derived solely from the perspectives ofyoung people who may not be aware of the policies andlegal regulations that influence their experiences.Factors that promote resiliency and prevent IDUThe factors identified in our study that protect againstthe transition to IDU were categorized as: fear, self-worth,stigma, support and inclusion, family/friend drug use, re-sponsibilities, and safe and engaging spaces. Although ourfindings are largely consistent with the dominant dis-course in the field of IDU prevention, the spin of resilienceelicited some new perspectives of the trajectory toward(and away from) IDU, not always seen in the literature.IndividualOur participants demonstrated a considerable knowledgeof the adverse health risks associated with injection druguse and frequently cited fear of needles, addiction, over-dose, and compromised health as reasons governing theirdecisions to avoid injection drug use. This may indicatethe success of education programs that go beyond “justsay no” messaging. Participants also noted their desires fora better life and future goals as reasons not to experimentwith injection drugs. The ability of the youth participantsto attribute their present actions to their future well-beingis worthy of pause and underscores the value of youthTozer et al. BMC Public Health  (2015) 15:800 Page 8 of 11workers employing motivational interviewing techniques[43] to reinforce self-efficacy and discuss drug use behav-ior in the context of longer term goals and values.SocialThe youth in our study appeared to be influenced by avariety of social forces including societal stigma, peer groupnorms and interestingly, street-involved adults. While it iscommonly noted that youth are influenced by the attitudesand behaviours of their peer groups, the comments regard-ing street-based adults who discourage youth IDU aresomewhat novel. These street-involved adults could play animportant role in IDU prevention and their cooperation/role in harm reduction interventions warrants further in-vestigation. Previous work has shown that peer outreachworkers are able to meet the youth ‘where they are’ andpeers can serve as successful service providers [44]. The‘Break the Cycle’ and “Change the Cycle” programs utilize asimilar model where peers help prevent others from IDUinitiation [45, 46].Inclusion and the sense of belonging to families andpeer groups was highly valued as a protective factor byparticipants, as was the support of positive role modelsand connections to cultural communities and practices.As previously noted in the literature [37, 47, 48], streetyouth’s ties to family and other social networks are keysources of resiliency upon which prevention programsshould be built. In addition to receiving social support,the moral obligation to provide support to dependentswas also discussed as a motivator to avoid IDU. Addition-ally, many youth referenced the negative experiences offriends and family members with IDU as reasons to avoidit themselves.PhysicalLastly, participants emphasized the need for safe, afford-able, stable housing to assist in the avoidance of IDU.Unger describes resiliency as a person’s ability to navi-gate and negotiate for resources to promote health [22];however, resources must be accessible and available inorder for youth to obtain them. Meeting youths’ basicneeds, including housing security, can aid in the preven-tion of IDU as when resources run out, short term solu-tions like drug use can become the best or only copingmechanism [23]. Indeed, youth in our study describeddrug use when living on the streets as a means to pro-vide shelter from the cold, reduce anxiety and create asense of security in a very unsecure environment. Previ-ous research has suggested that cumulative length oftime youth spend without a consistent place to live is as-sociated with an increased risk of an alcohol and/orillicit drug abuse disorder [49]. Further, shelter use hasbeen strongly associated with use of other health and so-cial services [50] making this a particularly salient issue.An in-depth discussion of youth homelessness is be-yond the scope of this paper; however, future resiliencystudies among street-involved youth may want to focuson the role of housing in preventing IDU as our studyfound inadequate housing as a barrier to resiliency. Pre-vious reports and research have suggested there are avariety of barriers at play for youth accessing adequateshelter: affordability, discrimination from landlords, alien-ation and isolation, lack of services for specific subgroups,lack of supports for 16–18 year olds, age of majority cut-off, lack of system flow and a lack of a provincial youthhousing strategy [51]. Single-room occupancy hotels, manyof which are located in the impoverished core of downtownVancouver, have been reported as the only affordable andaccessible housing option for at-risk youth; however, manyyouth resist this option as they view it as “giving up hopefor a return to mainstream society” [52].Implications for practiceA number of findings from the YIP study may be usefulfor service providers and administrators to considerwhen undertaking service re-design and quality improve-ment activities: including street-involved adults andyouth as peer outreach workers; providing opportunitiesfor youth to be responsible to or for someone or some-thing (jobs, pets, gardens, etc.); providing safe recreationalspaces for street-youth, offering skill building and jobplacement programs, facilitating cultural (re) connectionfor Aboriginal street-youth, and finally, as learned by trialand error within the YIP research team, framing questionsand leading conversations in a way that identifies strengthsand opportunities, in addition to risks.LimitationsThere are limitations to be noted when interpreting thefindings presented in this paper. Previous research hasshown that street youth are a heterogeneous populationand that different sub-groups may have very differentdrug use patterns [49]. The youth participants in thisstudy were referred by youth service provider organiza-tions; therefore, youth who were currently not interactingwith services were missed, and those “harder-to-reach”youth may hold different or unique perspectives regardinginjection drug use initiation. Additionally, youth in thestudy were welcomed to share stories and experiences oftheir peers, as well as themselves, as a means of creating asafe space to participate; however, this may have intro-duced an element of misinterpretation or exaggeration inthe data. The wide age range of the study participants(16–24) should also be considered when considering theperspectives shared; it is plausible that some of theseyouth, although at the time of the study were opposed toIDU, may progress to IDU later in life. This study did notconsider the differences in perspectives between street-Tozer et al. BMC Public Health  (2015) 15:800 Page 9 of 11youth with different drug use patterns; ie: those usingnon-injection heroin, opioid prescription drugs and meth-amphetamines vs those using marijuana, alcohol and clubdrugs. Exploring any related differences in perspectiveswould be an interesting area of investigation for futureresearch. Lastly, the YIP study and its findings are spe-cific to the Metro Vancouver area, and care should betaken around the transferability of the findings to othergeographic areas. As has previously been noted [53],there is a gap in research exploring the transition to IDUtransition among rural populations; factors may differfrom urban centers.StrengthsEngaging youth collaborators in the research process en-sured relevance of the research. Youth collaborator engage-ment in the research included developing and revising thequestioning guide, FG facilitation and note taking, a codingworkshop and a knowledge translation event with serviceproviders. These activities improved the reliability and val-idity of the results and enabled member checking by theseexperiential youth. The use of FG focus group observationnotes also enabled cross checking and internal validation ofthe research findings.ConclusionIt is hoped that this paper will help service providers torecognize factors that deter IDU and help youth to navi-gate and negotiate for resources in their environmentsthat promote healthy outcomes. People who work withat-risk youth should be mindful to not continually highlightrisks and problems when conversing with street–involvedyouth but where possible, ask questions that encouragestrength-identification and positive possibilities. Participantsemphasized having personal goals and ties to social net-works, supportive family and role models, and the need forsafe and stable housing as key to resiliency and upon whichprevention programs should be built. Gaining the perspec-tives of street-involved youth on factors that prevent IDUprovides a complementary perspective to risk-based studiesand encourages strength-based approaches for coachingand care of at-risk youth. Focusing on the personal, socialand structural factors of resiliency at play in youths’ lives,and encouraging those protective factors, may interrupt thetrajectory toward IDU.Competing interestsThe authors have no competing interests to declare.Authors’ contributionsKT and DTz analysed the findings and drafted the manuscript. AA providedcritical input into the manuscript. LC and NVB facilitated data acquisition andperformed primary data coding. DTa and ES provided input re study designand analysis. JB conceived and was principal investigator and providedcritical input into the manuscript. All authors have read and approved thefinal manuscript.AcknowledgementsWe would like to acknowledge the youth participants for sharing theirstories and perspectives, as well as the work and dedication of the youthcollaborators on the research team. We also wish to thank Dr. MichaelBotnick and Catherine Chambers for their support and guidance during thisproject. 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Subst Use Misuse. 2006;41(8):1111–24.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submitTozer et al. BMC Public Health  (2015) 15:800 Page 11 of 11


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