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Aboriginal street-involved youth experience elevated risk of incarceration Barker, Brittany; Alfred, Gerald R.; Fleming, Kim; Nguyen, Paul; Wood, Evan; Kerr, Thomas; DeBeck, Kora 2015

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Aboriginal Street-involved Youth Experience Elevated Risk of IncarcerationBrittany Barker, MPP1,2, Gerald Taiaiake Alfred, PhD3, Kim Fleming, MSW1, Paul Nguyen, PhD1, Evan Wood, MD, PhD1,4, Thomas Kerr, PhD1,4, and Kora DeBeck, PhD1,51Urban Health Research Initiative, British Columbia Centre for Excellence in HIV/AIDS2Interdisciplinary Studies Graduate Program, University of British Columbia3Indigenous Governance Program, University of Victoria4Division of AIDS, Department of Medicine, University of British Columbia5School of Public Policy, Simon Fraser UniversityAbstractObjectives—Past research has identified risk factors associated with incarceration among adult Aboriginal populations; however, less is known about incarceration among street-involved Aboriginal youth. Therefore, we undertook this study to longitudinally investigate recent reports of incarceration among a prospective cohort of street-involved youth in Vancouver, Canada.Study Design—Prospective cohort study.Methods—Data were collected from a cohort of street-involved, drug-using youth from September 2005 to May 2013. Multivariate generalized estimating equation analyses were employed to examine the potential relationship between Aboriginal ancestry and recent incarceration.Results—Among our sample of 1050 youth, 248 (24%) reported being of aboriginal ancestry, and 378 (36%) reported being incarcerated in the previous six months at some point during the study period. In multivariate analysis controlling for a range of potential confounders including drug use patterns and other risk factors, Aboriginal ancestry remained significantly associated with recent incarceration (adjusted odds ratio [AOR]=1.44; 95% confidence interval [CI]: 1.12–1.86).Send correspondence to: Kora DeBeck, PhD, Research Scientist, Urban Health Research Initiative, B.C. Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, 608-1081 Burrard Street, Vancouver, B.C., V6Z 1Y6, Canada, Tel: [604] 682-2344 ext 66784, Fax: [604] 806-9044, uhri-kd@cfenet.ubc.ca. Contributions: The specific contributions of each author are as follows: BB, KD, TK and EW designed the study and wrote the protocol with extensive consultations with GTA and KF; BB managed the literature searches and BB and KD prepared the first draft of the analysis, which was revised by GTA, TK, EW and KF; PN conducted the statistical analyses with input from BB and KD; all authors contributed to the main content and provided critical comments on the final draft. All authors approved the final manuscript.Competing interests: None declaredEthical approval: Providence Health Care/University of British Columbia Research Ethics Board has approved this studyPublisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.HHS Public AccessAuthor manuscriptPublic Health. Author manuscript; available in PMC 2016 December 01.Published in final edited form as:Public Health. 2015 December ; 129(12): 1662–1668. doi:10.1016/j.puhe.2015.08.003.Author ManuscriptAuthor ManuscriptAuthor ManuscriptAuthor ManuscriptConclusions—Even after adjusting for drug use patterns and other risk factors associated with incarceration, this study found that Aboriginal street-involved youth were still significantly more likely to be incarcerated than their non-Aboriginal peers. Given the established harms associated with incarceration these findings underscore the pressing need for systematic reform including culturally appropriate interventions to prevent Aboriginal youth from becoming involved with the criminal justice system.KeywordsAboriginal peoples; incarceration; street-involved youth; substance use; policing; discriminationIntroductionThe social and health-related harms associated with incarceration are well documented and include elevated rates of communicable disease and chronic illness1–4; diminished mental health4–7; long-term housing instability7,8; barriers to employment6,8,9; and both poor social integration and breakdown of interpersonal relationships.1,8 The negative impacts of incarceration are often more profound for young offenders, as evidence suggests incarcerated youth are more likely to be victimized, suffer developmental and cognitive delays, and exhibit physical and mental health issues, including suicidal ideation and attempts.10 It has also been shown that youth are more susceptible to peer pressure and do not have the same level of self-regulation and risk perception that adults exhibit.11–13 Despite the known harms of incarceration, previous studies have found that high juvenile incarceration rates did not foster future deterrence in criminal activity or an overall reduction in crime rates.10,14,15 Quite conversely, incarceration has been found to promote and reinforce risk-taking and delinquent behaviours,10,14,15 suggesting that incarcerating young people is a problematic policy approach from both a health and social perspective.Another concerning aspect of incarceration is the overrepresentation of ethnic minorities at all stages of the criminal justice system (e.g., investigation, remand, custody) across western nations1,16–18 Canada shares with the United States, New Zealand and Australia, a long history of high incarceration rates among Aboriginal1 populations.16,17,19–21 Specifically, in Australia, the proportion of Aboriginal people in the prison population is reported to be as high as 28% despite Aboriginal people accounting for approximately 3% of the total population.19 Similarly, in Canada, Aboriginal peoples comprise approximately 4% of the general population and 23–27% of inmates in federal and provincial correctional facilities,22,23 and there is evidence to suggest that this number has been on the rise since the early 2000s.16 This high number translates into Aboriginal adults being incarcerated at rates ten times higher than non-Aboriginal populations. While numerous studies contend that Aboriginal adults are overrepresented in criminal justice systems, there is limited empirical evidence that investigates whether this overrepresentation is similar among Aboriginal 1Aboriginal in this context refers to all status and non-status “Indians” or First Nations, Inuit, and Métis peoples. However, it is important to note that the term ‘Aboriginal’ homogenizes the diversity in terms of distinct communities or tribes, history, language and culture within the pan Aboriginal populations and that some scholars have found the word colonial and harmful55 - and First Nations inmates represent over 70% of the total Aboriginal incarcerated population, so the majority of injustices spoken to in this paper, fall disproportionately on First Nations youth and communities.23Barker et al. Page 2Public Health. Author manuscript; available in PMC 2016 December 01.Author ManuscriptAuthor ManuscriptAuthor ManuscriptAuthor Manuscriptyouth. A prior study examined the prevalence and correlates of incarceration among street-involved youth in our study setting (At-Risk Youth Study or ARYS),24 but similarly, it did not investigate the influence of Aboriginal ancestry on recent reports of incarceration. Likewise, previous research concerning Aboriginal involvement in the criminal justice system has focused on what characteristics and risk factors are associated with incarceration,16,17,20,21–23 not assessing whether this association persists despite controlling for them. To the best of our knowledge, this is the first longitudinal study to assess whether Aboriginal youth experienced an elevated risk of incarceration among an already high-risk population of street-involved youth, while controlling for drug use practices and engagement in other illicit activities.MethodsData for these analyses were collected between September 2005 and May 2013, through the At-Risk Youth Study (ARYS), which has been previously described in detail elsewhere.25 In brief, youth were eligible if they were: between the ages of 14–26 at time of enrolment; street-involved, defined as experiencing homelessness or being unstably housed (e.g., couch surfing, living in a SRO or shelter), or accessing street-based services (e.g., drop-in centres, street nurses) within the last year; had used illicit “hard” drugs in the past 30 days (e.g., crack, cocaine, heroin, or crystal methamphetamine); and provided written informed consent. At baseline and semi-annually, study participants complete an interviewer-administered questionnaire, which elicits a range of information, including items on sociodemographic information, drug use patterns, sexual and drug-related risk behaviors, engagement with health and social services, and involvement in the criminal justice system. At each study visit, participants receive a $30 CAD monetary compensation and the research ethics board of the University of British Columbia has approved the study.Our primary outcome of interest was recently being incarcerated, defined as having spent a night in detention, prison or jail in the last six months. The comparison group was those who reported not being incarcerated in the last six months. Our primary independent variable of interest was Aboriginal ancestry (self-identified as First Nations, Inuit, Métis vs. other).First, to adjust for variables that are known, or, hypothesized to be associated with both incarceration and Aboriginal ancestry, we examined a wide range of potential confounders. Sociodemographic factors included: age at baseline (per year older); gender (male vs. female); high school incompletion (yes vs. no); living in the Downtown Eastside (DTES) in the last six months, which is considered Vancouver’s drug use epicenter (yes vs. no); homelessness, defined as having no fixed address, sleeping on the street, couch surfing, or staying in a shelter or hostel in the last six months (yes vs. no); and having been in foster care, defined as living in an orphanage, foster home, group home, or being in the government custody as a child (yes vs. no). Behavioural and drug use variables, based on activities in the last six months, were treated as time-updated covariates on the basis of semiannual follow-up data and included: injection drug use (yes vs. no); non-fatal overdose, self-defined as having an adverse reaction as a result of consuming too much of a drug (yes vs. no); any injection or non-injection heroin use (yes vs. no); any injection or non-injection cocaine use (yes vs. no); any crack cocaine smoking (yes vs. no); any injection or non-Barker et al. Page 3Public Health. Author manuscript; available in PMC 2016 December 01.Author ManuscriptAuthor ManuscriptAuthor ManuscriptAuthor Manuscriptinjection crystal methamphetamine use (yes vs. no); binge drug use, defined as using injection or non-injection drugs more frequently than usual (yes vs. no); heavy alcohol consumption, defined for females as ≥ four drinks in one day in the last week or ≥ seven drinks containing alcohol per week and for males as ≥ five drinks in one day in the last week or ≥ fourteen drinks containing alcohol per week (yes vs. no); engaging in sex work, defined as exchanging sex for money, shelter, drugs or other commodities (yes vs. no); and participation in drug dealing (yes vs. no). Other factors examined included: having ever been a victim of sexual abuse (yes vs. no); having ever been a victim of physical abuse (yes vs. no); and recently experiencing an act of violence, defined as being attacked, assaulted, or suffering violence in the previous six months (yes vs. no).Initially, we examined the descriptive characteristics, stratified by reports of recent incarceration at the first study visit. Specifically, characteristics for participants who had been incarcerated were measured at their first visit (during the study period) that involved a report of being incarcerated, while characteristics for all other participants were measured from the first study visit during the study period. We assessed the associations with recent incarceration using the Pearson’s χ2-test for categorical variables and the Mann-Whitney test for continuous variables.As a next step, we used GEE analysis with a logit link function to assess the independent effect of incarceration and Aboriginal ancestry. The GEE methods provided standard errors adjusted by multiple observations per person using an exchangeable correlation structure.26,27 Our GEE analysis included an all-available-pairs procedure in order to account for individuals lost to follow-up or whose follow-up was intermittent. This method has been previously shown to account for missing data in GEE analyses while ensuring that bias remains negligible.28 To fit the multivariate confounding model, we employed a conservative variable selection approach.28 Specifically, we included all secondary variables (where p<0.10 in bivariate analyses) in a multivariate model and used a stepwise approach to fit a series of reduced models. After comparing the value of the coefficient associated with the main independent variable of interest (Aboriginal ancestry) in the full model to the value of the coefficient in each of the reduced models, we dropped the secondary variable associated with the smallest relative change. We continued this iterative process until the minimum change exceeded 5%. Remaining variables were considered confounders in multivariate analysis. Several authors have previously used this technique successfully.29–31 All statistical analyses were performed using SAS software version 9.3 (SAS, Cary, NC). All p-values are two-sided.ResultsIn total, 1050 street-involved youth were interviewed during the study period, including 718 (68%) males and 248 (24%) Aboriginal participants, with a median age at baseline of 21 (Interquartile Range [IQR]: 19–23). This sample contributed to 3,744 observations and a median number of three study visits (IQR: 1–5). Over the study period, 378 (36%) participants reported being incarcerated at least once. Characteristics of the study sample, stratified by recent reports of incarceration, are presented in Table 1.Barker et al. Page 4Public Health. Author manuscript; available in PMC 2016 December 01.Author ManuscriptAuthor ManuscriptAuthor ManuscriptAuthor ManuscriptThe results of the bivariate and multivariate GEE analyses are shown in Table 2. In the bivariate analyses, Aboriginal ancestry (odds ratio [OR]=1.27; 95% confidence interval [CI]: 1.00–1.62) was positively associated with recent incarceration. In the multivariate analysis, Aboriginal ancestry (adjusted odds ratio [AOR]=1.40; 95% CI: 1.09–1.80) remained significantly and positively associated with recent incarceration after adjusting for the following identified confounders: male gender, not completing high school, homelessness, heroin use, crack cocaine use, and drug dealing.DiscussionIn the present longitudinal study based on data from nearly eight years of observations, Aboriginal ancestry remained positively and significantly associated with incarceration despite adjustment for numerous potential confounders including gender, homelessness, drug use practices, and drug dealing. These data provide compelling evidence that the elevated risk of incarceration among Aboriginal street-involved youth is not solely due to their complex risk and need profile.A gamut of studies has identified the disproportionate number of Aboriginal individuals involved with criminal justice systems across western nations, as both offenders16,17,19–21 and victims.32–34 Two plausible scenarios present themselves: one, that Aboriginal peoples are committing a disproportionate number of crimes, or two, they are subjected to a discriminatory criminal justice system. Research indicates that people of Aboriginal ancestry are engaging in criminal activity at a higher rate than non-Aboriginal people,34,37 however, there are key underlying structural factors that are known to contribute to this observation. Specifically, previous research has identified numerous risk factors that disproportionately affect Aboriginal communities and are associated with an elevated risk of offending. These include residential instability, low levels of education, high levels of unemployment, alcohol and substance use issues, poverty, and severe family conflict.36,38 However, in the current study, even after adjusting for many of these risk factors, Aboriginal ancestry remained independently associated with incarceration, suggesting that policing practices or other aspects of the current criminal justice system may be partly responsible.The importance of social, structural and environmental factors in producing health inequities is becoming increasingly well recognized in the field of public health and policy.39–41 In the context of the overrepresentation of Aboriginal youth in the criminal justice system, key relevant structural factors include the legacy of colonization and multi-century long, state-sponsored oppression. From the expropriation of land37, prohibition of language and cultural practices42, forcible removal of Aboriginal children into Church-run residential schools in the late 1800s onwards,43,44 to the unaddressed intergenerational trauma38,44, continued economic marginalization,36,38,44 and elevated rates of substance use and poverty today,19,36,38 a myriad of factors contribute as underlying determinants of Aboriginal overrepresentation in prison populations. Indeed, an abundance of research has identified that Aboriginal peoples continue to experience marginalization and discrimination at much higher rates than non-Aboriginal peoples,36,45,46 which appears to be consistent with our study findings.Barker et al. Page 5Public Health. Author manuscript; available in PMC 2016 December 01.Author ManuscriptAuthor ManuscriptAuthor ManuscriptAuthor ManuscriptFor centuries, the Canadian police force has been charged with moving various culturally assimilative and destructive policies into action, yielding a long history of distrust and contempt.47,48 Today, Canadian police officers are accorded substantial discretionary power in how best to maintain peace and order on the street and research suggests that the viewpoint that Aboriginal peoples are criminal, violent or dangerous is prevalent among, at least, a minority of officers.48,49 Further, prior research has found that Aboriginal young people are more likely to be dealt punitive punishments (e.g., arrested and charged) rather than warnings compared to non-Aboriginal youth.50 These factors may contribute to why Aboriginal youth in our study experienced increase contact with the criminal justice system independent of drug use patterns and other relevant practices.Promising evidence suggests that alternative sentencing and diversionary community-based measures may be an effective way to both, prevent juvenile offenders from becoming repeat offenders while also protecting public order and safety.10,51 However, changing sentencing schemes or employing diversionary measures does not adequately address the underlying marginalization and discrimination that Aboriginal youth experience. This indicates that interventions on numerous fronts are required. Community policing practices have previously been demonstrated to bring tailored law enforcement strategies to meet the unique needs of the communities they serve and foster a shared sense of responsibility for community development and public order.52 These programs are developed in partnership with local public and non-profit agencies and community residents to ensure local applicability. There is an under-explored potential for community policing units to work harmoniously with First Nations and urban Aboriginal organizations to better understand the role of risk factors and the social determinants of incarceration with regard to Aboriginal youth. Additionally, given historical and ongoing systematic marginalization of Aboriginal peoples, solutions will need to be sought from outside traditional structures and processes. In particular, prior research has identified community-based alternative measures, designed and operated by self-governing Aboriginal nations to mitigate the post-colonial framework that the current criminal justice system exists within as a fundamental tenet to reform.38,50 Furthermore, Aboriginal communities have identified the need for upstream interventions to help at-risk Aboriginal youth connect with their communities, traditions and promote positive self-worth.53,54 In particular, as youth in our study often engage in problematic substance use, calls have been made for the implementation of culturally tailored addiction prevention programs that target Aboriginal youth (as both have a known association with incarceration), and programs that promote healthy family dynamics and conflict resolution.36 Actions on multiple fronts that help address the economic and social discrimination of Aboriginal youth may help this high-risk population avoid becoming entrenched in the criminal justice system, as well as mitigate the subsequent negative health impacts.This study has several limitations. First, as with all community-recruited research cohorts, the ARYS cohort is not a random sample and therefore may not generalize to other populations of street youth. Second, data were collected using self-reported interviews and is thus vulnerable to response biases. Given the sensitive nature of some interview questions, respondents may be inclined to report socially desirable responses leading to underreporting of stigmatizing behaviours such as illicit drug use and incarceration. Further, given the non-Barker et al. Page 6Public Health. Author manuscript; available in PMC 2016 December 01.Author ManuscriptAuthor ManuscriptAuthor ManuscriptAuthor Manuscriptrandomized nature of this study, the relationships studied may be influenced by confounders not measured.ConclusionTo our knowledge, this is the first study to examine the risk of incarceration among Aboriginal street-involved youth after controlling for drug use patterns and other risk behaviors. Even among a population at high-risk for incarceration and adjusting for known factors associated with incarceration, we found that Aboriginal street-involved youth are still more likely to experience involvement with the criminal justice system than their non-Aboriginal peers. Given the demonstrated inability of youth incarceration to prevent future deterrence or ameliorate the continued overrepresentation of Aboriginal people involved with the criminal justice system, and the harms associated with incarceration, evidence-based and culturally appropriate interventions are urgently needed to prevent more youth from becoming involved in the criminal justice system.AcknowledgmentsThe authors thank the study participants for their contribution to the research, as well as current and past researchers and staff. We would specifically like to thank Cody Callon, Jennifer Matthews, Deborah Graham, Peter Vann, Steve Kain, Tricia Collingham, Kristie Starr, and Carmen Rock for their research and administrative assistance.Funding: The study was supported by the US National Institutes of Health (R01DA028532, U01DA038886) and the Canadian Institutes of Health Research (MOP–102742). This research was undertaken, in part, thanks to funding from the Canada Research Chairs program through a Tier 1 Canada Research Chair in Inner City Medicine, which supports Dr. Evan Wood. Dr. Kora DeBeck is supported by a MSFHR/St. Paul’s Hospital Foundation-Providence Health Care Career Scholar Award and a Canadian Institutes of Health Research New Investigator Award. Brittany Barker is supported by a Canadian Institutes of Health Research Doctoral Award. 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Healing traditions: culture, community and mental health promotion with Canadian Aboriginal peoples. Australas Psychiatr. 2003; 11:15–23.Barker et al. Page 9Public Health. Author manuscript; available in PMC 2016 December 01.Author ManuscriptAuthor ManuscriptAuthor ManuscriptAuthor Manuscript54. Alfred, GT. Wasáse: Indigenous Pathways of Action and Freedom. Ontario, Canada: Broadview Press Ltd; 2005. 55. Alfred, GT. Peace, power, righteousness: an indigenous manifesto. 2. New York, NY: Oxford University Press; 2009. Barker et al. Page 10Public Health. Author manuscript; available in PMC 2016 December 01.Author ManuscriptAuthor ManuscriptAuthor ManuscriptAuthor Manuscript• 378 of the 1050 (36%) street-involved youth in this study reported being incarcerated in the previous six months at some point during the study period• Aboriginal ancestry remained significantly associated with incarceration, despite controlling for potential confounders such as sociodemographics, drug dealing and drug use practices• These findings suggest that policing practices or other aspects of the current criminal justice system may be partly responsibleBarker et al. Page 11Public Health. Author manuscript; available in PMC 2016 December 01.Author ManuscriptAuthor ManuscriptAuthor ManuscriptAuthor ManuscriptAuthor ManuscriptAuthor ManuscriptAuthor ManuscriptAuthor ManuscriptBarker et al. Page 12Table 1Baseline sociodemographic characteristics and substance use behaviours associated with incarcerationa among street-involved youth in Vancouver, Canada (n = 1050).Recent IncarcerationaCharacteristic Yes378 (36%)No672 (64%) Odds Ratio (95% CIb) p-valueAboriginal AncestryYes 108 (29) 140 (21) 1.52 (1.14 – 2.03) 0.005No 270 (71) 532 (79)Age (Median, IQRc) 22 (20 – 24) 21 (19 – 23) 1.07 (1.02 – 1.12) 0.013GenderMale 301 (80) 417 (62) 2.39 (1.78 – 3.21) <0.001Female 77 (20) 255 (38)High School IncompletionYes 308 (81) 484 (72) 1.67 (1.22 – 2.28) 0.001No 69 (18) 181 (27)Lives in the DTESdeYes 117 (31) 194 (29) 1.11 (0.84 – 1.45) 0.478No 261 (69) 478 (71)HomelessdYes 285 (75) 478 (71) 1.25 (0.94 – 1.67) 0.129No 91 (24) 191 (28)Foster Care ExposureYes 199 (53) 295 (44) 1.42 (1.10 – 1.83) 0.007No 174 (46) 366 (54)Heroin UsedYes 145 (38) 229 (34) 1.18 (0.91 – 1.54) 0.212No 232 (61) 433 (64)Cocaine UsedYes 160 (42) 336 (50) 0.73 (0.57 – 0.94) 0.016No 216 (57) 332 (49)Crystal Methamphetamine UsedYes 171 (45) 301 (45) 1.01 (0.78 – 1.30) 0.933No 204 (54) 363 (54)Crack Cocaine UsedYes 240 (63) 363 (54) 1.47 (1.14 – 1.91) 0.003No 137 (36) 305 (45)Any Injection Drug UsedYes 136 (36) 199 (30) 1.34 (1.02 – 1.75) 0.033No 241 (64) 472 (70)Heavy Alcohol UsedPublic Health. Author manuscript; available in PMC 2016 December 01.Author ManuscriptAuthor ManuscriptAuthor ManuscriptAuthor ManuscriptBarker et al. Page 13Recent IncarcerationaCharacteristic Yes378 (36%)No672 (64%) Odds Ratio (95% CIb) p-valueYes 143 (38) 246 (37) 1.05 (0.81 – 1.37) 0.694No 235 (62) 426 (63)Binge Drug UsedYes 186 (49) 265 (39) 1.50 (1.16 – 1.94) 0.002No 189 (50) 404 (60)Non-Fatal OverdosedYes 41 (11) 82 (12) 0.87 (0.59 – 1.30) 0.507No 337 (89) 589 (88)Victim of ViolencedYes 198 (52) 272 (40) 1.65 (1.28 – 2.13) <0.001No 175 (46) 397 (59)Sex WorkdYes 35 (9) 72 (11) 0.85 (0.56 – 1.30) 0.454No 343 (91) 600 (89)Drug DealingdYes 203 (54) 316 (47) 1.31 (1.02 – 1.68) 0.038No 175 (46) 356 (53)Sexual AbuseYes 266 (70) 441 (66) 1.22 (0.93 – 1.62) 0.155No 106 (28) 215 (32)Physical AbuseYes 322 (85) 550 (82) 1.22 (0.85 – 1.75) 0.289No 50 (13) 104 (15)Note: All column percentages may not sum to 100% due to missing data or rounding error.aCharacteristics for individuals who were incarcerated in the last six months, measured at their first report (during the study period) of being incarcerated. Characteristics for all other participants were measured from the first study visit during the study period;bCI = Confidence Interval;cIQR = Interquartile Range;dDenotes activities in the last six months;eDTES = downtown eastside, the epicenter of Vancouver’s drug scenePublic Health. Author manuscript; available in PMC 2016 December 01.Author ManuscriptAuthor ManuscriptAuthor ManuscriptAuthor ManuscriptBarker et al. Page 14Table 2Bivariate and multivariate GEE analyses of factors associated with incarceration and Aboriginal ancestry, controlling for confounding variables (n=1050).Unadjusted Odds Ratio Adjusted Odds RatioCharacteristic ORa (95% CIb) p-value AORc (95% CIb) p-valueAboriginal Ancestry 1.27 (1.00 – 1.62) 0.054 1.40 (1.09 – 1.80) 0.008Age (Per Year Older) 1.06 (1.01 – 1.10) 0.017Male Gender 2.42 (1.84 – 3.20) <0.001 2.31 (1.74 – 3.07) <0.001High School Incompletion 1.53 (1.16 – 2.01) 0.003 1.43 (1.08 – 1.89) 0.013Lives in the DTESde 1.19 (0.97 – 1.47) 0.089Homelessd 2.11 (1.75 – 2.54) <0.001 1.85 (1.52 – 2.26) <0.001Foster Care Exposure 1.20 (0.96 – 1.50) 0.117Heroin Used 1.58 (1.29 – 1.94) <0.001 1.42 (1.15 – 1.76) 0.001Cocaine Used 1.20 (1.00 – 1.43) 0.052Crystal Methamphetamine Used 1.35 (1.13 – 1.62) 0.001Crack Cocaine Used 1.59 (1.34 – 1.88) <0.001 1.12 (0.93 – 1.35) 0.218Any Injection Drug Used 1.50 (1.22 – 1.83) <0.001Heavy Alcohol Used 1.13 (0.94 – 1.35) 0.203Binge Drug Used 1.60 (1.35 – 1.91) <0.001Non-Fatal Overdosed 1.25 (0.95 – 1.64) 0.108Victim of Violenced 1.88 (1.57 – 2.24) <0.001Sex Workd 1.07 (0.78 – 1.47) 0.679Drug Dealingd 2.10 (1.75 – 2.53) <0.001 1.74 (1.43 – 2.12) <0.001Sexual Abuse 1.18 (0.93 – 1.52) 0.179Physical Abuse 1.04 (0.75 – 1.44) 0.817aOR = Odds Ratio;bCI = Confidence Interval;cAOR = Adjusted Odds Ratio;dRefers to activities in the previous six months;eDTES = downtown eastside, the epicenter of Vancouver’s drug scenePublic Health. Author manuscript; available in PMC 2016 December 01.

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