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Drug-related street disorder : evidence for public policy responses DeBeck, Kora 2010

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ȱ ȱ ȱ ȱ  DRUGȬRELATEDȱSTREETȱDISORDER:ȱEVIDENCEȱFORȱPUBLICȱPOLICYȱ RESPONSESȱ ȱ ȱ ȱ byȱ ȱ KORAȱDEBECKȱ BA,ȱMcGillȱUniversity,ȱCanada,ȱ2002ȱ MPP,ȱSimonȱFraserȱUniversity,ȱCanada,ȱ2007ȱ ȱ ȱ ȱ AȱTHESISȱSUBMITTEDȱINȱPARTIALȱFULFILMENTȱOFȱȱ THEȱREQUIREMENTSȱFORȱTHEȱDEGREEȱOFȱ ȱ ȱ DOCTORȱOFȱPHILOSOPHYȱ ȱ ȱ inȱ ȱ ȱ THEȱFACULTYȱOFȱGRADUATEȱSTUDIESȱ (InterdisciplinaryȱStudies)ȱ ȱ ȱ ȱ ȱ ȱ TheȱUniversityȱofȱBritishȱColumbiaȱ ȱ (Vancouver)ȱ ȱ Decemberȱ2010ȱ ȱ ©ȱKoraȱDeBeck,ȱ2010ȱ  ABSTRACTȱ Background:ȱTheȱobjectivesȱofȱthisȱthesisȱwereȱtoȱdescribeȱtheȱimpactsȱofȱdrugȬrelatedȱ streetȱdisorderȱonȱstreetȬbasedȱinjectionȱdrugȱusersȱ(IDU)ȱinȱVancouver,ȱCanadaȱandȱtoȱ exploreȱ theȱ potentialȱ impactsȱ ofȱ threeȱ policyȱ interventionsȱ (lowȬthresholdȱ supportiveȱ housing,ȱ lowȬthresholdȱ employment,ȱ andȱ supervisedȱ inhalationȱ facilities)ȱ onȱ theȱ reductionȱofȱstreetȱdisorder.ȱȱ Methods:ȱDataȱforȱtheseȱstudiesȱwereȱderivedȱfromȱtheȱVancouverȱInjectionȱDrugȱUsersȱ Studyȱ (VIDUS)ȱ whichȱ isȱ aȱ communityȱ recruitedȱ prospectiveȱ cohortȱ ofȱ IDU.ȱ Studyȱ participantsȱ wereȱ invitedȱ onȱ biȬannualȱ basesȱ toȱ completeȱ anȱ interviewerȬadministeredȱ questionnaire.ȱVariousȱmultivariateȱregressionȱtechniquesȱwereȱutilizedȱtoȱassessȱfactorsȱ associatedȱ withȱ exposureȱ toȱ drugȬrelatedȱ streetȱ disorder,ȱ socializingȱ inȱ Vancouver’’sȱ openȱ drugȱ scene,ȱ engagingȱ inȱ disorderlyȱ incomeȱ generationȱ activities,ȱ andȱ smokingȱ crackȱ cocaineȱ inȱ publicȱ areas.ȱ Furtherȱ multivariateȱ analysesȱ wereȱ conductedȱ toȱ assessȱ willingnessȱ toȱ reduceȱ engagementȱ inȱ behavioursȱ thatȱ contributeȱ toȱ drugȬrelatedȱ streetȱ disorder.ȱȱ Results:ȱAtȱbaseline,ȱ21%ȱofȱtheȱstudyȱsampleȱreportedȱspendingȱoverȱ15ȱhourȱperȱdayȱ inȱ Vancouver’’sȱ openȱ drugȱ sceneȱ onȱ average.ȱ Drugȱ sceneȱ exposureȱ wasȱ foundȱ toȱ beȱ associatedȱ inȱ aȱ doseȬdependentȱ fashionȱ withȱ higherȱ intensityȱ drugȱ useȱ andȱ multipleȱ markersȱ ofȱ vulnerabilityȱ toȱ adverseȱ healthȱ outcomes.ȱ Inȱ furtherȱ analyses,ȱ 43%ȱ ofȱ participantsȱ reportedȱ socializingȱ inȱ theȱ openȱ drugȱ sceneȱ forȱ 3ȱ orȱ moreȱ hoursȱ perȱ day,ȱ andȱhavingȱlimitedȱaccessȱtoȱprivateȱspaceȱwasȱtheȱfactorȱmostȱstronglyȱassociatedȱwithȱ thisȱbehaviour.ȱAmongȱthisȱgroupȱ65%ȱreportedȱbeingȱwillingȱtoȱrelocateȱifȱgivenȱaccessȱ toȱ moreȱ privateȱ space.ȱ 47%ȱ ofȱ participantsȱ whoȱ engagedȱ inȱ disorderlyȱ incomeȱ generationȱactivitiesȱwereȱwillingȱtoȱforgoȱtheseȱincomeȱsourcesȱifȱgivenȱlowȬthresholdȱ employment,ȱandȱ71%ȱofȱcrackȱcocaineȱsmokersȱwhoȱreportedȱrecentlyȱusingȱinȱpublicȱ areasȱwereȱwillingȱtoȱvisitȱaȱsupervisedȱinhalationȱfacility.ȱ Conclusions:ȱ Theseȱ studiesȱ highlightȱ theȱ importanceȱ ofȱ viewingȱ streetȱ disorderȱ inȱ theȱ contextȱ ofȱ currentȱ political,ȱ economic,ȱ andȱ socialȱ conditionsȱ andȱ provideȱ aȱ compellingȱ bodyȱ ofȱ evidenceȱ indicatingȱ thatȱ structuralȱ andȱ environmentalȱ levelȱ interventions,ȱ specificallyȱ inȱ theȱ areasȱ ofȱ housingȱ (i.e.,ȱ provisionȱ ofȱ privateȱ space),ȱ employmentȱ andȱ supervisedȱdrugȱconsumptionȱfacilities,ȱareȱlikelyȱtoȱhaveȱaȱpositiveȱinfluenceȱonȱpublicȱ healthȱandȱreduceȱengagementȱinȱdrugȬrelatedȱstreetȱdisorder.ȱȱ  ȱ  ii  PREFACEȱ Thisȱstatementȱisȱtoȱcertifyȱthatȱtheȱworkȱpresentedȱinȱthisȱthesisȱwasȱconceived,ȱ designed,ȱ written,ȱ andȱ disseminatedȱ byȱ Koraȱ DeBeckȱ (KD).ȱ Theȱ coȬauthorsȱ ofȱ theȱ manuscripts,ȱ includingȱ Dr.ȱ Julioȱ Montanerȱ (JM),ȱ Dr.ȱ Dougȱ McArthurȱ (DM),ȱ Dr.ȱ Janeȱ Buxtonȱ (JB),ȱ Dr.ȱ Evanȱ Woodȱ (EW),ȱ Dr.ȱ Thomasȱ Kerrȱ (TK),ȱ Ms.ȱ Ruthȱ Zhangȱ (RZ),ȱ Mr.ȱ Calvinȱ Laiȱ (CL),ȱ andȱ Ms.ȱ Jiezhiȱ Qiȱ (Qi)ȱ madeȱ contributionsȱ onlyȱ asȱ isȱ consistentȱ withȱ committee,ȱ collegial,ȱ orȱ coȬauthorȱ duties.ȱ Specificȱ contributionsȱ toȱ eachȱ thesisȱ chapterȱ areȱasȱfollows:ȱChaptersȱ1ȱandȱ8:ȱȱWithȱguidanceȱandȱinputȱfromȱJM,ȱDM,ȱJB,ȱEWȱandȱ TK,ȱ KDȱ conceivedȱ andȱ preparedȱ theȱ initialȱ drafts;ȱ JM,ȱ DM,ȱ JBȱ andȱ TKȱ reviewedȱ andȱ providedȱfeedbackȱonȱChaptersȱ1ȱandȱ8.ȱChapterȱ2:ȱWithȱguidanceȱandȱinputȱfromȱTK,ȱ JM,ȱJB,ȱandȱDM,ȱKDȱwasȱresponsibleȱforȱundertakingȱtheȱliteratureȱreviewȱandȱpreparedȱ theȱfirstȱdraftȱofȱtheȱreview;ȱDMȱcontributedȱtoȱtheȱmainȱcontent;ȱandȱTK,ȱJM,ȱJB,ȱandȱ DMȱprovidedȱcriticalȱcommentsȱonȱtheȱfinalȱdraft.ȱChapterȱ3:ȱWithȱguidanceȱandȱinputȱ fromȱ TK,ȱ JM,ȱ andȱ EW,ȱ KDȱ wasȱ responsibleȱ forȱ studyȱ designȱ andȱ wroteȱ theȱ researchȱ protocol;ȱ RZȱ conductedȱ theȱ statisticalȱ analyses;ȱ KDȱ preparedȱ theȱ firstȱ draftȱ ofȱ theȱ analysis;ȱTK,ȱJB,ȱDM,ȱJM,ȱandȱEWȱcontributedȱtoȱtheȱmainȱcontentȱandȱprovidedȱcriticalȱ commentsȱonȱtheȱfinalȱdraft.ȱChapterȱ4:ȱWithȱguidanceȱandȱinputȱfromȱTK,ȱJM,ȱandȱEW,ȱ KDȱwasȱresponsibleȱforȱstudyȱdesignȱandȱwroteȱtheȱresearchȱprotocol;ȱCLȱconductedȱtheȱ statisticalȱanalyses;ȱKDȱpreparedȱtheȱfirstȱdraftȱofȱtheȱanalysis;ȱTK,ȱJB,ȱDM,ȱJM,ȱandȱEWȱ contributedȱ toȱ theȱ mainȱ contentȱ andȱ providedȱ criticalȱ commentsȱ onȱ theȱ finalȱ draft.ȱ Chapterȱ 5Ȭ7:ȱ Withȱ guidanceȱ andȱ inputȱ fromȱ TK,ȱ JM,ȱ andȱ EW,ȱ KDȱ wasȱ responsibleȱ forȱ ȱ  iii  studyȱ designsȱ andȱ wroteȱ theȱ researchȱ protocols;ȱ JQȱ conductedȱ theȱ statisticalȱ analyses;ȱ KDȱpreparedȱtheȱfirstȱdraftsȱofȱtheȱanalysis;ȱTK,ȱJB,ȱDM,ȱJM,ȱandȱEWȱcontributedȱtoȱtheȱ mainȱcontentȱandȱprovidedȱcriticalȱcommentsȱonȱtheȱfinalȱdrafts.ȱ Allȱ manuscriptsȱ containedȱ inȱ thisȱ thesisȱ wereȱ preparedȱ andȱ writtenȱ byȱ KDȱ andȱ KDȱ wasȱ responsibleȱ forȱ revisingȱ theȱ manuscriptsȱ basedȱ onȱ theȱ suggestionsȱ ofȱ theȱ coȬ authors,ȱsubmittingȱmanuscriptsȱforȱpublicationȱandȱpreparingȱfinalȱrevisionsȱbasedȱonȱ theȱcommentsȱofȱtheȱjournalȱeditorsȱandȱexternalȱpeerȱreviewersȱ Allȱ researchȱ describedȱ inȱ thisȱ dissertationȱ wasȱ approvedȱ byȱ theȱ Universityȱ ofȱ Britishȱ Columbia/Providenceȱ Healthȱ Careȱ Researchȱ Ethicsȱ Board;ȱ certificateȱ numbers:ȱ P05Ȭ0234,ȱH05Ȭ50234,ȱH01Ȭ50086,ȱP05Ȭ0233.ȱȱȱ  ȱ  iv  TABLEȱOFȱCONTENTSȱ ABSTRACT ..................................................................................................................................ii PREFACE .................................................................................................................................... iii TABLEȱOFȱCONTENTS............................................................................................................. v LISTȱOFȱTABLES ....................................................................................................................... ix LISTȱOFȱFIGURES..................................................................................................................... xi ACKNOWLEDGEMENTS ......................................................................................................xii CHAPTERȱ1:ȱBackground,ȱRational,ȱObjectives,ȱandȱConceptualȱFramework.............. 1 1.1ȱBackground......................................................................................................................... 1 1.2ȱStudyȱJustification.............................................................................................................. 4 1.3ȱStudyȱObjectives................................................................................................................. 6 1.4ȱStudyȱDesign..................................................................................................................... 10 1.5ȱConceptualȱFramework................................................................................................... 11 1.6ȱSummary ........................................................................................................................... 14 CHAPTERȱ2:ȱDrugȬRelatedȱStreetȱDisorder:ȱAȱReviewȱofȱMeasuresȱandȱPolicyȱ Responses ................................................................................................................................... 18 2.1ȱIntroduction ...................................................................................................................... 18 2.2ȱReviewȱMethods............................................................................................................... 19 2.3ȱReviewȱFindings:ȱMeasuringȱDrugȬRelatedȱStreetȱDisorder..................................... 20 2.4ȱReviewȱFindings:ȱRespondingȱtoȱDrugȬRelatedȱStreetȱDisorder .............................. 25 2.4.1ȱLawȱEnforcementȱApproachesȱtoȱAddressȱDrugȬRelatedȱStreetȱDisorder....... 25 2.4.1.1ȱPoliceȱCrackȬDownȱCampaigns ....................................................................... 25 ȱ  v  2.4.1.2ȱOrderȬMaintenanceȱPolicingȱBasedȱonȱtheȱBrokenȱWindowsȱTheory ....... 28 2.4.1.3ȱProblemȱOrientedȱPolicing ............................................................................... 33 2.4.1.4ȱHotȬSpotȱPolicing ............................................................................................... 34 2.4.1.5ȱIncreasingȱPoliceȱPowersȱThroughȱLegislation ............................................. 35 2.4.1.6ȱSummaryȱofȱLawȱEnforcementȱBasedȱApproaches ...................................... 36 2.4.2ȱEnvironmentalȱDesignȱApproachesȱtoȱAddressȱDrugȬRelatedȱStreetȱDisorder ................................................................................................................................... 36 2.4.3ȱEngagingȱInterventionsȱthatȱEnableȱBehaviourȱChange ..................................... 39 2.4.3.1ȱSupervisedȱInjectionȱFacilities.......................................................................... 39 2.4.3.2ȱAddictionȱTreatment ......................................................................................... 41 2.4.3.3ȱLowȬThresholdȱEmploymentȱPrograms......................................................... 42 2.5ȱConclusionsȱandȱNextȱSteps........................................................................................... 44 2.5.1ȱUnderexploredȱandȱInnovativeȱEngagingȱApproaches ...................................... 45 2.5.2ȱSummary .................................................................................................................... 46 CHAPTERȱ3:ȱAȱDoseȬDependentȱRelationshipȱBetweenȱExposureȱtoȱaȱStreetȬBasedȱ DrugȱSceneȱandȱHealthȬRelatedȱHarmsȱamongȱPeopleȱWhoȱUseȱInjectionȱDrugs ..... 50 3.1ȱIntroduction ...................................................................................................................... 50 3.2ȱMethods............................................................................................................................. 52 3.3ȱResults................................................................................................................................ 56 3.4ȱDiscussion ......................................................................................................................... 58  ȱ  vi  CHAPTERȱ4:ȱTheȱValidityȱofȱReportingȱWillingnessȱgoȱUseȱaȱSupervisedȱInjectingȱ FacilityȱonȱSubsequentȱProgramȱUseȱamongȱPeopleȱWhoȱUseȱInjectionȱDrugs.......... 68 4.1ȱIntroduction ...................................................................................................................... 68 4.2ȱMethods............................................................................................................................. 69 4.3ȱResults................................................................................................................................ 73 4.4ȱDiscussion ......................................................................................................................... 75 CHAPTERȱ5:ȱSocializingȱinȱanȱOpenȱDrugȱScene:ȱTheȱRelationshipȱBetweenȱAccessȱ toȱPrivateȱSpaceȱandȱStreetȱDisorder..................................................................................... 82 5.1ȱIntroduction ...................................................................................................................... 82 5.2ȱMethods............................................................................................................................. 84 5.3ȱResults................................................................................................................................ 90 5.4ȱDiscussion ......................................................................................................................... 92 CHAPTERȱ6:ȱOpportunitiesȱforȱReducingȱEngagementȱinȱDisorderlyȱIncomeȱ GenerationȱActivitiesȱamongȱPeopleȱWhoȱInjectȱIllicitȱDrugs ...................................... 102 6.1ȱIntroduction .................................................................................................................... 102 6.2ȱMethods........................................................................................................................... 104 6.3ȱResults.............................................................................................................................. 107 6.4ȱDiscussion ....................................................................................................................... 109 CHAPTERȱ7:ȱPublicȱCrackȱCocaineȱUseȱandȱWillingnessȱtoȱuseȱaȱSupervisedȱ InhalationȱFacility:ȱImplicationsȱforȱStreetȱDisorder....................................................... 122 7.1ȱIntroduction .................................................................................................................... 122 7.2ȱMethods........................................................................................................................... 124 7.3ȱResults.............................................................................................................................. 127 ȱ  vii  7.4ȱDiscussion ....................................................................................................................... 128 CHAPTERȱ8:ȱConclusions ..................................................................................................... 136 8.1ȱSummaryȱofȱFindings .................................................................................................... 136 8.2ȱUniqueȱContributions.................................................................................................... 140 8.3ȱRecommendationsȱandȱImplications........................................................................... 142 8.3.1ȱMicroȱLevelȱRecommendationsȱandȱImplications.............................................. 143 8.3.2ȱMacroȱLevelȱRecommendationsȱandȱImplications............................................. 145 8.4ȱFutureȱResearch.............................................................................................................. 146 8.5ȱConclusions..................................................................................................................... 149 REFERENCES .......................................................................................................................... 151  ȱ ȱ  ȱ  viii  LISTȱOFȱTABLESȱ Tableȱ2.1.ȱȱ SummaryȱofȱmeasuresȱappropriateȱforȱdrugȬrelatedȱstreetȱdisorder.............. 24 Tableȱ2.2ȱȱ Descriptionȱofȱpolicyȱapproaches ......................................................................... 47 Tableȱ2.3ȱȱ Evidenceȱofȱimpactsȱofȱpolicyȱapproaches .......................................................... 48 Tableȱ3.1ȱȱ Baselineȱcharacteristicsȱofȱsampleȱstratifiedȱbyȱlevelȱofȱdrugȱsceneȱexposure64 Tableȱ3.2ȱȱ Univariateȱanalysesȱofȱfactorsȱassociatedȱwithȱdrugȱsceneȱexposure ............. 65 Tableȱ3.3ȱȱ Multivariateȱanalysesȱofȱfactorsȱassociatedȱwithȱdrugȱsceneȱexposure .......... 66 Tableȱ4.1ȱȱ CharacteristicsȱofȱstudyȱpopulationȱstratifiedȱbyȱattendanceȱatȱVancouver’’sȱ supervisedȱinjectionȱfacility................................................................................... 79 Tableȱ4.2ȱȱ Multivariateȱlogisticȱregressionȱanalysisȱofȱfactorsȱassociatedȱwithȱattendingȱ Vancouver’’sȱsupervisedȱinjectionȱfacility ........................................................... 80 Tableȱ4.3ȱȱ GEEȱanalysisȱofȱfactorsȱassociatedȱwithȱnotȱusingȱtheȱsupervisedȱinjectionȱ facilityȱinȱtheȱlastȱsixȱmonthsȱamongȱthoseȱwhoȱinitiallyȱreportedȱbeingȱ willingȱtoȱuseȱtheȱfacility........................................................................................ 80 Tableȱ5.1ȱȱ UnivariateȱanalysesȱofȱfactorsȱassociatedȱwithȱsocializingȱinȱVancouver’’sȱ openȱdrugȱsceneȱamongȱinjectionȱdrugȱusers..................................................... 97 Tableȱ5.2ȱȱ UnivariateȱanalysisȱofȱhousingȱstatusȱandȱsocializingȱinȱVancouver’’sȱopenȱ drugȱsceneȱamongȱinjectionȱdrugȱusers............................................................... 98 Tableȱ5.3ȱȱ Multivariateȱlogisticȱregressionȱanalysisȱofȱprimaryȱandȱsecondaryȱfactorsȱ associatedȱwithȱsocializingȱinȱVancouver’’sȱopenȱdrugȱsceneȱamongȱinjectionȱ drugȱusers ................................................................................................................ 98 Tableȱ5.4ȱȱ Univariateȱanalysesȱofȱinjectionȱdrugȱusersȱthatȱhaveȱlimitedȱaccessȱtoȱprivateȱ spaceȱandȱengageȱinȱsocializingȱinȱVancouver’’sȱopenȱdrugȱsceneȱstratifiedȱbyȱ willingnessȱtoȱrelocate............................................................................................ 99 Tableȱ5.5ȱȱ Univariateȱanalysisȱofȱhousingȱstatusȱandȱwillingnessȱtoȱrelocateȱamongȱ injectionȱdrugȱusers .............................................................................................. 100 Tableȱ5.6ȱȱ Multivariateȱlogisticȱregressionȱanalysisȱofȱfactorsȱassociatedȱwithȱ willingnessȱtoȱrelocateȱsocializingȱactivityȱamongȱinjectionȱdrugȱusers ...... 100  ȱ  ix  Tableȱ6.1ȱȱ Participationȱinȱdisorderlyȱincomeȱgenerationȱactivitiesȱamongȱinjectionȱdrugȱ users ........................................................................................................................ 117 Tableȱ6.2ȱȱ Univariateȱanalysesȱofȱfactorsȱassociatedȱwithȱengagingȱinȱdisorderlyȱincomeȱ generationȱactivitiesȱamongȱinjectionȱdrugȱusers ............................................ 118 Tableȱ6.3ȱȱ Multivariateȱlogisticȱregressionȱanalysisȱofȱfactorsȱassociatedȱwithȱ participationȱinȱdisorderlyȱincomeȱgenerationȱactivitiesȱamongȱinjectionȱdrugȱ users ........................................................................................................................ 119 Tableȱ6.4ȱȱ Univariateȱanalysesȱofȱfactorsȱassociatedȱwithȱwillingnessȱtoȱceaseȱengagingȱ inȱdisorderlyȱincomeȱgenerationȱactivitiesȱamongȱinjectionȱdrugȱusers....... 120 Tableȱ6.5ȱȱ Multivariateȱlogisticȱregressionȱanalysisȱofȱfactorsȱassociatedȱwithȱ willingnessȱtoȱceaseȱengagingȱinȱdisorderlyȱincomeȱgenerationȱamongȱ injectionȱdrugȱusers .............................................................................................. 121 Tableȱ7.1ȱȱ Characteristicsȱofȱcrackȱcocaineȱsmokersȱstratifiedȱbyȱpublicȱdrugȱuse ....... 132 Tableȱ7.2ȱȱ Univariateȱandȱmultivariateȱanalysesȱofȱfactorsȱassociatedȱwithȱpublicȱdrugȱ useȱamongȱcrackȱcocaineȱsmokers...................................................................... 133 Tableȱ7.3ȱȱ Characteristicsȱofȱcrackȱcocaineȱsmokersȱwhoȱuseȱdrugsȱinȱpublicȱstratifiedȱ byȱwillingnessȱtoȱuseȱaȱsupervisedȱinhalationȱroom ....................................... 134 Tableȱ7.4ȱȱ Univariateȱandȱmultivariateȱanalysesȱofȱfactorsȱassociatedȱwithȱwillingnessȱtoȱ useȱaȱsupervisedȱinhalationȱroomȱamongȱparticipantsȱthatȱsmokeȱcrackȱ cocaineȱandȱuseȱdrugsȱinȱpublicȱlocations......................................................... 135 ȱ ȱ  ȱ  x  LISTȱOFȱFIGURESȱ Figureȱ1.1.ȱTypesȱofȱdrugȬrelatedȱstreetȱdisorder.................................................................. 16 Figureȱ1.2.ȱProblemsȱassociatedȱwithȱdrugȬrelatedȱstreetȱdisorder .................................... 16 Figureȱ1.3.ȱSchematicȱofȱtheoreticalȱframework .................................................................... 17 Figureȱ3.1ȱFactorsȱassociatedȱwithȱdrugȱsceneȱexposure ..................................................... 67 Figureȱ4.1ȱStudyȱsample............................................................................................................ 81 Figureȱ5.1ȱHousingȱstatusȱamongȱinjectionȱdrugȱusers...................................................... 101 Figureȱ5.2ȱDistributionȱofȱinjectionȱdrugȱusersȱbyȱhousingȱstatusȱandȱaccessȱtoȱprivateȱ space........................................................................................................................ 101 ȱ  ȱȱ  ȱ  xi  ACKNOWLEDGEMENTSȱ Iȱ wouldȱ likeȱ toȱ expressȱ myȱ sincereȱ gratitudeȱ toȱ myȱ thesisȱ supervisorȱ Drȱ Julioȱ Montaner,ȱandȱmyȱcommitteeȱmembersȱDrsȱJaneȱBuxtonȱandȱDougȱMcArthurȱforȱtheirȱ generosity,ȱ encouragement,ȱ andȱ guidance.ȱ Iȱ wouldȱ alsoȱ likeȱ toȱ thankȱ myȱ committeeȱ specialȱ advisorsȱ Drsȱ Evanȱ Woodȱ andȱ Thomasȱ Kerrȱ forȱ theirȱ activeȱ involvementȱ andȱ constantȱ supportȱ throughoutȱ myȱ programȱ andȱ academicȱ training.ȱ Theȱ ongoingȱ mentorshipȱIȱhaveȱreceivedȱfromȱeachȱofȱtheseȱindividualsȱisȱinvaluableȱandȱIȱamȱveryȱ appreciativeȱ toȱ haveȱ hadȱ theȱ opportunityȱ toȱ beȱ guidedȱ byȱ suchȱ aȱ supportiveȱ andȱ experiencedȱ committee.ȱ Itȱ isȱ theirȱ energyȱ thatȱ madeȱ thisȱ projectȱ possibleȱ andȱ Iȱ willȱ foreverȱbeȱgratefulȱtoȱthem.ȱ NoneȱofȱthisȱworkȱwouldȱhaveȱbeenȱpossibleȱwithoutȱtheȱwillingnessȱofȱVIDUSȱ participantsȱ toȱ beȱ partȱ ofȱ theȱ studyȱ andȱ shareȱ theirȱ experiences.ȱ Iȱ extendȱ aȱ specialȱ acknowledgementȱandȱthanksȱtoȱallȱVIDUSȱparticipantsȱandȱhopeȱthisȱworkȱcanȱbeȱusedȱ toȱtheirȱbenefit.ȱȱIȱwouldȱalsoȱlikeȱtoȱthankȱallȱVIDUSȱfrontlineȱstaffȱforȱdoingȱtheȱhardȱ workȱofȱgatheringȱtheȱdataȱthatȱisȱtheȱbasisȱofȱthisȱproject.ȱȱȱ Iȱ wouldȱ likeȱ toȱ recognizeȱ aȱ largeȱ numberȱ ofȱ peopleȱ atȱ theȱ BCȱ Centreȱ forȱ Excellenceȱ inȱ HIV/AIDSȱ (CfE)ȱ andȱ theȱ Urbanȱ Healthȱ Researchȱ Initiativeȱ whoȱ haveȱ providedȱ invaluableȱ supportȱ toȱ me.ȱ Inȱ particularȱ Iȱ wouldȱ likeȱ toȱ thankȱ Kellyȱ Hsu,ȱ DeborahȱGraham,ȱTriciaȱCollingham,ȱCarmenȱRock,ȱPeterȱVann,ȱCaitlinȱJohnston,ȱSteveȱ KainȱandȱIreneȱDay.ȱThanksȱtoȱBrentonȱWaltersȱforȱcopyȱeditingȱthisȱwork.ȱIȱhaveȱalsoȱ receivedȱ outstandingȱ statisticalȱ supportȱ andȱ mentorshipȱ fromȱ Jiezhiȱ Qi,ȱ Ruthȱ Zhang,ȱ andȱCalvinȱLaiȱ––ȱthankȱyou.ȱAnotherȱhugeȱsourceȱofȱinspirationȱandȱsupportȱhasȱcomeȱ fromȱ aȱ trulyȱ exceptionalȱ groupȱ ofȱ friendsȱ andȱ colleaguesȱ atȱ theȱ CfE.ȱ Thisȱ includesȱ Brandonȱ Marshall,ȱ MȬJȱ Milloy,ȱ Willȱ Small,ȱ Elisaȱ LloydȬSmith,ȱ Kateȱ Shannon,ȱ Angelaȱ Kaida,ȱ Vivianeȱ Diasȱ Lima,ȱ Arankaȱ Aanema,ȱ Andreaȱ Krüsi,ȱ Danȱ Werb,ȱ Lindseyȱ Richardson,ȱ Codyȱ Callon,ȱ Danyaȱ Fast,ȱ Kannaȱ Hayashiȱ andȱ Nadiaȱ Fairbairn.ȱ Iȱ lookȱ forwardȱtoȱcontinuingȱtoȱcollaborateȱwithȱandȱlearnȱfromȱyouȱall.ȱȱ Iȱ wouldȱ likeȱ toȱ acknowledgeȱ myȱ doctoralȱ fundingȱ supportȱ fromȱ theȱ Canadianȱ Institutesȱ ofȱ Healthȱ Research,ȱ theȱ Michaelȱ Smithȱ Foundationȱ forȱ Healthȱ Research,ȱ theȱ BCȱCentreȱforȱExcellenceȱinȱHIV/AIDSȱandȱtheȱUrbanȱHealthȱResearchȱInitiative.ȱȱ Lastly,ȱ Iȱ wouldȱ likeȱ toȱ extendȱ myȱ gratitudeȱ toȱ myȱ partner,ȱ myȱ familyȱ andȱ myȱ friendsȱforȱtheirȱconstantȱsupportȱandȱendlessȱpatienceȱthroughoutȱmyȱPhDȱprogram.ȱȱ ȱ ȱ  ȱ  xii  CHAPTER 1: ȱ BACKGROUND,ȱRATIONAL,ȱOBJECTIVES,ȱANDȱ CONCEPTUALȱFRAMEWORKȱ  1.1 Backgroundȱ Theȱ everȬincreasingȱ expansionȱ andȱ revitalizationȱ ofȱ urbanȱ coresȱ isȱ generatingȱ uniqueȱpressuresȱforȱcityȱmanagersȱandȱpolicyȬmakers.ȱAsȱtheȱdensityȱofȱcitiesȱincreasesȱ andȱcitizensȱwithȱdiverseȱbackgroundsȱandȱinterestsȱareȱbroughtȱintoȱcloserȱproximity,ȱ tensionsȱrelatedȱtoȱtheȱuseȱofȱpublicȱspacesȱmayȱbecomeȱamplified.ȱȱ Oneȱ commonȱ areaȱ ofȱ contentionȱ isȱ theȱ presenceȱ ofȱ drugȬrelatedȱ streetȱ disorder.ȱ DrugȬrelatedȱstreetȱdisorderȱcanȱbeȱdefinedȱasȱactivitiesȱandȱbehavioursȱassociatedȱwithȱ illegalȱ drugȱ useȱ thatȱ detractsȱ fromȱ otherȱ citizens’’ȱ enjoymentȱ ofȱ publicȱ spaces.ȱ Streetȱ disorderȱisȱoftenȱdefinedȱtoȱincludeȱmarkersȱofȱ‘‘physical’’ȱdisorder,ȱsuchȱasȱgraffiti,ȱlitterȱ andȱstructuralȱdecayȱinȱneighbourhoodsȱ(e.g.,ȱbrokenȱwindows),ȱasȱwellȱasȱmarkersȱofȱ ‘‘social’’ȱ disorder,ȱ whichȱ refersȱ toȱ activitiesȱ andȱ behavioursȱ thatȱ takeȱ placeȱ inȱ publicȱ spaces.1ȱ ȱ ȱ Inȱ theȱ contextȱ ofȱ drugȬrelatedȱ streetȱ disorderȱ keyȱ activitiesȱ ofȱ relevanceȱ include:ȱ publicȱ drugȱ useȱ (consumingȱ illegalȱ drugsȱ inȱ publicȱ spacesȱ primarilyȱ throughȱ injectionȱ andȱ smoking);ȱ drugȬrelatedȱ litterȱ (includingȱ discardingȱ needlesȱ andȱ crackȱ pipesȱinȱpublicȱareas);ȱandȱpublicȱintoxicationȱ(loiteringȱorȱsocializingȱinȱpublicȱspacesȱ whileȱ underȱ theȱ influenceȱ ofȱ drugs).2Ȭ6ȱ ȱ Thereȱ areȱ alsoȱ aȱ numberȱ ofȱ incomeȱ generationȱ activitiesȱthatȱcontributeȱtoȱstreetȱdisorderȱwhich,ȱalthoughȱnotȱexclusivelyȱdrugȬrelated,ȱ  ȱ  1  areȱlargelyȱdrivenȱbyȱillegalȱdrugȱuseȱandȱaddiction.2,ȱ 7ȱTheseȱactivitiesȱinclude:ȱȱstreetȬ levelȱdrugȱtraffickingȱ(definedȱasȱsellingȱillegalȱdrugsȱinȱpublicȱspaces);ȱstreetȬbasedȱsexȱ workȱ(solicitingȱandȱcommunicatingȱforȱtheȱpurposesȱofȱsellingȱsexȱinȱpublicȱsettings);ȱ panhandlingȱ (solicitingȱ moneyȱ orȱ otherȱ goodsȱ fromȱ passersȱ byȱ inȱ publicȱ areas);ȱ squeegeeȱ cleaningȱ (cleaningȱ theȱ windshieldsȱ ofȱ carsȱ atȱ stopȱ lightsȱ inȱ exchangeȱ forȱ donationsȱ fromȱ vehicleȱ drivers);ȱ ȱ andȱ lastly,ȱ engagementȱ inȱ ‘‘binning’’,ȱ recycling,ȱȱ salvagingȱ orȱ unsanctionedȱ streetȬvendingȱ (collectingȱ bottlesȱ andȱ otherȱ goodsȱ fromȱ allies,ȱ dumpstersȱ andȱ otherȱ publicȱ areasȱ thatȱ areȱ returnedȱ forȱ refundȱ orȱ soldȱ onȱ theȱ streetȱforȱprofit)ȱ[seeȱFigureȱ1.1].2,ȱ8Ȭ10ȱ InȱVancouver,ȱCanada,ȱdrugȬrelatedȱstreetȱdisorderȱisȱparticularlyȱprevalentȱinȱanȱ areaȱofȱtheȱcityȱcalledȱtheȱDowntownȱEastsideȱ(DTES).ȱThisȱneighbourhoodȱcontainsȱaȱ highȱ portionȱ ofȱ theȱ city’’sȱ lowȬcostȱ housingȱ stockȱ andȱ largeȱ numbersȱ ofȱ citizensȱ livingȱ withȱmentalȱhealthȱandȱaddictionȱissues.11,ȱ12ȱȱOverȱtheȱyearsȱtheȱDTESȱhasȱbecomeȱaȱhubȱ ofȱdrugȱmarketȱactivityȱandȱdrugȬrelatedȱstreetȱdisorderȱisȱcommonȱinȱtheȱarea.ȱȱInȱtheȱ earlyȱ1990sȱtheȱneighbourhoodȱwasȱfloodedȱwithȱhighȱpurityȱheroinȱandȱcocaineȱwhichȱ exacerbatedȱ streetȱ disorderȱ problemsȱ andȱ resultedȱ inȱ aȱ publicȱ healthȱ disasterȱ amongȱ peopleȱwhoȱinjectȱdrugsȱ(IDU).ȱAlongȱwithȱanȱexplosiveȱincreaseȱinȱoverdoseȱdeaths,13ȱ researchersȱdocumentedȱanȱHIVȱepidemicȱamongȱlocalȱIDUȱthatȱrivaledȱHIVȱinfectionȱ ratesȱinȱBotswana,ȱAfrica.14,ȱ15ȱȱȱ  ȱ  2  Manyȱpublicȱhealthȱinitiativesȱ haveȱbeenȱimplementedȱtoȱ respondȱtoȱ theȱ healthȱ andȱ streetȱ disorderȱ problemsȱ associatedȱ withȱ problematicȱ drugȱ use.ȱ Theseȱ haveȱ includedȱ scalingȱ upȱ addictionȱ treatmentȱ services,ȱ particularlyȱ methadoneȱ maintenance,16ȱ restructuringȱ theȱ neighbourhood’’sȱ needleȱ exchangeȱ programs,17Ȭ19ȱ andȱ establishingȱaȱpilotȱsupervisedȱinjectionȱfacilityȱinȱ2003.20,ȱ21ȱȱAsȱaȱresultȱofȱtheseȱefforts,ȱ progressȱ hasȱ beenȱ madeȱ inȱ reducingȱ overdoseȱ deathsȱ andȱ HIVȱ infectionȱ ratesȱ amongȱ peopleȱwhoȱinjectȱdrugs.22ȱȱHowever,ȱthereȱareȱstillȱsignificantȱgapsȱinȱhealthȱservicesȱforȱ peopleȱwhoȱuseȱdrugsȱandȱstreetȱdisorderȱremainsȱaȱprominentȱproblemȱinȱtheȱDTES.23Ȭ 25  ȱȱȱ Inȱ addition,ȱ drugȱ useȱ trendsȱ inȱ theȱ neighbourhoodȱ haveȱ beenȱ changing.ȱ  Specifically,ȱtheȱpopularityȱofȱcrackȱcocaineȱhasȱsignificantlyȱincreasedȱinȱtheȱDTES,26,ȱ27ȱ yetȱ itsȱ proliferationȱ hasȱ notȱ beenȱ metȱ withȱ anȱ adequateȱ publicȱ healthȱ response.28,ȱ 29ȱ Comparedȱtoȱotherȱdrugȱuserȱpopulations,ȱcrackȱcocaineȱusersȱareȱoftenȱdescribedȱasȱaȱ particularlyȱhighȱriskȱpopulation.ȱCrackȱcocaineȱusingȱpopulationsȱareȱfoundȱtoȱbeȱmoreȱ likelyȱ toȱ engageȱ inȱ riskyȱ behaviours30Ȭ32ȱ andȱ illegalȱ activities,7,ȱ  33  ȱ toȱ experienceȱ  homelessness29ȱandȱhealthȱproblems,29,ȱ 34Ȭ37ȱyetȱareȱlessȱlikelyȱtoȱaccessȱhealthȱandȱsocialȱ services.38ȱ Indeed,ȱ recentȱ researchȱ indicatesȱ thatȱ afterȱ adjustingȱ forȱ establishedȱ riskȱ factors,ȱ frequentȱ crackȱ cocaineȱ smokingȱ remainsȱ independentlyȱ associatedȱ withȱ HIVȱ incidenceȱ amongȱ drugȱ usersȱ inȱ Vancouver.27ȱ ȱ Inȱ theȱ DTESȱ theȱ majorityȱ ofȱ evidenceȬ basedȱpublicȱhealthȱresponsesȱtoȱproblematicȱdrugȱuseȱareȱnotȱtailoredȱforȱcrackȱcocaineȱ  ȱ  3  usersȱandȱdoȱnotȱaddressȱtheirȱuniqueȱneeds.28,ȱ39ȱȱAsȱaȱresult,ȱhealthȱandȱstreetȱdisorderȱ problemsȱtendȱtoȱbeȱaccentuatedȱamongȱpeopleȱwhoȱuseȱcrackȱcocaine.ȱ  1.2 StudyȱJustificationȱ DrugȬrelatedȱstreetȱdisorderȱnegativelyȱimpactsȱcommunitiesȱandȱindividualsȱinȱ aȱ numberȱ ofȱ ways.ȱ Identifiedȱ problemsȱ primarilyȱ involveȱ economic,ȱ publicȱ safetyȱ andȱ publicȱhealthȱconcernsȱ[seeȱFigureȱ1.2].ȱWithȱrespectȱtoȱeconomicȱconsiderations,ȱstreetȱ disorderȱ isȱ citedȱ asȱ creatingȱ unpleasant,ȱ unwelcomingȱ environmentsȱ thatȱ discourageȱ retailȱactivityȱandȱdevelopment,ȱwhichȱinȱturnȱmayȱharmȱlocalȱbusinessesȱandȱerodeȱtheȱ economicȱ vitalityȱ andȱ growthȱ ofȱ areasȱ experiencingȱ drugȬrelatedȱ streetȱ disorder.8,ȱ 40Ȭ44ȱȱ Sinceȱstreetȱdisorderȱisȱtypicallyȱconcentratedȱinȱurbanȱcentres,ȱtheȱpresenceȱofȱdisorderȱ isȱfearedȱtoȱundermineȱurbanȱrenewalȱefforts,ȱwhichȱprovideȱimportantȱcommercialȱandȱ realȱestateȱinvestmentȱopportunitiesȱinȱmanyȱrapidlyȱexpandingȱurbanȱsettings.45ȱ Alongsideȱ economicȱ issues,ȱ publicȱ safetyȱ isȱ anotherȱ centralȱ concernȱ withȱ drugȬ relatedȱstreetȱdisorder.42ȱInȱparticular,ȱtheȱillegalȱdrugȱtradeȱcanȱbeȱviolent.46ȱȱBecauseȱofȱ theȱ illegalȱ statusȱ ofȱ drugs,ȱ individualsȱ engagedȱ inȱ theȱ drugȱ tradeȱ areȱ unableȱ toȱ seekȱ assistanceȱ fromȱ lawȱ enforcementȱ andȱ legalȱ institutionsȱ toȱ settleȱ disputes.46ȱ ȱ Inȱ theȱ absenceȱ ofȱ traditionalȱ disputeȱ resolutionȱ mechanismsȱ andȱ safeguardsȱ itȱ isȱ commonȱ inȱ someȱ areasȱ forȱ streetȬlevelȱ drugȱ dealersȱ toȱ carryȱ weaponsȱ (includingȱ firearms),ȱ andȱ toȱ engageȱ inȱ territorialȱ warsȱ orȱ useȱ violenceȱ toȱ resolveȱ disputes.41,ȱ 47ȱ Theseȱ actionsȱ oftenȱ bringȱ violenceȱ toȱ publicȱ spaces,ȱ andȱ engenderȱ aȱ senseȱ ofȱ dangerȱ amongȱ theȱ public.ȱȱ ȱ  4  Citizensȱ mayȱ alsoȱ fearȱ beingȱ approachedȱ inȱ anȱ aggressiveȱ mannerȱ byȱ panhandlersȱ orȱ squeegeeȱcleaners.43ȱTheȱerraticȱbehavioursȱassociatedȱwithȱtheȱuseȱofȱparticularȱdrugsȱ suchȱ asȱ crackȱ cocaineȱ mayȱ equallyȱ intimidateȱ citizensȱ andȱ makeȱ themȱ feelȱ thatȱ theirȱ safetyȱisȱbeingȱthreatened.48,ȱ49ȱȱDiscardedȱinjectionȱequipmentȱisȱalsoȱperceivedȱtoȱposeȱaȱ threatȱ toȱ publicȱ safety.ȱ Althoughȱ incidentsȱ areȱ extremelyȱ rare,ȱ thereȱ isȱ concernȱ thatȱ individualsȱmayȱbecomeȱinfectedȱwithȱbloodȬborneȱdiseasesȱifȱaccidentallyȱprickedȱbyȱaȱ discardedȱ contaminatedȱ needle.5ȱ Inȱ addition,ȱ oneȱ theoryȱ rootedȱ inȱ criminologyȱ andȱ urbanȱ sociologyȱ knownȱ asȱ ‘‘brokenȱ windows’’ȱ suggestsȱ thatȱ streetȱ disorderȱ mayȱ createȱ environmentsȱ thatȱ attractȱ moreȱ seriousȱ formsȱ ofȱ crimeȱ includingȱ robbery,ȱ theftȱ andȱ assaultȱandȱtherebyȱmayȱfurtherȱthreatenȱpublicȱsafety.40,ȱ50ȱ DrugȬrelatedȱstreetȱdisorderȱalsoȱhasȱimportantȱpublicȱhealthȱimplications.ȱAtȱtheȱ neighbourhoodȱlevel,ȱstudiesȱhaveȱlinkedȱneighbourhoodȱstreetȱdisorderȱtoȱpoorȱmentalȱ andȱ physicalȱ healthȱ outcomesȱ amongȱ neighbourhoodȱ residents.51Ȭ55ȱ Inȱ addition,ȱ thoseȱ whoȱpartakeȱinȱdrugȬrelatedȱ‘‘disorderly’’ȱactivitiesȱareȱtypicallyȱvulnerableȱindividualsȱ facingȱmultipleȱnegativeȱhealthȱissuesȱandȱengagingȱinȱdrugȬrelatedȱdisorderȱcanȱposeȱ additionalȱ healthȱ risks.7,ȱ 56ȱ ȱ Inȱ particular,ȱ itȱ isȱ wellȱ documentedȱ thatȱ asȱ aȱ resultȱ ofȱ theȱ unregulatedȱnatureȱofȱdrugȱmarkets,ȱstreetȬbasedȱsexȱworkersȱareȱespeciallyȱvulnerableȱ toȱ violentȱ encountersȱ andȱ theirȱ abilityȱtoȱ negotiateȱ condomȱ useȱcanȱbeȱconstrained.57Ȭ60ȱȱ Similarly,ȱ usingȱ injectionȱ drugsȱ inȱ publicȱ settingsȱ isȱ knownȱ toȱ increaseȱ vulnerabilityȱ amongȱinjectors.ȱPublicȱinjectingȱisȱassociatedȱwithȱrushingȱtheȱinjectionȱprocess,ȱwhichȱ  ȱ  5  canȱincreaseȱriskȱforȱaȱrangeȱofȱnegativeȱoutcomesȱincludingȱdrugȱoverdose,ȱsoftȬtissueȱ damage,ȱ andȱ acquisitionȱ ofȱ bloodȬborneȱ diseases.58,ȱ 61Ȭ65ȱ ȱ Althoughȱ theȱ negativeȱ healthȱ impactsȱ ofȱ engagingȱ inȱ streetȬbasedȱ sexȱ workȱ andȱ publicȱ injectionȱ drugȱ useȱ areȱ wellȱ described,ȱ theȱ healthȱ implicationsȱ ofȱ engagingȱ inȱ otherȱ disorderlyȱ activitiesȱ areȱ notȱ asȱ widelyȱunderstood.ȱThereȱisȱsomeȱevidenceȱtoȱsuggestȱthatȱindividualsȱwhoȱengageȱinȱ panhandlingȱ andȱ relatedȱ incomeȱ generationȱ activitiesȱ canȱ beȱ theȱ recipientȱ ofȱ verbalȱ hostilityȱ andȱ physicalȱ violence;2,ȱ 44,ȱ 66ȱ however,ȱ theȱ healthȱ impactsȱ ofȱ activitiesȱ suchȱ asȱ loiteringȱandȱsocializingȱremainȱlargelyȱunderstudied.ȱȱȱ Despiteȱ theȱ attentionȱ drugȬrelatedȱ streetȱ disorderȱ isȱ receivingȱ fromȱ theȱ generalȱ publicȱandȱpolicyȬmakers,ȱresponsesȱtoȱdateȱhaveȱbeenȱlargelyȱineffectiveȱinȱaddressingȱ theseȱ behavioursȱ andȱ resultingȱ harms.ȱ Indeed,ȱ lawȱ enforcementȱ basedȱ responsesȱ haveȱ beenȱshownȱtoȱoftenȱexacerbateȱtheȱharmsȱassociatedȱwithȱstreetȱdisorderȱinȱadditionȱtoȱ beingȱ unableȱ toȱ effectivelyȱ respondȱ toȱ theȱ activity.62,ȱ  67Ȭ69  ȱ Therefore,ȱ alternativeȱ  approachesȱ thatȱ haveȱ potentialȱ toȱ addressȱ drugȬrelatedȱ streetȱ disorderȱ areȱ urgentlyȱ required.ȱȱ  1.3 StudyȱObjectivesȱ GivenȱtheȱproblemsȱassociatedȱwithȱdrugȬrelatedȱstreetȱdisorderȱandȱtheȱlackȱofȱ effectiveȱ policyȱ responsesȱ toȱ date,ȱ theȱ centralȱ aimsȱ ofȱthisȱ thesisȱ areȱ toȱ identifyȱ factorsȱ contributingȱto,ȱexploreȱtheȱimpactsȱof,ȱandȱassessȱpotentialȱpolicyȱresponsesȱto,ȱdrugȬ relatedȱstreetȱdisorder.ȱAnalysesȱwillȱinvolveȱdescribingȱtheȱhealthȱandȱsocialȱimpactsȱofȱ ȱ  6  exposureȱ toȱ drugȬrelatedȱ streetȱ disorder,ȱ asȱ wellȱ asȱ exploringȱ theȱ potentialȱ impactsȱ ofȱ threeȱ policyȱ interventionsȱ toȱ reduceȱ drugȬrelatedȱ streetȱ disorder.ȱ Theseȱ interventionsȱ wereȱselectedȱbasedȱonȱaȱreviewȱofȱcurrentȱliteratureȱ(seeȱChapterȱ2),ȱandȱfeasibilityȱforȱ evaluation.ȱ Itȱ isȱ hopedȱ thatȱ theȱ findingsȱ ofȱ thisȱ workȱ willȱ beȱ usedȱ toȱ informȱ moreȱ effectiveȱpolicyȱinterventionsȱinȱthisȱarea.ȱȱ SpecificȱObjectivesȱandȱResearchȱHypothesis:ȱ 1. Toȱ assessȱ whetherȱ exposureȱ toȱ drugȬrelatedȱ streetȱ disorder,ȱ inȱ theȱ formȱ ofȱ Vancouver’’sȱstreetȬbasedȱdrugȱscene,ȱposesȱpublicȱhealthȱrisks.ȱȱ Chapterȱ 3ȱ setsȱ outȱ toȱ describeȱ factorsȱ associatedȱ withȱ exposureȱ toȱ streetȬbasedȱ drugsȱ scenesȱ andȱ determineȱ ifȱ thereȱ isȱ aȱ doseȱ dependentȱ relationshipȱ betweenȱ exposureȱ andȱ markersȱ ofȱ vulnerabilityȱ andȱ higherȱ intensityȱ addiction.ȱ Itȱ isȱ hypothesizedȱ thatȱ beingȱ exposedȱ toȱ theȱ drugȱ sceneȱ inȱ Vancouver’’sȱ Downtownȱ Eastsideȱ willȱ beȱ associatedȱ withȱ markersȱ ofȱ vulnerabilityȱ andȱ thatȱ thisȱ relationshipȱ willȱ beȱ inȱ aȱ doseȱ dependentȱ fashion.ȱ Itȱ isȱ alsoȱ hypothesizedȱ thatȱ beingȱ exposedȱ toȱ theȱ drugȱ sceneȱ inȱ Vancouver’’sȱ Downtownȱ Eastsideȱ willȱ beȱ associatedȱwithȱhigherȱintensityȱaddictionȱandȱthatȱthisȱrelationshipȱwillȱbeȱinȱaȱ doseȱdependentȱfashion.ȱ  ȱ  7  2. Toȱ assessȱ whetherȱ willingnessȱ measuresȱ mayȱ beȱ effectiveȱ toolsȱ forȱ planningȱ theȱdeliveryȱofȱpublicȱhealthȱprogramsȱforȱinjectionȱdrugȱuserȱpopulations.ȱȱ Sinceȱ Chaptersȱ 5Ȭ7ȱ relyȱ onȱ measuringȱ studyȱ participants’’ȱ willingnessȱ toȱ engageȱ withȱ variousȱ publicȱ healthȱ programsȱ andȱ services,ȱ itȱ isȱ criticalȱ toȱ determineȱ whetherȱtheseȱmeasuresȱhaveȱanyȱpredictiveȱvalidity.ȱToȱdetermineȱifȱwillingnessȱ measuresȱ areȱ reasonablyȱ validȱ tools,ȱ Chapterȱ 4ȱ comparesȱ priorȱ measuresȱ forȱ willingnessȱ toȱ useȱ aȱ supervisedȱ injectionȱ facilityȱ withȱ laterȱ attendanceȱ atȱ theȱ facilityȱ onceȱ itȱ wasȱ established.ȱ Itȱ isȱ hypothesizedȱ thatȱ reportedȱ willingnessȱ toȱ useȱaȱsupervisedȱinjectingȱfacility,ȱcollectedȱpriorȱtoȱtheȱopeningȱofȱVancouverȇsȱ supervisedȱ injectingȱ facility,ȱ willȱ beȱ significantlyȱ andȱ independentlyȱ associatedȱ withȱusingȱtheȱprogramȱafterȱitȱwasȱestablished.ȱ 3. Toȱ examineȱ theȱ relationshipȱ betweenȱ accessȱ toȱ privateȱ spaceȱ andȱ timeȱ spentȱ socializingȱinȱanȱopenȱdrugȱscene.ȱȱ Toȱ investigateȱ aȱ potentialȱ policyȱ interventionȱ toȱ addressȱ aȱ componentȱ ofȱ drugȬ relatedȱ streetȱ disorder,ȱ Chapterȱ 5ȱ usesȱ logisticȱ regressionȱ toȱ exploreȱ theȱ relationshipȱ betweenȱ timeȱ spentȱ onȱ theȱ streetȱ socializingȱ andȱ housingȱ structureȱ (notȱhavingȱaȱprivateȱindoorȱplaceȱtoȱsocialize).ȱLogisticȱregressionȱisȱalsoȱusedȱtoȱ profileȱparticipantsȱthatȱreportȱaȱwillingnessȱtoȱrelocateȱtoȱprivateȱspacesȱifȱsuchȱ spacesȱwereȱmadeȱavailable.ȱItȱisȱhypothesizedȱthatȱspendingȱtimeȱsocializingȱinȱ theȱ openȱ drugȱ sceneȱ willȱ beȱ associatedȱ withȱ havingȱ limitedȱ accessȱ toȱ privateȱ  ȱ  8  space.ȱ Itȱ isȱ alsoȱ hypothesizedȱ thatȱ ifȱ offeredȱ accessȱ toȱ privateȱ spaceȱ forȱ socializing,ȱ willingnessȱ toȱ relocateȱ toȱ privateȱ settingȱ willȱ beȱ associatedȱ withȱ markersȱofȱvulnerability.ȱ 4. Toȱassessȱengagementȱinȱdisorderlyȱincomeȱgenerationȱactivitiesȱandȱexamineȱ theȱ relationshipȱ betweenȱ providingȱ lowȬthresholdȱemploymentȱ opportunitiesȱ andȱengagingȱinȱdisorderlyȱincomeȱgenerationȱactivities.ȱ Toȱ investigateȱ anotherȱ potentialȱ policyȱ interventionȱ toȱ addressȱ aȱ componentȱ ofȱ drugȬrelatedȱ streetȱ disorder,ȱ Chapterȱ 6ȱ assessesȱ engagementȱ inȱ disorderlyȱ incomeȱgenerationȱandȱtheȱpotentialȱimpactȱofȱofferingȱalternativeȱlowȬthresholdȱ employmentȱ opportunitiesȱ onȱ engagementȱ inȱ disorderlyȱ incomeȱ generationȱ activities.ȱ Itȱ isȱ hypothesizedȱ thatȱ engagingȱ inȱ disorderlyȱ incomeȱ generationȱ activitiesȱ willȱ beȱ associatedȱ withȱ markersȱ ofȱ vulnerabilityȱ andȱ highȱ intensityȱ addiction.ȱ Itȱ isȱ alsoȱ hypothesizedȱ thatȱ ifȱ offeredȱ lowȬthresholdȱ employmentȱ opportunities,ȱ willingnessȱ toȱ giveȱ upȱ disorderlyȱ incomeȱ generationȱ behavioursȱ willȱbeȱassociatedȱwithȱmarkersȱofȱvulnerability.ȱ 5. Toȱcharacterizeȱpublicȱcrackȱcocaineȱsmokingȱandȱassessȱwhetherȱaȱsupervisedȱ inhalationȱ facilityȱ hasȱ potentialȱ toȱ addressȱ streetȱ disorderȱ byȱ reducingȱ theȱ prevalenceȱofȱthisȱbehaviour.ȱȱ Lastly,ȱ toȱ investigateȱ theȱ potentialȱ forȱ supervisedȱ inhalationȱ facilitiesȱ toȱ reduceȱ publicȱcrackȱcocaineȱsmoking,ȱChapterȱ7ȱprofilesȱpublicȱcrackȱcocaineȱusersȱandȱ  ȱ  9  assessȱ willingnessȱ toȱ useȱ aȱ supervisedȱ inhalationȱ facilityȱ amongȱ publicȱ crackȱ cocaineȱ smokers.ȱ Itȱ isȱ hypothesizedȱ thatȱ publicȱ crackȱ cocaineȱ smokingȱ willȱ beȱ commonȱ amongȱ localȱ crackȱ cocaineȱ usersȱ andȱ thisȱ practiceȱ willȱ beȱ associatedȱ withȱ markersȱ ofȱ vulnerabilityȱ andȱ higherȱ intensityȱ addiction.ȱ ȱ Itȱ isȱ alsoȱ hypothesizedȱthatȱtheȱmajorityȱofȱpublicȱcrackȱcocaineȱsmokersȱwillȱbeȱwillingȱtoȱ useȱaȱsupervisedȱinhalationȱfacility.ȱ  1.4 StudyȱDesignȱ TheȱproposedȱresearchȱwasȱundertakenȱusingȱdataȱfromȱtheȱVancouverȱInjectionȱ Drugȱ Usersȱ Studyȱ (VIDUS)ȱ whichȱ isȱ aȱ longstandingȱ prospectiveȱ communityȱ recruitedȱ cohortȱthatȱbeganȱenrollingȱparticipantsȱinȱMayȱ1996.ȱToȱbeȱeligibleȱparticipantsȱhadȱtoȱ haveȱ injectedȱ drugsȱ inȱ theȱ previousȱ month,ȱ liveȱ inȱ theȱ greaterȱ Vancouverȱ region,ȱ andȱ provideȱ writtenȱ informedȱ consent.ȱ VIDUSȱ participantsȱ areȱ invitedȱ toȱ visitȱ theȱ studyȱ officeȱ locatedȱ inȱ theȱ Downtownȱ Eastsideȱ ofȱ Vancouverȱ onȱ aȱ biȬannualȱ basisȱ andȱ completeȱ anȱ extensiveȱ interviewerȬadministeredȱ questionnaire.ȱ Theȱ surveyȱ elicitsȱ informationȱ pertainingȱ toȱ socioȬdemographicȱ characteristicsȱ includingȱ housingȱ status,ȱ incomeȱ generationȱ behaviours,ȱ sexualȱ behaviour,ȱ andȱ behaviouralȱ characteristicsȱ relatedȱ toȱ drugȱ useȱ andȱ injectionȱ practices.ȱ Respondentsȱ areȱ alsoȱ questionedȱ aboutȱ healthȱcareȱutilizationȱandȱuseȱofȱHIVȱpreventionȱandȱtreatmentȱservicesȱasȱwellȱasȱanyȱ significantȱcontactȱwithȱtheȱpoliceȱandȱtheȱcriminalȱjusticeȱsystem.ȱAlthoughȱmostȱofȱtheȱ measuresȱ onȱ theȱ questionnaireȱ remainȱ consistentȱ overȱ time,ȱ atȱ eachȱ sixȬmonthȱ studyȱ  ȱ  10  followȬupȱ thereȱ isȱ anȱ opportunityȱ toȱ amendȱ theȱ VIDUSȱ questionnaireȱ toȱ addȱ newȱ questionsȱofȱinterest.ȱAtȱeachȱstudyȱvisitȱbloodȱsamplesȱareȱalsoȱprovidedȱforȱdiagnosticȱ testing.ȱVIDUSȱparticipantsȱreceiveȱaȱstipendȱinȱtheȱamountȱofȱ$20ȱCDNȱforȱtheirȱtimeȱatȱ theȱ conclusionȱ ofȱ eachȱ studyȱ visit.ȱ Theȱ studyȱ hasȱ receivedȱ ethicalȱ approvalȱ fromȱ ProvidenceȱHealthȱandȱtheȱUniversityȱofȱBritishȱColumbia’’sȱResearchȱEthicsȱBoardȱ(seeȱ AppendixȱI).ȱ Dataȱ forȱ theȱ analysesȱ inȱ Chaptersȱ 3ȱ andȱ 4ȱ wereȱ availableȱ fromȱ theȱ VIDUSȱ questionnairesȱ administeredȱ betweenȱ Decemberȱ 2005ȱ andȱ Marchȱ 2009,ȱ andȱ Decemberȱ 2001ȱ toȱ Novemberȱ 2005ȱ respectively.ȱ Beginningȱ inȱ Juneȱ 2008ȱ measuresȱ forȱ socializingȱ andȱaccessȱtoȱprivateȱspaceȱwereȱaddedȱtoȱtheȱVIDUSȱquestionnaireȱandȱprovidedȱdataȱ forȱ theȱ analysesȱ inȱ Chapterȱ 5.ȱ Inȱ Novemberȱ 2008ȱ measuresȱ forȱ willingnessȱ toȱ takeȱ upȱ lowȬthresholdȱ employmentȱ andȱ toȱ useȱ aȱ supervisedȱ inhalationȱ facilityȱ wereȱ addedȱ toȱ theȱVIDUSȱquestionnaireȱandȱprovidedȱdataȱforȱtheȱanalysesȱinȱChaptersȱ6ȱandȱ7.ȱ  1.5 ConceptualȱFrameworkȱ Atȱtheȱbroadestȱlevel,ȱthisȱresearchȱisȱinformedȱbyȱaȱtheoreticalȱapproachȱcalledȱ theȱ ‘‘riskȱ environmentȱ framework’’.70ȱ ȱ Althoughȱ primarilyȱ developedȱ inȱ theȱ contextȱ ofȱ riskȱ behaviourȱ relatedȱ toȱ HIVȱ infectionȱ andȱ overdoseȱ amongȱ injectionȱ drugȱ users,ȱ theȱ riskȱenvironmentȱframeworkȱandȱtheȱrelatedȱconceptȱofȱ‘‘situatedȱrationality’’ȱprovideȱaȱ usefulȱ theoreticalȱ basisȱ toȱ approachȱ theȱ problemȱ ofȱ drugȬrelatedȱ streetȱ disorderȱ [seeȱ Figureȱ1.3].71,ȱ72ȱȱ ȱ  11  Inȱ reactionȱ toȱ anȱ observedȱ overrelianceȱ onȱ individuallyȱ orientedȱ modelsȱ ofȱ behaviourȱchangeȱthatȱappearedȱtoȱhaveȱlimitedȱsuccessȱinȱtheȱareaȱofȱHIVȱpreventionȱ andȱ healthȱ promotion,ȱgrowingȱ numbersȱ ofȱpublicȱ healthȱscholarsȱbeganȱ emphasizingȱ theȱimportanceȱofȱconsideringȱtheȱroleȱthatȱsocial,ȱstructuralȱandȱenvironmentalȱfactorsȱ playedȱ inȱ shapingȱ healthȱ relatedȱ behavioursȱ amongȱ peopleȱ whoȱ useȱ drugs.73Ȭ79ȱ ȱ Inȱ particular,ȱ Rhodesȱ proposedȱ thatȱ social,ȱ structuralȱ andȱ environmentalȱ factorsȱ createȱ aȱ ‘‘riskȱenvironment’’ȱthatȱmediatesȱbehaviour.70,ȱ80ȱExamplesȱofȱsocialȱfactorsȱincludeȱlocalȱ drugȱ useȱ practicesȱ andȱ peerȱ groupȱ norms.79ȱ Structuralȱ factorsȱ includeȱ economicȱ conditionsȱ (e.g.,ȱ employmentȱ opportunities),ȱ lawsȱ (e.g.,ȱ prohibitionȱ ofȱ drugs),ȱ socialȱ policiesȱ (e.g.,ȱ accessȱ toȱ lowȬthresholdȱ housing)ȱ andȱ localȱ policingȱ practices,ȱ whileȱ environmentalȱfactorsȱincludeȱfeaturesȱofȱtheȱbuiltȱenvironmentȱsuchȱasȱpublicȱinjectingȱ environments,ȱandȱneighbourhoodȬlevelȱconditionsȱsuchȱasȱdensityȱandȱdeprivation.70,ȱ80ȱȱ Rhodesȱarguesȱthatȱfocusingȱonȱtheȱinterplayȱofȱtheseȱfactorsȱandȱtheȱ‘‘riskȱenvironment’’ȱ thatȱ theyȱ formȱ isȱ aȱ betterȱ wayȱ toȱ conceptualizeȱ andȱ respondȱ toȱ theȱ healthȱ harmsȱ associatedȱwithȱdrugȱuse.79ȱȱ Unlikeȱconventionalȱapproachesȱinȱpublicȱhealthȱdominatedȱbyȱtheȱ‘‘healthȱbeliefȱ model’’,ȱtheȱ‘‘theoryȱofȱplannedȱbehaviour’’ȱandȱitsȱpredecessorȱ‘‘reasonedȱactionȱtheory’’,ȱ whichȱ locatedȱ responsibilityȱ forȱ healthȱ inȱ individualȱ actors,81,ȱ 82ȱ ȱ theȱ riskȱ environmentȱ approachȱgivesȱequalȱattentionȱtoȱcontextualȱfactorsȱthatȱshapeȱtheȱlivedȱexperiencesȱofȱ peopleȱ whoȱ useȱ drugs.70ȱ Fromȱ thisȱ perspective,ȱ responsibilityȱ forȱ riskȱ reductionȱ andȱ  ȱ  12  healthȱ promotionȱ restsȱ notȱ justȱ withȱ individuals,ȱ butȱ alsoȱ withȱ theȱ laws,ȱ policies,ȱ andȱ socialȱrelationsȱthatȱsurroundȱindividuals.ȱInȱturn,ȱtargetsȱforȱpolicyȱinterventionȱextendȱ intoȱ realmsȱ beyondȱ theȱ individualȱ toȱ includeȱ social,ȱ structuralȱ andȱ environmentalȱ factors.83,ȱ84ȱȱInȱtheȱcurrentȱproject,ȱdrugȬrelatedȱstreetȱdisorderȱisȱviewedȱthroughȱaȱriskȱ environmentȱ lensȱ whichȱ suggestsȱ thatȱ atȱ itsȱ coreȱ theȱ problemȱ ofȱ streetȱ disorderȱ isȱ notȱ solelyȱ aȱ matterȱ ofȱ individualsȱ choosingȱ toȱ engageȱ inȱ undesirableȱ behaviour;ȱ rather,ȱ streetȱdisorderȱisȱshapedȱbyȱenvironmental,ȱsocialȱandȱstructuralȱconditions.ȱȱ Anotherȱimportantȱconceptȱinformingȱthisȱworkȱisȱaȱmodifiedȱversionȱofȱ‘‘rationalȱ choiceȱtheory’’ȱpreviouslyȱdescribedȱbyȱRhodesȱandȱcolleaguesȱasȱ‘‘situatedȱrationality’’.72,ȱ ȱȱRationalȱchoiceȱtheoryȱpresumesȱthatȱindividualsȱareȱprimarilyȱselfȬinterestedȱutilityȱ  85  maximizersȱ thatȱ makeȱ decisionsȱ andȱ actȱ basedȱ onȱ assessmentsȱ ofȱ theȱ perceivedȱ costsȱ andȱbenefitsȱofȱavailableȱoptions.86,ȱ 87ȱȱAlthoughȱtheȱproposedȱresearchȱprojectȱisȱbasedȱ inȱ partȱ onȱ theseȱ assumptions,ȱ itȱ alsoȱ acknowledgesȱ thatȱ allȱ decisionsȱ andȱ actionsȱ areȱ influencedȱ byȱ social,ȱ structural,ȱ andȱ environmentalȱ conditions,ȱ andȱ thatȱ theseȱ factorsȱ areȱparticularlyȱrelevantȱinȱshapingȱtheȱperceptionsȱandȱexperiencesȱofȱpeopleȱwhoȱuseȱ illegalȱ drugs.ȱ Asȱ articulatedȱ byȱ Rhodes,ȱ thisȱ resultsȱ inȱ aȱ ‘‘situatedȱ rationality’’ȱ wherebyȱ theȱbasisȱofȱdecisionȱmakingȱremainsȱutilityȱmaximizing,ȱbutȱisȱsituationȱspecificȱwithinȱ theȱ contextȱ andȱ confinesȱ ofȱ social,ȱ structural,ȱ andȱ environmentalȱ pressures.ȱ Inȱ turn,ȱ individuals’’ȱperceptionsȱandȱassessmentsȱofȱtheȱcostsȱandȱbenefitsȱofȱavailableȱoptionsȱ areȱnotȱuniversalȱandȱareȱlikelyȱtoȱchangeȱoverȱtime.88ȱȱȱ  ȱ  13  Guidedȱ byȱ theȱ conceptȱ ofȱ ‘‘situatedȱ rationality’’,ȱ thisȱ researchȱ proposesȱ thatȱ despiteȱ theȱ individualȱ andȱ communityȱ harmsȱ associatedȱ withȱ it,ȱ engagingȱ inȱ drugȬ relatedȱstreetȱdisorderȱservesȱvariousȱ‘‘rational’’ȱpurposesȱinȱtheȱlivesȱofȱpeopleȱwhoȱuseȱ drugsȱ whenȱ social,ȱ structuralȱ andȱ environmentalȱ factorsȱ areȱ takenȱ intoȱ account.ȱ Fromȱ thisȱ perspective,ȱ theȱ typesȱ ofȱ interventionsȱ thatȱ areȱ likelyȱ toȱ beȱ successfulȱ inȱ gettingȱ individualsȱ toȱ reduceȱ engagementȱ inȱ streetȱ disorderȱ areȱ onesȱ thatȱ engageȱ streetȬ involvedȱ drugȱ usersȱ andȱ provideȱ alternativesȱ thatȱ fitȱ withȱ drugȱ users’’ȱ prioritiesȱ andȱ enableȱ themȱ toȱ reduceȱ behavioursȱ thatȱ generateȱ streetȱ disorder.ȱ Toȱ beȱ effective,ȱ theseȱ interventionsȱmustȱalsoȱsuccessfullyȱinfluenceȱdrugȱusers’’ȱperceptionsȱandȱassessmentsȱ ofȱ theȱ costsȱ andȱ benefitsȱ ofȱ availableȱ optionsȱ inȱ favourȱ ofȱ alternativesȱ thatȱ areȱ lessȱ harmfulȱtoȱtheȱindividualȱandȱtheȱbroaderȱcommunity.ȱThisȱframeworkȱisȱtheȱbasisȱforȱ theȱanalysesȱthatȱaddressȱobjectivesȱthree,ȱfourȱandȱfiveȱandȱFigureȱ1.3ȱoutlinesȱtheȱthreeȱ respectiveȱareasȱofȱintervention.ȱ  1.6 Summaryȱ ThisȱthesisȱconsistsȱofȱeightȱChapters.ȱChapterȱ1ȱprovidesȱaȱbackgroundȱtoȱdrugȬ relatedȱ streetȱ disorderȱ andȱ problemsȱ associatedȱ withȱ it.ȱ Itȱ alsoȱ presentsȱ theȱ studyȱ objectives,ȱ studyȱ design,ȱ andȱ theȱ conceptualȱ frameworkȱ ofȱ theȱ thesis.ȱ Chapterȱ 2ȱ providesȱ aȱ reviewȱ ofȱ theȱ scientificȱ literatureȱ onȱ drugȬrelatedȱ streetȱ disorder.ȱ Thisȱ includesȱ aȱ summaryȱ ofȱ measuresȱ usedȱ toȱ operationalizeȱ streetȱ disorder,ȱ asȱ wellȱ asȱ anȱ overviewȱofȱtheȱimpactsȱofȱpreviousȱpolicyȱapproachesȱthatȱhaveȱbeenȱimplementedȱtoȱ  ȱ  14  addressȱthisȱissue.ȱChapterȱ3ȱisȱtheȱfirstȱdataȱdrivenȱanalysisȱandȱitȱdescribesȱtheȱhealthȱ andȱsocialȱimpactsȱofȱexposureȱtoȱdrugȬrelatedȱstreetȱdisorder.ȱChaptersȱ5Ȭ7ȱexploreȱtheȱ potentialȱ impactsȱ ofȱ threeȱ policyȱ interventionsȱ toȱ reduceȱ drugȬrelatedȱ streetȱ disorder.ȱ Potentialȱinterventionsȱthatȱwillȱbeȱexploredȱrelateȱtoȱhousingȱstructuresȱ(theȱpotentialȱ impactȱ ofȱ providingȱ privateȱ spaceȱ onȱ timeȱ spentȱ socializingȱ inȱ anȱ openȱ drugȱ sceneȱ –– Chapterȱ 5),ȱ economicȱ opportunitiesȱ (theȱ potentialȱ impactȱ ofȱ providingȱ lowȬthresholdȱ employmentȱonȱengagementȱinȱdisorderlyȱincomeȱgenerationȱactivitiesȱ––Chapterȱ6)ȱandȱ drugȱ consumptionȱ facilitiesȱ (theȱ potentialȱ impactȱ ofȱ providingȱ supervisedȱ inhalationȱ roomsȱ onȱ publicȱcrackȱ cocaineȱsmokingȱ––Chapterȱ7).ȱ Toȱassessȱtheȱ potentialȱ impactȱofȱ theseȱthreeȱinterventions,ȱtheseȱanalysesȱrelyȱonȱmeasuresȱofȱparticipants’’ȱ‘‘willingness’’ȱ toȱ changeȱ theirȱ behaviourȱ basedȱ onȱ opportunitiesȱ relatedȱ toȱ accessȱ toȱ privateȱ space,ȱ employment,ȱ andȱ drugȱ consumptionȱ environments.ȱ Therefore,ȱ anȱ additionalȱ analyisȱ wasȱundertakenȱtoȱdetermineȱwhetherȱwillingnessȱmeasuresȱwereȱreasonableȱpredictorsȱ ofȱactualȱbehaviourȱ(Chapterȱ4).ȱȱȱ  ȱ  15  ȱFigureȱ1.1ȱTypesȱofȱdrugȬrelatedȱstreetȱdisorderȱ  Drug-Related Street Disorder Public Drug Use •• i.e. using drugs in public areas  Public Intoxication & Loitering •• i.e., socializing on the street while intoxicated  Income Generating Activities •• •• •• •• ••  Drug Dealing Sex Work Panhandling Squeegeeing Binning, Recycling, Street Vending  ȱ Figureȱ1.2ȱProblemsȱassociatedȱwithȱdrugȬrelatedȱstreetȱdisorderȱ Economic x Discourages retail activity & development x Erodes economic vitality x Undermines urban renewal efforts  Public Safety x x  Violence associated with drug markets Aggressive behaviour when under the influence of illicit drugs Discarded drug paraphernalia Disorder may encourage additional crime (broken windows theory)  x x  Public Health x x  Disorder linked with poor health outcomes at neighbourhood level Engagement in disorderly activities often poses risks to individuals (e.g. increased risk of overdose, infectious disease, soft tissue damage, violence…… etc.)  ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ  16  ȱȱȱFigureȱ1.3ȱSchematicȱofȱtheoreticalȱframeworkȱ ȱ  Problem: Drug-Related Street Disorder  ȱ Framework for Risk Environment and Situated Rationality Approach to Street Disorder  Framework for Conventional Responses to Street Disorder  ȱ  ȱ  Root of Problem  ȱ Individual Behaviour (e.g. personal choice, deviance, laziness)  ȱ  Approaches to Address Problem •• ••  Individual Behaviour & Social, Structural, & Environmental Conditions (e.g. poor access to housing; lack of employment opportunities; marginalization of drug users)  Coercion Deterrence based Objective: make disorder more costly and less attractive  •• ••  Engage to Enable Change Focus on changing the social, structural and environmental conditions that foster disorder Objective: enable positive change in behaviours by decreasing barriers and providing alternatives perceived as having greater benefit  Tools to Address the Problem  Policing •• Crackdowns •• Legislation against disorder •• Incarceration  Spatial Design •• Barriers and restrictions to accessing public space  Documented Outcomes  •• Displacement of disorder to surrounding areas •• Ineffective in reducing overall prevalence of disorder •• Discriminatory policing practices •• Exacerbates marginalization  Housing •• Increase access to private space  Expected Outcomes  Ļ Public Intoxication Ļ Loitering Ļ Outdoor Socializing  Low-threshold Employment •• Viable income generation opportunities Expected Outcomes  Ļ Drug dealing Ļ Sex-work Ļ Panhandling Ļ Squeegeeing Ļ Recycling, Binning, Vending  Inhalation Rooms •• Alternative drug consumption environments  Expected Outcomes  Ļ Public drug use  •• Reduce overall prevalence of disorder •• Protect the health of individuals and communities  ȱ  17  CHAPTER 2: ȱ DRUGȬRELATEDȱSTREETȱDISORDER:ȱAȱREVIEWȱOFȱ MEASURESȱANDȱPOLICYȱRESPONSES 1ȱ  2.1 Introductionȱ CitizensȱinȱurbanȱcentresȱthroughoutȱtheȱworldȱconsistentlyȱidentifyȱdrugȬrelatedȱ streetȱ disorderȱ asȱ aȱ primaryȱ concernȱ inȱ theirȱ community,25,ȱ 42,ȱ 89,ȱ 90ȱ ȱ andȱ inȱ someȱ areasȱ streetȱ disorderȱ isȱ rankedȱ asȱ aȱ greaterȱ concernȱ thanȱ homicide,ȱ sexualȱ assault,ȱ andȱ robbery.40,ȱ 50,ȱ 91ȱ ȱ Inȱ turn,ȱ governmentsȱ inȱ manyȱ urbanȱ environmentsȱ areȱ increasinglyȱ directingȱ theirȱ attentionȱtoȱ streetȱ disorderȱandȱareȱintroducingȱtargetedȱpublicȱ policiesȱ inȱattemptsȱtoȱeliminateȱorȱcontrolȱpublicȱdisorder,ȱparticularlyȱdisorderȱassociatedȱwithȱ illegalȱdrugȱmarketsȱandȱtheȱuseȱofȱillegalȱdrugs.ȱ MarkersȱofȱdrugȬrelatedȱstreetȱdisorderȱincludeȱpublicȱdrugȱuse,ȱstreetȬlevelȱdrugȱ trafficking,ȱ drugȬrelatedȱlitter,ȱ publicȱintoxicationȱandȱ loitering,ȱstreetȬbasedȱsexȱwork,ȱ panhandling,ȱ squeegeeȱ cleaning,ȱ andȱ engagingȱ inȱ ‘‘binning’’,ȱ recycling,ȱ salvagingȱ andȱ unsanctionedȱstreetȱvendingȱ(collectingȱbottlesȱandȱotherȱgoodsȱfromȱallies,ȱdumpstersȱ andȱotherȱpublicȱareasȱthatȱareȱreturnedȱforȱrefundȱorȱsoldȱonȱtheȱstreetȱforȱprofit).2Ȭ6,ȱ8Ȭ10,ȱ 25,ȱ 40,ȱ 53,ȱ 89Ȭ92  ȱ Althoughȱ streetȱ disorderȱ isȱ notȱ aȱ newȱ phenomenon,ȱ policyȬmakersȱ inȱ manyȱ  urbanȱareasȱhaveȱbeenȱunableȱtoȱsuccessfullyȱmanageȱtheseȱbehavioursȱandȱcontinueȱtoȱ  ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 1  ȱAȱversionȱofȱthisȱchapterȱhasȱbeenȱsubmittedȱforȱpublicationȱas:ȱDeBeck,ȱK.ȱMcArthur,ȱ D.ȱDrugȬrelatedȱstreetȱdisorder:ȱAȱreviewȱofȱpolicyȱresponses.ȱȱ 18 ȱ  struggleȱ toȱ determineȱ howȱ toȱ bestȱ respondȱ toȱ thisȱ persistentȱ policyȱ issue.ȱ Toȱ provideȱ evidenceȬbasedȱdirectionȱforȱpolicyȬmakers,ȱaȱreviewȱofȱliteratureȱonȱdrugȬrelatedȱstreetȱ disorderȱwasȱconducted.ȱStreetȱdisorderȱisȱaȱbroadȱtopicȱencompassingȱmanyȱactivitiesȱ andȱ areasȱ ofȱ research.ȱ Toȱ manageȱ theȱ breadthȱ ofȱ availableȱ literature,ȱ theȱ scopeȱ ofȱ thisȱ reviewȱconcentratesȱonȱmethodsȱofȱmeasuringȱstreetȱdisorderȱandȱtheȱimpactsȱofȱcurrentȱ interventionsȱintroducedȱtoȱaddressȱstreetȱdisorder.ȱTheȱobjectivesȱofȱthisȱreviewȱareȱto:ȱ 1)ȱ identifyȱ andȱ summarizeȱ methodsȱ thatȱ haveȱ beenȱ previouslyȱ employedȱ toȱ operationalizeȱandȱmeasureȱdrugȬrelatedȱstreetȱdisorder,ȱandȱ2)ȱprovideȱanȱoverviewȱofȱ evidenceȱ documentingȱ theȱimpactsȱofȱstrategiesȱthatȱ haveȱ beenȱimplementedȱinȱ urbanȱ settingsȱtoȱaddressȱdrugȬrelatedȱstreetȱdisorder.ȱȱȱȱ  2.2 ReviewȱMethodsȱ Publishedȱ studiesȱ forȱ thisȱ reviewȱ wereȱ identifiedȱ byȱ conductingȱ computerizedȱ searchesȱ ofȱ Medline,ȱ PubMed,ȱ Scienceȱ Citationȱ Indexȱ Expanded,ȱ Socialȱ Sciencesȱ Citationȱ Index,ȱ andȱ PAISȱ (Publicȱ Affairsȱ Informationȱ Services).ȱ Searchȱ termsȱ includedȱ ““publicȱ disorder””,ȱ ““publicȱ drugȱ use””,ȱ ““streetȬlevelȱ drugȱ dealing””,ȱ ““panhandling””,ȱ ““publicȱintoxication””,ȱ““streetȬlevelȱsexȬwork””ȱ““brokenȱwindows””,ȱ““orderȬmaintenance””,ȱ ““qualityȬofȬlifeȱ policing””,ȱ andȱ ““crimeȱ preventionȱ throughȱ environmentalȱ design””.ȱ Additionalȱmaterialsȱwereȱlocatedȱbyȱreviewingȱbibliographiesȱofȱrelevantȱpublications.ȱ Whileȱ theȱ reviewȱ focusedȱ onȱ peerȬreviewedȱ literature,ȱ someȱ considerationȱ wasȱ alsoȱ  ȱ  19  givenȱ toȱ pertinentȱ governmentȱ andȱ publicȱ agencyȱ reports.ȱ Theȱ searchȱ wasȱ limitedȱ toȱ Englishȱlanguageȱpublicationsȱandȱthereȱwereȱnoȱtimeȱperiodȱrestrictionsȱonȱmaterials.ȱȱ  2.3 ReviewȱFindings:ȱMeasuringȱDrugȬRelatedȱStreetȱDisorderȱ Studiesȱ ofȱ streetȱ disorderȱ haveȱ utilizedȱ aȱ numberȱ ofȱ approachesȱ toȱ measureȱ physicalȱ andȱ socialȱ markersȱ ofȱpublicȱdisorder.ȱSelectedȱfromȱtheȱbroaderȱliteratureȱofȱ publicȱdisorder,ȱthisȱsectionȱoutlinesȱmeasurementȱapproachesȱappropriateȱtoȱtheȱstudyȱ ofȱdrugȬrelatedȱstreetȱdisorder.ȱOneȱcommonȱapproachȱtoȱmeasureȱpublicȱdisorderȱisȱtoȱ useȱperceptionsȱofȱstreetȱdisorderȱreportedȱbyȱindividualsȱwhoȱresideȱinȱorȱareȱinȱsomeȱ wayȱ exposedȱ toȱ aȱ geographicallyȱ definedȱ areaȱ ofȱ interest.ȱ Surveys,ȱ qualitativeȱ interviewsȱ andȱ focusȱgroupsȱ withȱ residents,ȱ localȱ merchants,ȱ localȱ policeȱ andȱ relevantȱ cityȱworkersȱhaveȱallȱbeenȱusedȱinȱstudiesȱofȱpublicȱdisorderȱtoȱelicitȱperceptionsȱofȱtheȱ frequencyȱandȱprevalenceȱofȱstreetȱdisorder.2,ȱ53,ȱ68,ȱ92ȱOneȱbenefitȱofȱthisȱapproachȱisȱthatȱ dataȱ onȱ aȱ wideȱ rangeȱ ofȱ activitiesȱ relevantȱ toȱ drugȬrelatedȱ streetȱ disorderȱ canȱ beȱ collected;ȱ asȱ well,ȱ recruitingȱ aȱ sampleȱ ofȱ civiliansȱ isȱ highlyȱ feasibleȱ forȱ mostȱ investigators.ȱHowever,ȱevidenceȱsuggestsȱthatȱperceivedȱmeasuresȱofȱdisorderȱmayȱbeȱ influencedȱ byȱ fearȱ ofȱ crimeȱ andȱ previousȱ victimizationȱ experiencesȱ whichȱ willȱ biasȱ someȱmeasuresȱofȱperceptionsȱofȱdisorder.1,ȱ93ȱȱ OtherȱstudiesȱhaveȱdirectlyȱsurveyedȱandȱinterviewedȱlocalȱdrugȱusersȱorȱstreetȬ involvedȱ personsȱ asȱ aȱ meansȱ ofȱ collectingȱ selfȬreportedȱ levelsȱ ofȱ engagementȱ inȱ drugȬ relatedȱstreetȱdisorder.6,ȱ7,ȱ10,ȱ56ȱThisȱapproachȱisȱbeneficialȱasȱitȱcanȱcaptureȱaȱwideȱrangeȱ ȱ  20  ofȱ activitiesȱ relevantȱ toȱ drugȬrelatedȱ streetȱ disorderȱ andȱ willȱ captureȱ activitiesȱ notȱ directlyȱobservedȱbyȱothers.ȱHowever,ȱrecallȱissuesȱandȱsociallyȱdesirableȱreportingȱmayȱ weakenȱ theȱ reliabilityȱ ofȱ selfȬreportedȱ measuresȱ ofȱ engagementȱ inȱ drugȬrelatedȱ streetȱ disorder.94ȱ Asȱ well,ȱ obtainingȱ aȱ representativeȱ sampleȱ ofȱ streetȬinvolvedȱ drugȱ usersȱ requiresȱconsiderableȱresourcesȱandȱmayȱnotȱbeȱfeasibleȱinȱsomeȱsettings.ȱȱȱ Officialȱ dataȱ capturingȱ theȱ numberȱ ofȱ policingȱ responsesȱ toȱ orȱ arrestsȱ forȱ disorderlyȱ activitiesȱ canȱ alsoȱ beȱ usedȱ asȱ anȱ indicatorȱ ofȱ streetȱ disorder.53ȱ Aȱ benefitȱ ofȱ usingȱ officialȱ dataȱ isȱ thatȱ itȱ isȱ alreadyȱ collectedȱ andȱ generallyȱ readilyȱ available.ȱ However,ȱthereȱareȱaȱnumberȱofȱlimitationsȱ withȱthisȱapproach.ȱForȱone,ȱmanyȱactsȱofȱ disorderȱ doȱ notȱ getȱ reportedȱ toȱ police.ȱ Inȱ addition,ȱ officialȱ statisticsȱ areȱ directlyȱ influencedȱ byȱ theȱ levelȱ ofȱ policingȱ activity;ȱ hence,ȱ theyȱ mayȱ reflectȱ policingȱ effortsȱ orȱ focusȱmoreȱthanȱtheȱprevalenceȱorȱincidenceȱofȱdisorderlyȱactivities.ȱ49,ȱ95ȱFurthermore,ȱinȱ manyȱ jurisdictionsȱ policeȱ officers’’ȱ performancesȱ areȱ gaugedȱ byȱ arrestȱ statistics,ȱ whichȱ generatesȱaȱpotentialȱsourceȱofȱbias.96,ȱ97ȱȱ Streetȱdisorderȱhasȱalsoȱbeenȱmeasuredȱbyȱtheȱnumberȱofȱcivilianȱcomplaintȱcallsȱ madeȱtoȱemergencyȱservices,ȱtipȱlines,ȱandȱcityȱofficialsȱregardingȱdisorderlyȱactivities.2,ȱ 53,ȱ91  ȱComparedȱtoȱofficialȱstatisticsȱthisȱapproachȱisȱoftenȱconsideredȱaȱbetterȱindicatorȱofȱ  disorderȱasȱitȱisȱnotȱbiasȱbyȱtheȱlevelȱofȱpoliceȱactivity.91ȱHowever,ȱcomplainȱcallsȱonlyȱ captureȱ aȱ limitedȱ rangeȱ ofȱ disorderlyȱ activities,ȱ typicallyȱ onlyȱ veryȱ disruptiveȱ behaviours.ȱȱ  ȱ  21  Anotherȱrecognizedȱbutȱlabourȱintensiveȱapproachȱtoȱmeasuringȱstreetȱdisorderȱ isȱ throughȱ ‘‘Systematicȱ Socialȱ Observations’’ȱ (SSO).92,ȱ 98ȱ SSOȱ involvesȱ usingȱ multipleȱ independentȱ meansȱ toȱ systematicallyȱ recordȱ observations,ȱ whichȱ areȱ replicatedȱ overȱ time.1,ȱ 53ȱ Typically,ȱ SSOȱ involvesȱ drivingȱ throughȱ aȱ neighbourhoodȱ withȱ aȱ recordingȱ videoȱcameraȱasȱwellȱasȱtrainedȱobservers,ȱeachȱofȱwhomȱareȱrecordingȱtheȱnumberȱofȱ presentȱ indicatorsȱ ofȱ streetȱ disorderȱ onȱ eachȱ streetȱ block.ȱ Whileȱ theȱ trainedȱ observersȱ areȱ recordingȱ observationsȱ inȱ realȱ time,ȱ theȱ videoȱ providesȱ aȱ permanentȱ recordȱ thatȱ allowsȱ codingȱ andȱ measuresȱ toȱ beȱ replicatedȱ byȱ independentȱ observers.ȱ Forȱ drugȬ relatedȱstreetȱdisorderȱpotentialȱrelevantȱindicatorsȱincludeȱtheȱpresenceȱandȱfrequencyȱ of:ȱ injectionȱ relatedȱ debris;ȱ peopleȱ injectingȱ drugsȱ inȱ public;ȱ peopleȱ smokingȱ drugsȱ inȱ public;ȱ intoxicatedȱ individualsȱ loiteringȱ orȱ congregating;ȱ individualsȱ panhandlingȱ orȱ squeegeeȬcleaning;ȱ individualsȱ whoȱ appearȱ toȱ beȱ sellingȱ sex;ȱ andȱ individualsȱ goingȱ throughȱ streetȱ garbage,ȱ collectingȱ bottles,ȱ orȱ vending.53ȱ Anȱ importantȱ strengthȱ ofȱ thisȱ approachȱisȱthatȱtheȱvideoȱrecordingȱallowsȱforȱtheȱcodingȱofȱindicatorsȱofȱdisorderȱtoȱbeȱ replicatedȱ whichȱ canȱ detectȱ observerȱ biasȱ andȱ errorsȱ inȱ differentialȱ classificationȱ orȱ differentialȱ measurementȱ ofȱ objectsȱ andȱ events;ȱ thisȱ providesȱ greaterȱ reliabilityȱ ofȱ recordedȱobservations.92,ȱ 98ȱFurthermore,ȱtheȱSSOȱapproachȱcapturesȱmoreȱindicatorsȱofȱ disorderȱ thanȱ officialȱ statisticsȱ orȱ civilianȱ complaintȱ calls.ȱ Inȱ addition,ȱ SSOȱ isȱ notȱ vulnerableȱtoȱbiasesȱofȱperceivedȱmeasuresȱofȱdisorderȱasȱitȱcapturesȱdirectlyȱobservedȱ eventsȱofȱdisorder.97ȱ ȱThereȱare,ȱhowever,ȱlimitationsȱtoȱtheȱSSOȱapproach.ȱSpecifically,ȱ  ȱ  22  SSOȱ isȱ costlyȱ andȱ veryȱ labourȬintensive.99ȱ Inȱ addition,ȱ SSOȱ isȱ vulnerableȱ toȱ observerȱ effects.97,ȱ98ȱ Aȱ variationȱ onȱ SSOȱ isȱ basicȱ observationȱ ofȱ streetȱ disorderȱ inȱ whichȱ trainedȱ observersȱpassȱthroughȱanȱareaȱofȱinterestȱandȱcodeȱeventsȱandȱobservationsȱrelevantȱtoȱ streetȱdisorder.ȱTheȱdifference,ȱhowever,ȱisȱthatȱtheseȱobservationsȱareȱnotȱreplicatedȱorȱ verifiedȱ byȱ videoȱ orȱ anyȱ otherȱ permanentȱ recordȱ ofȱ events.ȱ Directȱ observationȱ isȱ lessȱ costlyȱ thanȱ SSOȱ andȱ canȱ captureȱ aȱ wideȱ rangeȱ ofȱ relevantȱ indicatorsȱ ofȱ drugȬrelatedȱ streetȱdisorder,ȱwhichȱisȱbeneficial.ȱHowever,ȱdirectȱobservation,ȱlikeȱSSO,ȱisȱvulnerableȱ toȱpotentialȱobserverȱeffects.ȱȱTheȱkeyȱcomponentsȱofȱeachȱmeasurementȱapproachȱandȱ studiesȱinȱwhichȱeachȱmethodȱhasȱbeenȱutilizedȱareȱsummarizedȱinȱTableȱ2.1.ȱȱȱȱ  ȱ  23  ȱ  Tableȱ2.1ȱSummaryȱofȱmeasuresȱappropriateȱforȱdrugȬrelatedȱstreetȱdisorderȱ Measurement  Description  Strengths  Limitations  Studies Skogan 199040 Zimmer 199068 Perkins et al. 199293 Perkins & Taylor 1996100 Ross et al. 200055 Sampson & Raudenbush 200453 x Salmon et al. 2007101 x Cusick & Kimber 200742  Perceived  x Surveys, qualitative interviews, and focus groups with residents, local merchants, police, city workers and others exposed to neighbourhood or area of interest x Questions relate to prevalence and frequency of indicators of interest  x Gathering data is highly feasible x Can capture wide range of activities relevant to drugrelated street disorder  x Perceptions of disorder can be influenced by fear and past experience of victimization, hence reports of disorder may be biased  x x x x x x  Self-Report  x Surveys of active drug users (or street-involved persons) to assess engagement in drugrelated street disorder  x Can capture activities not directly observed by others x Can capture wide range of activities relevant to drugrelated street disorder  x Resource intensive to recruit representative sample x Socially desirable reporting x Recall issues  x x x x x  Official Statistics  x Police responses and arrests for disorderly activities  x Data already compiled, often readily available  x Reflects police efforts x Potential tampering of statistics x Limited range of activities recorded  x Green 1995102 x Weisburd & Mazerolle 200091 x Sampson & Raudenbush 200453  Civilian Complaint Calls  x Complaint calls to 911, city officials & tip lines re: disorderly activities  x Not biased by police activity  x Limited range of activities recorded; only particularly disruptive behaviours  x Sherman & Weisburd 1995103 x Cohen et al. 200354 x Weisburd & Mazerolle 200091  Systematic Social Observation  x Multiple independent systematically recorded observations replicated over time x Involves filming and having trained observers record observations in log  x Can measure wide range of aspects of street disorder x Filming allows for replication & greater reliability x Captures observed rather than perceived measures  x Labour intensive and expensive x Potential for observer effects  x Reiss 197198 x Sampson & Raudenbush 19991 x Sampson & Raudenbush 200453  x Trained observers pass through area of interest and code events and observations relevant to street disorder  x Like SSO, avoids potential perception bias x Can capture wide range of activities relevant to drugrelated street disorder  x Potential for observer effects x Unlike SSO, reliability of measures and classification of observations are not easily verified  x x x x x x x  Direct Observation  Lee & Farrell 200356 Navarro & Leonard 20046 DeBeck et al. 20077 Shannon et al. 200760 DeBeck et al. 20093  Perkins 199293 Koper 199597 Sherman & Weisburd 1995103 Perkins & Taylor 1996100 Cohen et al. 200052 Caughy et al. 200199 Wood et al. 2004104 24  ȱ  ȱ  2.4 ReviewȱFindings:ȱRespondingȱtoȱDrugȬRelatedȱStreetȱDisorderȱ Aȱ reviewȱ ofȱ theȱ publishedȱ literatureȱ identifiedȱ aȱ rangeȱ ofȱ policyȱ responsesȱ implementedȱ toȱ addressȱ drugȬrelatedȱ streetȱ disorderȱ (seeȱ Tableȱ 2.2).ȱ Theseȱ responsesȱ primarilyȱ fitȱ intoȱ theȱ categoriesȱ ofȱ lawȱ enforcementȱ (policeȱ crackȬdownȱ campaigns,ȱ orderȬmaintenanceȱ policing,ȱ problemȬorientedȱ policing,ȱ hotȬspotȱ policingȱ andȱ increasingȱ policeȱ powersȱ throughȱ legislation)ȱ environmentalȱ design,ȱ andȱ engagingȱ interventionsȱ consistentȱ withȱ publicȱ healthȱ principlesȱ (supervisedȱ injectionȱ facilities,ȱ addictionȱ treatment,ȱ andȱ lowȬthresholdȱ employmentȱ programs).ȱ ȱ Asȱ outlinedȱ inȱ Tableȱ 2.2,ȱsomeȱresponsesȱtargetȱaȱbroadȱrangeȱofȱactivitiesȱthatȱgenerateȱstreetȱdisorderȱwhileȱ othersȱfocusȱonȱparticularȱbehavioursȱorȱcomponentsȱofȱdisorder.ȱAnȱoverviewȱofȱeachȱ responseȱ andȱ currentȱ evidenceȱ ofȱ itsȱ impactsȱ areȱ presentedȱ below.ȱ Evidenceȱ ofȱ theȱ impactsȱofȱeachȱresponseȱareȱalsoȱsummarizedȱinȱTableȱ2.3.ȱȱ  2.4.1 LawȱEnforcementȱApproachesȱtoȱAddressȱDrugȬRelatedȱStreetȱDisorderȱ 2.4.1.1 PoliceȱCrackȬDownȱCampaignsȱ Policeȱ crackȬdownȱ campaignsȱ areȱ aȱ widelyȱ employedȱ responseȱ toȱ drugȬrelatedȱ streetȱ disorder62Ȭ64ȱ andȱ canȱ beȱ describedȱ asȱ temporaryȱ dramaticȱ increasesȱ inȱ policeȱ presenceȱ toȱ increaseȱ theȱ threatȱ ofȱ apprehensionȱ andȱ punishmentȱ forȱ criminalȱ orȱ misdemeanourȱoffences.105ȱPoliceȱcrackȬdownsȱcanȱbeȱoffenseȬspecificȱsuchȱasȱtargetingȱ parkingȱviolationsȱorȱdrunkȱdriving.ȱAlternatively,ȱtheyȱcanȱbeȱgeographicallyȱfocusedȱ andȱinvolveȱtheȱstrictȱenforcementȱofȱallȱtypesȱofȱoffencesȱinȱoneȱparticularȱarea.ȱTacticsȱ usedȱ inȱ policeȱ crackȬdownsȱ ofȱ openȱ airȱ drugȱ marketsȱ includeȱ increasingȱ policeȱ patrolȱ ȱ  25  ȱ  andȱ surveillance,ȱ raidingȱ drugȱ dealingȱ locations,ȱ andȱ increasingȱ arrestsȱ forȱ observedȱ drugȱtransactions,ȱundercoverȱdrugȱbuys,ȱandȱunrelatedȱmisdemeanourȱviolations.63,ȱ105,ȱ 106  ȱȱ Studiesȱ evaluatingȱ theȱ impactȱ ofȱ policeȬcrackdownsȱ haveȱ foundȱ thatȱ theyȱ areȱ  generallyȱeffectiveȱinȱreducingȱdrugȱmarketȱactivityȱduringȱandȱoftenȱimmediatelyȱafterȱ crackȬdownȱ operations.63,ȱ 107ȱ However,ȱ visibleȱ reductionsȱ inȱ drugȱ marketȱ activityȱ areȱ usuallyȱ temporary,ȱ andȱ theȱ deterrentȱ effectȱ rarelyȱ lastsȱ afterȱ theȱ interventionȱ hasȱ ceased.62,ȱ 105,ȱ 108ȱStudiesȱexploringȱtheȱimpactȱofȱcrackȬdownȱcampaignsȱonȱtheȱpriceȱandȱ frequencyȱofȱdrugȱuseȱamongȱlocalȱdrugȱusersȱfoundȱnoȱdiscernableȱimpacts,ȱsuggestingȱ thatȱ theȱ impactsȱ ofȱ crackȬdownsȱ areȱ limitedȱ toȱ theȱ visibleȱ reductionȱ ofȱ drugȬrelatedȱ streetȱdisorder.69,ȱ109ȱDespiteȱtheȱmoderateȱbenefitsȱofȱpoliceȱcrackȬdownsȱonȱtheȱvisibilityȱ ofȱ drugȬrelatedȱ streetȱ disorder,ȱ theseȱ approachesȱ haveȱ beenȱ associatedȱ withȱ aȱ wideȱ rangeȱofȱseriousȱnegativeȱconsequences.ȱ Oneȱ ofȱ theȱ mostȱ wellȬdocumentedȱ unintendedȱ consequencesȱ ofȱ policeȱ crackȬ downȱcampaignsȱisȱdisplacement.69,ȱ 110ȱResearchȱtoȱdateȱsuggestsȱthatȱtypicallyȱpolicingȱ effortsȱdoȱnotȱdecreaseȱtheȱoverallȱprevalenceȱofȱdisorderlyȱactivity,ȱbutȱinsteadȱdisplaceȱ itȱtoȱsurroundingȱareas.48,ȱ62,ȱ64,ȱ67Ȭ69,ȱ107,ȱ108ȱȱThisȱcanȱhaveȱaȱnumberȱofȱnegativeȱimplicationsȱ forȱ theȱ individualsȱ engagingȱ inȱ disorderlyȱ activity,ȱ asȱ wellȱ asȱ forȱ theȱ surroundingȱ communitiesȱwhereȱtheȱactivityȱrelocates.62,ȱ 111,ȱ 112ȱInȱparticular,ȱdisplacementȱinterruptsȱ andȱ discouragesȱ contactȱ betweenȱ marginalizedȱ drugȱ usersȱ andȱ healthȱ services107ȱ andȱ  ȱ  26  ȱ  mayȱincreaseȱtheȱriskȱofȱfatalȱdrugȱoverdoseȱasȱinjectionȱdrugȱusersȱhaveȱbeenȱfoundȱtoȱ relocateȱtoȱmoreȱisolatedȱlocationsȱduringȱperiodsȱofȱpoliceȱcrackȬdowns.113,ȱ114ȱ Byȱdisruptingȱdrugȱmarkets,ȱpoliceȱcrackȬdownsȱhaveȱalsoȱbeenȱassociatedȱwithȱ increasingȱ levelsȱ ofȱ violenceȱ inȱ surroundingȱ area.62,ȱ 108,ȱ 115ȱ Furthermore,ȱ highȱ levelsȱ ofȱ policeȱmisconductȱhaveȱbeenȱdocumentedȱduringȱperiodsȱofȱcrackȬdowns,ȱspecifically,ȱ unnecessaryȱ useȱ ofȱ forceȱ andȱ illegalȱ searches.116ȱ Otherȱconcerningȱ findingsȱ includeȱ theȱ impactȱ ofȱ crackȬdownsȱ onȱ injectingȱ practicesȱ amongȱ injectionȱ drugȱ users.ȱ Itȱ hasȱ beenȱ reportedȱ thatȱ crackȬdownsȱ reduceȱ injectionȱ drugȱ users’’ȱ accessȱ toȱ HIVȱ preventionȱ suppliesȱ (condoms,ȱ syringes),106,ȱ 107ȱ andȱ fearȱ ofȱ policeȱ searchesȱ makeȱ drugȱ injectorsȱ reluctanceȱtoȱcarryȱcleanȱsyringes.63,ȱ64,ȱ107,ȱ116ȱReducedȱaccessȱtoȱandȱfearȱofȱcarryingȱHIVȱ preventionȱ suppliesȱ increasesȱ theȱ chancesȱ ofȱ engagingȱ inȱ unprotectedȱ sexȱ andȱ usedȱ syringeȱ sharingȱ whichȱ areȱ theȱ leadingȱ routesȱ ofȱ transmissionȱ forȱ HIVȱ andȱ otherȱ infectiousȱ diseases.117,ȱ 118ȱ ȱ Inȱ responseȱ toȱ increasedȱ policeȱ surveillanceȱ ofȱ openȱ drugȱ scenesȱ duringȱ crackȬdowns,ȱ IDUȱ alsoȱ reportȱ beingȱ moreȱ likelyȱ toȱ rushȱ theirȱ injectionsȱ whichȱoftenȱresultsȱinȱskippingȱimportantȱoverdoseȱandȱHIVȱpreventionȱstepsȱasȱwellȱasȱ otherȱsafetyȱmeasures.62,ȱ63,ȱ106,ȱ107ȱTheȱpressureȱtoȱrushȱinjectionsȱdueȱtoȱfearȱofȱpoliceȱhasȱ alsoȱbeenȱfoundȱtoȱdiscourageȱsafeȱneedleȱandȱsyringeȱdisposalȱasȱinjectorsȱreportȱbeingȱ reluctantȱtoȱcarryȱtheirȱusedȱsyringesȱtoȱsafeȱdepositȱlocations.62,ȱ64,ȱ107ȱInȱsomeȱsettingsȱtoȱ preventȱ beingȱ arrestedȱ byȱ policeȱ duringȱ crackȬdowns,ȱ drugȱ usersȱ haveȱ beenȱ foundȱ toȱ storeȱ drugsȱ inȱ theirȱ mouthȱ orȱ nasalȱ cavitiesȱ andȱ willȱ swallowȱ drugsȱ whenȱ theyȱ areȱ  ȱ  27  ȱ  stoppedȱ byȱ policeȱ toȱ avoidȱ havingȱ drugsȱ discovered.64ȱ Theseȱ behavioursȱ poseȱ risksȱ ofȱ spreadingȱinfectionsȱasȱwellȱasȱaccidentalȱoverdose.ȱ Otherȱ concerningȱ outcomesȱ associatedȱ withȱ policeȱ crackȬdownsȱ includeȱ increasingȱ stigmaȱ andȱ marginalizationȱ ofȱ peopleȱ whoȱ useȱ drugs,ȱ whichȱ isȱ associatedȱ withȱincreasingȱHIVȱriskȱandȱunderminingȱimportantȱpublicȱhealthȱobjectives,ȱasȱwellȱasȱ increasingȱ ratesȱ ofȱ arrestȱ andȱ incarcerationȱ amongȱ peopleȱ whoȱ useȱ drugs.106ȱ Althoughȱ arrestingȱ andȱ incarceratingȱ largerȱ numbersȱ ofȱ individualsȱ mayȱ provideȱ shortȬtermȱ benefitsȱbyȱlimitingȱtheirȱopportunityȱtoȱengageȱinȱdisorderlyȱbehaviour,ȱincarcerationȱ isȱ associatedȱ withȱ manyȱ negativeȱ individualȱ andȱ communityȱ consequences.ȱ Theseȱ includeȱdisruptingȱfamilyȱstructures,ȱincreasingȱalienationȱandȱstigma,ȱincreasingȱrisksȱ ofȱ HIVȱ infectionȱ andȱ otherȱ healthȱ harmsȱ includingȱ fatalȱ drugȱ overdose,ȱ andȱ creatingȱ barriersȱ toȱ labourȱ marketȱ participation,ȱ allȱ ofȱ whichȱ damageȱ communityȱ tiesȱ andȱ mayȱ actuallyȱperpetuateȱfurtherȱdisorderlyȱandȱcriminalȱbehaviour.119Ȭ1252,ȱ124,ȱ125ȱ Inȱ summary,ȱ currentȱ evidenceȱ suggestsȱ thatȱ policeȱ crackȬdownȱ campaignsȱ canȱ reduceȱ theȱ visibilityȱ ofȱ streetȱ disorderȱ butȱ thoseȱ benefitsȱ areȱ associatedȱ withȱ manyȱ seriousȱnegativeȱunintendedȱconsequences.ȱ 2.4.1.2 OrderȬMaintenanceȱPolicingȱBasedȱonȱtheȱBrokenȱWindowsȱTheoryȱ Anotherȱ lawȱ enforcementȱ approachȱ thatȱ isȱ relevantȱ toȱ streetȱ disorderȱ isȱ ‘‘orderȬ maintenanceȱ policing’’.ȱ Thisȱ approachȱ isȱ rootedȱ inȱ theȱ ‘‘brokenȱ windowsȱ theory’’ȱ andȱ focusesȱ onȱ theȱ aggressiveȱ enforcementȱ ofȱ misdemeanourȱ violationsȱ asȱ aȱ meansȱ ofȱ maintainingȱorderȱinȱpublicȱareas.50ȱTheȱcentralȱpremiseȱofȱtheȱbrokenȱwindowsȱtheoryȱ ȱ  28  ȱ  isȱ thatȱ streetȱ disorder,ȱ includingȱ panhandling,ȱ publicȱ drugȱ dealing,ȱ litter,ȱ andȱ graffiti,ȱ makesȱ neighbourhoodsȱ susceptibleȱ toȱ moreȱ seriousȱ crime.ȱ Theȱ proposedȱ mechanismsȱ byȱ whichȱ theseȱ formsȱ ofȱ disorderȱ wouldȱ breedȱ seriousȱ crimeȱ areȱ multifaceted.ȱ Specifically,ȱitȱisȱsuggestedȱthatȱpublicȱdisorderȱsendsȱsignalsȱtoȱpotentialȱcriminalsȱthatȱ residentsȱ inȱ ‘‘disorderly’’ȱ neighbourhoodsȱ areȱ apatheticȱ andȱ unlikelyȱ toȱ beȱ vigilantȱ ofȱ suspiciousȱ activityȱ inȱ theirȱ community.ȱ Thisȱ isȱ saidȱ toȱ makeȱ theseȱ neighbourhoodsȱ appealingȱ targetsȱ forȱ moreȱ seriousȱ crime.ȱ Additionally,ȱ itȱ isȱ suggestedȱ thatȱ publicȱ disorderȱ detersȱ nonȬcriminallyȬinvolvedȱ citizensȱ fromȱ occupyingȱ publicȱ spaces,ȱ whichȱ inȱ turnȱ leadsȱ toȱ unmonitoredȱ environmentsȱ thatȱ furtherȱ encourageȱ potentialȱ criminalsȱ toȱ offend.50ȱ Theȱ brokenȱ windowsȱ theoryȱ suggestsȱ thatȱ toȱ reduceȱ seriousȱ crimeȱ andȱ protectȱpublicȱsafetyȱitȱisȱcriticalȱforȱpoliceȱofficersȱtoȱfocusȱtheirȱeffortsȱonȱmaintainingȱ strictȱorderȱinȱpublicȱareasȱandȱaggressivelyȱenforceȱallȱmisdemeanourȱviolations.ȱThisȱ typeȱ ofȱ orderȬmaintenanceȱ policingȱ basedȱ onȱ theȱ brokenȱ windowȱ theoryȱ hasȱ gainedȱ tractionȱinȱmanyȱpolicyȱcirclesȱandȱitsȱemphasisȱonȱpoliceȱtargetingȱandȱpunishingȱactsȱ ofȱ disorderȱ hasȱ beenȱ incorporatedȱ intoȱ theȱ policingȱ cultureȱ ofȱ manyȱ urbanȱ areas.126ȱ Althoughȱ theȱ chiefȱ objectiveȱ ofȱ orderȬmaintenanceȱ policingȱ isȱ toȱ deterȱ moreȱ seriousȱ formsȱofȱcrime,ȱitsȱtargetȱisȱstreetȱdisorder.ȱTherefore,ȱaȱpresentationȱofȱresearchȱrelatedȱ toȱ theȱ impactsȱ ofȱ orderȬmaintenanceȱ policingȱ isȱ relevantȱ toȱ thisȱ reviewȱ ofȱ policyȱ responsesȱtoȱstreetȱdisorder.ȱȱȱ TheȱmostȱwidelyȱcitedȱexampleȱofȱorderȬmaintenanceȱpolicingȱhasȱbeenȱinȱNewȱ YorkȱCityȱ(NYC)ȱinȱtheȱearlyȱ1990sȱunderȱMayorȱRudolphȱGiuliani.49,ȱ68,ȱ92ȱFollowingȱtheȱ ȱ  29  ȱ  implementationȱ ofȱ NYC’’sȱ orderȬmaintenanceȱ policingȱ initiative,ȱ misdemeanourȱ arrestȱ ratesȱ inȱ theȱ cityȱ increasedȱ significantly,49,ȱ 127ȱ andȱ throughoutȱ theȱ 1990sȱ theȱ physicalȱ appearanceȱ ofȱ disorderȱ onȱ theȱ streetsȱ decreasedȱ dramaticallyȱ andȱ theȱ rateȱ ofȱ seriousȱ crime,ȱ includingȱ homicides,ȱ declined.49,ȱ  128  ȱ Asȱ aȱ result,ȱ NYC’’sȱ orderȬmaintenanceȱ  policingȱinitiativeȱisȱoftenȱcitedȱasȱanȱexampleȱofȱtheȱeffectivenessȱofȱorderȬmaintenanceȱ policingȱ andȱ theȱ brokenȱ windowsȱ theoryȱ andȱ hasȱ beenȱ usedȱ toȱ legitimizeȱ theȱ employmentȱ ofȱ thisȱ approachȱ towardsȱ streetȱ disorderȱ inȱ jurisdictionsȱ asȱ farȱ awayȱ asȱ GreatȱBritain.48,ȱ49ȱ Theȱ apparentȱ successȱ ofȱ Newȱ York’’sȱ policingȱ initiativeȱ has,ȱ however,ȱ beenȱ widelyȱcontestedȱandȱmanyȱcompetingȱexplanationsȱhaveȱbeenȱputȱforwardȱtoȱaccountȱ forȱtheȱdramaticȱreductionȱinȱcriminalȱactivityȱinȱNYC.49,ȱ124,ȱ128ȱȱTheseȱincludeȱchangesȱinȱ patternsȱ ofȱ crackȱ cocaineȱ useȱ andȱ distributionȱ andȱ changesȱ inȱ theȱ Americanȱ economyȱ andȱ labourȱ markets.ȱ 48,ȱ 49,ȱ 128ȱ ȱ Furthermore,ȱ theȱ declineȱ inȱ ratesȱ ofȱ homicideȱ andȱ otherȱ seriousȱcrimeȱwasȱnotȱexclusiveȱtoȱNYC,ȱnorȱdidȱitȱbeginȱafterȱNYC’’sȱorderȬmaintenanceȱ policingȱinitiativeȱwasȱimplemented.ȱIndeed,ȱnationalȱhomicidesȱratesȱbeganȱtoȱdeclineȱ inȱ1991ȱ(twoȱyearsȱbeforeȱNYC’’sȱinitiativeȱwasȱintroduced),48,ȱ92ȱandȱotherȱcitiesȱthatȱdidȱ notȱ implementȱ newȱ policingȱ practicesȱ experiencedȱ similar,ȱ andȱ atȱ timesȱ evenȱ moreȱ dramatic,ȱdeclinesȱthanȱthoseȱobservedȱinȱNYC.48,ȱ 92,ȱ 127ȱ ȱInȱaddition,ȱaggressiveȱpolicingȱ initiativesȱthatȱhaveȱbeenȱimplementedȱinȱpreviousȱtimeȱperiodsȱhaveȱactuallyȱcoincidedȱ withȱincreasesȱinȱhomicideȱrates.48ȱTheseȱobservationsȱsuggestȱthatȱaggressiveȱpolicingȱ  ȱ  30  ȱ  ofȱstreetȱdisorderȱisȱneitherȱaȱnecessaryȱnorȱaȱsufficientȱelementȱtoȱreduceȱhomicideȱandȱ otherȱseriousȱcrime.ȱȱ Theseȱ factorsȱ highlightȱ thatȱ thereȱ areȱ multipleȱ potentialȱ explanationsȱ forȱ theȱ reductionȱ inȱ crimeȱ observedȱ inȱ NYC.ȱ Whenȱ takenȱ togetherȱ itȱ suggestsȱ thatȱ theȱ linksȱ betweenȱNewȱYork’’sȱorderȬmaintenanceȱpolicingȱinitiativeȱandȱsupportȱforȱtheȱbrokenȱ windowsȱ theoryȱ areȱ unconvincing.ȱ Indeed,ȱ toȱ dateȱ thereȱ isȱ noȱ reliableȱ scientificȱ evidenceȱinȱ theȱpeerȬreviewȱliteratureȱtoȱ validateȱtheȱ accuracyȱofȱtheȱbrokenȱ windowsȱ theory.ȱAlthoughȱaȱnumberȱofȱlargeȱscaleȱstudiesȱreportȱaȱtenuousȱrelationshipȱbetweenȱ markersȱ ofȱ publicȱ disorderȱ andȱ robbery,ȱ afterȱ adjustingȱ forȱ importantȱ neighbourhoodȱ characteristicsȱsuchȱasȱ povertyȱandȱ race,ȱtheseȱstudiesȱfoundȱnoȱ significantȱ connectionȱ betweenȱ streetȱ disorderȱ andȱ allȱ otherȱ markersȱ ofȱ seriousȱ crime,ȱ includingȱ homicide,ȱ burglary,ȱphysicalȱassault,ȱsexualȱassault,ȱandȱpurseȬsnatching/pickȬpocketing.1,ȱ40,ȱ92,ȱ129ȱ Studiesȱ specificȱ toȱ NYCȱ undertakenȱ byȱ Kellingȱ andȱ Sousaȱ (2001)ȱ andȱ Cormanȱ andȱ Mocanȱ (2005)ȱ reportedȱ significantȱ inverseȱ relationshipsȱ betweenȱ misdemeanourȱ arrestsȱandȱratesȱofȱviolentȱcrime.130,ȱ131ȱȱHowever,ȱaȱlaterȱstudyȱbyȱHarcourtȱandȱLudwigȱ (2006)ȱthatȱusedȱimprovedȱmeasuresȱforȱkeyȱindicatorsȱandȱattemptedȱtoȱaddressȱotherȱ weaknessesȱinȱtheȱKellingȱandȱCormanȱstudiesȱwasȱunableȱtoȱreplicateȱtheseȱfindings.132ȱ AȱmoreȱrecentȱstudyȱbyȱMessnerȱandȱcolleaguesȱ(2007)ȱanalysedȱmisdemeanourȱarrestsȱ andȱ homicideȱ ratesȱ disaggregatedȱ intoȱ gunȬrelatedȱ andȱ nonȬgunȬrelatedȱ homicidesȱ inȱ NewȱYorkȱCity.49ȱTheyȱfoundȱthatȱwhileȱmisdemeanourȱarrestsȱwereȱinverselyȱrelatedȱtoȱ  ȱ  31  ȱ  gunȬrelatedȱ homicides,ȱ thereȱ wasȱ noȱ relationshipȱ betweenȱ misdemeanourȱ arrestsȱ andȱ nonȬgunȬrelatedȱ homicidesȱ inȱ Newȱ Yorkȱ City.ȱ Theȱ failureȱ toȱ detectȱ aȱ relationshipȱ betweenȱmisdemeanourȱarrestsȱandȱbothȱtypesȱofȱhomicidesȱindicatesȱthatȱNewȱYork’’sȱ ‘‘qualityȬofȬlife’’ȱinitiativeȱdoesȱnotȱlendȱsupportȱtoȱtheȱbrokenȱwindowsȱtheory.ȱȱ Althoughȱ theȱ evidenceȬbaseȱ toȱ supportȱ theȱ crimeȱ reductionȱ benefitsȱ ofȱ orderȬ maintenanceȱ policingȱ isȱ unconvincing,ȱ similarȱ toȱ policeȱ crackȬdownȱ campaigns,ȱ itsȱ impactȱonȱreducingȱtheȱvisibleȱsignsȱofȱdisorderȱappearȱtoȱbeȱsuccessful.49,ȱ 124ȱHowever,ȱ alsoȱ similarȱ toȱ policeȱ crackȬdownȱ campaigns,ȱ orderȬmaintenanceȱ policingȱ hasȱ beenȱ associatedȱ withȱ aȱ numberȱ ofȱ unintendedȱ negativeȱ impacts.ȱ Theseȱ includeȱ displacement,48,ȱ 67,ȱ 68ȱasȱwellȱasȱracialȱprofilingȱandȱprejudicialȱenforcementȱofȱlaws.ȱForȱ instance,ȱ oneȱ studyȱ analysingȱ theȱ applicationȱ ofȱ Newȱ York’’sȱ orderȬmaintenanceȱ initiativeȱfoundȱthatȱinsteadȱofȱallocatingȱpolicingȱeffortsȱbasedȱonȱtheȱlevelȱofȱphysicalȱ disorderȱ presentȱ inȱ aȱ neighbourhood,ȱ policingȱ attentionȱ wasȱ concentratedȱ inȱ neighbourhoodsȱ withȱ largeȱ ethnicȱ minorityȱ populations.ȱ Asȱ aȱ result,ȱ thisȱ orderȬ maintenanceȱpolicingȱinitiativeȱexposedȱneighbourhoodsȱcharacterizedȱbyȱpovertyȱandȱ socialȱ disadvantageȱ toȱ theȱ highestȱ levelsȱ ofȱ policing.127ȱ Givenȱ theseȱ findingsȱ itȱ isȱ notȱ surprisingȱ thatȱ orderȬmaintenanceȱ policingȱ initiativesȱ haveȱ alsoȱ beenȱ foundȱ toȱ leadȱ toȱ theȱ disproportionateȱ incarcerationȱ ofȱ minorityȱ groups.133ȱ Asȱ previouslyȱ noted,ȱ incarcerationȱisȱassociatedȱwithȱmanyȱharmsȱincludingȱincreasedȱstigmaȱandȱheightenedȱ risksȱforȱHIVȱinfectionȱandȱotherȱnegativeȱhealthȱoutcomes.119Ȭ125ȱȱ  ȱ  32  ȱ  OrderȬmaintenanceȱ policingȱ hasȱ alsoȱ beenȱ linkedȱ withȱ policeȱ misconductȱ includingȱcorruption,ȱexcessiveȱuseȱofȱforceȱandȱhumanȱrightsȱabuses.40,ȱ48,ȱ49,ȱ49,ȱ116,ȱ124ȱTheȱ numberȱ ofȱ civilȱ rightsȱ claimsȱ filedȱ againstȱ Newȱ Yorkȱ policeȱ forȱ abusiveȱ conductȱ wasȱ reportedȱtoȱhaveȱincreasedȱbyȱ75%ȱinȱtheȱyearsȱfollowingȱtheȱintroductionȱofȱtheȱcity’’sȱ orderȬmaintenanceȱ initiative.ȱ Inȱ addition,ȱ civilianȱ complaintsȱ filedȱ withȱ theȱ Civilianȱ ComplaintȱReviewȱBoardȱ increasedȱbyȱ60%ȱduringȱthisȱperiod.124ȱItȱisȱ noteworthyȱthatȱ alsoȱ duringȱ thisȱ timeȱ Sanȱ Diego,ȱ whichȱ didȱ notȱ implementȱ aggressiveȱ orderȬ maintenanceȱ policing,ȱ experiencedȱ aȱ reductionȱ inȱ complaintsȱ filedȱ againstȱ itsȱ policeȱ force,ȱevenȱthoughȱtheȱcityȱalsoȱenjoyedȱreductionsȱinȱitsȱcrimeȱratesȱcomparableȱtoȱNewȱ Yorkȱ City.124ȱ ȱ Surgesȱ inȱ policeȱ misconductȱ complaintsȱ haveȱ beenȱ foundȱ toȱ undermineȱ trustȱandȱgoodȱrelationsȱwithȱcitizensȱandȱmayȱcreateȱhostilityȱinȱaȱcommunity.48,ȱ134ȱ AȱreviewȱofȱevidenceȱindicatesȱthatȱorderȬmaintenanceȱpolicingȱandȱpoliceȱcrackȬ downȱ campaignsȱ shareȱ manyȱ ofȱ theȱ sameȱ unintendedȱ negativeȱ impactsȱ whileȱ producingȱlimitedȱbenefitsȱthatȱdoȱnotȱtranslateȱintoȱtheȱlongȬtermȱsustainableȱreductionȱ ofȱstreetȱdisorder,ȱorȱotherȱindicatorsȱofȱcrime.ȱ 2.4.1.3 ProblemȱOrientedȱPolicingȱ ProblemȬorientedȱ policingȱ canȱ beȱ describedȱ asȱ aȱ collaborative,ȱ communityȱ orientedȱ approachȱ toȱ policingȱ whereȱ theȱ roleȱ ofȱ policeȱ includesȱ engagingȱ withȱ theȱ communitiesȱ theyȱ workȱ inȱ toȱ considerȱ theȱ rootȱ causesȱ ofȱ crimeȱ andȱ disorderȱ andȱ identifyȱ potentialȱ solutionsȱ whichȱ areȱ thenȱ implementedȱ andȱ evaluated.49,ȱ 135ȱ Withȱ thisȱ approachȱ theȱ primaryȱ emphasisȱ forȱ policeȱ officersȱ isȱ toȱ workȱ toȱ preventȱ crimeȱ andȱ ȱ  33  ȱ  addressȱ neighbourhoodȱ crimeȱ issues.92ȱ ȱ Althoughȱ studiesȱ evaluatingȱ theȱ impactsȱ ofȱ problemȬorientedȱ policingȱ reportȱ areȱ limited,136,ȱ 137ȱ someȱ positiveȱ effectsȱ onȱ reducingȱ streetȱ disorderȱ haveȱ beenȱ documented,138ȱ andȱ aȱ recentȱ metaȬanalysisȱ ofȱ problemȬ orientedȱ policingȱ interventionsȱ foundȱ theyȱ hadȱ aȱ significant,ȱ althoughȱ marginal,ȱ effectȱ onȱstreetȱdisorder.139ȱDespiteȱtheseȱpositiveȱfindings,ȱreviewȱauthorsȱacknowledgeȱthatȱ theȱevidenceȬbaseȱtoȱsupportȱproblemȬorientedȱpolicingȱisȱweakȱandȱconcludeȱthatȱthereȱ isȱ insufficientȱ evidenceȱ toȱ supportȱ theȱ levelȱ ofȱ endorsementȱ governmentsȱ andȱ policeȱ agenciesȱ haveȱ beenȱ directingȱ towardsȱ problemȬorientedȱ policing.139ȱ Noȱ studiesȱ wereȱ identifiedȱ thatȱ documentȱ negativeȱ consequencesȱ associatedȱ withȱ problemȬorientedȱ policing.ȱȱ 2.4.1.4 HotȬSpotȱPolicingȱ Oneȱ variationȱ ofȱ theseȱ aforementionedȱ lawȱ enforcementȱ basedȱ approachesȱ isȱ ‘‘hotȬspot’’ȱ policingȱ whichȱ involvesȱ concentratingȱ policingȱ effortsȱ inȱ areasȱ withȱ highȱ levelsȱ ofȱ drugȱ marketȱ activityȱ andȱ disorder.91,ȱ 97ȱ ȱ Policingȱ tacticsȱ withinȱ theȱ ‘‘hotȬspot’’ȱ approachȱvaryȱwidelyȱandȱincludeȱpoliceȱcrackȬdownsȱandȱraids,95,ȱ140ȱproblemȬorientedȱ policing,141ȱ andȱ increasedȱ patrolȱ andȱ surveillance.97,ȱ 142ȱ Aȱ numberȱ ofȱ studiesȱ evaluatingȱ theȱ impactsȱ ofȱ variousȱ typesȱ ofȱ ‘‘hotȬspot’’ȱ policingȱ reportȱ measurableȱ shortȬtermȱ reductionsȱ inȱ markersȱ ofȱ streetȱ disorder,97,ȱ 138,ȱ 142ȱ includingȱ disorderȬrelatedȱ emergencyȱ callsȱ forȱ services,140ȱ andȱ drugȱ dealingȱ inȱ theȱ area.95ȱ Consistentȱ withȱ studiesȱ ofȱ specificȱ policingȱ approaches,ȱ thereȱ wasȱ littleȱ evidenceȱ toȱ suggestȱ thatȱ theseȱ effectsȱ wereȱ sustainedȱlongȬterm.ȱAlthoughȱoneȱstudyȱhadȱaȱpostȱinterventionȱassessmentȱperiodȱofȱ ȱ  34  ȱ  sevenȱ monthsȱ andȱ foundȱ sustainedȱ effectȱ atȱ thisȱ time,ȱ otherȱ studiesȱ notedȱ thatȱ initialȱ reductionsȱ inȱ streetȱ disorderȱ largelyȱ disappearedȱ onceȱ theȱ targetedȱ enforcementȱ campaignȱ ceased.95ȱ Twoȱ studiesȱ wereȱ identifiedȱ thatȱ consideredȱ whetherȱ policingȱ interventionsȱ inȱ twoȱ particularȱ instancesȱ wereȱ accompaniedȱ withȱ displacementȱ ofȱ disorderȱandȱfoundȱnoȱevidenceȱofȱsignificantȱdisplacement.138,ȱ140ȱNoȱotherȱstudiesȱwereȱ identifiedȱ thatȱ consideredȱ unintendedȱ negativeȱ consequencesȱ specificȱ toȱ hotȬspotȱ policing;ȱ however,ȱ theȱ unintendedȱ consequencesȱ associatedȱ withȱ theȱ previouslyȱ describedȱ lawȱ enforcementȱ approachesȱ (i.e.,ȱ policeȱ crackȬdownȱ campaigns,ȱ orderȬ maintenanceȱ policing)ȱ wouldȱ stillȱ beȱ relevantȱ toȱ theȱ hotȬspotȱ interventionsȱ thatȱ employedȱtheseȱapproaches.ȱȱ 2.4.1.5 IncreasingȱPoliceȱPowersȱThroughȱLegislationȱ Increasingȱpoliceȱpowersȱthroughȱlegislationȱspecificallyȱdesignedȱtoȱprovideȱlawȱ enforcementȱ officersȱ withȱ additionalȱ powersȱ toȱ regulateȱ activitiesȱ inȱ publicȱ spacesȱ isȱ anotherȱ lawȱ enforcementȱ basedȱ approachȱ thatȱ hasȱ beenȱ usedȱ toȱ addressȱ streetȱ disorder.43,ȱ143,ȱ144ȱAlthoughȱthisȱenforcementȱtacticȱcanȱbeȱimplementedȱtoȱsupportȱpoliceȱ crackȬdownsȱ orȱ orderȬmaintenanceȱ approaches,ȱ itȱ canȱ alsoȱ beȱ implementedȱ independently.ȱCommonȱelementsȱofȱlegislativeȱinitiatives,ȱsuchȱasȱtheȱ‘‘SafeȱStreetsȱAct’’ȱ inȱ Ontarioȱ andȱ Britishȱ Columbia,ȱ Canada,ȱ includingȱ placingȱ restrictionsȱ onȱ theȱ time,ȱ mannerȱandȱlocationȱthatȱpanhandlingȱmayȱoccur.8ȱTheseȱtypesȱofȱlegislativeȱmeasuresȱ allowȱlawȱ enforcementȱ officersȱtoȱ moreȱdirectlyȱ interveneȱ andȱ controlȱpeopleȱengagedȱ inȱ certainȱ disorderlyȱ behaviours.ȱ Theȱ useȱ ofȱ additionalȱ powersȱ grantedȱ throughȱ ȱ  35  ȱ  legislativeȱ initiativesȱ hasȱ beenȱ notedȱ toȱ accomplishȱ reductionsȱ inȱ markersȱ ofȱ streetȱ disorder.68,ȱ  97,ȱ 105,ȱ 124,ȱ 140  ȱ However,ȱ legislationȱ banningȱ orȱ strictlyȱ regulatingȱ certainȱ  behavioursȱ(suchȱasȱpanhandling)ȱinȱpublicȱspacesȱhasȱinȱmanyȱinstancesȱbeenȱfoundȱtoȱ violateȱ civilȱ liberties.8,ȱ 133ȱ ȱ Noȱ studiesȱ wereȱ identifiedȱ thatȱ assessȱ theȱ impactȱ ofȱ thisȱ approachȱonȱdisplacementȱorȱotherȱpotentialȱrelevantȱimpacts.ȱȱ 2.4.1.6 SummaryȱofȱLawȱEnforcementȱBasedȱApproachesȱ Despiteȱ moderateȱ benefitsȱ inȱ theȱ visibleȱ reductionȱ ofȱ streetȱ disorder,ȱ currentȱ evidenceȱ suggestsȱ thatȱ mostȱ lawȱ enforcementȱ basedȱ approachesȱ areȱ associatedȱ withȱ seriousȱ unintendedȱ consequences,ȱ whichȱ includeȱ displacingȱ streetȱ disorder,ȱ increasingȱ violence,ȱ policeȱ misconduct,ȱ compromisingȱ HIVȱ andȱ drugȱ overdoseȱ prevention,ȱ racialȱ profiling,ȱ increasingȱ stigmaȱ andȱ discrimination,ȱ andȱ increasingȱ overallȱ incarcerationȱ ratesȱ amongȱ vulnerableȱ drugȱ usingȱ populations.ȱ Theȱ extentȱ ofȱ theseȱ negativeȱ impactsȱ appearsȱtoȱoverwhelmȱtheȱmarginalȱbenefitsȱofȱdrugȱlawȱenforcementȱandȱsuggestsȱthatȱ alternativeȱapproachesȱareȱurgentlyȱrequired.ȱ  2.4.2 EnvironmentalȱDesignȱApproachesȱtoȱAddressȱDrugȬRelatedȱStreetȱDisorderȱ Givenȱ theȱ limitsȱ ofȱ conventionalȱ lawȱ enforcementȱ basedȱ approaches,ȱ ‘‘Crimeȱ PreventionȱThroughȱEnvironmentalȱDesign’’ȱ(CPTED),ȱalsoȱknownȱasȱ‘‘SituationalȱCrimeȱ Prevention’’,ȱ hasȱ receivedȱ increasingȱ attentionȱ asȱ aȱ potentialȱ methodȱ toȱ controlȱ drugȬ relatedȱstreetȱdisorder.25,ȱ 42,ȱ 67,ȱ 83ȱȱByȱwayȱofȱstrategiesȱrelatedȱtoȱterritorialityȱ(definedȱasȱ ensuringȱ thatȱ allȱ spacesȱ haveȱ aȱ clearlyȱ definedȱ andȱ apparentȱ purpose),ȱ surveillance,ȱ accessȱcontrol,ȱandȱtargetȱhardeningȱ(definedȱasȱmakingȱlocationsȱdifficultȱtoȱaccessȱorȱ ȱ  36  ȱ  penetrate),ȱCPTEDȱproposesȱthatȱalteringȱfeaturesȱofȱtheȱbuiltȱenvironmentȱcanȱincreaseȱ theȱ perceivedȱ costsȱ ofȱ committingȱ criminalȱ orȱ disorderlyȱ actsȱ (i.e.,ȱ increaseȱ perceivedȱ riskȱ ofȱ apprehension),ȱ whichȱ inȱ turnȱ detersȱ crimeȱ andȱ undesirableȱ behavioursȱ suchȱ asȱ streetȱdisorder.ȱ145,ȱ146ȱȱAȱkeyȱassumptionȱinherentȱinȱCPTEDȱisȱthatȱpotentialȱoffendersȱorȱ disorderlyȱ peopleȱ makeȱ rationalȱ calculatedȱ decisionsȱ aboutȱ theȱ potentialȱ costsȱ andȱ benefitsȱ ofȱ theirȱ actionsȱ thatȱ canȱ beȱ manipulatedȱ throughȱ changesȱ toȱ theȱ builtȱ environment.ȱȱ Typicalȱ designȱ featuresȱ toȱ deterȱ crimeȱ andȱ disorderȱ include:ȱ installingȱ lighting,ȱ fences,ȱ gates,ȱ andȱ closedȱ circuitȱ televisionȱ cameras,ȱ asȱ wellȱ asȱ alteringȱ landscapesȱ toȱ increaseȱ visibilityȱ andȱ removeȱ potentialȱ hidingȱ spots.42,ȱ 145,ȱ 146ȱ ȱ Inȱ theȱ contextȱ ofȱ drugȬ relatedȱ streetȱ disorder,ȱ proposedȱ designȱ featuresȱ toȱ deterȱ activitiesȱ relatedȱ toȱ publicȱ disorderȱinvolveȱremovingȱpublicȱwaterȱtapsȱtoȱrestrictȱaccessȱtoȱwaterȱforȱdrinkingȱandȱ washing,ȱ restrictingȱ accessȱ toȱ restrooms,ȱ lockingȱ unsecuredȱ garbageȱ dumpsters,ȱ andȱ blockingȱaccessȱtoȱprotectedȱareasȱwhereȱpeopleȱcanȱsitȱorȱlieȱdown.2,ȱ25,ȱ67ȱȱOneȱstrengthȱ ofȱenvironmentalȱdesignȱapproachesȱisȱthatȱcomparedȱtoȱlawȱenforcementȱapproaches,ȱ theyȱareȱtypicallyȱinexpensiveȱandȱeasyȱtoȱimplement.ȱ Existingȱ evaluationȱ studiesȱ ofȱ environmentalȱ designȱ interventionsȱ haveȱ beenȱ undertakenȱtoȱassessȱtheirȱimpactȱonȱdeterringȱcriminalȱbehavioursȱspecificȱtoȱpropertyȱ crime,ȱtheftȱandȱrobberyȱandȱdoȱnotȱdirectlyȱconsiderȱbehavioursȱassociatedȱwithȱdrugȬ relatedȱ streetȱ disorder.145,ȱ 146ȱ Nevertheless,ȱ thereȱ isȱ limitedȱ evidenceȱ suggestingȱ thatȱ  ȱ  37  ȱ  environmentalȱ designȱ mayȱ playȱ aȱ roleȱ inȱ reducingȱ certainȱ crimesȱ inȱ certainȱ situationsȱ andȱ thatȱ potentialȱ effectsȱ areȱ likelyȱ mediatedȱ byȱ socialȱ andȱ economicȱ factors.83,ȱ 146Ȭ148ȱ However,ȱtoȱdateȱnoneȱofȱtheseȱstudiesȱprovideȱevidenceȱthatȱempiricallyȱdemonstratesȱ theȱ effectivenessȱ ofȱ environmentalȱ designȱ inȱ crimeȱ reductionȱ andȱ noȱ evidenceȱ wasȱ locatedȱthatȱsuggestsȱenvironmentalȱdesignȱreducesȱstreetȱdisorder.145,ȱ146ȱ ȱ Althoughȱ theȱ evidenceȬbaseȱ surroundingȱ environmentalȱ designȱ isȱ limited,146ȱ concernsȱidentifiedȱwithȱemployingȱenvironmentalȱdesignȱstrategiesȱincludeȱdisplacingȱ undesirableȱ behavioursȱ andȱ negativelyȱ impactingȱ minorityȱ groups.ȱ Similarȱ toȱ lawȱ enforcementȱbasedȱinterventions,ȱenvironmentalȱdesignȱinterventionsȱhaveȱbeenȱfoundȱ toȱ displaceȱ undesirableȱ behaviourȱ toȱ surroundingȱ areas.147ȱ ȱ Asȱ previouslyȱ mentioned,ȱ displacementȱisȱknownȱtoȱhaveȱaȱnumberȱofȱnegativeȱhealthȱconsequencesȱbothȱforȱtheȱ individualsȱengagedȱinȱtheȱdisorderlyȱbehaviour,ȱasȱwellȱasȱforȱtheȱcommunitiesȱwhereȱ theȱ behaviourȱ relocates.62,ȱ  67,ȱ 69,ȱ 106,ȱ 110  ȱ ȱ Furthermore,ȱ asȱ withȱ orderȬmaintenanceȱ  approaches,ȱeffortsȱtoȱregulateȱandȱcontrolȱpublicȱspacesȱthroughȱsurveillanceȱandȱotherȱ environmentalȱ designȱ featuresȱ haveȱ beenȱ foundȱ toȱ disproportionatelyȱ affectȱ andȱ excludeȱ marginalizedȱ populations.83ȱ Whileȱ environmentalȱ designȱ interventionsȱ areȱ typicallyȱinexpensiveȱandȱeasyȱtoȱimplement,ȱthereȱisȱnoȱevidenceȱtoȱsuggestȱthatȱtheyȱ reduceȱdisorderlyȱactivityȱandȱthereȱisȱevidenceȱtoȱsuggestȱtheyȱdisplaceȱbehaviourȱandȱ negativelyȱaffectȱmarginalizedȱpopulations.ȱ  ȱ  38  ȱ  2.4.3 EngagingȱInterventionsȱthatȱEnableȱBehaviourȱChangeȱ Comparedȱwithȱlawȱenforcementȱandȱenvironmentalȱdesignȱinterventions,ȱwhichȱ areȱ largelyȱ coerciveȱ inȱ theirȱ approachesȱ toȱ deterringȱ disorderlyȱ behaviour,ȱ engagingȱ interventionsȱ thatȱ enableȱ behaviourȱ changeȱ representȱ aȱ differentȱ typeȱ ofȱ responseȱ toȱ drugȬrelatedȱ streetȱ disorder.ȱ Engagingȱ interventionsȱ areȱ consistentȱ withȱ publicȱ healthȱ principlesȱ andȱ recognizeȱ theȱ importanceȱ ofȱ promotingȱ andȱ enablingȱ behavioursȱ thatȱ protectȱ healthȱ andȱ limitȱ risks.ȱ Examplesȱ ofȱ engagingȱ interventionsȱ includeȱ manyȱ addictionsȬfocusedȱpublicȱhealthȱprogramsȱthatȱaimȱtoȱengageȱmarginalizedȱdrugȱusingȱ populationsȱandȱconnectȱthemȱwithȱappropriateȱhealthȱandȱsocialȱservices.149ȱAlthoughȱ fewȱ ofȱ theseȱ engagingȱ addictionsȬfocusedȱ publicȱ healthȱ programsȱ areȱ implementedȱ toȱ specificallyȱaddressȱstreetȱdisorder,ȱthereȱareȱaȱnumberȱthatȱhaveȱbeenȱevaluatedȱinȱtheȱ contextȱ ofȱ streetȱ disorder.ȱ Theseȱ includeȱ supervisedȱ injectionȱ facilities,ȱ addictionȱ treatmentȱprograms,ȱandȱlowȬthresholdȱemploymentȱprograms.ȱȱ 2.4.3.1 SupervisedȱInjectionȱFacilitiesȱ Supervisedȱ injectionȱ facilitiesȱ (SIFs)ȱ representȱ anȱ engagingȱ interventionȱ thatȱ isȱ explicitlyȱ intendedȱ toȱ addressȱ aspectsȱ ofȱ drugȬrelatedȱ streetȱ disorder.20,ȱ  150,ȱ 151  ȱ Byȱ  providingȱ aȱ hygienicȱ environmentȱ whereȱ drugȱ usersȱ canȱ injectȱ illegalȱ drugsȱ withoutȱ fearȱ ofȱ arrestȱ orȱ harassment,ȱ SIFsȱ offerȱ aȱ uniqueȱ alternativeȱ forȱ streetȬbasedȱ injectionȱ drugȱusers.ȱ 20,ȱ 150,ȱ 151152ȱWithinȱSIFs,ȱclientsȱareȱprovidedȱwithȱsterileȱinjectingȱequipmentȱ andȱemergencyȱinterventionȱinȱtheȱeventȱofȱanȱaccidentalȱoverdose,ȱasȱwellȱasȱmedicalȱ  ȱ  39  ȱ  careȱeitherȱonȱsiteȱorȱthroughȱreferral.153,ȱ154ȱȱThereȱareȱnowȱapproximatelyȱ65ȱsanctionedȱ supervisedȱdrugȱconsumptionȱfacilitiesȱinȱoperationȱinternationally.155ȱȱ TheȱimpactȱofȱSIFsȱonȱstreetȱdisorderȱhasȱbeenȱrigorouslyȱevaluatedȱinȱAustraliaȱ andȱ Canadaȱ usingȱ bothȱ communityȱ perceptionȱ surveysȱ andȱ directȱ observationȱ techniques.ȱ Resultsȱ suggestȱ thatȱ SIFsȱ areȱ effectiveȱ inȱ reducingȱ bothȱ observedȱ andȱ perceivedȱ measuresȱ ofȱ publicȱ injectionȱ drugȱ useȱ andȱ injectionȱ relatedȱ debrisȱ inȱ areasȱ surroundingȱ injectionȱ facilities.101,ȱ 104ȱ VancouverȬbasedȱ studiesȱ haveȱ soughtȱ toȱ measureȱ potentialȱ unintendedȱ negativeȱ consequencesȱ ofȱ SIFsȱ butȱ foundȱ noȱ adverseȱ changesȱ inȱ communityȱdrugȱuseȱpatterns,156ȱnoȱincreasesȱinȱinitiationȱintoȱinjectionȱdrugȱuse,157ȱandȱ noȱ increasesȱ inȱ drugȬrelatedȱ crimeȱ associatedȱ withȱ theȱ establishmentȱ ofȱ Vancouver’’sȱ SIF.158ȱ Despiteȱevidenceȱ ofȱpositiveȱimpactsȱonȱtheȱreductionȱofȱ streetȱdisorderȱ andȱ noȱ evidenceȱ ofȱ adverseȱ impacts,ȱ theȱ coverageȱ ofȱ SIFsȱ remainsȱ minuteȱ comparedȱ toȱ theȱ prevalenceȱ ofȱ publicȱ drugȱ useȱ andȱ drugȬrelatedȱ streetȱ disorder.ȱ SIFsȱ inȱ Australiaȱ andȱ Canadaȱ areȱ singleȱ pilotȱ trialȱ facilitiesȱ andȱ areȱ notȱ comprehensiveȱ programsȱ ofȱ supervisedȱ injecting.ȱ Capacityȱ constraintsȱ resultingȱ inȱ longȱ waitȱ timesȱ toȱ accessȱ theȱ Vancouverȱ injectionȱ facilityȱ haveȱ beenȱ identifiedȱ asȱ aȱ leadingȱ factorȱ contributingȱ toȱ publicȱdrugȱuseȱamongȱlocalȱinjectors.159ȱToȱdate,ȱnoȱSIFsȱhaveȱbeenȱimplementedȱinȱtheȱ UnitedȱStates.ȱ  ȱ  40  ȱ  2.4.3.2 AddictionȱTreatmentȱ Addictionȱ treatmentȱ programsȱ areȱ anotherȱ highlyȱ relevantȱ engagingȱ publicȱ healthȱinterventionȱinȱtheȱcontextȱofȱstreetȱdisorder.ȱThereȱareȱmanyȱdifferentȱtypesȱofȱ addictionȱ treatmentȱ includingȱ behaviouralȱ andȱ pharmacologicalȱ treatmentsȱ (drugȱ substitutionȱ andȱ maintenanceȱ therapies),ȱ andȱ theȱ objectivesȱ ofȱ addictionȱ treatmentȱ rangeȱfromȱreducingȱillicitȱdrugȱuseȱtoȱfullȱabstinenceȱfromȱallȱdrugȱuse.160ȱȱ Reducingȱ drugȱ dependenceȱ andȱ useȱ throughȱ substitution,ȱ maintenance,ȱ orȱ abstinenceȬbasedȱ addictionȱ treatmentsȱ haveȱ allȱ beenȱ foundȱ toȱ limitȱ participationȱ inȱ drugȬrelatedȱstreetȱdisorder,ȱparticularlyȱparticipationȱinȱdisorderlyȱincomeȱgenerationȱ activities.161Ȭ165ȱ Inȱ particular,ȱ aȱ wideȱ bodyȱ ofȱ literatureȱ hasȱ foundȱ thatȱ methadoneȱ maintenanceȱ isȱ anȱ effectiveȱ treatmentȱ forȱ opiodȱ addictionȱ andȱ isȱ associatedȱ withȱ reductionsȱ inȱ participationȱ inȱ disorderlyȱ incomeȱ generationȱ activities.162ȱ Similarly,ȱ heroinȱ maintenanceȱ trialsȱ includingȱ theȱ mostȱ recentȱ Northȱ Americanȱ Opiateȱ Medicationȱ Initiativeȱ(NAOMI)ȱtrial,ȱfoundȱthatȱprescribingȱinjectableȱdiacetylmorphineȱ(theȱactiveȱ ingredientȱinȱheroin)ȱreducedȱtheȱuseȱofȱandȱneedȱtoȱpurchaseȱillicitȱstreetȱdrugs,ȱwhichȱ hasȱaȱdirectȱpositiveȱimpactȱonȱreducingȱparticipationȱinȱdisorderlyȱincomeȱgenerationȱ activities.163ȱȱȱ Althoughȱtheȱlinksȱbetweenȱaddictionȱtreatmentȱandȱreductionsȱinȱparticipationȱ inȱdisorderlyȱincomeȱgenerationȱactivitiesȱareȱwellȱestablished,ȱtheȱlongȬtermȱdrugȱuseȱ patternsȱofȱinjectionȱdrugȱusersȱsuggestȱthatȱdrugȱaddictionȱisȱoftenȱaȱchronicȱrelapsingȱ conditionȱandȱaddictionȱtreatmentȱsuccessȱisȱtypicallyȱperiodicȱandȱfollowedȱbyȱperiodsȱ ȱ  41  ȱ  ofȱ relapseȱ intoȱ drugȱ use.166Ȭ169ȱ Furthermore,ȱ thereȱ areȱ currentlyȱ noȱ substitutionȱ orȱ maintenanceȱ treatmentȱ therapiesȱforȱstimulantȱdrugȱ users.ȱTheȱoverallȱ effectivenessȱ ofȱ currentȱ addictionȱ treatmentȱ modalitiesȱ toȱ reduceȱ participationȱ inȱ disorderlyȱ incomeȱ generationȱactivitiesȱisȱlimited.ȱ 2.4.3.3 LowȬThresholdȱEmploymentȱProgramsȱ TheȱeffectsȱofȱdrugȱaddictionȱandȱstreetȬentrenchmentȱoftenȱmakeȱitȱdifficultȱforȱ illicitȱdrugȱusersȱtoȱobtainȱandȱretainȱformalȱemployment.ȱFormalȱemploymentȱtypicallyȱ requiresȱemployeesȱtoȱabstainȱfromȱdrugȱuseȱandȱfollowȱaȱregularȱworkȱscheduleȱwhichȱ isȱ oftenȱ unrealisticȱ forȱ manyȱ streetȬbasedȱ drugȱ users.33,ȱ 170Ȭ174ȱ Givenȱ theȱ barriersȱ toȱ engagingȱ inȱ formalȱ employment,ȱ itȱ isȱ commonȱ forȱ drugȱ usersȱ toȱ resortȱ toȱ prohibitedȱ incomeȱ generationȱ strategiesȱ thatȱ contributeȱ toȱ drugȬrelatedȱ streetȱ disorder.7,ȱ  ȱ  171  Althoughȱ thereȱ areȱ employmentȱ programsȱ targetedȱ towardsȱ peopleȱ whoȱ useȱ drugs,ȱ theyȱ areȱ oftenȱ integratedȱ intoȱ addictionȱ treatmentȱ programsȱ andȱ intendedȱ toȱ supportȱ addictionȱrecovery.172ȱAsȱaȱresult,ȱtheseȱtypesȱofȱemploymentȱprogramsȱareȱinaccessibleȱ forȱactiveȱdrugȱusersȱandȱareȱthereforeȱunableȱtoȱaddressȱdisorderlyȱincomeȱgenerationȱ activities.ȱȱ Conversely,ȱlowȬthresholdȱemploymentȱprogramsȱareȱanȱalternativeȱstrategyȱthatȱ initialȱ researchȱ suggestsȱ canȱ engageȱ streetȬinvolvedȱ drugȱ usersȱ andȱ reduceȱ theirȱ participationȱ inȱ someȱ typesȱ ofȱ disorderlyȱ incomeȱ generationȱ activities.ȱ Theȱ conceptȱ ofȱ ‘‘lowȬthreshold’’ȱisȱtoȱcreateȱprogramsȱthatȱareȱeasilyȱaccessibleȱforȱactiveȱdrugȱusersȱandȱ aȱkeyȱcomponentȱofȱlowȬthresholdȱprogramsȱisȱthatȱtheyȱdoȱnotȱrequireȱabstinenceȱfromȱ ȱ  42  ȱ  drugȱ use.ȱ Anȱ evaluationȱ ofȱ aȱ jewelleryȱ makingȱ economicȱ empowermentȱ programȱ forȱ womenȱ whoȱ useȱ illicitȱ drugsȱ foundȱ theȱ programȱ wasȱ associatedȱ withȱ significantȱ reductionsȱinȱengagingȱinȱsexȱwork.175ȱȱ Additionalȱ studiesȱ evaluatingȱ theȱ impactsȱ ofȱ lowȬthresholdȱ employmentȱ programsȱonȱdisorderlyȱincomeȱgenerationȱwereȱnotȱlocatedȱandȱtheȱprevalenceȱofȱtheseȱ initiativesȱ appearsȱ sparse.ȱ However,ȱ aȱ limitedȱ numberȱ ofȱ lowȬthresholdȱ employmentȱ opportunitiesȱ inȱ Vancouver,ȱ Canadaȱ wereȱ identified.ȱ Theseȱ includeȱ aȱ communityȱ caféȱ andȱ cateringȱ socialȱ enterpriseȱ companyȱ thatȱ offersȱ anȱ estimatedȱ nineȱ lowȬthresholdȱ employmentȱ positions,176,ȱ  177  ȱ asȱ wellȱ asȱ anȱ organizationȱ thatȱ processesȱ recyclableȱ  containersȱ whichȱ providesȱ roughlyȱ 33ȱ lowȬthresholdȱ positions178,ȱ  ȱ andȱ aȱ photoȱ  179  calendarȱ projectȱ initiatedȱ byȱ aȱ socialȱ justiceȱ organizationȱ thatȱ offersȱ aȱ programȱ forȱ residentsȱofȱVancouver’’sȱdrugȱuseȱepicentreȱtoȱbecomeȱvendorsȱandȱsellȱcalendarsȱandȱ books.180Ȭ182ȱActiveȱdrugȱuseȱdoesȱnotȱprecludeȱparticipationȱinȱanyȱofȱtheseȱemploymentȱ opportunities.ȱ Givenȱ initialȱ positiveȱ findingsȱ ofȱ lowȬthresholdȱ employmentȱ programsȱ onȱdisorderlyȱincomeȱgenerationȱinȱotherȱsettings,ȱevaluatingȱtheȱimpactsȱofȱtheȱaboveȱ identifiedȱlowȬthresholdȱemploymentȱprogramsȱinȱVancouverȱ appearsȱwarranted.ȱ Theȱ expansionȱ ofȱ lowȬthresholdȱ employmentȱ opportunitiesȱ mayȱ presentȱ anȱ importantȱ opportunityȱ toȱ significantlyȱ reduceȱ participationȱ inȱ componentsȱ ofȱ drugȬrelatedȱ streetȱ disorder.ȱ  ȱ  43  ȱ  2.5 ConclusionsȱandȱNextȱStepsȱ Theȱ findingsȱ ofȱ thisȱ reviewȱ indicateȱ thatȱ althoughȱ lawȱ enforcementȬbasedȱ approachesȱareȱtheȱmostȱcommonlyȱemployedȱresponseȱtoȱdrugȬrelatedȱstreetȱdisorder,ȱ theirȱ impactsȱ areȱ typicallyȱ shortȬtermȱ andȱ areȱ oftenȱ accompaniedȱ byȱ negativeȱ unintendedȱconsequences,ȱincludingȱdisplacementȱandȱaȱrangeȱofȱharmfulȱpublicȱhealthȱ andȱ communityȱ impacts.ȱ Similarly,ȱ althoughȱ environmentalȱ designȱ interventionsȱ mayȱ haveȱlimitedȱimpactȱonȱtheȱvisibleȱreductionȱofȱstreetȱdisorder,ȱtheseȱmarginalȱgainsȱareȱ associatedȱwithȱunintendedȱconsequencesȱincludingȱdisplacementȱandȱtheȱexclusionȱofȱ marginalizedȱpopulations.ȱConversely,ȱinterventionsȱthatȱareȱinȱlineȱwithȱpublicȱhealthȱ principlesȱ andȱ engageȱ drugȱ usersȱ toȱ enableȱ themȱ toȱ changeȱ theirȱ behaviourȱ areȱ notȱ associatedȱ withȱ seriousȱ unintendedȱ negativeȱ consequences;ȱ however,ȱ theirȱ impactsȱ onȱ streetȱ disorderȱ areȱ restrictedȱ byȱ aȱ numberȱ ofȱ factors.ȱ Inȱ theȱ casesȱ ofȱ SIFsȱ andȱ lowȬ thresholdȱemployment,ȱlimitedȱcoverageȱappearsȱtoȱbeȱaȱkeyȱconstraintȱsuggestingȱthatȱ theȱ expansionȱ andȱ furtherȱ developmentȱ ofȱ theseȱ interventionsȱ shouldȱ beȱ pursued.ȱ Whileȱ thereȱ isȱ aȱ needȱ toȱ scaleȱ upȱ andȱ expandȱ existingȱ interventionsȱ thatȱ haveȱ aȱ demonstratedȱ positiveȱ impactȱ onȱ theȱ reductionȱ ofȱ markersȱ ofȱ drugȬrelatedȱ streetȱ disorder,ȱ givenȱ theȱ identifiedȱ limitationsȱ withȱ theȱ currentȱ rangeȱ ofȱ interventionsȱ toȱ addressȱ drugȬrelatedȱ streetȱ disorder,ȱ considerationȱ forȱ underexploredȱ andȱ innovativeȱ interventionsȱshouldȱalsoȱbeȱaȱpriorityȱforȱhealthȱandȱpolicyȱresearch.ȱȱ  ȱ  44  ȱ  2.5.1 UnderexploredȱandȱInnovativeȱEngagingȱApproachesȱ Specificȱengagingȱpublicȱhealthȱprogramsȱimplementedȱforȱpurposesȱunrelatedȱtoȱ streetȱ disorderȱ canȱ directlyȱ impactȱ theȱ prevalenceȱ ofȱ drugȬrelatedȱ streetȱ disorder;ȱ however,ȱ inȱ manyȱ instancesȱ thisȱ impactȱ hasȱ notȱ beenȱ recognized.ȱ LowȬthresholdȱ supportiveȱ housingȱ isȱ anȱ exampleȱ ofȱ anȱ engagingȱ interventionȱ thatȱ hasȱ beenȱ underexploredȱ inȱ connectionȱ toȱ drugȬrelatedȱ streetȱ disorder.ȱ Whileȱ theȱ benefitsȱ ofȱ providingȱ lowȬthresholdȱ supportiveȱ housingȱ forȱ marginalizedȱ populationsȱ haveȱ longȱ beenȱ recognizedȱ inȱ theȱ contextȱ ofȱ physicalȱ andȱ mentalȱ health,183ȱ theȱ relationshipȱ betweenȱ lowȬthresholdȱ housing,ȱ accessȱ toȱ privateȱ spaceȱ andȱ engagementȱ inȱ publicȱ disorderȱhasȱnotȱbeenȱfullyȱexplored.ȱIndeed,ȱhomelessnessȱhasȱbeenȱfoundȱtoȱbeȱaȱkeyȱ predictorȱ ofȱ publicȱ injectionȱ drugȱ useȱ andȱ surveysȱ ofȱ individualsȱ engagedȱ inȱ otherȱ disorderlyȱ behavioursȱ repeatedlyȱ identifyȱ thisȱ populationȱ asȱ underȬhoused,3,ȱ  6ȱ  suggestingȱthatȱusingȱdrugsȱandȱloiteringȱinȱpublicȱspacesȱmayȱbeȱaȱfunctionȱofȱhavingȱ limitedȱ accessȱ toȱ privateȱ space.ȱ Hence,ȱ lowȬthresholdȱ housingȱ programsȱ mayȱ haveȱ potentialȱ toȱ greatlyȱ reduceȱ someȱ disorderlyȱ activitiesȱ ifȱ theyȱ provideȱ individualsȱ withȱ privateȱspacesȱthatȱaccommodateȱsocializingȱandȱdrugȱuse.ȱȱ Basedȱ onȱ theȱ successesȱ ofȱ opiodȱ maintenanceȱ andȱ substitutionȱ treatmentȱ therapies,ȱ oneȱ promisingȱ areaȱ forȱ innovativeȱ explorationȱ isȱ developingȱ drugȱ substitutionȱ andȱ maintenanceȱ addictionȱ treatmentȱ programsȱ forȱ stimulantȱ drugȱ users.ȱ Similarly,ȱ basedȱ onȱ theȱ successesȱ ofȱ SIFs,ȱ theȱ potentialȱ forȱ supervisedȱ inhalationȱ facilitiesȱ toȱ provideȱ alternativeȱ locationsȱ forȱ crackȱ cocaineȱ andȱ methamphetamineȱ ȱ  45  ȱ  smokersȱtoȱconsumeȱdrugsȱshouldȱbeȱevaluated.ȱInhalationȱfacilitiesȱoperateȱinȱEurope;ȱ however,ȱtheirȱimpactȱonȱstreetȱdisorderȱhasȱnotȱbeenȱformallyȱevaluated.ȱ  2.5.2 Summaryȱ Inȱ summary,ȱ thisȱ reviewȱ findsȱ thatȱ lawȱ enforcementȱ andȱ environmentalȱ designȱ basedȱinterventionsȱdoȱnotȱappropriatelyȱmanageȱorȱmeaningfullyȱreduceȱdrugȬrelatedȱ streetȱdisorderȱwhileȱengagingȱinterventionsȱconsistentȱwithȱpublicȱhealthȱprinciplesȱareȱ notȱ associatedȱ withȱ seriousȱ unintendedȱ consequencesȱ butȱ tendȱ toȱ beȱ limitedȱ inȱ theirȱ impactȱdueȱinȱpartȱtoȱlimitedȱcoverage.ȱBasedȱonȱtheȱsuccessȱofȱengagingȱpublicȱhealthȱ approaches,ȱ furtherȱ researchȱ shouldȱ beȱ directedȱ towardsȱ identifyingȱ innovativeȱ interventionsȱ toȱ addressȱ streetȱ disorderȱ asȱ wellȱ asȱ assessingȱ theȱ impactȱ thatȱ underexploredȱ publicȱ healthȱ basedȱ interventionsȱ mightȱ haveȱ onȱ reducingȱ engagementȱ inȱstreetȱdisorder.ȱȱȱ  ȱ  46  ȱ  Tableȱ2.2ȱDescriptionȱofȱpolicyȱapproaches Policy Response  Type of Approach  Public Drug  Description  Use  Street Drug Dealing  Sex Work  X  X  X  Pan Binning Loiterhandling Vending ing  Police crack-down campaigns*  Law Enforcement  x Temporary sudden increase in policing efforts either in one geographic area or targeted towards one type of offence63 x Often targeted at open drug markets and involves increasing police patrol and surveillance105  Order-maintenance policing*  Law Enforcement  x Strict enforcement of any minor bi-law, or misdemeanour offences, with chief objective of reducing more serious crime (informed by ‘broken windows theory’50)  X  X  X  X  X  X  Problem-oriented policing  Law Enforcement  x Police officers partner with community members to jointly prevent crime and address neighbourhood crime issues135, 139  X  X  X  X  X  X  Hot-spot policing*  Law Enforcement  x Sub-section of enforcement approaches: involves increasing police patrol and presence in areas with concentrated crime and disorder91, 97 x Police tactics with hot-spot approaches vary and include order-maintenance policing or crack-down campaigns or other (problem-oriented policing)  X  X  X  Increasing police powers through legislation  Law Enforcement  x Increase powers of police to regulate activities in public spaces (prohibits public sleeping, panhandling, loitering), example: ‘Safe Streets Act’ in British Columbia and Ontario, Canada  Environmental design  Environmental Design  x Alters built environment to deter undesirable behaviours in public  X  Supervised injection facilities  Engaging Intervention  x Provides hygienic, sanctioned indoor space to inject illicit drugs  X  Addiction treatment  Engaging Intervention  x Aimed at reducing or eliminating illicit drug use x Wide range of approaches including behavioural and pharmacological treatments160  X  Low-threshold employment  Engaging Intervention  x Employment programs that do not require employees to be abstinent from drugs  X  X  X  X  X  X  X  X  X  X X  X  X  X  X  X  X  X  X 47  ȱ  ȱ  Tableȱ2.3ȱEvidenceȱofȱimpactsȱofȱpolicyȱapproaches Policy Response  Observed Impacts  Observed Unintended Negative Impacts  Law Enforcement Based Approaches x Reduced drug market activity during operation63, 107 x Visible reduction only temporary, deterrent effect not lasting62, 105, 105, 108 x No change in drug prices or frequency of drug use among local IDU69, 109  x x x x x  Police crack-down campaigns* x x x x  Ordermaintenance policing*  Problem-oriented policing*  Displacement62, 64, 69, 107, 108 Discourages contact between IDU and health services107 Increases violence in area62, 108, 115 Associated with police misconduct (unnecessary force, illegal searches)116 Discourages safe injecting practices –police searches make IDU reluctance to carry syringes,63, 64, 107, 116 reduces access to HIV prevention supplies (condoms, syringes),106, 107 and increased police surveillance leads to rushed injecting which means skipping HIV and overdose prevention steps and other safety measures, as well as62, 63, 106, 107 discourages safe needle and syringe disposal62, 64, 107 Encourages nasal storage, increases risk of accidental overdose and spread of infections64 Increases risk of fatal drug overdose as injectors choose more isolated locations113, 114 Increases stigma and contributes to inequalities that are determinants of HIV risk106 Increases vulnerability to incarceration which is risk environment for HIV106  x Reductions in visible signs of street disorder49, 124 x Credited with reductions in homicide and violence crimes130, 131 but findings are contested49, 132  x x x x  Displacement48, 67, 68 Racial profiling and prejudicial enforcement of laws127 Disproportionate incarceration of minority groups133 Increases risk of incarceration which is associated with many harms including increasing stigma, risks for HIV acquisition and other health harms119-125 x Associated with increased civil rights complaints124  x Moderate reductions in disorder139, 184 x Evidence-base limited136, 137, 139  x No identified unintended consequences  48 ȱ  ȱ  Policy Response  Hot-spot policing  Increasing police powers through legislation  Observed Impacts  Observed Unintended Negative Impacts  x Deterrent effect during hot-spot crack-down campaign95, 97, 142 x Moderate reductions in disorder after hot-spot crackdown campaign140, 141 x Moderate reductions in disorder after hot-spot problem-oriented campaign138, 141  x No identified unintended consequences associated specifically with hot-spot approach; however, hot-spot approach is paired with other policing approaches (i.e., crack-down campaign) and the unintended consequences of those policing strategies would be relevant  x Reductions in markers of street disorder.68, 97, 105, 124, 140  x Associated with civil liberty violations8, 133  Environmental Design Environmental design*  x No studies specifically evaluating impact on street disorder145, 146 x Some evidence indicating might reduce some measures of crime in certain situations83, 146-148  x Displacement83, 145, 147 x Disproportionately affects and excludes marginalized populations83  Engaging Interventions that Enable Behaviour Change x No identified unintended consequences  Supervised injection facilities  x Associated with reductions in observed and perceived measures of markers of street disorder101, 104 x No evidence of adverse changes in community drug use patterns,156 nor increases in initiation into injection drug use,157 nor increases in drug-related crime158  x No identified unintended consequences  Addiction treatment  x Associated with reductions in disorderly income generation161-165 x Among high intensity drug users treatment success is typically periodic and followed by periods of relapse back into drug use166-169  Low-threshold employment  x Associated with reductions in engagement in some disorderly income generation activities175 x Evaluation studies of low-threshold employment program limited  x No identified unintended consequences  *Note:ȱTheȱoutcomesȱofȱinterestȱforȱmanyȱofȱtheȱstudiesȱevaluatingȱtheȱimpactȱofȱtheseȱinterventionsȱwereȱcrimeȱratesȱnotȱstreetȱdisorder.  49 ȱ  ȱ  CHAPTER 3: ȱ AȱDOSEȬDEPENDENTȱRELATIONSHIPȱBETWEENȱEXPOSUREȱ TOȱAȱSTREETȬBASEDȱDRUGȱSCENEȱANDȱHEALTHȬRELATEDȱ HARMSȱAMONGȱPEOPLEȱWHOȱUSEȱINJECTIONȱDRUGS 2ȱ  3.1 Introductionȱ Inȱmanyȱurbanȱareasȱglobally,ȱstreetȱdisorderȱrelatedȱtoȱtheȱuseȱandȱtradeȱofȱillicitȱ drugsȱ isȱ aȱ growingȱ publicȱ policyȱ concern.25,ȱ 40,ȱ 42,ȱ 50,ȱ 89Ȭ91ȱ Commonȱ signsȱ ofȱ drugȬrelatedȱ streetȱ disorderȱ includeȱ theȱ consumptionȱ ofȱ illegalȱ drugsȱ inȱ publicȱ areasȱ andȱ publicȱ intoxicationȱ (i.e.,ȱ loiteringȱ orȱ socializingȱ inȱ publicȱ spacesȱ whileȱ underȱ theȱ influenceȱ ofȱ drugs).1Ȭ6ȱ Inȱ addition,ȱ activitiesȱ includingȱ streetȬlevelȱ drugȱ dealing,ȱ streetȬbasedȱ sexȱ work,ȱ panhandling,ȱ andȱ engagingȱ inȱ ‘‘binning’’,ȱ recycling,ȱ salvagingȱ andȱ unsanctionedȱ streetȬvendingȱ areȱ examplesȱ ofȱ everydayȱ incomeȱ generationȱ strategiesȱ usedȱ byȱ manyȱ streetȬbasedȱ drugȱ usersȱ whichȱ furtherȱ contributeȱ toȱ streetȱ disorder.2,ȱ 3,ȱ 8Ȭ10ȱ Theȱ physicalȱ locationsȱwhereȱtheseȱdisorderlyȱactivitiesȱareȱhighlyȱconcentratedȱareȱoftenȱreferredȱtoȱ asȱ ‘‘drugȱ scenes’’ȱ andȱ areȱ widelyȱ recognizedȱ andȱ wellȱ describedȱ inȱ manyȱ urbanȱ areas,ȱ includingȱ Vancouver,ȱ Canada,ȱ whereȱ aȱ largeȱ openȱ drugȱ sceneȱ hasȱ persistedȱ forȱ decades.185Ȭ189ȱȱ  ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 2  ȱAȱversionȱofȱthisȱchapterȱhasȱbeenȱsubmittedȱforȱpublication.ȱDeBeck,ȱK.,ȱWood,ȱE.,ȱ Zhang,ȱR.,ȱBuxton,ȱJ.,ȱMontaner,ȱJ.,ȱKerr,ȱT.ȱAȱdoseȬdependentȱrelationshipȱbetweenȱ exposureȱtoȱaȱstreetȬbasedȱdrugȱsceneȱandȱhealthȬrelatedȱharmsȱamongȱpeopleȱwhoȱ useȱinjectionȱdrugs.ȱ ȱ  50  ȱ  Toȱdate,ȱtheȱharmfulȱimpactsȱofȱdrugȬrelatedȱstreetȱdisorderȱareȱmostȱfrequentlyȱ discussedȱinȱreferenceȱtoȱtheirȱnegativeȱeffectsȱonȱsurroundingȱcommunities.25,ȱ 40ȱȱItȱhasȱ beenȱ reportedȱ thatȱ whenȱ questioned,ȱ aȱ highȱ proportionȱ ofȱ urbanȱ citizensȱ rankȱ streetȱ disorderȱasȱaȱtopȱconcernȱinȱtheirȱcommunity,ȱoftenȱaboveȱveryȱseriousȱcrimesȱincludingȱ homicide,ȱsexualȱassaultȱandȱrobbery.25,ȱ40,ȱ42,ȱ50,ȱ89Ȭ91ȱȱIndeed,ȱtheȱatmosphereȱofȱstreetȬlevelȱ drugȱdealingȱcanȱbeȱintimidatingȱforȱtheȱgeneralȱpublicȱandȱmayȱdiscourageȱtheȱuseȱofȱ publicȱ spacesȱ inȱ theȱ vicinityȱ ofȱ streetȬbasedȱ drugȱ scenes.48,ȱ 49,ȱ 143ȱ ȱ Highȱ levelsȱ ofȱ streetȱ disorderȱhaveȱalsoȱbeenȱlinkedȱtoȱdepressedȱretailȱactivityȱandȱeconomicȱinvestmentȱinȱ surroundingȱareas.8,ȱ40Ȭ45ȱȱ WhileȱtheȱcommunityȱimpactsȱofȱdrugȬrelatedȱstreetȱdisorderȱareȱgenerallyȱwellȱ understood,ȱ lesserȱ attentionȱ hasȱ beenȱ givenȱ toȱ theȱ potentialȱ healthȱ andȱ socialȱ impactsȱ thatȱ exposureȱ toȱ andȱ immersionȱ inȱ streetȬbasedȱ drugȱ scenesȱ hasȱ onȱ streetȬinvolvedȱ peopleȱwhoȱuseȱillicitȱdrugs.190ȱȱExistingȱpublicȱhealthȱresearchȱhasȱdocumentedȱaȱwideȱ rangeȱofȱhealthȱrisksȱassociatedȱwithȱengagingȱinȱspecificȱdisorderlyȱactivities,ȱsuchȱasȱ streetȬbasedȱsexȱwork,57,ȱ 58,ȱ 191ȱtheȱuseȱofȱinjectionȱdrugsȱinȱpublicȱareas,3,ȱ 61,ȱ 83ȱandȱstreetȬ levelȱ drugȱ dealing;4,ȱ 192ȱ however,ȱ theseȱ studiesȱ focusedȱ onȱ specificȱ behavioursȱ andȱ didȱ notȱ considerȱ theȱ roleȱ thatȱ exposureȱ toȱ drugȱ scenesȱ itselfȱ mayȱ playȱ inȱ shapingȱ healthȱ behavioursȱandȱoutcomes.ȱȱ Toȱ addressȱ thisȱ gapȱ andȱ provideȱ improvedȱ understandingsȱ ofȱ theȱ impactsȱ ofȱ drugȬrelatedȱ streetȱ disorder,ȱ weȱ soughtȱ toȱ assessȱ whetherȱ exposureȱ toȱ drugȬrelatedȱ  ȱ  51  ȱ  streetȱdisorder,ȱinȱtheȱformȱofȱVancouver’’sȱwellȬdescribedȱstreetȬbasedȱdrugȱscene,ȱwasȱ associatedȱwithȱmarkersȱofȱvulnerabilityȱtoȱharmȱandȱadverseȱhealthȱoutcomesȱsuchȱasȱ unstableȱ housing,ȱ highȱ intensityȱ drugȱ use,ȱ exposureȱ toȱ violence,ȱ andȱ encountersȱ withȱ lawȱenforcement.ȱWeȱalsoȱsoughtȱtoȱdetermineȱwhetherȱtheȱlevelȱofȱdrugȱsceneȱexposureȱ wasȱ associatedȱ withȱ varyingȱ degreesȱ ofȱ vulnerabilityȱ toȱ harmȱ andȱ adverseȱ healthȱ outcomes.ȱ Itȱ wasȱ hopedȱ thatȱ theseȱ findingsȱ wouldȱ informȱ moreȱ effectiveȱ policyȱ interventionsȱtoȱaddressȱdrugȬrelatedȱstreetȱdisorder.ȱ  3.2 Methodsȱ Dataȱ forȱ thisȱ studyȱ wereȱ obtainedȱ fromȱ theȱ Vancouverȱ Injectionȱ Drugȱ Usersȱ Studyȱ (VIDUS).ȱ Forȱ aȱ fullȱ descriptionȱ ofȱ theȱ studyȱ pleaseȱ referȱ toȱ sectionȱ 1.4ȱ ofȱ thisȱ thesis.ȱȱTheȱpresentȱstudyȱisȱrestrictedȱtoȱVIDUSȱparticipantsȱseenȱforȱstudyȱfollowȬupȱ duringȱtheȱperiodȱofȱDecemberȱ2005ȱtoȱMarchȱ2009,ȱasȱtheȱmeasureȱforȱourȱoutcomeȱofȱ interestȱwasȱavailableȱonlyȱforȱthisȱperiod.ȱȱ Theȱ primaryȱ outcomeȱ ofȱ interestȱ forȱ thisȱ analysisȱ wasȱ ‘‘drugȱ sceneȱ exposure’’,ȱ broadlyȱ definedȱ asȱ spendingȱ timeȱ onȱ theȱ streetȱ inȱ Vancouver’’sȱ drugȱ useȱ epicenter,ȱ whichȱ isȱ aȱ wellȬdescribedȱ andȱ definedȱ areaȱ ofȱ theȱ cityȱ referredȱ toȱ asȱ theȱ ‘‘Downtownȱ Eastside’’.14,ȱ 193ȱ ȱ Ourȱ measureȱ forȱ thisȱ variableȱ wasȱ basedȱ onȱ responsesȱ toȱ theȱ question:ȱ ““Onȱaverage,ȱhowȱmanyȱhoursȱaȱdayȱdoȱyouȱspendȱonȱtheȱstreet?””ȱToȱcaptureȱexposureȱ toȱdrugȱscenesȱandȱnotȱgeneralȱexposureȱtoȱcityȱstreetsȱweȱlimitedȱourȱmeasureȱofȱdrugȱ sceneȱexposureȱtoȱparticipantsȱthatȱresidedȱinȱorȱfrequentlyȱvisitedȱ(dailyȱorȱ2Ȭ3ȱtimesȱaȱ ȱ  52  ȱ  week)ȱ Vancouver’’sȱ drugȱ useȱ epicenter.ȱ Becauseȱ weȱ wereȱ interestedȱ inȱ assessingȱ whetherȱ theȱ levelȱ ofȱ drugȱ sceneȱ exposureȱ wasȱ associatedȱ withȱ differingȱ levelsȱ ofȱ riskȱ behaviourȱ andȱ harm,ȱ weȱ createdȱ fourȱ categoriesȱ ofȱ drugȱ sceneȱ exposure.ȱ Weȱ definedȱ ourȱreferenceȱcategoryȱofȱ‘‘noȱexposure’’ȱtoȱincludeȱallȱindividualsȱwhoȱdidȱnotȱresideȱinȱ orȱfrequentlyȱvisitȱVancouver’’sȱdrugȱuseȱepicenter,ȱasȱwellȱasȱindividualsȱwhoȱreportedȱ spendingȱnoȱmoreȱthanȱanȱaverageȱofȱ1ȱhourȱorȱlessȱonȱtheȱstreetȱeachȱdayȱoverȱtheȱlastȱ sixȱ months.ȱ Afterȱ examiningȱ theȱ distributionȱ ofȱ oneȱ smallȱ crossȬsectionalȱ sampleȱ ofȱ reportsȱofȱtheȱnumberȱofȱhoursȱspentȱonȱtheȱstreet,ȱweȱdividedȱtheȱresponsesȱintoȱthreeȱ groupsȱ ofȱ similarȱ size.ȱ Theseȱ areȱ referredȱ toȱ asȱ theȱ ‘‘low’’,ȱ ‘‘moderate’’,ȱ andȱ ‘‘high’’ȱ exposureȱ groups,ȱ whichȱ includedȱ individualsȱ thatȱ residedȱ inȱ orȱ frequentlyȱ visitedȱ Vancouver’’sȱdrugȱuseȱepicenterȱandȱspentȱonȱaverageȱbetweenȱ2Ȭ6,ȱ7Ȭ15,ȱandȱmoreȱthanȱ 15ȱhoursȱonȱtheȱstreetȱeachȱdayȱoverȱtheȱlastȱsixȱmonths,ȱrespectively.ȱ Explanatoryȱ variablesȱ ofȱ interestȱ includedȱ socioȬdemographicȱ information:ȱ genderȱ (femaleȱ vs.ȱ male),ȱ ageȱ (perȱ yearȱ older),ȱ Aboriginalȱ ancestryȱ (yesȱ vs.ȱ no)ȱ andȱ unstableȱhousing,ȱdefinedȱasȱlivingȱinȱaȱsingleȱoccupancyȱroomȱinȱhotel,ȱaȱtreatmentȱorȱ recoveryȱhouse,ȱjail,ȱshelterȱorȱhostel,ȱorȱhavingȱnoȱfixedȱaddressȱforȱtheȱlastȱsixȱmonthsȱ (yesȱvs.ȱno).ȱDrugȱuseȱandȱriskȱbehaviourȱvariablesȱconsideredȱreferȱtoȱbehavioursȱinȱtheȱ pastȱsixȱmonthsȱandȱincluded:ȱdailyȱcocaineȱinjectionȱ(yesȱvs.ȱno),ȱdailyȱheroinȱinjectionȱ (yesȱ vs.ȱ no),ȱ dailyȱ crackȱ cocaineȱ smokingȱ (yesȱ vs.ȱ no),ȱ nonȬfatalȱ overdoseȱ (yesȱ vs.ȱ no),ȱ andȱsyringeȱsharingȱdefinedȱasȱborrowingȱorȱlendingȱsyringesȱalreadyȱusedȱbyȱsomeoneȱ elseȱ toȱ injectȱ drugsȱ (yesȱ vs.ȱ no).ȱ Otherȱ factorsȱ consideredȱ included:ȱ encountersȱ withȱ ȱ  53  ȱ  policeȱ inȱ theȱ lastȱ month,ȱ definedȱ asȱ beingȱ questioned,ȱ searchedȱ orȱ stoppedȱ byȱ policeȱ (yesȱ vs.ȱ no),ȱ beingȱ aȱ victimȱ ofȱ violence,ȱ definedȱ asȱ beingȱ physicallyȱ assaultedȱ (yesȱ vs.ȱ no),ȱhavingȱmultipleȱsexȱpartnersȱ(yesȱvs.ȱno),ȱengagingȱinȱanyȱunprotectedȱsexȱ(yesȱvs.ȱ no),ȱhavingȱregularȱemployment,ȱdefinedȱasȱhavingȱaȱregularȱorȱtemporaryȱjobȱ(yesȱvs.ȱ no),ȱ sexȱ tradeȱ involvement,ȱ definedȱ asȱ exchangingȱ sexȱ forȱ money,ȱ shelter,ȱ drugsȱ orȱ otherȱ commoditiesȱ (yesȱ vs.ȱ no),ȱ participationȱ inȱ drugȱ dealingȱ (yesȱ vs.ȱ no),ȱ andȱ participationȱ inȱ anyȱ addictionȱ treatmentȱ program,ȱ definedȱ asȱ reportingȱ beingȱ enrolledȱ inȱ methadoneȱ treatment,ȱ aȱ detoxificationȱ program,ȱ aȱ recoveryȱ house,ȱ aȱ residentialȱ addictionȱtreatmentȱcentreȱorȱengagingȱwithȱanȱaddictionsȱcounselorȱorȱparticipatingȱinȱ peerȱ supportȱ programsȱ suchȱ asȱ Narcoticsȱ Anonymousȱ (yesȱ vs.ȱ no).ȱ Unlessȱ otherwiseȱ stated,ȱ allȱ behaviouralȱ variablesȱ referȱ toȱ theȱ previousȱ sixȱ months.ȱ Toȱ accountȱ forȱ aȱ potentialȱseasonalȱinfluenceȱonȱtheȱamountȱofȱtimeȱindividualsȱspendȱonȱtheȱstreet,ȱweȱ alsoȱincludedȱaȱcategoricalȱvariableȱrepresentingȱtheȱmonthȱthatȱparticipantsȱcompletedȱ ourȱ study.ȱ Thisȱ helpedȱ ensureȱ thatȱ ourȱ analysisȱ adjustedȱ forȱ seasonalȱ variationsȱ inȱ responses.ȱ Toȱ identifyȱ factorsȱ associatedȱ withȱ drugȱ sceneȱ exposureȱ andȱ considerȱ whetherȱ theȱlevelȱofȱexposureȱwasȱassociatedȱwithȱvaryingȱdegreesȱofȱvulnerabilityȱtoȱharmȱandȱ adverseȱhealthȱoutcomes,ȱweȱconstructedȱthreeȱseparateȱregressionȱmodels.ȱAllȱmodelsȱ usedȱ theȱ ‘‘noȱ exposure’’ȱ categoryȱ asȱ theȱ referenceȱ category.ȱ Theȱ firstȱ modelȱ consideredȱ theȱ ‘‘lowȱ exposure’’ȱ category,ȱ theȱ secondȱ modelȱ consideredȱ theȱ ‘‘moderateȱ exposure’’ȱ  ȱ  54  ȱ  categoryȱandȱtheȱthirdȱmodelȱconsideredȱtheȱ‘‘highȱexposure’’ȱcategoryȱasȱtheȱexposureȱ ofȱinterest.ȱ Sinceȱ analysesȱ ofȱ factorsȱ potentiallyȱ associatedȱ withȱ ourȱ outcomesȱ ofȱ interestȱ includedȱ serialȱ measuresȱ forȱ eachȱ subject,ȱ weȱ usedȱ generalizedȱ estimatingȱ equationsȱ (GEE)ȱ forȱ binaryȱ outcomesȱ withȱ logitȱ linkȱ forȱ theȱ analysisȱ ofȱ correlatedȱ dataȱ toȱ determineȱfactorsȱassociatedȱwithȱeachȱlevelȱofȱdrugȱsceneȱexposureȱthroughoutȱtheȱ40Ȭ monthȱ followȬupȱ period.194ȱ Theseȱ methodsȱ providedȱ standardȱ errorsȱ adjustedȱ byȱ multipleȱ observationsȱ perȱ personȱ usingȱ anȱ exchangeableȱ correlationȱ structure.ȱ Therefore,ȱdataȱfromȱeveryȱparticipantȱfollowȬupȱvisitȱwereȱconsideredȱinȱtheseȱanalysesȱ andȱweȱwereȱableȱtoȱaccommodateȱchangesȱinȱcategoriesȱoverȱtime.ȱMissingȱdataȱwereȱ addressedȱ throughȱ theȱ GEEȱ estimatingȱ mechanismȱ whichȱ usesȱ allȱ availableȱ pairsȱ method.ȱ Allȱ nonȬmissingȱ pairsȱ ofȱ dataȱ areȱ usedȱ inȱ theȱ estimatorsȱ ofȱ theȱ workingȱ correlationȱparameters.ȱȱ Asȱ aȱ firstȱ step,ȱ GEEȱ univariateȱ analysesȱ wereȱ conductedȱ toȱ obtainȱ unadjustedȱ oddsȱratiosȱandȱ95%ȱconfidenceȱintervalsȱforȱvariablesȱofȱinterestȱandȱeachȱlevelȱofȱdrugȱ sceneȱ exposure.ȱ Inȱ orderȱ toȱ adjustȱ forȱ potentialȱ confounding,ȱ allȱ variablesȱ thatȱ wereȱ associatedȱ withȱ theȱ dependentȱ variableȱ atȱ pȱ <ȱ 0.05ȱ inȱ GEEȱ univariateȱ analysesȱ wereȱ enteredȱinȱeachȱmultivariateȱlogisticȱGEEȱmodel.ȱAlthoughȱallȱmultivariateȱmodelsȱwereȱ runȱ independently,ȱ allȱ variablesȱ thatȱ reachedȱ significanceȱ atȱ anyȱ levelȱ ofȱ drugȱ sceneȱ exposureȱinȱunivariateȱanalysesȱwereȱincludedȱinȱeachȱmultivariateȱmodel.ȱThisȱwasȱtoȱ  ȱ  55  ȱ  ensureȱ thatȱallȱ threeȱmodelsȱadjustedȱforȱtheȱ sameȱvariablesȱallowingȱforȱcomparisonsȱ betweenȱ multivariateȱ models.ȱ Allȱ statisticalȱ analysesȱ wereȱ performedȱ usingȱ SASȱ softwareȱversionȱ9.1ȱ(SAS,ȱCary,ȱNC).ȱȱAllȱpȬvaluesȱareȱtwoȱsided.ȱ  3.3 Resultsȱ Duringȱtheȱstudyȱperiodȱaȱtotalȱofȱ1,486ȱparticipantsȱcompletedȱfollowȬupȱvisits,ȱ includingȱ 527ȱ (35%)ȱ womenȱ andȱ 497ȱ (33%)ȱ personsȱ whoȱ identifiedȱ asȱ beingȱ ofȱ Aboriginalȱ ancestry.ȱ Theȱ medianȱ ageȱ ofȱ participantsȱ atȱ baselineȱ wasȱ 42ȱ yearsȱ (interquartileȱ rangeȱ [IQR]ȱ =ȱ 35Ȭ48).ȱ Thisȱ sampleȱ contributedȱ 3,994ȱ observations:ȱ 1,237ȱ observationsȱ fitȱ theȱ criteriaȱ forȱ noȱ exposure,ȱ 1,121ȱ observationsȱ fitȱ theȱ criteriaȱ forȱ lowȱ exposure,ȱ779ȱobservationsȱfitȱtheȱcriteriaȱforȱmoderateȱexposureȱandȱ757ȱobservationsȱ fitȱtheȱcriteriaȱforȱhighȱdrugȱsceneȱexposure.ȱTheȱmedianȱnumberȱofȱfollowȬupȱvisitsȱwasȱ 3ȱ (IQR=ȱ 2Ȭ4),ȱ andȱ 1157ȱ (77.9%)ȱ participantsȱ completedȱ atȱ leastȱ twoȱ studyȱ visits.ȱ Theȱ baselineȱ characteristicsȱ ofȱ theȱ studyȱ sampleȱ stratifiedȱ byȱ levelȱ ofȱ drugȱ sceneȱ exposureȱ areȱ presentedȱ inȱ Tableȱ 3.1.ȱ Inȱ thisȱ baselineȱ table,ȱ characteristicsȱ forȱ individualsȱ fittingȱ theȱ criteriaȱ forȱ eitherȱ low,ȱ moderateȱ orȱ highȱ drugȱ sceneȱ exposureȱ wereȱ measuredȱ atȱ theirȱfirstȱvisitȱ(duringȱtheȱstudyȱperiod,ȱDecȱ2005ȱ––Marchȱ2009)ȱwhichȱinvolvedȱaȱreportȱ ofȱlow,ȱmoderateȱorȱhighȱdrugȱsceneȱexposure.ȱCharacteristicsȱforȱparticipantsȱinȱtheȱ‘‘noȱ exposure’’ȱcategoryȱwereȱmeasuredȱfromȱtheȱfirstȱstudyȱvisitȱduringȱtheȱstudyȱperiod.ȱ TheȱunivariateȱGEEȱanalysesȱofȱbehaviouralȱandȱsocioȬdemographicȱvariablesȱareȱ presentedȱinȱTableȱ3.2,ȱandȱtheȱmultivariateȱGEEȱanalysesȱareȱshownȱinȱTableȱ3.3.ȱFigureȱ ȱ  56  ȱ  3.1ȱ showsȱ aȱ selectionȱ ofȱ behaviouralȱ andȱ drugȱ useȱ factorsȱ associatedȱ withȱ eachȱ ofȱ theȱ threeȱ levelsȱ ofȱ drugȱ sceneȱ exposureȱ (note:ȱ unstableȱ housingȱ wasȱ notȱ includedȱ inȱ theȱ figureȱ dueȱ toȱ theȱ largeȱ scaleȱ differenceȱ inȱ AOR).ȱ Inȱ multivariateȱ analyses,ȱ unstableȱ housingȱ wasȱ significantlyȱ associatedȱ withȱ allȱ levelsȱ ofȱ drugȱ sceneȱ exposureȱ andȱ theȱ strengthȱ ofȱ theȱ associationȱ increasedȱ fromȱ lowȱ (adjustedȱ oddsȱ ratioȱ [AOR]ȱ =ȱ 3.10,ȱ CI:ȱ 2.52––3.80)ȱ toȱ moderateȱ (AORȱ =ȱ 3.73,ȱ CI:ȱ 2.92––4.77)ȱ toȱ highȱ exposureȱ (AORȱ =ȱ 9.50,ȱ CI:ȱ 6.36––14.20).ȱ Similarly,ȱ theȱ associationsȱ betweenȱ drugȱ sceneȱ exposureȱ andȱ drugȱ useȱ practicesȱ increasedȱ withȱ levelȱ ofȱ exposure.ȱ Dailyȱ crackȱ cocaineȱ useȱ wasȱ significantlyȱ associatedȱ withȱ allȱ levelsȱ ofȱ drugȱ sceneȱ exposureȱ andȱ thisȱ associationȱ increasedȱ fromȱ lowȱ(AORȱ=1.49,ȱCI:ȱ1.20Ȭ1.85)ȱtoȱmoderateȱ(AORȱ=1.90,ȱCI:ȱ1.50Ȭ2.40)ȱtoȱhighȱexposureȱ (AORȱ =2.70,ȱ CI:ȱ 2.07Ȭ3.52).ȱ Dailyȱ heroinȱ injectionȱ wasȱ notȱ significantlyȱ associatedȱ withȱ lowȱdrugȱsceneȱexposureȱ(AORȱ=0.82,ȱCI:ȱ0.63Ȭ1.08),ȱbutȱbecameȱsignificantlyȱassociatedȱ withȱ moderateȱ exposureȱ (AORȱ =1.43,ȱ CI:ȱ 1.07Ȭ1.91),ȱ andȱ theȱ strengthȱ ofȱ associationȱ increasedȱwithȱhighȱexposureȱ(AORȱ=1.84,ȱCI:ȱ1.37Ȭ2.47).ȱDailyȱcocaineȱinjectionȱwasȱnotȱ significantlyȱ associatedȱ withȱ lowȱ (AORȱ =0.87,ȱ CI:ȱ 0.60Ȭ1.26)ȱ orȱ moderateȱ drugȱ sceneȱ exposureȱ(AORȱ=1.09,ȱCI:ȱ0.72Ȭ1.64)ȱbutȱbecameȱsignificantȱwithȱhighȱexposureȱ(AORȱ=ȱ 1.73,ȱCI:ȱ1.15Ȭ2.61).ȱLikewise,ȱbeingȱaȱvictimȱofȱviolence,ȱhavingȱencountersȱwithȱpolice,ȱ andȱinvolvementȱinȱdrugȱdealingȱwereȱnotȱassociatedȱwithȱlowȱdrugȱsceneȱexposureȱbutȱ becameȱ significantȱ forȱ bothȱ moderateȱ andȱ highȱ exposureȱ (seeȱ Tableȱ 3.3).ȱ Aboriginalȱ ancestryȱalsoȱwasȱnotȱsignificantlyȱassociatedȱwithȱlowȱdrugȱsceneȱexposureȱbutȱbecameȱ significantȱ withȱ bothȱ moderateȱ andȱ highȱ exposure.ȱ Regularȱ employmentȱ wasȱ ȱ  57  ȱ  significantlyȱ negativelyȱ associatedȱ withȱ allȱ levelsȱ ofȱ drugȱ sceneȱ exposure.ȱ Althoughȱ addictionȱ treatmentȱ wasȱ notȱ significantlyȱ associatedȱ withȱ lowȱ drugȱ sceneȱ exposure,ȱ itȱ becameȱsignificantlyȱnegativelyȱassociatedȱwithȱmoderateȱandȱhighȱexposure.ȱȱ  3.4 Discussionȱ Inȱ thisȱ studyȱ weȱ foundȱ thatȱ drugȱ sceneȱ exposureȱ wasȱ associatedȱ inȱ aȱ doseȬ dependentȱfashionȱwithȱmultipleȱmarkersȱofȱvulnerabilityȱtoȱharmȱandȱadverseȱhealthȱ outcomes,ȱ includingȱ beingȱ unstablyȱ housed,ȱ beingȱ aȱ victimȱ ofȱ violence,ȱ havingȱ encountersȱwithȱpoliceȱandȱparticipatingȱinȱdrugȱdealing.ȱDrugȱsceneȱexposureȱwasȱalsoȱ associatedȱwithȱhigherȱintensityȱdrugȱuse.ȱIndividualsȱwhoȱreportedȱhighȱlevelsȱofȱdrugȱ sceneȱ exposureȱ wereȱ significantlyȱ moreȱ likelyȱ toȱ injectȱ cocaineȱ andȱ heroinȱ onȱ aȱ dailyȱ basis,ȱ andȱ dailyȱ crackȱ cocaineȱ smokingȱ wasȱ significantlyȱ associatedȱ withȱ allȱ levelsȱ ofȱ drugȱ sceneȱ exposure.ȱ Theseȱ associations,ȱ inȱ mostȱ instances,ȱ alsoȱ increasedȱ inȱ aȱ doseȬ dependentȱ fashionȱ withȱ greaterȱ exposureȱ toȱ drugȱ scenes.ȱ Theȱ doseȬdependentȱ effectȱ wasȱparticularlyȱstrongȱforȱunstableȱhousing,ȱintensityȱofȱdrugȱuseȱandȱencountersȱwithȱ police.ȱ Ourȱ analysisȱ furtherȱ foundȱ thatȱ employmentȱ andȱ addictionȱ treatmentȱ wereȱ associatedȱwithȱdecreasedȱdrugȱsceneȱexposure.ȱȱ Ourȱ findingȱ thatȱ peopleȱ withȱ greaterȱ levelsȱ ofȱ drugȱ sceneȱ exposureȱ wereȱ moreȱ likelyȱ toȱ beȱ higherȱ intensityȱ drugȱ usersȱ andȱ haveȱ multipleȱ markersȱ ofȱ vulnerabilityȱ isȱ consistentȱ withȱ aȱ broaderȱ literatureȱ highlightingȱ theȱ relationshipȱ betweenȱ structuralȱ environmentalȱfactorsȱ(i.e.,ȱdrugȱuseȱsettingsȱandȱtheȱlawsȱandȱpoliciesȱregulatingȱdrugȱ ȱ  58  ȱ  use)ȱ andȱ healthȱ behavioursȱ andȱ outcomes.71,ȱ 73,ȱ 75Ȭ78,ȱ 78,ȱ 79,ȱ 84,ȱ 190,ȱ 195Ȭ197ȱ ȱ However,ȱ previousȱ workȱlookingȱatȱtheȱimpactȱofȱdrugsȱscenesȱhasȱhistoricallyȱfocusedȱonȱinvolvementȱinȱ drugȱscenesȱinȱtheȱcontextȱofȱspecificȱbehavioursȱsuchȱasȱincomeȱgenerationȱacts,4,ȱ7,ȱ10,ȱ57Ȭ59ȱ publicȱ injecting61Ȭ65ȱ andȱ drugȱ sceneȱ roles.186ȱ ȱ Ourȱ studyȱ isȱ uniqueȱ inȱ thatȱ itȱ considersȱ exposureȱtoȱdrugȱscenesȱindependentȱofȱengagementȱinȱspecificȱactivities.ȱȱ Aȱ keyȱ implicationȱ ofȱ ourȱ findingsȱ isȱ thatȱ theȱ negativeȱ impactsȱ ofȱ streetȬbasedȱ drugȱ scenesȱ areȱ notȱ feltȱ onlyȱ byȱ surroundingȱ communitiesȱ andȱ theȱ generalȱ public.ȱ Rather,ȱstreetȬbasedȱdrugȱscenesȱhaveȱsignificantȱnegativeȱhealthȱandȱsocialȱimplicationsȱ forȱpeopleȱwhoȱareȱexposedȱtoȱthem,ȱandȱtheseȱnegativeȱeffectsȱappearȱtoȱincreaseȱwithȱ greaterȱ levelsȱ ofȱ drugȱ sceneȱ exposure.ȱ ȱ Thisȱ suggestsȱ thatȱ effortsȱ toȱ reduceȱ streetȱ disorderȱhaveȱpotentialȱtoȱbenefitȱpeopleȱwhoȱareȱengagedȱinȱdrugȱscenes,ȱasȱwellȱasȱtheȱ broaderȱcommunity.ȱ  ȱ  Itȱ isȱ importantȱ toȱ recognizeȱ that,ȱ toȱ date,ȱ interventionsȱ toȱ addressȱ drugȬrelatedȱ streetȱdisorderȱhaveȱlargelyȱreliedȱonȱlawȱenforcementȱbasedȱapproachesȱthatȱhaveȱbeenȱ shownȱtoȱbeȱlimitedȱinȱtheirȱabilityȱtoȱmeaningfullyȱaddressȱstreetȱdisorder.62,ȱ 63,ȱ 69,ȱ106,ȱ110,ȱ 198Ȭ200  ȱȱFurthermore,ȱmanyȱlawȱenforcementȱbasedȱstrategiesȱhaveȱalsoȱbeenȱlinkedȱwithȱ  negativeȱ individualȱ andȱ communityȱ outcomes.59,ȱ 59,ȱ 107,ȱ 111,ȱ 133ȱ ȱ Innovativeȱ solutionsȱ thatȱ bothȱ reduceȱ drugȬrelatedȱ streetȱ disorderȱ andȱ protectȱ theȱ healthȱ ofȱ peopleȱ whoȱ areȱ engagedȱinȱdrugȱscenesȱareȱthereforeȱrequired.ȱȱ  ȱ  59  ȱ  Inȱtheȱcurrentȱanalysis,ȱtheȱrelationshipȱbetweenȱemploymentȱandȱreducedȱdrugȱ sceneȱ exposureȱ isȱ consistentȱ withȱ previousȱ researchȱ demonstratingȱ theȱ positiveȱ influenceȱofȱemploymentȱonȱsocialȱintegrationȱandȱhealthȱoutcomes172,ȱ201Ȭ203ȱandȱsuggestsȱ thatȱ interventionsȱ inȱ thisȱ areaȱ mayȱ helpȱ toȱ addressȱ streetȱ disorderȱ andȱ drugȱ sceneȱ exposure.ȱ ȱ However,ȱ existingȱ employmentȱ programsȱ forȱ peopleȱ whoȱ useȱ drugsȱ areȱ oftenȱlinkedȱwithȱaddictionȱtreatmentȱobjectivesȱandȱintendedȱtoȱengageȱparticipantsȱinȱ regularȱ steadyȱ employmentȱ andȱ abstinenceȱ fromȱ illicitȱ drugȱ use.172,ȱ  204  ȱ ȱ Theseȱ  programmaticȱ conditionsȱ andȱ goalsȱ areȱ notȱ suitableȱ orȱ realisticȱ forȱ manyȱ streetȱ entrenchedȱ drugȱ users.170,ȱ 175ȱ ȱ Alternatively,ȱ lowȬthresholdȱ employmentȱ programsȱ thatȱ doȱ notȱ requireȱ abstinenceȱ fromȱ drugȱ useȱ mayȱ provideȱ importantȱ benefitsȱ forȱ IDU,ȱ includingȱ aȱ reductionȱ inȱ exposureȱ toȱ streetȬbasedȱ drugȱ scenes.175,ȱ 205,ȱ 206ȱ ȱ Theȱ potentialȱ relationshipȱ betweenȱ streetȱ disorderȱ andȱ lowȬthresholdȱ employmentȱ isȱ anȱ areaȱ thatȱ shouldȱbeȱconsideredȱforȱfutureȱstudy.ȱ Ourȱ findingsȱ relatedȱ toȱ unstableȱ housingȱ provideȱ additionalȱ directionȱ forȱ theȱ developmentȱ ofȱ policyȱ optionsȱ thatȱ mightȱ helpȱ toȱ addressȱ exposureȱ toȱ streetȱ disorder.ȱ Specifically,ȱ providingȱ stableȱ housingȱ toȱ homelessȱ peopleȱ whoȱ useȱ drugsȱ isȱ oneȱ promisingȱapproachȱtoȱdecreaseȱstreetȱdisorderȱandȱexposureȱtoȱdrugȱscenes.ȱHowever,ȱ itȱisȱnotableȱthatȱinȱadditionȱtoȱoutrightȱhomelessnessȱourȱdefinitionȱofȱunstableȱhousingȱ includedȱ livingȱ inȱ singleȱ roomȱ occupancyȱ hotelsȱ asȱ wellȱ asȱ treatmentȱ andȱ recoveryȱ homes,ȱsuggestingȱthatȱitȱisȱnotȱjustȱpeopleȱwhoȱareȱhomelessȱwhoȱareȱgeneratingȱstreetȱ disorder.ȱ Forȱ instance,ȱ spaceȱ constraintsȱ andȱ regulatoryȱ policiesȱ withinȱ singleȱ roomȱ ȱ  60  ȱ  occupancyȱ hotelsȱ andȱ recoveryȱ housesȱ (i.e.,ȱ guestȱ fees,ȱ andȱ bansȱ onȱ substanceȱ useȱ and/orȱintoxicationȱonȱtheȱpremises)ȱmayȱdeterȱdrugȱusersȱfromȱspendingȱtimeȱinȱtheirȱ placeȱofȱresidenceȱandȱtherebyȱcontributeȱtoȱstreetȱdisorder.207ȱȱFurtherȱexaminationȱofȱ theȱ roleȱ thatȱ spaceȱ constraintsȱ andȱ restrictiveȱ regulatoryȱ policiesȱ mayȱ playȱ inȱ encouragingȱexposureȱtoȱdrugȱscenesȱwouldȱbeȱbeneficial.ȱȱ Finally,ȱ ourȱ findingȱ thatȱ thoseȱ moreȱ involvedȱ inȱ theȱ localȱ drugȱ sceneȱ wereȱ lessȱ likelyȱtoȱbeȱreceivingȱaddictionȱtreatmentȱsuggestsȱthatȱeffortsȱtoȱencourageȱaccessȱandȱ engagementȱ inȱ addictionȱ treatmentȱ mayȱ furtherȱ helpȱ toȱ reduceȱ streetȱ disorder.ȱ Innovativeȱ addictionȱ treatmentȱ methodsȱ mayȱ beȱ requiredȱ asȱ theȱ longȬtermȱ drugȱ useȱ patternsȱ ofȱ IDUȱ suggestȱ thatȱ currentȱ treatmentȱ modalitiesȱ haveȱ limitedȱ successȱ inȱ sustainingȱ injectionȱ cessationȱ amongȱ aȱ largeȱ proportionȱ ofȱ establishedȱ injectionȱ drugȱ users.166ȱ Furthermore,ȱ theȱ rapidȱ increaseȱ inȱ crackȱ cocaineȱ useȱ inȱ ourȱ studyȱ settingȱ andȱ elsewhereȱsuggestsȱthatȱaddictionȱtreatmentȱforȱstimulantȱusersȱisȱanȱemergingȱpriority.ȱ Inȱ theȱ Vancouverȱ setting,ȱ ourȱ analysisȱ alsoȱ suggestsȱ thatȱ toȱ beȱ effective,ȱ interventionsȱ mustȱbeȱculturallyȱsensitiveȱandȱappropriateȱforȱAboriginalȱpeopleȱwhoȱuseȱdrugs.ȱȱThisȱ willȱ likelyȱ requireȱ tailoringȱ interventionsȱ withȱ theȱ directȱ inputȱ ofȱ drugȱ usersȱ whoȱ identifyȱasȱbeingȱofȱAboriginalȱancestry.ȱȱȱ Thereȱ areȱ aȱ numberȱ ofȱ limitationsȱ inȱ ourȱ study.ȱ Firstly,ȱ ourȱ studyȱ sampleȱ wasȱ communityȱ recruitedȱ andȱ notȱ aȱ randomȱ sampleȱ ofȱ peopleȱ whoȱ injectȱ drugs.ȱ Itȱ is,ȱ however,ȱ believedȱ toȱ beȱ reflectiveȱ ofȱ theȱ populationȱ ofȱ injectionȱ drugȱ usersȱ inȱ theȱ  ȱ  61  ȱ  community.208ȱȱSecondly,ȱalthoughȱtheȱcurrentȱstudyȱshowsȱthatȱdrugȱsceneȱexposureȱisȱ associatedȱ withȱ multipleȱ riskȱ factorsȱ forȱ negativeȱ healthȱ outcomes,ȱ theȱ natureȱ ofȱ ourȱ observationalȱ studyȱ canȱ notȱ untangleȱ whetherȱ theseȱ relationshipsȱ areȱ revealingȱ antecedentȱ causes,ȱ orȱ consequencesȱ ofȱ exposureȱ toȱ drugȱ scenes.ȱ ȱ Withȱ respectȱ toȱ antecedentȱ causes,ȱ theȱ relationshipȱ betweenȱ housingȱ andȱ drugȱ sceneȱ exposureȱ isȱ consistentȱ withȱ aȱ wellȱ establishedȱ literatureȱ demonstratingȱ thatȱ housingȱ isȱ aȱ keyȱ influenceȱonȱhealthȱstatusȱamongȱdrugȱusingȱpopulations.183,ȱ 209Ȭ211ȱInȱourȱstudyȱcontext,ȱ unstableȱ housingȱ conditionsȱ (whichȱ includedȱ outrightȱ homelessness)ȱ mayȱ leadȱ toȱ exposureȱtoȱandȱimmersionȱinȱopenȱdrugȱscenes.ȱHowever,ȱindividualsȱwhoȱareȱstablyȱ housedȱmayȱbecomeȱinvolvedȱinȱopenȱdrugȱscenesȱthroughȱotherȱmechanismsȱandȱthisȱ immersionȱ mayȱ haveȱ aȱ destabilizingȱ influenceȱ thatȱ couldȱ leadȱ toȱ deteriorationȱ inȱ housingȱstatus.ȱSimilarly,ȱourȱanalysesȱcanȱnotȱdetermineȱwhetherȱtheȱelevatedȱintensityȱ ofȱdrugȱuseȱthatȱcoincidesȱwithȱexposureȱisȱbecauseȱhighȱintensityȱdrugȱuseȱpredisposesȱ individualsȱ toȱ becomeȱ immersedȱ inȱ openȱ drugȱ scenes,ȱ orȱ ifȱ exposureȱ toȱ drugȱ scenesȱ leadsȱ toȱ heightenedȱ drugȱ use.ȱ ȱ However,ȱ despiteȱ uncertaintyȱ regardingȱ theȱ causalȱ directionȱ ofȱ theȱ observedȱ relationships,ȱ itȱ remainsȱ clearȱ thatȱ exposureȱ toȱ streetȬbasedȱ drugȱscenesȱisȱassociatedȱwithȱpublicȱhealthȱharms.ȱAnotherȱlimitationȱofȱourȱstudyȱisȱ thatȱseveralȱofȱourȱmeasuresȱareȱbasedȱonȱselfȬreportingȱandȱareȱthereforeȱvulnerableȱtoȱ sociallyȱ desirableȱ respondingȱ andȱ recallȱ bias.ȱ Inȱ theȱ currentȱ studyȱ sociallyȱ desirableȱ respondingȱmayȱhaveȱledȱtoȱanȱunderestimationȱofȱriskȱbehaviourȱandȱexposureȱtoȱdrugȱ scenesȱ suggestingȱ thatȱ ourȱ estimatesȱ areȱ conservative.ȱ Althoughȱ recallȱ issuesȱ areȱ ȱ  62  ȱ  particularlyȱrelevantȱtoȱourȱmeasuresȱforȱexposureȱtoȱstreetȱdisorder,ȱweȱhaveȱnoȱreasonȱ toȱ suspectȱ thisȱ wouldȱ systematicallyȱ differȱ amongȱ exposuresȱ ofȱ interest.ȱ Therefore,ȱ ifȱ recallȱissuesȱareȱpresentȱweȱwouldȱsuspectȱthisȱwouldȱbiasȱourȱresultsȱtowardsȱtheȱnull.ȱȱȱȱ Inȱ summary,ȱ increasedȱ exposureȱ toȱ streetȬbasedȱ drugȱ scenesȱ isȱ associatedȱ withȱ increasedȱvulnerabilityȱandȱintensityȱofȱaddiction,ȱsuggestingȱthatȱbothȱindividualȱdrugȱ usersȱ andȱ surroundingȱ communitiesȱ areȱ negativelyȱ impactedȱ byȱ streetȱ disorder.ȱ Thisȱ suggestsȱ thatȱ reducingȱ streetȱ disorderȱ andȱ exposureȱ toȱ itȱ canȱ haveȱ aȱ wideȱ rangeȱ ofȱ publicȱ healthȱ andȱ communityȱ benefits.ȱ Theseȱ findingsȱ highlightȱ importantȱ opportunitiesȱforȱpolicyȱinterventionsȱtoȱaddressȱexposureȱtoȱstreetȱdisorderȱinȱtheȱareasȱ ofȱemployment,ȱhousingȱandȱaddictionȱtreatment.ȱȱ  ȱ  63  ȱ  Tableȱ3.1ȱBaselineȱcharacteristicsȱofȱsampleȱstratifiedȱbyȱlevelȱofȱdrugȱsceneȱexposureȱ [nȱ=ȱ1486]ȱ Levelȱofȱdrugȱsceneȱexposureȱa Characteristicȱ ȱ b  NoȱExposureȱ  LowȱExposureȱ  n=ȱ490,ȱnȱ(%)ȱ  n=ȱ405,ȱnȱ(%)ȱ  Medianȱageȱ(IQR)ȱȱ  43ȱ(36Ȭ49)  43ȱ(38Ȭ49)  FemaleȱGenderȱȱ  183ȱ (37)  AboriginalȱAncestryȱȱ UnstableȱHousingȱcȱȱ  ModerateȱExpo.ȱ n=ȱ277,ȱnȱ(%)ȱ  Highȱ Exposureȱ n=ȱ314,ȱnȱ(%)ȱ  42ȱ(35Ȭ48)  38ȱ(31Ȭ44)  136ȱ (34)  91ȱ (33)  117ȱ (37)  139ȱ (28)  129ȱ (32)  98ȱ (35)  131ȱ (42)  219ȱ (45)  325ȱ (80)  237ȱ (86)  302ȱ (96)  DailyȱCocaineȱInjectȱcȱ  36ȱ (7)  28ȱ (7)  29ȱ (10)  53ȱ (17)  DailyȱHeroinȱInjectȱcȱ  79ȱ (16)  70ȱ (17)  88ȱ (32)  149ȱ (47)  119ȱ (24)  146ȱ (36)  152ȱ (55)  212ȱ (68)  Overdoseȱ(nonȬfatal)ȱcȱ  25ȱ (5)  16ȱ (4)  21ȱ (8)  31ȱ (10)  SyringeȱSharingȱcȱ  46ȱ (9)  24ȱ (6)  17ȱ (6)  33ȱ (11)  Encountersȱw/ȱPoliceȱdȱ  80ȱ (16)  92ȱ (23)  106ȱ (38)  144ȱ (46)  VictimȱofȱViolenceȱcȱ  58ȱ (12)  83 (20)  79ȱ (29)  93ȱ (30)  MultipleȱSexȱPartnerȱcȱ  64ȱ (13)  69ȱ (17)  64ȱ (23)  75ȱ (24)  UnprotectedȱSexȱcȱ  161ȱ (33)  123ȱ (30)  89ȱ (32)  87ȱ (28)  RegȱEmploymentȱcȱ  175ȱ (36)  88ȱ (22)  62ȱ (22)  45ȱ (14)  SexȱWorkȱcȱ  38ȱ (8)  59ȱ (15)  48ȱ (17)  58ȱ (18)  DrugȱDealingȱcȱ  90ȱ (18)  98ȱ (24)  112ȱ (40)  169ȱ (54)  InȱTreatmentȱcȱ  277ȱ (57)  222ȱ (55)  115ȱ (42)  120ȱ (38)  DailyȱCrackȱUseȱcȱ  Notes:ȱ ȱLevelsȱofȱdrugȱsceneȱexposureȱwereȱdefinedȱbasedȱonȱtheȱaverageȱnumberȱofȱhoursȱparticipantsȱ reportedȱspendingȱonȱtheȱstreetȱeachȱdayȱinȱVancouver’’sȱdrugȱuseȱepicenterȱinȱtheȱpreviousȱsixȱmonths:ȱ ””noȱ drugȱ sceneȱ exposure””ȱ includedȱ reportsȱ ofȱ 1ȱ hourȱ orȱ less;ȱ ““lowȱ exposure””ȱ includedȱ reportsȱ ofȱ 2Ȭ6ȱ hours;ȱ ““moderateȱ exposure””ȱ includedȱ reportsȱ ofȱ 7Ȭ15ȱ hours;ȱ andȱ ““highȱ exposure””ȱ includedȱ reportsȱ ofȱ moreȱthanȱ15ȱhours.ȱbCharacteristicsȱforȱindividualsȱinȱtheȱlow,ȱmoderateȱandȱhighȱdrugȱsceneȱexposureȱ categoriesȱ wereȱ measuredȱ atȱ theirȱ firstȱ visitȱ (duringȱ theȱ studyȱ period,ȱ Decȱ 2005ȱ ––Marchȱ 2009)ȱ whichȱ involvedȱaȱreportȱofȱdrugȱsceneȱexposure.ȱCharacteristicsȱforȱparticipantsȱinȱtheȱ‘‘noȱexposure’’ȱcategoryȱ wereȱ measuredȱ fromȱ theȱ firstȱ studyȱ visitȱ duringȱ theȱ studyȱ period;ȱ cȱ Denotesȱ activitiesȱ orȱ situationsȱ referringȱtoȱpreviousȱ6ȱmonths;ȱdȱDenotesȱactivitiesȱorȱsituationsȱreferringȱtoȱpreviousȱmonth. a  ȱ  ȱ  64  ȱ  Tableȱ3.2ȱUnivariateȱanalysesȱofȱfactorsȱassociatedȱwithȱdrugȱsceneȱexposure*ȱ ȱ Characteristicȱ  GEEaȱforȱLowȱvs.ȱNoȱ Exposureȱ ORȱ(95%ȱCI)ȱbȱ  ȱ  pȬvalue  GEEȱforȱModerateȱvs.ȱ NoȱExposureȱ ORȱ(95%ȱCI)ȱ  ȱ  pȬvalueȱ  GEEȱforȱHighȱvs.ȱNoȱ Exposureȱ ORȱ(95%ȱCI)ȱ  ȱ  pȬvalue  OlderȱAgeȱȱ 0.95ȱ(0.93ȱȬȱ0.96)ȱ <.001ȱ 1.00 (0.99 - 1.02)ȱ 0.457ȱ 0.99ȱ(0.97ȱȬȱ1.00)ȱ 0.017ȱ Perȱyearȱolderȱ ȱ ȱ ȱ ȱ ȱ ȱ Genderȱȱ 0.87 (0.71 - 1.07)ȱ 0.183ȱ 0.95ȱ(0.76ȱȬȱ1.19)ȱ 0.659ȱ 1.03ȱ(0.81ȱȬȱ1.30)ȱ 0.836ȱ ȱ ȱ ȱ ȱ ȱ ȱ Femaleȱvs.ȱMaleȱ AboriginalȱAncestryȱȱ 0.013ȱ 1.52ȱ(1.19ȱȬȱ1.93)ȱ <.001ȱ 1.11 (0.90 - 1.36)ȱ 0.330ȱ 1.34ȱ(1.06ȱȬȱ1.68)ȱ ȱ ȱ ȱ Yesȱvs.ȱNoȱ ȱ ȱ ȱ ȱc UnstableȱHousing ȱ 3.29 (2.71 - 4.01)ȱ <.001ȱ 4.22ȱ(3.36ȱȬȱ5.31)ȱ <.001ȱ 11.25ȱ(7.97Ȭ15.88)ȱ <.001ȱ ȱ ȱ Yesȱvs.ȱNoȱ ȱ ȱ ȱ ȱ DailyȱCocaineȱInjectȱcȱ 1.95ȱ(1.46ȱȬȱ2.59)ȱ <.001ȱ 1.07 (0.76 - 1.51)ȱ 0.680ȱ 1.37ȱ(0.99ȱȬȱ1.91)ȱ 0.060ȱ ȱ ȱ ȱ ȱ Yesȱvs.ȱNoȱ ȱ ȱ <.001ȱ 3.09ȱ(2.45ȱȬȱ3.89)ȱ <.001ȱ DailyȱHeroinȱInjectȱcȱ 0.99 (0.78 - 1.27)ȱ 0.963ȱ 2.19ȱ(1.71ȱȬȱ2.80)ȱ ȱ ȱ ȱ ȱ ȱ ȱ Yesȱvs.ȱNoȱ 1.87 (1.53 - 2.27)ȱ <.001ȱ 2.71ȱ(2.20ȱȬȱ3.33)ȱ <.001ȱ 4.09ȱ(3.32ȱȬȱ5.04)ȱ <.001ȱ DailyȱCrackȱUseȱcȱ ȱ ȱ ȱ ȱ ȱ ȱ Yesȱvs.ȱNoȱ 1.38ȱ(1.04ȱȬȱ1.84)ȱ 0.026ȱ Overdoseȱ(nonȬfatal)ȱcȱ 0.74 (0.49 - 1.12)ȱ 0.152ȱ 1.32ȱ(0.94ȱȬȱ1.87)ȱ 0.108ȱ ȱ ȱ ȱ ȱ Yesȱvs.ȱNoȱ ȱ ȱ ȱc SyringeȱSharing ȱ 0.96 (0.68 - 1.33)ȱ 0.788ȱ 1.19ȱ(0.84ȱȬȱ1.68)ȱ 0.318ȱ 1.16ȱ(0.86ȱȬȱ1.56)ȱ 0.331ȱ ȱ ȱ ȱ ȱ Yesȱvs.ȱNoȱ EncountersȱwithȱPoliceȱdȱ 1.36 (1.10 - 1.69)ȱ 0.004ȱ 2.01ȱ(1.63ȱȬȱ2.48)ȱ <.001ȱ 2.30ȱ(1.88ȱȬȱ2.82)ȱ <.001ȱ ȱ ȱ ȱ Yesȱvs.ȱNoȱ ȱ ȱc VictimȱofȱViolence ȱ <.001ȱ 1.70ȱ(1.42ȱȬȱ2.02)ȱ <.001ȱ 1.22 (0.97 - 1.53)ȱ 0.092ȱ 1.76ȱ(1.45ȱȬȱ2.13)ȱ ȱ ȱ ȱ Yesȱvs.ȱNoȱ ȱ MultipleȱSexȱPartnersȱcȱ 0.019ȱ 1.44ȱ(1.17ȱȬȱ1.78)ȱ <.001ȱ 1.09 (0.86 - 1.38)ȱ 0.477ȱ 1.34ȱ(1.05ȱȬȱ1.72)ȱ ȱ ȱ ȱ Yesȱvs.ȱNoȱ ȱ UnprotectedȱSexȱcȱ 0.88 (0.73 - 1.06)ȱ 0.176ȱ 0.92ȱ(0.76ȱȬȱ1.12)ȱ 0.420ȱ 0.92ȱ(0.76ȱȬȱ1.10)ȱ 0.347ȱ ȱ ȱ ȱ Yesȱvs.ȱNoȱ ȱ 0.67 (0.55 - 0.81)ȱ <.001ȱ 0.61ȱ(0.50ȱȬȱ0.75)ȱ <.001ȱ 0.47ȱ(0.39ȱȬȱ0.57)ȱ <.001ȱ RegularȱEmploymentȱcȱ ȱ ȱ ȱ Yesȱvs.ȱNoȱ ȱ 1.70 (1.29 - 2.23)ȱ <.001ȱ 1.99ȱ(1.50ȱȬȱ2.65)ȱ <.001ȱ 2.09ȱ(1.56ȱȬȱ2.79)ȱ <.001ȱ SexȱWorkȱcȱ ȱ ȱ ȱ Yesȱvs.ȱNoȱ ȱ ȱc DrugȱDealing ȱ 1.37 (1.12 - 1.67)ȱ 0.002ȱ 2.06ȱ(1.66ȱȬȱ2.55)ȱ <.001ȱ 2.91ȱ(2.40ȱȬȱ3.55)ȱ <.001ȱ ȱ ȱ ȱ Yesȱvs.ȱNoȱ ȱ AddictionȱTreatmentȱcȱ 0.003ȱ 0.68ȱ(0.56ȱȬȱ0.82)ȱ <.001ȱ 1.10 (0.92 - 1.30)ȱ 0.293ȱ 0.75ȱ(0.63ȱȬȱ0.91)ȱ ȱ Yesȱvs.ȱNoȱ ȱ ȱ ȱ ȱ ȱ a b cȱ Note:ȱ GEEȱ =ȱ Generalizedȱ Estimatingȱ Equation;ȱ ORȱ =ȱ Oddsȱ Ratio;ȱ CIȱ =ȱ Confidenceȱ Interval;ȱ Denotesȱ activitiesȱorȱsituationsȱreferringȱtoȱpreviousȱ6ȱmonths;ȱ dȱ Denotesȱactivitiesȱorȱsituationsȱreferringȱtoȱpreviousȱ month.*Levelsȱ ofȱ drugȱ sceneȱ exposureȱ wereȱ definedȱ basedȱ onȱ theȱ numberȱ ofȱ hoursȱ participantsȱ reportedȱ spendingȱonȱ averageȱ onȱtheȱstreetȱ eachȱdayȱinȱVancouver’’sȱdrugȱuseȱepicenterȱinȱtheȱpreviousȱsixȱ months:ȱ ””noȱdrugȱsceneȱexposure””ȱincludedȱreportsȱofȱ1ȱhourȱorȱless;ȱ““lowȱexposure””ȱincludedȱreportsȱofȱ2Ȭ6ȱhours;ȱ ““moderateȱexposure””ȱincludedȱreportsȱofȱ7Ȭ15ȱhours;ȱandȱ““highȱexposure””ȱincludedȱreportsȱofȱmoreȱthanȱ15ȱ hours.ȱȱ  ȱ  ȱ  65  ȱ  ȱ  Tableȱ3.3ȱMultivariateȱanalysesȱofȱfactorsȱassociatedȱwithȱdrugȱsceneȱexposure*ȱ ȱ Characteristicȱ  GEEȱforȱLowȱvs.ȱNoȱ Exposureȱ AORȱȱ(95%ȱCI)ȱbȱ  ȱ pȬvalueȱ  GEEȱforȱModerateȱvs.ȱNoȱ GEEȱforȱHighȱvs.ȱNoȱ ȱ Exposureȱ Exposureȱ AORȱ(95%ȱCI)ȱ  pȬvalueȱ  AORȱ(95%ȱCI)ȱ  ȱ  pȬvalueȱ  OlderȱAgeȱȱ 0.97ȱ(0.96ȱȬȱ0.99)ȱ <.001ȱ 1.01ȱ(1.00ȱȬȱ1.02)ȱ 0.071ȱ 1.00ȱ(0.99ȱȬȱ1.02)ȱ 0.684ȱ ȱ ȱ Perȱyearȱolderȱ ȱ ȱ ȱ ȱ AboriginalȱAncestryȱȱ 1.52ȱ(1.18ȱȬȱ1.95)ȱ 0.001ȱ 1.74ȱ(1.30ȱȬȱ2.34)ȱ <.001ȱ 1.19ȱ(0.96ȱȬȱ1.48)ȱ 0.105ȱ ȱ ȱ ȱ ȱ ȱ ȱ Yesȱvs.ȱNoȱ 3.10ȱ(2.52ȱȬȱ3.80)ȱ <.001ȱ 3.73ȱ(2.92ȱȬȱ4.77)ȱ <.001ȱ 9.50ȱ(6.36ȱȬȱ14.20)ȱ <.001ȱ UnstableȱHousingȱcȱȱ ȱ ȱ ȱ ȱ ȱ ȱ Yesȱvs.ȱNoȱ 1.73ȱ(1.15ȱȬȱ2.61)ȱ 0.009ȱ DailyȱCocaineȱInjectȱcȱ 0.87ȱ(0.60ȱȬȱ1.26)ȱ 0.461ȱ 1.09ȱ(0.72ȱȬȱ1.64)ȱ 0.680ȱ ȱ ȱ ȱ ȱ ȱ ȱ Yesȱvs.ȱNoȱ 1.43ȱ(1.07ȱȬȱ1.91)ȱ 0.014ȱ 1.84ȱ(1.37ȱȬȱ2.47)ȱ <.001ȱ DailyȱHeroinȱInjectȱcȱ 0.82ȱ(0.63ȱȬȱ1.08)ȱ 0.154ȱ ȱ ȱ ȱ ȱ ȱ ȱ Yesȱvs.ȱNoȱ DailyȱCrackȱUseȱcȱ 1.49ȱ(1.20ȱȬȱ1.85)ȱ <.001ȱ 1.90ȱ(1.50ȱȬȱ2.40)ȱ <.001ȱ 2.70ȱ(2.07ȱȬȱ3.52)ȱ <.001ȱ Yesȱvs.ȱNoȱ ȱ ȱ ȱ ȱ ȱ ȱ 0.62ȱ(0.40ȱȬȱ0.96)ȱ 0.031ȱ Overdoseȱ(nonȬfatal)ȱcȱ 0.94ȱ(0.62ȱȬȱ1.44)ȱ 0.783ȱ 0.85ȱ(0.57ȱȬȱ1.25)ȱ 0.400ȱ ȱ ȱ ȱ ȱ ȱ ȱ Yesȱvs.ȱNoȱ EncountersȱwithȱPoliceȱdȱ 1.63ȱ(1.28ȱȬȱ2.08)ȱ <.001ȱ 2.11ȱ(1.62ȱȬȱ2.75)ȱ <.001ȱ 1.25ȱ(0.99ȱȬȱ1.57)ȱ 0.061ȱ ȱ ȱ ȱ ȱ Yesȱvs.ȱNoȱ ȱ ȱ VictimȱofȱViolenceȱcȱ 1.50ȱ(1.19ȱȬȱ1.89)ȱ <.001ȱ 1.49ȱ(1.14ȱȬȱ1.95)ȱ 0.003ȱ 1.12ȱ(0.88ȱȬȱ1.44)ȱ 0.365ȱ ȱ ȱ ȱ ȱ ȱ ȱ Yesȱvs.ȱNoȱ MultipleȱSexȱPartnersȱcȱ 1.05ȱ(0.82ȱȬȱ1.36)ȱ 0.693ȱ 1.11ȱ(0.83ȱȬȱ1.49)ȱ 0.489ȱ 1.17ȱ(0.85ȱȬȱ1.61)ȱ 0.341ȱ ȱ ȱ ȱ ȱ ȱ ȱ Yesȱvs.ȱNoȱ RegularȱEmploymentȱcȱ 0.77ȱ(0.63ȱȬȱ0.94)ȱ 0.010ȱ 0.75ȱ(0.60ȱȬȱ0.95)ȱ 0.015ȱ 0.50ȱ(0.38ȱȬȱ0.65)ȱ <.001ȱ ȱ ȱ ȱ ȱ ȱ ȱ Yesȱvs.ȱNoȱ 1.44ȱ(1.08ȱȬȱ1.92)ȱ 0.013ȱ 1.63ȱ(1.20ȱȬȱ2.21)ȱ 0.002ȱ SexȱWorkȱcȱ 1.28ȱ(0.88ȱȬȱ1.86)ȱ 0.202ȱ ȱ ȱ ȱ ȱ ȱ ȱ Yesȱvs.ȱNoȱ 1.35ȱ(1.05ȱȬȱ1.73)ȱ 0.019ȱ 1.46ȱ(1.14ȱȬȱ1.87)ȱ 0.003ȱ DrugȱDealingȱcȱ 1.05ȱ(0.84ȱȬȱ1.33)ȱ 0.655ȱ ȱ ȱ Yesȱvs.ȱNoȱ ȱ ȱ ȱ ȱ 0.69ȱ(0.56ȱȬȱ0.85)ȱ <.001ȱ 0.58ȱ(0.45ȱȬȱ0.75)ȱ <.001ȱ AddictionȱTreatmentȱcȱ 1.04ȱ(0.86ȱȬȱ1.25)ȱ 0.688ȱ Yesȱvs.ȱNoȱ ȱ ȱ ȱ ȱ ȱ ȱ Note:ȱ aGEEȱ =ȱ Generalizedȱ Estimatingȱ Equation;ȱ bAORȱ =ȱ Adjustedȱ Oddsȱ Ratio;ȱ CIȱ =ȱ Confidenceȱ Interval;ȱ cȱ Denotesȱ activitiesȱorȱsituationsȱreferringȱtoȱpreviousȱ6ȱmonths;ȱdȱDenotesȱactivitiesȱorȱsituationsȱreferringȱtoȱpreviousȱmonth.ȱ *Levelsȱ ofȱ drugȱ sceneȱ exposureȱ wereȱ definedȱ basedȱ onȱ theȱ numberȱ ofȱ hoursȱ participantsȱ reportedȱ spendingȱ onȱ averageȱ onȱ theȱ streetȱ eachȱ dayȱ inȱ Vancouver’’sȱ drugȱ useȱ epicenterȱ inȱ theȱ previousȱ sixȱ months:ȱ ””noȱ drugȱ sceneȱ exposure””ȱ includedȱ reportsȱ ofȱ 1ȱ hourȱorȱless;ȱ““lowȱ exposure””ȱ includedȱ reportsȱ ofȱ 2Ȭ6ȱ hours;ȱ ““moderateȱ exposure””ȱ includedȱreportsȱofȱ7Ȭ15ȱhours;ȱandȱ““highȱexposure””ȱincludedȱreportsȱofȱmoreȱthanȱ15ȱhours.ȱ **Theȱ‘‘noȱexposure’’ȱcategoryȱincludedȱ1,237ȱobservations,ȱtheȱ‘‘lowȱexposure’’ȱcategoryȱincludedȱ1,121ȱobservations,ȱ theȱ ‘‘moderateȱ exposure’’ȱ categoryȱ includedȱ 779ȱ observations,ȱ andȱ theȱ ‘‘highȱ exposure’’ȱ categoryȱ includedȱ 757ȱ observations.ȱ ȱ***Allȱmodelsȱwereȱadjustedȱforȱtheȱmonthȱeachȱinterviewȱwasȱconducted.ȱ  ȱ  66  ȱ  ȱ  Figureȱ3.1ȱFactorsȱassociatedȱwithȱdrugȱsceneȱexposureȱ Factors Associated with Drug Scene Exposure  Adjusted Odds Ratio  4 3 2 1 0 Low Med High Low Med High Low Med High Low Med High Low Med High Low Med High Low Med High Low Med High Daily Cocaine  Daily Heroin  Injection  Injection  Daily Crack Use  Drug Dealing  Encounters  Victim of  Regular  Addiction  with Police  Violence  Employment  Treatment  Levels of Drug Scene Exposure  ȱ  *Levelsȱ ofȱ drugȱ sceneȱ exposureȱ wereȱ definedȱ basedȱ onȱ theȱ numberȱ ofȱ hoursȱ participantsȱ reportedȱ spendingȱonȱaverageȱonȱtheȱstreetȱeachȱdayȱinȱVancouver’’sȱdrugȱuseȱepicentreȱinȱtheȱpreviousȱsixȱmonths.ȱ Allȱaboveȱestimatesȱusedȱtheȱreferenceȱcategoryȱofȱ””noȱdrugȱsceneȱexposure””ȱdefinedȱasȱspendingȱ1ȱhourȱ orȱlessȱinȱVancouver’’sȱdrugȱscene.ȱ““Lowȱexposure””ȱincludedȱreportsȱofȱ2Ȭ6ȱhours;ȱ““moderateȱexposure””ȱ includedȱreportsȱofȱ7Ȭ15ȱhours;ȱandȱ““highȱexposure””ȱincludedȱreportsȱofȱmoreȱthanȱ15ȱhours.ȱȱ **Allȱmodelsȱwereȱadjustedȱforȱandȱincludedȱtheȱfollowingȱvariables:ȱage,ȱAboriginalȱancestry,ȱunstableȱ housing,ȱdailyȱcocaineȱinjection,ȱdailyȱheroinȱinjection,ȱdailyȱcrackȱcocaineȱuse,ȱdrugȱoverdose,ȱencountersȱ withȱ police,ȱ victimȱ ofȱ violence,ȱ multipleȱ sexȱ partners,ȱ regularȱ employment,ȱ sexȱ work,ȱ drugȱ dealing,ȱ addictionȱtreatment,ȱandȱmonthȱinterviewȱwasȱconducted.ȱ  ȱ  67  ȱ  CHAPTER 4: ȱ THEȱVALIDITYȱOFȱREPORTINGȱWILLINGNESSȱTOȱUSEȱAȱ SUPERVISEDȱINJECTINGȱFACILITYȱONȱSUBSEQUENTȱPROGRAMȱ USEȱAMONGȱPEOPLEȱWHOȱUSEȱINJECTIONȱDRUGS 3ȱ  4.1 Introductionȱ Illicitȱdrugȱuseȱcontinuesȱtoȱbeȱassociatedȱwithȱaȱbroadȱrangeȱofȱhealthȱandȱsocialȱ harmsȱ andȱ thereȱ isȱ growingȱ recognitionȱ thatȱ innovativeȱ interventionsȱ areȱ neededȱ toȱ addressȱproblemsȱinȱthisȱarea,ȱincludingȱdrugȬrelatedȱstreetȱdisorder.197,ȱ 212Ȭ214ȱHowever,ȱ illicitȱdrugȱuse,ȱandȱparticularlyȱinjectionȱdrugȱuse,ȱisȱhighlyȱstigmatized,215Ȭ217ȱandȱitȱcanȱ beȱ difficultȱ toȱ determineȱ ifȱ aȱ proposedȱ interventionȱ willȱ beȱ acceptedȱ byȱ drugȱ usingȱ communities.218Ȭ221ȱ Oneȱ strategyȱ thatȱ hasȱ beenȱ employedȱ toȱ assessȱ theȱ levelȱ ofȱ acceptanceȱ ofȱ innovativeȱhealthȱprograms,ȱsuchȱasȱsupervisedȱinjectionȱfacilitiesȱ(SIF)ȱwhereȱinjectionȱ drugȱ usersȱ canȱ bringȱ preȬobtainedȱ illicitȱ drugsȱ andȱ injectȱ underȱ theȱ supervisionȱ ofȱ aȱ nurse,ȱhasȱbeenȱtoȱsurveyȱtheȱtargetȱpopulationȱandȱmeasureȱtheirȱwillingnessȱtoȱuseȱtheȱ proposedȱ service.222Ȭ224ȱ Althoughȱ thisȱ approachȱ hasȱ beenȱ usedȱ toȱ determineȱ acceptanceȱ ofȱsaferȱsupervisedȱinjectionȱfacilitiesȱinȱseveralȱsettingsȱincludingȱVancouver,ȱMontreal,ȱ SanȱFrancisco,ȱLondon,ȱIreland,ȱMelbourneȱandȱSydney,193,ȱ 222,ȱ 225Ȭ230ȱtheȱvalidityȱofȱtheseȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 3  ȱAȱversionȱofȱthisȱchapterȱhasȱbeenȱsubmittedȱforȱpublicationȱas:ȱDeBeck,ȱK.,ȱKerr,ȱT.,ȱ Lai,ȱC.,ȱBuxton,ȱJ.,ȱMontaner,ȱJ.,ȱWood,ȱE.ȱTheȱvalidityȱofȱreportingȱwillingnessȱtoȱuseȱ aȱsupervisedȱinjectingȱfacilityȱonȱsubsequentȱprogramȱuseȱamongȱpeopleȱuseȱwhoȱ useȱinjectionȱdrugs.ȱ ȱ  68  ȱ  surveysȱhasȱnotȱbeenȱfullyȱevaluated.ȱToȱassessȱwhetherȱwillingnessȱmeasuresȱmayȱbeȱ effectiveȱ toolsȱ forȱ planningȱ theȱ deliveryȱ ofȱ publicȱ healthȱ programsȱ forȱ injectionȱ drugȱ userȱ populationsȱ andȱ helpȱ determineȱ theȱ feasibilityȱ ofȱ innovativeȱ interventionsȱ toȱ addressȱ drugȬrelatedȱ streetȱ disorder,ȱ weȱ soughtȱ toȱ determineȱ whetherȱ measuresȱ ofȱ willingnessȱcollectedȱpriorȱtoȱtheȱopeningȱofȱaȱCanadianȱSIFȱaccuratelyȱpredictedȱlaterȱ useȱofȱtheȱprogram.ȱȱ  4.2 Methodsȱ Dataȱ forȱ thisȱ studyȱ wereȱ obtainedȱ fromȱ theȱ Vancouverȱ Injectionȱ Drugȱ Usersȱ Studyȱ (VIDUS).ȱ Forȱ aȱ fullȱ descriptionȱ ofȱ theȱ studyȱ pleaseȱ referȱ toȱ sectionȱ 1.4ȱ ofȱ thisȱ thesis.ȱInȱtheȱprimaryȱanalysis,ȱweȱassessedȱwhetherȱreportsȱofȱwillingnessȱtoȱuseȱaȱSIFȱ beforeȱtheȱprogramȱopenedȱwereȱassociatedȱwithȱsubsequentȱselfȬreportedȱattendanceȱatȱ theȱfacilityȱ afterȱitȱwasȱestablishedȱinȱtheȱDowntownȱ Eastsideȱ(DTES)ȱofȱVancouverȱinȱ Septemberȱ2003.ȱInitialȱwillingnessȱmeasuresȱwereȱassessedȱduringȱtheȱpreȬSIFȱperiodȱofȱ Decemberȱ 2001ȱ ––ȱ Mayȱ 2003ȱ basedȱ onȱ theȱ question:ȱ ““Ifȱ aȱ supervisedȱ safeȱ injectionȱ siteȱ wasȱ available,ȱ wouldȱ youȱ useȱ it?””ȱ ȱ ‘‘Yes’’ȱ responsesȱ wereȱ comparedȱ toȱ ‘‘No’’ȱ responses,ȱ andȱ individualsȱ whoȱ repliedȱ thatȱ theyȱ wereȱ ‘‘Unsure’’ȱ wereȱ assessedȱ inȱ subȬanalyses.ȱ AttendanceȱatȱtheȱfacilityȱwasȱmeasuredȱduringȱtheȱpostȬSIFȱperiodȱofȱDecemberȱ2003ȱ––ȱ Novemberȱ2005ȱbasedȱonȱtheȱquestion:ȱ““HaveȱyouȱeverȱusedȱtheȱInSiteȱSIS?””ȱȱ Ourȱ primaryȱ analysisȱ soughtȱ toȱ determineȱ whetherȱ thereȱ wasȱ aȱ significantȱ relationshipȱ betweenȱ ourȱ mainȱ dependentȱ variableȱ ofȱ interestȱ (attendanceȱ atȱ theȱ SIF)ȱ ȱ  69  ȱ  andȱourȱprimaryȱindependentȱvariableȱ(priorȱreportȱofȱwillingnessȱtoȱattendȱaȱSIF).ȱToȱ considerȱthisȱassociationȱwhileȱevaluatingȱpotentialȱconfounders,ȱweȱaȱprioriȱselectedȱaȱ rangeȱ ofȱ secondaryȱ explanatoryȱ independentȱ variablesȱ hypothesizedȱ toȱ beȱ associatedȱ withȱbothȱattendanceȱandȱinitialȱwillingnessȱtoȱattendȱbasedȱonȱpreviousȱresearch.193,ȱ222,ȱ 231  ȱ Secondaryȱexplanatoryȱfactorsȱincluded:ȱ ageȱ(youngerȱ thanȱ 39ȱ yrsȱ ofȱageȱvs.ȱ older);ȱ  genderȱ (femaleȱ vs.ȱ male);ȱ unstableȱ housing,ȱ definedȱ asȱ livingȱ inȱ aȱ singleȱ occupancyȱ roomȱinȱaȱhotel,ȱaȱtreatmentȱorȱrecoveryȱhouse,ȱjail,ȱshelterȱorȱhostel,ȱorȱhavingȱnoȱfixedȱ addressȱ forȱ theȱ lastȱ sixȱ months,ȱ (yesȱ vs.ȱ no);ȱ frequentȱ exposureȱ toȱ theȱ Downtownȱ Eastsideȱ(DTES),ȱwhichȱisȱVancouver’’sȱwellȱdescribedȱdrugȱuseȱepicentreȱandȱwhereȱtheȱ VancouverȱSIFȱisȱsituated,193ȱwasȱdefinedȱasȱresidingȱinȱorȱvisitingȱtheȱDTESȱatȱleastȱ2Ȭ3ȱ timesȱ perȱ weekȱ (yesȱ vs.ȱ no);ȱ dailyȱ cocaineȱ injectionȱ (yesȱ vs.ȱ no);ȱ dailyȱ heroinȱ injectionȱ (yesȱ vs.ȱ no);ȱ dailyȱ crackȱ cocaineȱ smokingȱ (yesȱ vs.ȱ no);ȱ nonȬfatalȱ overdoseȱ (yesȱ vs.ȱ no);ȱ andȱusingȱinjectionȱdrugsȱinȱpublicȱlocations,ȱsuchȱasȱcityȱstreets,ȱparksȱandȱalleysȱ(yesȱ vs.ȱno).ȱAllȱdrugȱuseȱandȱbehaviouralȱvariablesȱreferȱtoȱtheȱpreviousȱsixȱmonthȱperiodȱ andȱwereȱmeasuredȱatȱparticipantsȇȱfirstȱstudyȱvisitȱduringȱourȱstudyȱperiod.ȱȱ Asȱ aȱ firstȱ step,ȱ weȱ comparedȱ baselineȱ characteristicsȱ stratifiedȱ byȱ attendanceȱ atȱ theȱ Vancouverȱ SIF.ȱ Weȱ usedȱ Pearson’’sȱ ChiȬSquareȱ testȱ forȱ dichotomousȱ variablesȱ andȱ theȱ MannȬWhitneyȱ testȱ forȱ continuousȱ variables.ȱ Weȱ wereȱ primarilyȱ concernedȱ withȱ identifyingȱwhetherȱthereȱwasȱanȱindependentȱrelationshipȱbetweenȱjustȱtwoȱvariablesȱ (attendanceȱatȱtheȱSIFȱandȱpriorȱreportȱofȱwillingnessȱtoȱattendȱaȱSIF).ȱToȱaddressȱthis,ȱ weȱ usedȱ aȱ backwardsȱ selectionȱ processȱ withȱ automatedȱ procedures,ȱ previouslyȱ ȱ  70  ȱ  describedȱ byȱ Maldonadoȱ andȱ Greenland232ȱ andȱ Rothmanȱ andȱ Greenland,233ȱ whichȱ isȱ specificȱ toȱ fittingȱ multivariateȱ modelsȱ inȱ theseȱ instances.ȱ Specifically,ȱ weȱ beganȱ byȱ includingȱ allȱ variablesȱ inȱ aȱ fixedȱ model.ȱ Weȱ subsequentlyȱ generatedȱ aȱ seriesȱ ofȱ confoundingȱmodelsȱbyȱremovingȱsecondaryȱvariablesȱoneȱatȱaȱtime.ȱForȱeachȱofȱtheseȱ models,ȱweȱassessedȱtheȱrelativeȱchangeȱinȱtheȱcoefficientȱforȱourȱprimaryȱindependentȱ variableȱofȱinterestȱ(priorȱwillingnessȱtoȱuseȱaȱSIF).ȱTheȱsecondaryȱvariableȱthatȱresultedȱ inȱtheȱsmallestȱabsoluteȱrelativeȱchangeȱinȱtheȱcoefficientȱofȱ‘‘priorȱwillingnessȱtoȱuseȱaȱ SIF’’ȱ wasȱ thenȱ removed.ȱ Thisȱ approachȱ allowedȱ usȱ toȱ identifyȱ theȱ secondaryȱ variablesȱ thatȱ hadȱ theȱ strongestȱinfluenceȱonȱ theȱcoefficientȱforȱourȱprimaryȱ variableȱofȱinterest.ȱ Usingȱthisȱautomatedȱprocedure,ȱsecondaryȱvariablesȱcontinuedȱtoȱbeȱremovedȱuntilȱtheȱ smallestȱrelativeȱchangeȱinȱtheȱcoefficientȱofȱ‘‘priorȱwillingnessȱtoȱuseȱaȱSIF’’ȱexceededȱ5%ȱ ofȱ theȱ valueȱofȱ theȱcoefficient.ȱTheȱfinalȱmodelȱincludedȱ priorȱwillingnessȱtoȱuseȱaȱ SIFȱ andȱallȱremainingȱsecondaryȱexplanatoryȱvariables.ȱ Toȱfurtherȱexploreȱtheȱrelationshipȱbetweenȱinitialȱwillingnessȱandȱlaterȱuseȱofȱaȱ SIF,ȱ weȱ conductedȱ aȱ numberȱ ofȱ subȬanalyses.ȱ First,ȱ amongȱ individualsȱ whoȱ reportedȱ thatȱ theyȱ hadȱ notȱ attendedȱ theȱ SIF,ȱ weȱ assessedȱ ratesȱ ofȱ nonȬinjectionȱ drugȱ useȱ inȱ theȱ pastȱ sixȱ monthsȱ duringȱ theȱ postȬSIFȱ period,ȱ asȱ wellȱ asȱ infrequentȱ exposureȱ toȱ theȱ neighbourhoodȱ whereȱ theȱ supervisedȱ injectionȱ siteȱ wasȱ located.ȱ Infrequentȱ exposureȱ wasȱdefinedȱasȱnotȱresidingȱinȱtheȱDowntownȱEastsideȱandȱvisitingȱtheȱneighbourhoodȱ lessȱthanȱmonthly.ȱWeȱthenȱsoughtȱtoȱidentifyȱfactorsȱassociatedȱwithȱnotȱattendingȱtheȱ SIFȱ amongȱ participantsȱ whoȱ initiallyȱ reportedȱ aȱ willingnessȱ toȱ useȱ theȱ facility.ȱ Factorsȱ ȱ  71  ȱ  thatȱ weȱ hypothesizedȱ mightȱ beȱ associatedȱ withȱ notȱ attendingȱ theȱ Vancouverȱ SIFȱ included:ȱ ageȱ (youngerȱ thanȱ 39ȱ yrsȱ ofȱ ageȱ vs.ȱ older),ȱ genderȱ (femaleȱ vs.ȱ male);ȱ infrequentȱexposureȱtoȱtheȱDTESȱ(yesȱvs.ȱno);ȱinfrequentȱcocaineȱinjectionȱ(<ȱdailyȱvs.ȱ>ȱ daily);ȱandȱinfrequentȱheroinȱinjectionȱ(<ȱdailyȱvs.ȱ>ȱdaily);ȱbeingȱrecentlyȱincarceratedȱ (yesȱ vs.ȱ no)ȱ andȱ recentlyȱ beingȱ involvedȱ inȱ anyȱ kindȱ ofȱ addictionȱ treatmentȱ programȱ (yesȱvs.ȱno).ȱAllȱvariables,ȱincludingȱourȱoutcomeȱofȱinterest,ȱreferȱtoȱbehavioursȱinȱtheȱ previousȱsixȱmonths.ȱȱ Sinceȱ forȱ thisȱ analysisȱ weȱ wereȱ interestedȱ inȱ identifyingȱ multipleȱ factorsȱ thatȱ mightȱbeȱassociatedȱwithȱnotȱusingȱtheȱSIF,ȱweȱdidȱnotȱuseȱtheȱpreviousȱmodelȱbuildingȱ protocolȱwhichȱisȱdesignedȱtoȱadjustȱforȱconfoundingȱandȱdetermineȱwhetherȱthereȱisȱanȱ independentȱ relationshipȱ betweenȱ justȱ twoȱ factorsȱ ofȱ interest.ȱ ȱ Anotherȱ distinguishingȱ featureȱ ofȱ thisȱ subȬanalysisȱ wasȱ thatȱ itȱ focusedȱ onȱ theȱ postȬSIFȱ followȬupȱ periodȱ ofȱ 24ȱ months,ȱandȱweȱhadȱmultipleȱobservationsȱperȱpersonȱforȱfactorsȱpotentiallyȱassociatedȱ withȱ notȱ usingȱ theȱ SIFȱ asȱ wellȱ asȱ serialȱ measuresȱ forȱ eachȱ subject.ȱ Therefore,ȱ toȱ determineȱ factorsȱ associatedȱ withȱ ourȱ outcomeȱ ofȱ interestȱ throughoutȱ theȱ entireȱ 24Ȭ monthȱ followȬupȱ periodȱ weȱ usedȱ generalizedȱ estimatingȱ equationsȱ (GEE)ȱ forȱ binaryȱ outcomesȱwithȱlogitȱlinkȱforȱtheȱanalysisȱofȱcorrelatedȱdata.194ȱTheseȱmethodsȱprovidedȱ standardȱ errorsȱ adjustedȱ byȱ multipleȱ observationsȱ perȱ personȱ usingȱ anȱ exchangeableȱ correlationȱ structure.ȱ Withȱ thisȱ approachȱ dataȱ fromȱ everyȱ participantȱ followȬupȱ visitȱ wereȱ consideredȱ inȱ thisȱ analysis.ȱ Missingȱ dataȱ wereȱ addressedȱ throughȱ theȱ GEEȱ  ȱ  72  ȱ  estimatingȱmechanismȱwhichȱusesȱtheȱallȱavailableȱpairsȱmethod.ȱAllȱnonȬmissingȱpairsȱ ofȱdataȱareȱusedȱinȱtheȱestimatorsȱofȱtheȱworkingȱcorrelationȱparameters.ȱȱ Asȱ aȱ firstȱ step,ȱ GEEȱ univariateȱ analysesȱ wereȱ conductedȱ toȱ obtainȱ unadjustedȱ oddsȱratiosȱandȱ95%ȱconfidenceȱintervalsȱforȱvariablesȱofȱinterest.ȱInȱorderȱtoȱadjustȱforȱ potentialȱconfounding,ȱallȱvariablesȱthatȱwereȱpȱ<ȱ0.05ȱinȱGEEȱunivariateȱanalysesȱwereȱ enteredȱintoȱaȱmultivariateȱlogisticȱGEEȱmodel.ȱAllȱstatisticalȱanalysesȱwereȱperformedȱ usingȱSASȱsoftwareȱversionȱ9.1ȱ(SAS,ȱCary,ȱNC).ȱȱAllȱpȬvaluesȱareȱtwoȱsided.ȱ  4.3 Resultsȱ Aȱtotalȱofȱ640ȱindividualsȱwereȱseenȱforȱstudyȱfollowȬupȱduringȱtheȱpreȬSIFȱstudyȱ periodȱ (seeȱ Figureȱ 4.1.).ȱ Inȱ theȱ preȬSIFȱ periodȱ 344ȱ (54%)ȱ participantsȱ reportedȱ beingȱ willingȱ toȱ useȱ aȱ SIF,ȱ 256ȱ reportedȱ beingȱ unwillingȱ (40%)ȱ andȱ 40ȱ (6%)ȱ wereȱ unsure.ȱ Amongȱtheȱ’’unsure’’ȱgroupȱ11ȱ(28%)ȱwereȱnotȱseenȱforȱstudyȱfollowȬupȱduringȱtheȱpostȬ SIFȱstudyȱperiod,ȱandȱofȱtheȱremainingȱ29ȱ‘‘unsure’’ȱindividuals,ȱ18ȱ(62%)ȱsubsequentlyȱ usedȱ theȱ facility.ȱ Amongȱ theȱ 600ȱ participantsȱ whoȱ reportedȱ eitherȱ beingȱ willingȱ orȱ unwillingȱtoȱuseȱaȱSIF,ȱ158ȱ(70ȱandȱ88ȱrespectively)ȱwereȱnotȱseenȱforȱstudyȱfollowȬupȱ duringȱ theȱ postȬSIFȱ studyȱ periodȱ andȱ wereȱ thereforeȱ excludedȱ fromȱ furtherȱ analyses.ȱ ThoseȱlostȱtoȱfollowȬupȱwereȱsignificantlyȱlessȱlikelyȱtoȱreportȱbeingȱwillingȱtoȱuseȱaȱSIFȱ (pȱ<ȱ0.001).ȱTheȱremainingȱ442ȱparticipantsȱwereȱincludedȱinȱourȱprimaryȱcomparisonȱofȱ thoseȱ thatȱ reportedȱ yesȱ vs.ȱ noȱ willingness.ȱ Amongȱ theȱ 274ȱ participantsȱ withinȱ thisȱ groupȱ whoȱ reportedȱ beingȱ initiallyȱ willingȱ toȱ useȱ aȱ SIF,ȱ 198ȱ (72%)ȱ laterȱ reportedȱ ȱ  73  ȱ  attendingȱ theȱ SIF,ȱ whileȱ 91ȱ (54%)ȱ ofȱ thoseȱ whoȱ wereȱ initiallyȱ unwillingȱ reportedȱ laterȱ attendingȱ theȱ SIF.ȱ Theȱ characteristicsȱ ofȱ theȱ studyȱ sampleȱ stratifiedȱ byȱ reportedȱ attendanceȱatȱtheȱSIFȱareȱpresentedȱinȱTableȱ4.1.ȱTheȱunivariateȱanalysesȱofȱbehaviouralȱ andȱ socioȬdemographicȱ variablesȱ areȱ alsoȱ presentedȱ inȱ Tableȱ 4.1.ȱ Initialȱ willingnessȱ toȱ useȱ aȱ SIFȱ wasȱ significantlyȱ associatedȱ withȱ laterȱ useȱ ofȱ theȱ facilityȱ (oddsȱ ratioȱ [OR]ȱ =ȱ 2.20,ȱ95%ȱconfidenceȱintervalȱ[CI]ȱ1.47Ȭ3.30).ȱTheȱresultsȱofȱtheȱfinalȱmultivariateȱlogisticȱ regressionȱareȱshownȱinȱTableȱ4.2.ȱOurȱprimaryȱexplanatoryȱvariable,ȱinitialȱwillingnessȱ toȱuseȱaȱSIF,ȱremainedȱindependentlyȱassociatedȱwithȱattendingȱtheȱSIFȱ(AdjustedȱOddsȱ Ratioȱ[AOR]ȱ=1.67,ȱ95%ȱCI:ȱ1.09Ȭ2.55).ȱȱUnstableȱhousingȱ(AORȱ=ȱ1.54,ȱ95%ȱCIȱ1.01Ȭ2.34)ȱ andȱusingȱinjectionȱdrugsȱinȱpublicȱwereȱalsoȱindependentlyȱassociatedȱwithȱusingȱtheȱ SIFȱ(AORȱ=ȱ2.35,ȱ95%ȱCIȱ1.46Ȭ3.77).ȱȱ InȱsubȬanalyses,ȱweȱfoundȱthatȱamongȱparticipantsȱwhoȱdidȱnotȱattendȱtheȱSIF,ȱ31ȱ (19%)ȱ reportedȱ atȱ someȱ pointȱ duringȱ theȱ postȬSIFȱ studyȱ periodȱ thatȱ theyȱ hadȱ notȱ injectedȱdrugsȱinȱtheȱpreviousȱsixȱmonth.ȱSimilarly,ȱduringȱtheȱsameȱperiodȱandȱamongȱ theȱsameȱgroup,ȱ32ȱ(21%)ȱindividualsȱreportedȱinfrequentȱexposureȱtoȱtheȱDTES.ȱȱ InȱtheȱsubȬanalysisȱrestrictedȱtoȱtheȱ274ȱindividualsȱwhoȱinitiallyȱreportingȱbeingȱ willingȱ toȱ useȱ aȱ SIFȱ (seeȱ Tableȱ 4.3),ȱ beingȱ youngerȱ thanȱ 39ȱ yearsȱ ofȱ age,ȱ infrequentȱ exposureȱ toȱ theȱ DTES,ȱ infrequentȱ cocaineȱ injection,ȱ infrequentȱ heroinȱ injectionȱ andȱ engagementȱinȱanyȱaddictionȱtreatmentȱprogramȱwereȱsignificantlyȱassociatedȱwithȱnotȱ usingȱ theȱ SIFȱ inȱ univariateȱ GEEȱ analyses.ȱ Inȱ multivariateȱ GEEȱ analyses,ȱ infrequentȱ  ȱ  74  ȱ  exposureȱtoȱtheȱDTESȱ(AORȱ=ȱ1.89,ȱ95%ȱCI:ȱ1.31Ȭ2.71),ȱinfrequentȱcocaineȱinjectionȱ(AORȱ =ȱ1.54,ȱ95%ȱCI:ȱ1.13Ȭ2.09),ȱandȱinfrequentȱheroinȱinjectionȱ(AORȱ=ȱ2.37,ȱ95%ȱCI:ȱ1.77Ȭ3.17)ȱ wereȱ significantlyȱ positivelyȱ associatedȱ withȱ notȱ usingȱ theȱ SIF,ȱ whileȱ beingȱ youngerȱ thanȱ 39ȱ yearsȱ ofȱ ageȱ (AORȱ =ȱ 0.03,ȱ 95%ȱ CI:ȱ 0.01Ȭ0.05)ȱ wasȱ significantlyȱ negativelyȱ associatedȱwithȱnotȱusingȱtheȱSIF.ȱȱ  4.4 Discussionȱ Ourȱ studyȱ foundȱ thatȱ initialȱ willingnessȱ toȱ useȱ aȱ SIFȱ wasȱ independentlyȱ associatedȱ withȱ subsequentȱ attendanceȱ atȱ Vancouver’’sȱ SIF,ȱ evenȱ afterȱ adjustingȱ forȱ otherȱ determinantsȱ ofȱ willingness.ȱ Weȱ alsoȱ foundȱ thatȱ notȱ activelyȱ injectingȱ drugs,ȱ asȱ wellȱ asȱ infrequentȱ exposureȱ toȱ theȱ neighbourhoodȱ whereȱ Vancouver’’sȱ SIFȱ isȱ located,ȱ wereȱfactorsȱthatȱappearȱtoȱnegativelyȱinfluenceȱwhetherȱindividualsȱuseȱaȱSIFȱfollowingȱ aȱreportȱofȱbeingȱwillingȱtoȱuseȱtheȱprogramȱbeforeȱitȱopened.ȱȱ Theseȱ findingsȱ areȱ largelyȱ consistentȱ withȱ aȱ broadȱ literatureȱ suggestingȱ thatȱ behaviouralȱ intentionȱ isȱ aȱ reasonableȱ predictorȱ ofȱ laterȱ action.234,ȱ 235ȱ Indeed,ȱ intentionȱ measuresȱhaveȱbeenȱfoundȱtoȱbeȱcorrelatedȱwithȱhealthȬrelatedȱbehavioursȱinȱaȱnumberȱ ofȱareasȱincludingȱadolescentȱsmoking,ȱillicitȱdrugȱuse,ȱandȱsexualȱhealth.236Ȭ241ȱAlthoughȱ behaviouralȱ willingnessȱ isȱ consideredȱ toȱ beȱ distinctȱ fromȱ behaviouralȱ intention,ȱ asȱ willingnessȱ isȱ typicallyȱ conceivedȱ inȱ relationȱ toȱ whatȱ anȱ individualȱ isȱ willingȱ toȱ doȱ whileȱ intentionȱ reflectsȱ whatȱ anȱ individualȱ plansȱ toȱ do,235,ȱ 240ȱ someȱ studiesȱ reportȱ thatȱ  ȱ  75  ȱ  comparedȱtoȱintentionȱmeasures,ȱwillingnessȱmeasuresȱareȱactuallyȱbetterȱpredictorsȱofȱ behaviours.235,ȱ236,ȱ242,ȱ243ȱ Similarly,ȱwhileȱourȱstudyȱindicatesȱthatȱwillingnessȱpredictsȱfutureȱSIFȱuse,ȱitȱisȱ alsoȱ noteworthyȱ thatȱ changesȱ inȱ personalȱ circumstances,ȱ includingȱ cessationȱ fromȱ injectionȱ drugȱ use,ȱ lowerȱ intensityȱ injectionȱ drugȱ useȱ andȱ infrequentȱ exposureȱ toȱ theȱ DTES,ȱappearȱtoȱhaveȱanȱexpectedȱdeterrentȱeffectȱonȱSIFȱuse.ȱIndeed,ȱactivelyȱinjectingȱ drugsȱ isȱ aȱ prerequisiteȱ forȱ usingȱ theȱ SIF,ȱ andȱ theȱ SIFȱ hasȱ beenȱ shownȱ toȱ attractȱ highȱ intensityȱdrugȱinjectors.244ȱInȱtheȱcontextȱofȱusingȱaȱSIFȱthereȱareȱaȱnumberȱofȱfactorsȱthatȱ couldȱ influenceȱ anȱ individual’’sȱ behaviour,ȱ i.e.ȱ whetherȱ orȱ notȱ theyȱ useȱ theȱ SIF.ȱ Forȱ example,ȱtravelȱandȱwaitingȱtimesȱandȱoperatingȱregulationsȱsuchȱasȱaȱbanȱonȱassistedȱ injectionsȱcouldȱconstrainȱindividualsȱandȱhinderȱtheirȱabilityȱtoȱuseȱtheȱfacilityȱdespiteȱ anȱ initialȱ willingnessȱ orȱ intentionȱ toȱ useȱ it.ȱ Indeed,ȱ previousȱ studiesȱ haveȱ foundȱ thatȱ IDUȱ identifyȱ travelȱ timeȱ toȱ theȱ SIFȱ fromȱ whereȱ theyȱ resideȱ andȱ purchaseȱ drugsȱ asȱ aȱ significantȱ barrierȱ toȱ visitingȱ theȱ facility.245ȱ Clearly,ȱ situationalȱ factorsȱ willȱ influenceȱ whetherȱanȱindividualȱwillȱuseȱaȱsupervisedȱinjectionȱfacility;ȱhowever,ȱweȱfoundȱthatȱ despiteȱ theseȱ multipleȱ factors,ȱ willingnessȱ measuresȱ areȱ meaningfulȱ indicatorsȱ ofȱ laterȱ SIFȱuse.ȱȱ Theseȱfindingsȱhaveȱimplicationsȱforȱtheȱvalidityȱofȱwillingnessȱstudiesȱthatȱhaveȱ beenȱ conductedȱ inȱ otherȱ settingsȱ toȱ assessȱ theȱ acceptabilityȱ ofȱ establishingȱ SIFs.ȱ Forȱ instance,ȱaȱwillingnessȱstudyȱconductedȱamongȱIDUȱinȱSanȱFranciscoȱrecentlyȱreportedȱ  ȱ  76  ȱ  thatȱ 85%ȱ ofȱ localȱ IDUȱ wereȱ willingȱ toȱ useȱ aȱ SIF.225ȱ Ourȱ studyȱ suggestsȱ thatȱ policyȱ plannersȱinȱSanȱFranciscoȱcanȱbeȱconfidentȱthatȱthisȱmeasureȱisȱaȱgoodȱindicatorȱofȱclientȱ uptakeȱshouldȱaȱSIFȱbeȱestablishedȱinȱthatȱarea.ȱȱ Ourȱ findingsȱ areȱ alsoȱ relevantȱ toȱ theȱ planningȱ ofȱ otherȱ typesȱ ofȱ publicȱ healthȱ programsȱ andȱ servicesȱ forȱ injectionȱ drugȱ userȱ populationsȱ asȱ theyȱ suggestȱ thatȱ willingnessȱmeasuresȱareȱrelativelyȱaccurateȱmarkersȱofȱaȱpopulation’’sȱintentionȱtoȱuseȱaȱ particularȱ service.ȱ Weȱ shouldȱ noteȱ thatȱ directlyȱ engagingȱ withȱ peopleȱ whoȱ useȱ drugsȱ andȱ assessingȱ willingnessȱ priorȱ toȱ theȱ establishmentȱ ofȱ aȱ healthȱ serviceȱ orȱ programȱ isȱ consistentȱwithȱaȱgrowingȱrecognitionȱofȱtheȱimportanceȱofȱinvolvingȱtargetȱpopulationsȱ inȱ theȱ planningȱ andȱ deliveryȱ ofȱ healthȱ andȱ socialȱ services,ȱ particularlyȱ amongȱ vulnerableȱ populations.216,ȱ 246ȱ Althoughȱ assessingȱ willingnessȱ isȱ notȱ aȱ substituteȱ forȱ meaningfulȱ involvement,ȱ weȱ suggestȱ itȱ canȱ beȱ aȱ usefulȱ firstȱ stepȱ inȱ engagingȱ aȱ targetȱ populationȱinȱserviceȱdesignȱandȱdelivery.ȱ Ourȱstudyȱhasȱaȱnumberȱofȱpotentialȱlimitations.ȱFirstly,ȱourȱmeasuresȱreliedȱonȱ selfȬreportȱ whichȱ canȱ beȱ subjectȱ toȱ sociallyȱ desirableȱ reportingȱ andȱ recallȱ bias.ȱ Mostȱ importantly,ȱ sociallyȱ desirableȱ reportingȱ couldȱ haveȱ inflatedȱ ourȱ measureȱ ofȱ SIFȱ attendanceȱ givenȱ itsȱ widespreadȱ supportȱ andȱ acceptanceȱ amongȱ localȱ drugȱ users.ȱ Anotherȱ potentialȱ limitationȱ ofȱ ourȱ studyȱ isȱ theȱ generalizabilityȱ ofȱ ourȱ findings.ȱ Theȱ Vancouverȱ Injectionȱ Drugȱ Usersȱ Studyȱ isȱ notȱ aȱ randomizedȱ sampleȱ ofȱ injectionȱ drugȱ usersȱandȱmayȱnotȱbeȱreflectiveȱofȱotherȱdrugȱuserȱpopulations.ȱAlthoughȱthisȱmustȱbeȱ  ȱ  77  ȱ  takenȱ intoȱ considerationȱ whenȱ extrapolatingȱ theseȱ findingsȱ toȱ otherȱ locationsȱ andȱ populationsȱ ofȱ drugȱ users,ȱ asȱ mentionedȱ previously,ȱ priorȱ researchȱ hasȱ shownȱ willingnessȱtoȱbeȱgoodȱpredictorȱofȱhealthȱrelatedȱbehaviour.235ȱȱȱȱ Inȱsummary,ȱweȱfoundȱthatȱindividualsȱwhoȱindicatedȱthatȱtheyȱwereȱwillingȱtoȱ useȱaȱSIFȱwereȱmoreȱlikelyȱtoȱlaterȱattendȱtheȱVancouverȱSIFȱonceȱitȱwasȱopened,ȱevenȱ afterȱ weȱ adjustedȱ forȱ factorsȱ expectedȱ toȱ beȱ associatedȱ withȱ willingness.ȱ Theseȱ dataȱ suggestȱthatȱwillingnessȱmeasuresȱmayȱbeȱvalidȱtoolsȱforȱplanningȱtheȱdeliveryȱofȱhealthȱ servicesȱ amongȱ injectionȱ drugȱ userȱ populationsȱ andȱ shouldȱ beȱ consideredȱ byȱ futureȱ healthȱprogramȱplanners.ȱ  ȱ  78  ȱ  Tableȱ4.1ȱCharacteristicsȱofȱstudyȱpopulationȱstratifiedȱbyȱattendanceȱatȱVancouver’’sȱ supervisedȱinjectionȱfacilityȱ(n=442)ȱ AttendedȱSIF Characteristicȱaȱ PriorȱWillingnessȱtoȱUseȱSIFȱ Yesȱ Noȱ Youngerȱthanȱ39ȱYrsȱofȱAgeȱdȱȱ Yesȱ Noȱ FemaleȱGenderȱȱ Yesȱ Noȱ UnstableȱHousingȱdȱ Yesȱ Noȱ FrequentȱExposureȱtoȱDTESȱdȱ Yesȱ Noȱ DailyȱCocaineȱInjectionȱdȱ Yesȱ Noȱ DailyȱHeroinȱInjectionȱdȱ Yesȱ Noȱ DailyȱCrackȱUseȱdȱ Yesȱ Noȱ Overdoseȱ(nonȬfatal)ȱdȱ Yesȱ Noȱ PublicȱInjectingȱdȱ Yesȱ Noȱ  Univariateȱ  Yesȱn=ȱ289,ȱnȱ(%) Noȱn=ȱ153,ȱnȱ(%) ȱ ORȱbȱ(95%ȱCI)ȱcȱ ȱ 198ȱ(69)ȱ 91ȱ(31)ȱ ȱ 160ȱ(55)ȱ 129ȱ(45)ȱ ȱ 122ȱ(42)ȱ 167ȱ(58)ȱ ȱ 162ȱ(56)ȱ 127ȱ(44)ȱ ȱ 163ȱ(56)ȱ 126ȱ(44)ȱ ȱ 94ȱ(33)ȱ 195ȱ(67)ȱ ȱ 95ȱ(33)ȱ 194ȱ(67)ȱ ȱ 153ȱ(53)ȱ 136ȱ(47)ȱ ȱ 21ȱ(7)ȱ 268ȱ(93)ȱ ȱ 142ȱ(49)ȱ 147ȱ(51)ȱ  ȱ 76ȱ(50)ȱ 77ȱ(50)ȱ ȱ 60ȱ(39)ȱ 93ȱ(61)ȱ ȱ 64ȱ(42)ȱ 89ȱ(58)ȱ ȱ 64ȱ(42)ȱ 89ȱ(58)ȱ ȱ 77ȱ(50)ȱ 76ȱ(50)ȱ ȱ 31ȱ(20)ȱ 122ȱ(80)ȱ ȱ 24ȱ(16)ȱȱȱȱ 129ȱ(84)ȱ ȱ 57ȱ(37)ȱ 96ȱ(63)ȱ ȱ 1ȱ(1)ȱ 152ȱ(99)ȱ ȱ 36ȱ(24)ȱ 117ȱ(76)ȱ  ȱ ȱ ȱ 2.20ȱȱ(1.47ȱ––ȱ3.30)ȱ ȱ ȱ ȱ ȱ ȱ 1.92ȱȱ(1.29ȱ––ȱ2.86)ȱ ȱ ȱ ȱ ȱ ȱ 1.02ȱȱ(0.68ȱ––ȱ1.51)ȱ ȱ ȱ ȱ ȱ ȱ 1.77ȱȱ(1.19ȱ––ȱ2.64)ȱ ȱ ȱ ȱ ȱ ȱ 1.28ȱȱ(0.86ȱ––ȱ1.89)ȱ ȱ ȱ ȱ ȱ ȱ 1.90ȱȱ(1.19ȱ––ȱ3.02)ȱ ȱ ȱ ȱ ȱ ȱ 2.63ȱȱ(1.60ȱ––ȱ4.34)ȱ ȱ ȱ ȱ ȱ ȱ 1.89ȱȱ(1.27ȱ––ȱ2.83)ȱ ȱ ȱ ȱ ȱ ȱ 11.91ȱȱ(1.59ȱ––ȱ89.42)ȱ ȱ ȱ ȱ ȱ ȱ 3.14ȱȱ(2.02ȱ––ȱ4.87)ȱ ȱ ȱ  pȬvalueȱ <0.001  <0.001  0.938  0.005  0.223  0.007  <0.001  0.002  0.016  <0.001  Note:ȱaȱAllȱexplanatoryȱvariablesȱmeasuredȱatȱfirstȱstudyȱvisitȱduringȱstudyȱperiod;ȱbȱ ORȱ=ȱOddsȱRatio;ȱcȱCIȱ=ȱ ConfidenceȱInterval;ȱdȱDenotesȱactivitiesȱorȱsituationsȱreferringȱtoȱpreviousȱ6ȱmonths.ȱ  ȱ  ȱ ȱ ȱ  ȱ  79  ȱ  Tableȱ4.2ȱMultivariateȱlogisticȱregressionȱanalysisȱofȱfactorsȱassociatedȱwithȱ attendingȱVancouver’’sȱsupervisedȱinjectionȱfacilityȱ(n=442)ȱ Characteristicȱaȱ PriorȱWillingnessȱtoȱUseȱSIFȱ UnstableȱHousingȱbȱ DailyȱCocaineȱInjectionȱbȱ DailyȱHeroinȱInjectionȱbȱ PublicȱInjectingȱbȱ  Adjustedȱ (95%ȱConfidenceȱInterval)ȱ OddsȱRatio 1.67ȱ ȱ(1.09ȱ––ȱ2.55)ȱ 1.54ȱ ȱ(1.01ȱ––ȱ2.34)ȱ 1.52ȱ ȱ(0.93ȱ––ȱ2.48)ȱ 1.63ȱ ȱ(0.95ȱ––ȱ2.81)ȱ 2.35ȱ ȱ(1.46ȱ––ȱ3.77)ȱ  pȬvalue 0.019 0.044 0.095 0.076 <0.001  Note:ȱaAllȱexplanatoryȱvariablesȱwereȱmeasuredȱatȱfirstȱstudyȱvisitȱduringȱstudyȱperiod;ȱȱ bDenotesȱactivitiesȱorȱsituationsȱreferringȱtoȱpreviousȱ6ȱmonths.ȱȱȱ *Overdoseȱwasȱnotȱconsideredȱinȱthisȱmodelȱdueȱtoȱlowȱfrequencyȱcounts.ȱȱ  ȱ  Tableȱ4.3ȱGEEȱanalysisȱofȱfactorsȱassociatedȱwithȱnotȱusingȱtheȱsupervisedȱinjectionȱ facilityȱinȱtheȱlastȱsixȱmonthsȱ(n=76)ȱamongȱthoseȱwhoȱinitiallyȱreportedȱbeingȱ willingȱtoȱuseȱtheȱfacilityȱ(n=274)ȱ  ȱ  Univariateȱȱ  ȱȱȱ Multivariateȱ  ORbȱȱ(95%ȱCIc) pȬvalueȱ Characteristicȱaȱ Youngerȱthanȱ39ȱYrsȱofȱAgeȱ Yesȱvs.ȱNoȱ 1.65ȱ(1.18ȱ––ȱ2.29) ȱ 0.003ȱ Genderȱȱ Femaleȱvs.ȱMaleȱ 1.09ȱ(0.75ȱ––ȱ1.58) 0.660ȱ ȱe InfrequentȱExposureȱtoȱDTES ȱȱ Yesȱvs.ȱNoȱ 1.93ȱ(1.38ȱ––ȱ2.71) <0.001ȱ InfrequentȱCocaineȱInjectionȱeȱ <ȱdailyȱvs.ȱ>ȱdailyȱȱ 1.82ȱ(1.36ȱ––ȱ2.44) <0.001ȱ InfrequentȱHeroinȱInjectionȱeȱ <ȱdailyȱvs.ȱ>ȱdailyȱ 2.80ȱ(2.11ȱ––ȱ3.71) <0.001ȱ ȱe Incarceration ȱ Yesȱvs.ȱNoȱ 0.78ȱ(0.59ȱ––ȱ1.09) 0.141ȱ ȱe AnyȱAddictionȱTreatment ȱ Yesȱvs.ȱNoȱ 1.42ȱ(1.05ȱ––ȱ1.93) 0.024ȱ  AORdȱ(95%ȱCI)ȱ pȬvalue 1.68ȱ(1.21ȱ––ȱ2.34)ȱ  0.002  1.86ȱ(1.30ȱ––ȱ2.66)ȱ  <0.001  1.52ȱ(1.12ȱ––ȱ2.06)ȱ  0.007  2.46ȱ(1.84ȱ––ȱ3.28)ȱ  <0.001  1.23ȱ(0.90ȱ––ȱ1.68)ȱ  0.185  Note:ȱaȱVariableȱmeasuresȱcollectedȱbetweenȱDecemberȱ2003ȱ––ȱNovemberȱ2005;ȱbORȱ=ȱOddsȱ Ratio;ȱcCIȱ=ȱConfidenceȱInterval;ȱdAORȱ=ȱAdjustedȱOddsȱRatio;ȱȱeȱDenotesȱactivitiesȱorȱsituationsȱ referringȱtoȱpreviousȱ6ȱmonths.ȱȱ  ȱ  ȱ  80  ȱ  Figureȱ4.1ȱStudyȱsampleȱ ȱȱ  Initial Sample Pre-SIF Period N=640 N=600  Willing N=344 57%  N=274 62%  Attend N=198 72%  Not Willing N=256 43% Not seen post SIF N=70 20%  No Attend N=76 28%  Unsure N=40 6% Not seen post SIF N=88 34%  N=168 38%  Attend N=91 54%  No Attend N=77 46%  N=29  Attend N=18 62%  Not Seen post SIF N=11 28%  No Attend N=11 38%  Included in statistical analyses n=442  ȱ  81  ȱ  CHAPTER 5: ȱ SOCIALIZINGȱINȱANȱOPENȱDRUGȱSCENE:ȱTHEȱ RELATIONSHIPȱBETWEENȱACCESSȱTOȱPRIVATEȱSPACEȱANDȱ STREETȱDISORDER 4ȱ  5.1 Introductionȱ DrugȬrelatedȱ streetȱ disorder,ȱ includingȱ publicȱ drugȱ useȱ andȱ intoxicationȱ andȱ loiteringȱ inȱ publicȱ areas,ȱ negativelyȱ impactsȱ neighbourhoodȱ businessesȱ andȱ surroundingȱ communitiesȱ andȱ canȱ detractȱ fromȱ theȱ enjoymentȱ ofȱ publicȱ spaces.40Ȭ42ȱ DrugȬrelatedȱ streetȱ disorderȱ isȱ aȱ burdenȱ forȱ lawȱ enforcementȱ agenciesȱ andȱ recentȱ evidenceȱ suggestsȱ thatȱ exposureȱ toȱ streetȬbasedȱ drugȱ scenesȱ posesȱ risksȱ toȱ individualȱ drugȱusers.49,ȱ68,ȱ247ȱPolicyȱresponsesȱtoȱaddressȱstreetȱdisorderȱinȱopenȱdrugȱscenesȱhave,ȱ toȱ date,ȱ largelyȱ reliedȱ onȱ lawȱ enforcementȱ measuresȱ toȱ deterȱ disorderlyȱ behaviourȱ inȱ publicȱsettings.62,ȱ68,ȱ127ȱ Inȱ someȱ areasȱ withȱ concentratedȱ drugȱ andȱ streetȱ disorderȱ problems,ȱ policeȱ agenciesȱhaveȱinitiatedȱcrackdownȱcampaigns,ȱwhichȱinvolveȱtargetingȱpolicingȱeffortsȱ onȱ drugȬrelatedȱ streetȱ disorder.62,ȱ  68,ȱ 127  ȱ Increasedȱ policeȱ presenceȱ andȱ patrolȱ andȱ  arrestingȱ individualsȱ forȱ disorderlyȱ behavioursȱ areȱ someȱ keyȱ featuresȱ ofȱ crackȬdownȱ campaigns.62ȱ ȱ Inȱ Canada,ȱ someȱ provincesȱ haveȱ alsoȱ introducedȱ legislationȱ specificȱ toȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 4  ȱAȱversionȱofȱthisȱchapterȱhasȱbeenȱsubmittedȱforȱpublicationȱas:ȱDeBeck,ȱK.,ȱWood,ȱE.,ȱ Qi,ȱJ.,ȱMcArthur,ȱD.,ȱMontaner,ȱJ.,ȱKerr,ȱT.ȱSocializingȱinȱanȱopenȱdrugȱscene:ȱTheȱ relationshipȱbetweenȱaccessȱtoȱprivateȱspaceȱandȱstreetȱdisorder.ȱ ȱ  82  ȱ  streetȱ disorder.ȱ Forȱ instance,ȱ legislationȱ inȱ severalȱ Canadianȱ provincesȱ (i.e.,ȱ theȱ ‘‘Safeȱ Streetsȱ Act’’ȱ inȱ Ontarioȱ andȱ Britishȱ Columbia)ȱ provideȱ lawȱ enforcementȱ officersȱ withȱ additionalȱ toolsȱ toȱ limitȱ solicitingȱ inȱ publicȱ locations.8,ȱ 144ȱ Althoughȱ lawȱ enforcementȱ measuresȱhaveȱbeenȱfoundȱtoȱreduceȱtheȱvisualȱpresenceȱofȱstreetȱdisorder,97,ȱ105,ȱ140ȱtheseȱ effectsȱ areȱ typicallyȱ shortȬlivedȱ andȱ areȱ oftenȱ associatedȱ withȱ unintendedȱ negativeȱ consequences.69ȱ Theseȱ includeȱ displacingȱ disorderlyȱ behaviourȱ toȱ surroundingȱ areasȱ andȱdisplacingȱillicitȱdrugȱusersȱawayȱfromȱhealthȱandȱsocialȱservices.107,ȱ110,ȱ112,ȱ125,ȱ133,ȱ144,ȱ248Ȭ 250  ȱȱGivenȱtheȱapparentȱlimitationsȱofȱlawȱenforcementȱbasedȱapproaches,ȱthereȱisȱaȱneedȱ  toȱidentifyȱnovelȱinterventionsȱwithȱpotentialȱtoȱaddressȱstreetȱdisorder.ȱȱ Toȱ date,ȱ policyȬmakersȱ andȱ researchersȱ haveȱ givenȱ limitedȱ considerationȱ toȱ theȱ potentialȱroleȱthatȱtheȱstructureȱofȱtheȱhousingȱavailableȱtoȱpeopleȱwhoȱareȱentrenchedȱ inȱdrugȱscenesȱmayȱplayȱinȱinfluencingȱtheȱamountȱofȱtimeȱindividualsȱspendȱonȱpublicȱ streetsȱ andȱ whetherȱ changingȱ thisȱ structureȱ mightȱ impactȱ theȱ amountȱ ofȱ timeȱ drugȱ usersȱ spendȱ inȱ theȱ openȱ drugȱ scene.ȱ Restrictionsȱ onȱ socializingȱ inȱ residentialȱ spaces,ȱ eitherȱthroughȱspaceȱconstraintsȱorȱregulationsȱthatȱimposeȱbarriersȱtoȱhavingȱguestsȱinȱ privateȱvenues,ȱmayȱinadvertentlyȱcontributeȱtoȱstreetȱdisorder.ȱ Therefore,ȱweȱsoughtȱtoȱexamineȱtheȱrelationshipȱbetweenȱtimeȱspentȱsocializingȱ inȱVancouver’’sȱopenȱdrugȱsceneȱandȱaccessȱtoȱprivateȱspaceȱamongȱlocalȱinjectionȱdrugȱ usersȱ (IDU).ȱ Weȱ hypothesizedȱ thatȱ spendingȱ timeȱ socializingȱ inȱ theȱ openȱ drugȱ sceneȱ wouldȱ beȱ associatedȱ withȱ havingȱ limitedȱ accessȱ toȱ privateȱ space.ȱ Weȱ alsoȱ soughtȱ toȱ  ȱ  83  ȱ  assessȱwhetherȱIDUȱwhoȱreportȱfrequentlyȱsocializingȱinȱVancouver’’sȱopenȱdrugȱsceneȱ wouldȱbeȱwillingȱtoȱreduceȱtheȱamountȱofȱtimeȱspentȱsocializingȱinȱthisȱlocationȱifȱtheyȱ wereȱofferedȱmoreȱaccessȱtoȱprivateȱindoorȱspace.ȱ  5.2 Methodsȱ Dataȱ forȱ thisȱ studyȱ wereȱ obtainedȱ fromȱ theȱ Vancouverȱ Injectionȱ Drugȱ Usersȱ Studyȱ (VIDUS).ȱ Forȱ aȱ fullȱ descriptionȱ ofȱ theȱ studyȱ pleaseȱ referȱ toȱ sectionȱ 1.4ȱ ofȱ thisȱ thesis.ȱTheȱpresentȱanalysesȱareȱrestrictedȱtoȱVIDUSȱparticipantsȱseenȱforȱstudyȱfollowȬ upȱduringȱtheȱperiodȱofȱJuneȱ2008ȱtoȱJuneȱ2009ȱasȱmeasuresȱforȱkeyȱvariablesȱofȱinterestȱ areȱavailableȱonlyȱforȱthisȱperiod.ȱIfȱindividualsȱwereȱseenȱforȱmultipleȱstudyȱfollowȬupȱ visitsȱduringȱthisȱstudyȱperiodȱonlyȱdataȱfromȱtheirȱfirstȱvisitȱwereȱused.ȱ Inȱ ourȱ initialȱ analysisȱ theȱ outcomeȱ ofȱ interestȱ wasȱ spendingȱ timeȱ socializingȱ inȱ Vancouver’’sȱopenȱdrugȱmarketȱscene.ȱToȱmeasureȱ‘‘socializing’’ȱweȱaskedȱrespondentsȱtoȱ estimateȱtheȱaverageȱnumberȱofȱhoursȱtheyȱspendȱonȱtheȱstreetȱeachȱday,ȱandȱthenȱweȱ askedȱ themȱ toȱ specifyȱ howȱ manyȱ ofȱ thoseȱ hoursȱ onȱ averageȱ wereȱ spentȱ socializing.ȱ Becauseȱ weȱ wereȱ interestedȱ inȱ socializingȱ inȱ theȱ openȱ drugȱ sceneȱ asȱ anȱ indicatorȱ ofȱ drugȬrelatedȱ streetȱ disorderȱ (andȱ notȱ simplyȱ spendingȱ timeȱ anywhereȱ inȱ theȱ city),ȱ weȱ restrictedȱourȱdefinitionȱofȱsocializingȱtoȱindividualsȱwhoȱreportedȱspendingȱanȱaverageȱ ofȱthreeȱorȱmoreȱhoursȱonȱtheȱstreetȱeachȱdayȱsocializingȱandȱwhoȱeitherȱresidedȱinȱorȱ frequentlyȱvisitȱ(atȱleastȱtwoȱtimesȱperȱweek)ȱVancouver’’sȱdrugȱuseȱepicenter,ȱwhichȱisȱaȱ wellȱ definedȱ andȱ describedȱ areaȱ ofȱ theȱ cityȱ knownȱ asȱ theȱ Downtownȱ Eastside.69ȱ Allȱ ȱ  84  ȱ  respondentsȱwhoȱdidȱnotȱfrequentlyȱvisitȱorȱresideȱinȱVancouver’’sȱdrugȱuseȱepicenterȱorȱ whoȱreportedȱspendingȱlessȱthanȱthreeȱhoursȱonȱaverageȱsocializingȱonȱtheȱstreetȱeachȱ dayȱwereȱincludedȱinȱtheȱcomparisonȱgroup.ȱȱ Theȱ primaryȱ explanatoryȱ variableȱ ofȱ interestȱ forȱ theȱ initialȱ analysisȱ wasȱ havingȱ ‘‘limitedȱprivateȱspaceȱforȱsocializing’’.ȱIndividualsȱwhoȱansweredȱ““no””ȱtoȱtheȱquestion:ȱ ““Doȱ youȱ haveȱ aȱ privateȱ indoorȱ spaceȱ forȱ socializingȱ withȱ friendsȱ andȱ acquaintances?””ȱ wereȱ includedȱ inȱ thisȱ category.ȱ Becauseȱ weȱ wantedȱ toȱ includeȱ anȱ objectiveȱ markerȱ inȱ ourȱmeasureȱofȱaccessȱtoȱprivateȱspaceȱforȱsocializingȱweȱalsoȱconsideredȱtheȱnumberȱofȱ guestsȱindividualsȱwereȱallowedȱtoȱhaveȱinȱtheirȱresidenceȱatȱoneȱtimeȱandȱallȱreportsȱofȱ beingȱ allowedȱlessȱthanȱthreeȱ guestsȱ atȱoneȱtimeȱwereȱ includedȱinȱtheȱ‘‘limitedȱ privateȱ space’’ȱcategoryȱevenȱifȱrespondentsȱinitiallyȱreportedȱ““yes””ȱtoȱhavingȱprivateȱspaceȱforȱ socializing.ȱ Similarly,ȱ ifȱ otherȱ significantȱ barriersȱ toȱ havingȱ guestsȱ inȱ theirȱ residenceȱ wereȱ reportedȱ theseȱ individualsȱ wereȱ alsoȱ includedȱ inȱ theȱ categoryȱ ofȱ havingȱ ‘‘limitedȱ privateȱ spaceȱ forȱ socializing’’.ȱ Significantȱ barriersȱ includedȱ ‘‘guestȱ fees’’ȱ (typicallyȱ $5Ȭ10ȱ perȱ guest),ȱ timeȱ restrictionsȱ onȱ visitors,ȱ restrictionsȱ onȱ theȱ appearanceȱ ofȱ guestsȱ (e.g.,ȱ visitorsȱ mustȱ beȱ wellȱ groomed,ȱ canȱ notȱ appearȱ intoxicated)ȱ andȱ theȱ requirementȱ thatȱ guestsȱ mustȱ showȱ pictureȱ ID.ȱ Participantsȱ thatȱ reportedȱ ““yes””ȱ toȱ havingȱ accessȱ toȱ privateȱ spaceȱ andȱ reportedȱ noneȱ ofȱ theȱ aboveȱ restrictionsȱ toȱ havingȱ guestsȱ wereȱ includedȱinȱtheȱcomparisonȱgroup.ȱȱ  ȱ  85  ȱ  Toȱdetermineȱwhetherȱthereȱwasȱaȱsignificantȱrelationshipȱbetweenȱourȱoutcomeȱ ofȱ interestȱ andȱ ourȱ primaryȱ explanatoryȱ variableȱ weȱ aȱ prioriȱ selectedȱ aȱ rangeȱ ofȱ secondaryȱ explanatoryȱ variablesȱ weȱ hypothesizedȱ mightȱ beȱ associatedȱ withȱ bothȱ socializingȱ inȱ theȱ openȱ drugȱ sceneȱ andȱ havingȱ accessȱ toȱ privateȱ space.ȱ Secondaryȱ explanatoryȱfactorsȱincluded:ȱageȱ(perȱyearȱolder);ȱgenderȱ(femaleȱvs.ȱmale);ȱAboriginalȱ ancestryȱ(yesȱvs.ȱno);ȱdailyȱcocaineȱinjectionȱ(yesȱvs.ȱno);ȱdailyȱheroinȱinjectionȱ(yesȱvs.ȱ no);ȱ dailyȱ crackȱ cocaineȱ smokingȱ (yesȱ vs.ȱ no);ȱ bingeȱ drugȱ use,ȱ definedȱ asȱ aȱ periodȱ ofȱ usingȱ drugsȱ moreȱ oftenȱ thanȱ usualȱ (yesȱ vs.ȱ no);ȱ sexȱ tradeȱ involvement,ȱ definedȱ asȱ exchangingȱ sexȱ forȱ money,ȱ shelter,ȱ drugsȱ orȱ otherȱ commoditiesȱ (yesȱ vs.ȱ no);ȱ participationȱ inȱ drugȱ dealingȱ (yesȱ vs.ȱ no);ȱ havingȱ beenȱ employedȱ (yesȱ vs.ȱ no);ȱ havingȱ beenȱincarceratedȱ(yesȱvs.ȱno);ȱparticipationȱinȱanyȱaddictionȱtreatmentȱprogramȱ(yesȱvs.ȱ no);ȱandȱeverȱtestingȱpositiveȱforȱHIVȱ(whichȱinȱourȱsettingȱmightȱinfluenceȱtheȱtypesȱofȱ housingȱ optionsȱ available)ȱ (yesȱ vs.ȱ no).ȱ Unlessȱ otherwiseȱ stated,ȱ allȱ drugȱ useȱ andȱ behaviouralȱvariablesȱreferȱtoȱtheȱpreviousȱsixȬmonthȱperiod.ȱToȱaccountȱforȱaȱpotentialȱ seasonalȱ influenceȱ onȱ theȱ aboutȱ ofȱ timeȱ individualsȱ spendȱ onȱ theȱ street,ȱ weȱ alsoȱ includedȱaȱcategoricalȱvariableȱrepresentingȱtheȱmonthȱthatȱparticipantsȱcompletedȱourȱ studyȱ questionnaire.ȱ Thisȱ insuredȱ thatȱ ourȱ analysisȱ adjustedȱ forȱ seasonalȱ variationȱ inȱ responses.ȱȱ Weȱalsoȱsoughtȱtoȱassessȱtheȱrelationshipȱbetweenȱsocializingȱandȱdifferentȱtypesȱ ofȱhousingȱstatuses.ȱToȱdoȱthisȱweȱcreatedȱaȱcategoricalȱvariableȱforȱhousingȱwithȱ‘‘stableȱ housing’’ȱ asȱ theȱ referenceȱ andȱ conductedȱ univariateȱ analysesȱ forȱ housingȱ statusȱ andȱ ȱ  86  ȱ  socializing.ȱCategoriesȱforȱhousingȱstatusȱwereȱmutuallyȱexclusiveȱandȱbasedȱonȱwhereȱ participantsȱ wereȱ residingȱ atȱ theȱ timeȱ ofȱ theȱ interview.ȱ Categoriesȱ included:ȱ stableȱ housing,ȱ definedȱ asȱ livingȱ inȱ aȱ houseȱ orȱ apartment;ȱ singleȱ roomȱ occupancyȱ (SRO),ȱ definedȱasȱaȱsingleȱroomȱinȱaȱhotel;ȱshelter,ȱdefinedȱasȱsleepingȱinȱtemporaryȱsheltersȱforȱ homelessȱindividualsȱwhichȱareȱtypicallyȱonlyȱopenȱatȱnight;ȱnoȱfixedȱaddress,ȱdefinedȱ asȱ havingȱ noȱ stableȱ residence,ȱ includingȱ sleepingȱ onȱ theȱ streetȱ asȱ wellȱ asȱ stayingȱ withȱ friendsȱorȱacquaintancesȱonȱaȱshortȱtermȱbasis,ȱi.e.,ȱ‘‘couchȱsurfing’’;ȱtreatmentȱcentreȱorȱ recoveryȱ house,ȱ definedȱ asȱ livingȱ inȱ residentialȱ addictionȱ treatmentȱ centresȱ orȱ transitionalȱaddictionȱtreatmentȱrecoveryȱhouses;ȱjail,ȱdefinedȱasȱbeingȱincarceratedȱinȱaȱ prison;ȱ andȱ other,ȱ whichȱ includesȱ situationsȱ thatȱ didȱ notȱ fitȱ intoȱ theȱ aboveȱ categories.ȱȱ Becauseȱhousingȱstatusȱandȱaccessȱtoȱprivateȱspaceȱareȱcloselyȱassociated,ȱthisȱvariableȱ wasȱ notȱ includedȱ asȱ aȱ secondaryȱ outcomeȱ ofȱ interestȱ inȱ theȱ analysisȱ assessingȱ theȱ relationshipȱbetweenȱsocializingȱandȱaccessȱtoȱprivateȱspace.ȱȱȱȱ Toȱ assessȱ theȱ relationshipȱ betweenȱ socializingȱ andȱ accessȱ toȱ privateȱ space,ȱ asȱ aȱ firstȱstepȱweȱconductedȱunivariateȱanalysesȱforȱourȱprimaryȱandȱsecondaryȱoutcomesȱofȱ interestȱstratifiedȱbyȱsocializingȱinȱtheȱopenȱdrugȱscene.ȱWeȱusedȱPearson’’sȱchiȬsquareȱȱ testȱ forȱ dichotomousȱ variablesȱ andȱ theȱ MannȬWhitneyȱ testȱ forȱ continuousȱ variables.ȱ Fisher’’sȱexactȱtestȱwasȱusedȱwhenȱoneȱorȱmoreȱofȱtheȱcellȱcountsȱwasȱlessȱthanȱorȱequalȱ toȱfive.ȱToȱfitȱourȱmultivariateȱmodel,ȱweȱusedȱaȱbackwardsȱselectionȱprocessȱpreviouslyȱ describedȱbyȱMaldonadoȱandȱGreenland232ȱandȱRothmanȱandȱGreenland.233ȱSpecifically,ȱ weȱbeganȱwithȱallȱoutcomesȱofȱinterestȱinȱaȱfullȱmodel.ȱUsingȱanȱautomatedȱprocedure,ȱ ȱ  87  ȱ  weȱ subsequentlyȱ generatedȱ aȱ seriesȱ ofȱ confoundingȱ modelsȱ byȱ removingȱ eachȱ secondaryȱ factorȱ ofȱ interestȱ oneȱ atȱ aȱ time.ȱ Forȱ eachȱ ofȱ theseȱ modelsȱ weȱ assessedȱ theȱ relativeȱ changeȱ inȱ theȱ coefficientȱ forȱ ourȱ primaryȱ factorȱ ofȱ interestȱ (limitedȱ accessȱ toȱ privateȱspace).ȱTheȱsecondaryȱoutcomeȱofȱinterestȱthatȱresultedȱinȱtheȱsmallestȱabsoluteȱ relativeȱchangeȱinȱtheȱcoefficientȱforȱ‘‘limitedȱaccessȱtoȱprivateȱspace’’ȱwasȱthenȱremoved.ȱ Thisȱ approachȱ allowedȱ usȱ toȱ identifyȱ theȱ secondaryȱ outcomesȱ ofȱ interestȱ thatȱ hadȱ theȱ strongestȱ influenceȱ onȱ theȱ coefficientȱ forȱ ourȱ primaryȱ variableȱ ofȱ interestȱ whileȱ removingȱthoseȱthatȱhadȱtheȱweakestȱrelationshipȱwithȱ‘‘limitedȱaccessȱtoȱprivateȱspace’’.ȱ Secondaryȱ variablesȱ continuedȱ toȱ beȱ removedȱ throughȱ thisȱ processȱ untilȱ theȱ smallestȱ relativeȱchangeȱinȱtheȱcoefficientȱofȱ‘‘limitedȱaccessȱtoȱprivateȱspace’’ȱexceededȱ5%ȱofȱtheȱ valueȱofȱtheȱcoefficient.ȱTheȱfinalȱmodelȱincludedȱlimitedȱaccessȱtoȱprivateȱspaceȱandȱallȱ remainingȱsecondaryȱexplanatoryȱvariables.ȱ Inȱ secondaryȱ analysis,ȱ weȱ soughtȱ toȱ assessȱ andȱ identifyȱ factorsȱ associatedȱ withȱ willingnessȱ toȱ relocateȱ toȱ indoorȱ privateȱ locationsȱ ifȱ suchȱ spacesȱ wereȱ madeȱ availableȱ amongȱ participantsȱ whoȱ reportedȱ socializingȱ inȱ theȱ openȱ drugȱ sceneȱ andȱ whoȱ haveȱ limitedȱ accessȱ toȱ privateȱ indoorȱ space.ȱ Toȱ measureȱ willingnessȱ toȱ relocateȱ weȱ askedȱ participantsȱ““Wouldȱyouȱspendȱlessȱtimeȱsocializingȱonȱtheȱstreetȱifȱyouȱhadȱaȱprivateȱ indoorȱ spaceȱ (orȱ moreȱ privateȱ indoorȱ space)ȱ forȱ socializingȱ withȱ friendsȱ andȱ acquaintances?””ȱ Theȱ geographicȱ locationȱ ofȱ whereȱ privateȱ indoorȱ spaceȱ mightȱ beȱ locatedȱwasȱnotȱspecifiedȱandȱnoȱadditionalȱdescriptionȱofȱtheȱtypeȱofȱprivateȱspaceȱwasȱ given.ȱ Variablesȱ ofȱ interestȱ forȱ secondaryȱ analysisȱ includedȱ allȱ variablesȱ (withȱ theȱ ȱ  88  ȱ  exceptionȱ ofȱ limitedȱ accessȱ toȱ privateȱ space)ȱ fromȱ theȱ primaryȱ analysis,ȱ inȱ additionȱ toȱ otherȱriskȱfactorsȱthatȱmayȱinfluenceȱwillingnessȱtoȱrelocate.ȱSpecifically,ȱweȱconsideredȱ selfȬreportsȱ ofȱ recentȱ nonȬfatalȱ overdoseȱ eventsȱ (yesȱ vs.ȱ no),ȱ borrowingȱ andȱ lendingȱ syringesȱalreadyȱusedȱtoȱinjectȱdrugsȱ(yesȱvs.ȱno),ȱhavingȱmultipleȱsexȱpartnersȱ(yesȱvs.ȱ no)ȱandȱHIVȱpositiveȱserostatusȱ(yesȱvs.ȱno).ȱWeȱalsoȱconsideredȱrecentȱencountersȱwithȱ policeȱ(lastȱ30ȱdays)ȱandȱbeingȱaȱrecentȱvictimȱofȱviolence,ȱasȱindividualsȱentrenchedȱinȱ drugȱ marketȱ scenesȱ haveȱ beenȱ identifiedȱ asȱ beingȱ particularlyȱ vulnerableȱ toȱ theseȱ experiences.247ȱ Toȱ assessȱ whetherȱ theȱ levelȱ ofȱ socializingȱ influencedȱ willingnessȱ toȱ relocateȱweȱalsoȱconsideredȱtheȱnumberȱofȱhoursȱparticipantsȱreportedȱsocializingȱinȱtheȱ openȱdrugȱsceneȱasȱaȱcontinuousȱvariableȱ(perȱadditionalȱhourȱreported).ȱAsȱinȱprimaryȱ analysis,ȱ unlessȱ otherwiseȱ stated,ȱ allȱ drugȱ useȱ andȱ behaviouralȱ variablesȱ referȱ toȱ theȱ previousȱ sixȬmonthȱ period.ȱ Asȱ aȱ firstȱ step,ȱ weȱ usedȱ univariateȱ analysesȱ toȱ determineȱ factorsȱ associatedȱ withȱ willingnessȱ toȱ relocate.ȱ Categoricalȱ explanatoryȱ variablesȱ wereȱ analyzedȱusingȱPearson’’sȱchiȬsquareȱtestȱandȱcontinuousȱvariablesȱwereȱanalyzedȱusingȱ theȱMannȬWhitneyȱtest.ȱFisher’’sȱexactȱtestȱwasȱusedȱwhenȱoneȱorȱmoreȱofȱtheȱcellȱcountsȱ wasȱ lessȱ thanȱ orȱ equalȱ toȱ five.ȱ Allȱ variablesȱ thatȱ wereȱ associatedȱ withȱ theȱ dependentȱ variableȱ atȱ pȱ <ȱ 0.05ȱ inȱ univariateȱ analysesȱ wereȱ thenȱ enteredȱ inȱ aȱ multivariateȱ logisticȱ model.ȱAsȱwithȱtheȱprimaryȱanalysis,ȱweȱalsoȱcreatedȱaȱcategoricalȱvariableȱforȱhousingȱ statusȱandȱconductedȱunivariateȱanalysesȱtoȱassessȱtheȱrelationshipȱbetweenȱwillingnessȱ toȱrelocateȱandȱdifferentȱtypesȱofȱhousingȱstatuses.ȱSimilarly,ȱgivenȱtheȱcloseȱassociationȱ betweenȱ numberȱ ofȱ hoursȱ socializingȱ andȱ housingȱ statusȱ thisȱ variableȱ wasȱ notȱ ȱ  89  ȱ  consideredȱinȱtheȱmultivariateȱmodel.ȱAllȱstatisticalȱanalysesȱwereȱperformedȱusingȱSASȱ softwareȱversionȱ9.1ȱ(SAS,ȱCary,ȱNC).ȱȱAllȱpȬvaluesȱareȱtwoȱsided.ȱ  5.3 Resultsȱ Duringȱtheȱstudyȱperiodȱaȱtotalȱofȱ1,121ȱparticipantsȱcompletedȱfollowȬupȱvisits,ȱ includingȱ 396ȱ (35%)ȱ womenȱ andȱ 396ȱ (35%)ȱ personsȱ whoȱ identifiedȱ asȱ beingȱ ofȱ Aboriginalȱ ancestry.ȱ Theȱ medianȱ ageȱ ofȱ allȱ participantsȱ wasȱ 44ȱ yearsȱ (interquartileȱ rangeȱ [IQR]ȱ =ȱ 38Ȭ50),ȱ andȱ theȱ housingȱ statusesȱ ofȱ studyȱ participantsȱ areȱ displayedȱ inȱ Figureȱ5.1.ȱAmongȱourȱsampleȱofȱ1,121ȱparticipants,ȱ477ȱindividualsȱ(43%)ȱfitȱtheȱcriteriaȱ forȱsocializingȱinȱtheȱopenȱdrugȱscene.ȱȱTheȱcharacteristicsȱofȱtheȱstudyȱsampleȱstratifiedȱ byȱsocializingȱinȱtheȱopenȱdrugȱsceneȱareȱpresentedȱinȱTableȱ5.1ȱandȱtheȱdistributionȱofȱ theȱwholeȱsampleȱbyȱhousingȱstatusȱandȱaccessȱtoȱprivateȱspaceȱisȱdisplayedȱinȱFigureȱ 5.2.ȱȱ Univariateȱ associationsȱ betweenȱ differentȱ typesȱ ofȱ housingȱ statusesȱ andȱ socializingȱ areȱ presentedȱ inȱ Tableȱ 5.2.ȱ Whenȱ comparedȱ toȱ participantsȱ withȱ stableȱ housingȱtheȱnoȱfixedȱaddressȱcategoryȱwasȱalmostȱsevenȱtimesȱmoreȱlikelyȱtoȱsocializeȱ inȱtheȱopenȱdrugȱscene,ȱwhileȱindividualsȱlivingȱinȱSROsȱandȱsheltersȱwereȱoverȱthreeȱ timesȱ moreȱ likelyȱ toȱ socialize.ȱ Theȱ univariateȱ analysesȱ ofȱ associationsȱ betweenȱ socializingȱ inȱ theȱ openȱ drugȱ sceneȱ andȱ otherȱ socioȬdemographicȱ andȱ behaviouralȱ variablesȱ areȱ presentedȱ inȱ Tableȱ 5.1.ȱ Havingȱ limitedȱ accessȱ toȱ privateȱ spaceȱ forȱ socializingȱ wasȱ significantlyȱ associatedȱ withȱ socializingȱ inȱ theȱ openȱ drugȱ sceneȱ (Oddsȱ ȱ  90  ȱ  Ratioȱ [OR]ȱ =ȱ 2.85,ȱ 95%ȱ Confidenceȱ Intervalȱ [CI]:ȱ 2.11Ȭ3.86).ȱ Theȱ resultsȱ ofȱ theȱ finalȱ multivariateȱ logisticȱ regressionȱ areȱ shownȱ inȱ Tableȱ 5.3.ȱ Theȱ primaryȱ explanatoryȱ variable,ȱ limitedȱ accessȱ toȱ privateȱ space,ȱ remainedȱ independentlyȱ associatedȱ withȱ socializingȱinȱtheȱopenȱdrugȱsceneȱ(AdjustedȱOddsȱRatioȱ[AOR]ȱ=2.33,ȱ95%ȱCI:ȱ1.68Ȭ3.24)ȱ afterȱ adjustingȱ forȱ Aboriginalȱ ancestry,ȱ dailyȱ crackȱ cocaineȱ use,ȱ bingeȱ drugȱ use,ȱ drugȱ dealingȱandȱengagementȱinȱanyȱaddictionȱtreatment.ȱȱ Inȱ subȬanalysis,ȱ 256ȱ (65%)ȱ ofȱ theȱ 392ȱ participantsȱ thatȱ reportedȱ havingȱ limitedȱ accessȱ toȱ privateȱ spaceȱ andȱ socializingȱ inȱ theȱ openȱ drugȱ sceneȱ alsoȱ reportedȱ beingȱ willingȱtoȱrelocateȱifȱtheyȱwereȱprovidedȱwithȱmoreȱaccessȱtoȱprivateȱindoorȱspace.ȱTheȱ characteristicsȱofȱtheseȱindividualsȱstratifiedȱbyȱwillingnessȱtoȱrelocateȱareȱpresentedȱinȱ Tableȱ 5.4.ȱ Univariateȱ associationsȱ betweenȱ differentȱ typesȱ ofȱ housingȱ statusesȱ andȱ willingnessȱtoȱrelocateȱareȱpresentedȱinȱTableȱ5.5.ȱWhenȱcomparedȱtoȱparticipantsȱwithȱ stableȱ housingȱ theȱ noȱ fixedȱ addressȱ categoryȱ wasȱ overȱ tenȱ timesȱ moreȱ likelyȱ toȱ beȱ willingȱtoȱrelocate,ȱwhileȱindividualsȱlivingȱinȱSROsȱandȱsheltersȱwereȱtwoȱandȱsixȱtimesȱ moreȱ likelyȱ toȱ relocateȱ respectively.ȱ Theȱ univariateȱ analysesȱ ofȱ associationsȱ betweenȱ willingnessȱ toȱ relocateȱ andȱ otherȱ socioȬdemographicȱ andȱ behaviouralȱ variablesȱ areȱ presentedȱ inȱ Tableȱ 5.4.ȱ Factorsȱ thatȱ wereȱ significantlyȱ associatedȱ withȱ willingnessȱ toȱ relocateȱinclude:ȱnumberȱofȱhoursȱspentȱsocializingȱ(ORȱ=1.05,ȱ95%ȱCI:ȱ1.01ȱ––ȱ1.09);ȱageȱ (ORȱ =0.97,ȱ 95%ȱ CI:ȱ 0.95ȱ ––ȱ 0.99);ȱ dailyȱ heroinȱ injectionȱ (ORȱ =2.71,ȱ 95%ȱ CI:ȱ 1.60ȱ ––ȱ 4.64);ȱ encountersȱ withȱ policeȱ (ORȱ =1.90,ȱ 95%ȱ CI:ȱ 1.19ȱ ––ȱ 3.04);ȱ andȱ beingȱ aȱ victimȱ ofȱ violenceȱ (ORȱ =2.01,ȱ 95%ȱ CI:ȱ 1.15ȱ ––ȱ 3.53).ȱ Inȱ multivariateȱ logisticȱ regression,ȱ presentedȱ inȱ Tableȱ ȱ  91  ȱ  5.6,ȱ dailyȱ heroinȱ injectionȱ (AORȱ =2.27,ȱ 95%ȱ CI:ȱ 1.28Ȭ3.88)ȱ andȱ beingȱ aȱ recentȱ victimȱ ofȱ violenceȱ(AORȱ=1.81,ȱ95%ȱCI:ȱ1.02Ȭ3.23)ȱwereȱindependentlyȱassociatedȱwithȱwillingnessȱ toȱrelocate.ȱȱ  5.4 Discussionȱ Inȱ theȱ presentȱ studyȱ weȱ foundȱ that,ȱ amongȱ localȱ injectionȱ drugȱ users,ȱ havingȱ limitedȱprivateȱspaceȱwasȱsignificantlyȱassociatedȱwithȱspendingȱanȱaverageȱofȱthreeȱorȱ moreȱhoursȱperȱdayȱsocializingȱinȱtheȱopenȱdrugȱscene.ȱThisȱassociationȱpersistedȱafterȱ adjustmentȱ forȱ aȱrangeȱ ofȱpotentialȱconfoundingȱfactors.ȱȱ Socializingȱ inȱtheȱopenȱdrugȱ sceneȱwasȱalsoȱindependentlyȱpositivelyȱassociatedȱwithȱdailyȱcrackȱcocaineȱuse,ȱbingeȱ drugȱ useȱ andȱ drugȱ dealing,ȱ whileȱ addictionȱ treatmentȱ wasȱ negativelyȱ associatedȱ withȱ socializingȱinȱthisȱenvironment.ȱȱTheȱmajorityȱ(65%)ȱofȱthoseȱwhoȱhadȱlimitedȱaccessȱtoȱ privateȱ spaceȱ andȱ spendȱ significantȱ timeȱ socializingȱ inȱ theȱ openȱ drugȱ sceneȱ reportedȱ thatȱ theyȱ wouldȱ beȱ willingȱ toȱ relocateȱ awayȱ fromȱ theȱ openȱ drugȱ sceneȱ ifȱ theyȱ wereȱ providedȱwithȱprivateȱspaceȱforȱsocializing.ȱItȱisȱnotableȱthatȱdailyȱheroinȱinjectorsȱandȱ individualsȱwhoȱwereȱrecentȱvictimsȱofȱviolenceȱreportedȱbeingȱmostȱwillingȱtoȱrelocateȱ socializingȱ activities.ȱ Whenȱ comparedȱ toȱ IDUȱ whoȱ livedȱ inȱ stableȱ housing,ȱ studyȱ participantsȱ whoȱ livedȱ inȱ SROs,ȱ sheltersȱ andȱ hadȱ noȱ fixedȱ addressȱ wereȱ significantlyȱ moreȱlikelyȱtoȱsocializeȱinȱtheȱopenȱdrugȱsceneȱandȱwereȱsignificantlyȱmoreȱlikelyȱtoȱbeȱ willingȱtoȱrelocate.ȱȱ  ȱ  92  ȱ  Theseȱ findingsȱ areȱ consistentȱ withȱ existingȱ dataȱ highlightingȱ thatȱ openȱ drugȱ scenesȱ andȱ congregationsȱ ofȱ drugȱ usersȱ oftenȱ existȱ inȱ locationsȱ whereȱ ratesȱ ofȱ homelessnessȱandȱunstableȱhousingȱareȱaȱproblemȱamongȱdrugȱuserȱpopulations.40,ȱ152,ȱ251ȱ Althoughȱ theȱ linksȱ betweenȱ homelessnessȱ andȱ streetȱ disorderȱ haveȱ beenȱ previouslyȱ described,3,ȱ6,ȱ152ȱtoȱourȱknowledgeȱourȱstudyȱisȱtheȱfirstȱtoȱhighlightȱthatȱaȱlackȱofȱaccessȱ toȱ privateȱ spaceȱ isȱ likelyȱ playingȱ aȱ roleȱ inȱ generatingȱ streetȱ disorderȱ inȱ openȱ drugȱ scenes.ȱ Aȱ centralȱ implicationȱ ofȱ theseȱ findingsȱ isȱ thatȱ providingȱ streetȬinvolvedȱ drugȱ usersȱwithȱareasȱwhereȱtheyȱcanȱsocializeȱinȱcomfortȱandȱprivacyȱmayȱofferȱpotentialȱtoȱ reduceȱ aȱ componentȱ ofȱ drugȬrelatedȱ streetȱ disorder.ȱ ȱ Theȱ benefitsȱ ofȱ relocatingȱ streetȬ involvedȱ individualsȱ toȱ indoorȱ locationsȱ byȱ providingȱ housingȱ orȱ creatingȱ alternativeȱ venuesȱforȱsocializingȱappearsȱparticularlyȱvaluableȱgivenȱtheȱburdenȱthatȱdrugȬrelatedȱ streetȱ disorderȱ posesȱ forȱ lawȱ enforcementȱ agenciesȱ andȱ surroundingȱ communities,ȱ asȱ wellȱasȱpotentialȱharmsȱthatȱexposureȱtoȱdrugȱscenesȱposesȱtoȱdrugȱusersȱthemselves.3,ȱ68ȱȱ Althoughȱitȱcanȱbeȱchallengingȱtoȱprovideȱhousingȱforȱsomeȱchaoticȱdrugȱusingȱ individuals,ȱthereȱisȱaȱgrowingȱbodyȱofȱliteratureȱwhichȱsuggestsȱthatȱapproachesȱsuchȱ asȱtheȱ““housingȱfirst””ȱmodel,ȱwhichȱprovideȱdrugȱusingȱindividualsȱwithȱindependentȱ stableȱ housingȱ regardlessȱ ofȱ theirȱ drugȱ useȱ practices,ȱ areȱ moreȱ successfulȱ thanȱ abstinenceȬbasedȱsupportiveȱhousingȱinȱretainingȱandȱstabilizingȱactiveȱdrugȱusers.252Ȭ254ȱ Ourȱ studyȱ suggestsȱ thatȱ ifȱ theseȱ housingȱ modelsȱ canȱ accommodateȱ activeȱ drugȱ usersȱ  ȱ  93  ȱ  andȱ provideȱ housingȱ withȱ socialȱ spacesȱ forȱ thisȱ population,ȱ theyȱ couldȱ playȱ anȱ importantȱroleȱinȱtheȱreductionȱofȱstreetȱdisorder.ȱȱItȱisȱimportantȱtoȱrecognize,ȱhowever,ȱ thatȱthereȱareȱpotentialȱunintendedȱharmsȱthatȱmightȱresultȱfromȱrelocatingȱactiveȱdrugȱ usersȱintoȱprivateȱindoorȱlocations,ȱparticularlyȱifȱtheseȱlocationsȱareȱunsupervisedȱandȱ doȱnotȱhaveȱsafeguardsȱtoȱmanageȱbehavioursȱthatȱmightȱbeȱassociatedȱwithȱactiveȱdrugȱ use,ȱ suchȱ asȱ drugȱ overdoseȱ eventsȱ orȱ illicitȱ drugȱ dealingȱ whichȱ isȱ oftenȱ linkedȱ withȱ violenceȱgivenȱtheȱunregulatedȱnatureȱofȱtheȱillicitȱdrugȱmarket.46ȱȱȱ Toȱ addressȱ risksȱ associatedȱ withȱ activeȱ drugȱ use,ȱ thereȱ mayȱ beȱ aȱ roleȱ forȱ supervisedȱ drugȱ consumptionȱ facilitiesȱ integratedȱ intoȱ supportiveȱ housingȱ models.ȱ Indeed,ȱ theȱ integrationȱ ofȱ supervisedȱ drugȱ consumptionȱ facilitiesȱ inȱ oneȱ supportiveȱ housingȱ facilityȱ forȱ peopleȱ withȱ HIV/AIDSȱ inȱ Vancouverȱ hasȱ beenȱ shownȱ toȱ beȱ successfulȱinȱreducingȱriskyȱdrugȱuseȱpracticesȱonȱtheȱpremises.255ȱFurthermore,ȱinȱourȱ studyȱ settingȱ aȱ numberȱ ofȱ nonȬprofitȱ housingȱ societiesȱ haveȱ beenȱ ableȱ toȱ successfullyȱ provideȱsupportiveȱhousingȱforȱindividualsȱwhoȱactivelyȱuseȱdrugsȱandȱhaveȱbeenȱableȱ toȱmanageȱbehavioursȱassociatedȱwithȱillicitȱdrugȱuse.256,ȱ257ȱWithinȱtheseȱmodels,ȱspecialȱ considerationȱisȱgivenȱtoȱensuringȱthatȱresidents’’ȱhealthȱandȱphysicalȱsecurityȱneedsȱareȱ met.ȱInȱparticular,ȱmeasuresȱareȱtakenȱtoȱaccommodateȱandȱaddressȱtheȱrisksȱassociatedȱ withȱ drugȱ use,ȱ includingȱ drugȱ useȱ whichȱ normallyȱ wouldȱ takeȱ placeȱ inȱ outdoorȱ locationsȱwithinȱtheȱopenȱdrugȱscene.256ȱTheȱPortlandȱHotelȱSocietyȱisȱanȱexampleȱofȱaȱ housingȱproviderȱthatȱmanagesȱroughlyȱ450ȱhousingȱunitsȱinȱtheȱDTES,ȱtheȱmajorityȱofȱ whichȱareȱoccupiedȱbyȱindividualsȱwhoȱactivelyȱuseȱdrugȱandȱwhoȱfitȱtheȱdescriptionȱofȱ ȱ  94  ȱ  ‘‘hardȱ toȱ house’’.256ȱ Theȱ clientȬcentredȱ philosophyȱ ofȱ theȱ Portlandȱ Hotelȱ Societyȱ isȱ creditedȱ withȱ enablingȱ themȱ toȱ buildȱ relationshipsȱ withȱ theirȱ clientsȱ thatȱ facilitateȱ theȱ protectionȱofȱclients’’ȱphysicalȱsecurityȱandȱpromoteȱclients’’ȱoverallȱwellȬbeing.256,ȱ258,ȱ259ȱȱ Althoughȱ thereȱ isȱ nowȱ aȱ wideȱ literatureȱ suggestingȱ thatȱ lowȬthresholdȱ housingȱ optionsȱ inȱ lineȱ withȱ aȱ housingȱ firstȱ modelȱ successfullyȱ supportȱ andȱ retainȱ individualsȱ withȱhighȱintensityȱaddictionȱand,ȱasȱourȱstudyȱindicates,ȱhaveȱpotentialȱtoȱreduceȱstreetȱ disorder,ȱlowȬthresholdȱhousingȱcurrentlyȱmakesȱupȱonlyȱaȱsmallȱproportionȱofȱexistingȱ housingȱunits.11,ȱ 260ȱOurȱdataȱaddȱtoȱexistingȱevidenceȱhighlightingȱtheȱneedȱtoȱincreaseȱ theȱ supplyȱ ofȱ lowȬthresholdȱ supportiveȱ housingȱ thatȱ includesȱ safeguardsȱ toȱ manageȱ behavioursȱ associatedȱ withȱ activeȱ illicitȱ drugȱ useȱ includingȱ drugȱ overdoseȱ eventsȱ andȱ drugȱdealingȱandȱaccompanyingȱrisksȱforȱviolence.261,ȱ262ȱȱȱȱȱ Thereȱ areȱ aȱ numberȱ ofȱ limitationsȱ inȱ thisȱ study.ȱ Inȱ particular,ȱ Vancouver’’sȱ housingȱ situationȱ andȱ openȱ drugȱ sceneȱ haveȱ uniqueȱ featuresȱ thatȱ mayȱ limitȱ theȱ generalizabilityȱ ofȱ theseȱ finding.ȱ However,ȱ drugȬrelatedȱ streetȱ disorderȱ andȱ lackȱ ofȱ supportiveȱhousingȱforȱdrugȱusingȱpopulationsȱareȱissuesȱinȱmanyȱotherȱurbanȱsettingsȱ andȱ thereforeȱ theȱ findingsȱ ofȱ thisȱ studyȱ mayȱ beȱ relevantȱ toȱ otherȱ areas.ȱ Inȱ addition,ȱ aȱ numberȱofȱourȱmeasuresȱwereȱbasedȱuponȱselfȬreportȱdataȱandȱareȱthereforeȱvulnerableȱ toȱ recallȱ biasȱ andȱ socialȱ desirableȱ responding.ȱ Inȱ thisȱ study,ȱ issuesȱ withȱ recallȱ couldȱ haveȱresultedȱinȱanȱoverȬȱorȱunderestimationȱofȱtheȱnumberȱofȱhoursȱspentȱonȱtheȱstreetȱ socializing,ȱ suggestingȱ thatȱ ifȱ recallȱ issuesȱ wereȱ presentȱ theyȱ wouldȱ haveȱ biasedȱ ourȱ  ȱ  95  ȱ  resultȱ towardsȱ theȱ null.ȱ Ifȱ socialȱ desirableȱ respondingȱ wasȱ anȱ issueȱ weȱ suspectȱ thisȱ responseȱbiasȱwouldȱhaveȱledȱtoȱanȱunderreportingȱofȱtheȱnumberȱofȱhoursȱspentȱonȱtheȱ street,ȱ whichȱ inȱ turnȱ mayȱ haveȱ ledȱ toȱ anȱ underestimationȱ ofȱ theȱ associationȱ betweenȱ accessȱ toȱ privateȱ spaceȱ andȱ socializingȱ inȱ theȱ openȱ drugȱ scene.ȱ Finally,ȱ ourȱ secondȱ analysisȱ reliedȱ onȱ willingnessȱ responsesȱ andȱ doesȱ notȱ representȱ actualȱ behaviourȱ change.ȱThereȱareȱlikelyȱmultipleȱfactorsȱthatȱcontributeȱtoȱsocializingȱinȱpublicȱspacesȱ andȱ providingȱ privateȱ spaceȱ mayȱ notȱ changeȱ thisȱ behaviour.ȱ However,ȱ previousȱ analysesȱ evaluatingȱ theȱ validityȱ ofȱ reportingȱ willingnessȱ toȱ useȱ aȱ supervisedȱ injectionȱ facilityȱ onȱ subsequentȱ ratesȱ ofȱ useȱ amongȱ illicitȱ injectionȱ drugȱ usersȱ foundȱ thatȱ willingnessȱmeasuresȱwereȱreasonableȱpredictorsȱofȱlaterȱbehaviour.263ȱ Inȱ summary,ȱ ourȱ dataȱ indicateȱ thatȱ aȱ lackȱ ofȱ accessȱ toȱ privateȱ spaceȱ amongȱ peopleȱ whoȱ useȱ drugsȱ mayȱ contributeȱ toȱ streetȱ disorderȱ inȱ openȱ drugȱ scenes.ȱ Studyȱ findingsȱ furtherȱ suggestȱ thatȱ increasingȱ accessȱ toȱ privateȱ spacesȱ thatȱ accommodateȱ socializingȱ amongȱ activeȱ drugȱ usersȱ andȱ includeȱ safeguardsȱ toȱ manageȱ behavioursȱ associatedȱ withȱ activeȱ illicitȱ drugȱ useȱ hasȱ potentialȱ toȱ reduceȱ oneȱ componentȱ ofȱ streetȱ disorder.ȱ LowȬthresholdȱ supportiveȱ housingȱ approachesȱ basedȱ onȱ theȱ housingȱ firstȱ modelȱappearȱtoȱofferȱimportantȱopportunitiesȱtoȱmeetȱtheseȱobjectives.ȱ ȱ  ȱ  96  ȱ  Tableȱ 5.1ȱ Univariateȱ analysesȱ ofȱ factorsȱ associatedȱ withȱ socializingȱ inȱ Vancouver’’sȱ openȱdrugȱsceneȱamongȱinjectionȱdrugȱusersȱ(n=1121)ȱ ȱ  Socializesȱinȱopenȱdrugȱsceneȱaȱ  ȱ Univariateȱ  Characteristicȱ  Yesȱn=ȱ477,ȱnȱ(%)ȱ  ȱ ORbȱȱ(95%ȱCI)ȱ  LimitedȱPrivateȱSpaceȱdȱ Yesȱ Noȱ Ageȱ(Median,ȱIQR)ȱcȱ Perȱyearȱolderȱ FemaleȱGenderȱȱ Yesȱ Noȱ AboriginalȱAncestryȱȱ Yesȱ Noȱ DailyȱCocaineȱInjectionȱdȱ Yesȱ Noȱ DailyȱHeroinȱInjectionȱdȱ Yesȱ Noȱ DailyȱCrackȱUseȱdȱ Yesȱ Noȱ BingeȱDrugȱUsedȱ Yesȱ Noȱ SexȱTradeȱdȱ Yesȱ Noȱ DrugȱDealingȱdȱ Yesȱ Noȱ Employmentȱdȱ Yesȱ Noȱ RecentȱIncarcerationȱdȱ Yesȱ Noȱ AnyȱAddictionȱTreatmentȱdȱ Yesȱ Noȱ HIVȱPositiveȱdȱ Yesȱ Noȱ  Noȱn=ȱ644,ȱnȱ(%)ȱ  ȱ 407ȱ(85)ȱ 70ȱ(15)ȱ ȱ 43ȱ(37Ȭ49)ȱ ȱ 173ȱ(36)ȱ 304ȱ(64)ȱ ȱ 196ȱ(41)ȱ 281ȱ(59)ȱ ȱ 53ȱ(11)ȱ 424ȱ(89)ȱ ȱ 121ȱ(25)ȱ 356ȱ(75)ȱ ȱ 261ȱ(55)ȱ 216ȱ(45)ȱ ȱ 233ȱ(49)ȱ 244ȱ(51)ȱ ȱ 68ȱ(14)ȱ 409ȱ(86)ȱ ȱ 186ȱ(39)ȱ 291ȱ(61)ȱ ȱ 86ȱ(18)ȱ 391ȱ(82)ȱ ȱ 72ȱ(15)ȱ 405ȱ(85)ȱ ȱ 243ȱ(51)ȱ 234ȱ(49)ȱ ȱ 151ȱ(32)ȱ 322ȱ(68)ȱ  ȱ 432ȱ(67)ȱ 212ȱ(33)ȱ ȱ 45ȱ(39Ȭ52)ȱ ȱ 223ȱ(35)ȱ 421ȱ(65)ȱ ȱ 200ȱ(31)ȱ 444ȱ(69)ȱ ȱ 45ȱ(7)ȱ 599ȱ(93)ȱ ȱ 97ȱ(15)ȱ 547ȱ(85)ȱ ȱ 187ȱ(29)ȱȱȱȱ 457ȱ(71)ȱ ȱ 198ȱ(31)ȱ 446ȱ(69)ȱ ȱ 53ȱȱȱȱ(8)ȱ 591ȱ(92)ȱ ȱ 135ȱ(21)ȱ 509ȱ(79)ȱ ȱ 160ȱ(25)ȱ 484ȱ(75)ȱ ȱ 65ȱ(10)ȱ 579ȱ(90)ȱ ȱ 394ȱ(61)ȱȱȱȱ 250ȱ(39)ȱ ȱ 214ȱ(34)ȱ 423ȱ(66)ȱ  ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ  ȱ 2.85ȱȱ(2.11ȱ––ȱ3.86)ȱ ȱ ȱ 0.97ȱȱ(0.96ȱ––ȱ0.98)ȱ ȱ 1.07ȱȱ(0.84ȱ––ȱ1.38)ȱ ȱ ȱ 1.55ȱȱ(1.21ȱ––ȱ1.98)ȱ ȱ ȱ 1.66ȱȱ(1.10ȱ––ȱ2.52)ȱ ȱ ȱ 1.92ȱȱ(1.42ȱ––ȱ2.58)ȱ ȱ ȱ 2.95ȱȱ(2.30ȱ––ȱ3.78)ȱ ȱ ȱ 2.15ȱȱ(1.68ȱ––ȱ2.75)ȱ ȱ ȱ 1.85ȱȱ(1.27ȱ––ȱ2.71)ȱ ȱ ȱ 2.41ȱȱ(1.85ȱ––ȱ3.14)ȱ ȱ ȱ 0.67ȱȱ(0.50ȱ––ȱ0.89)ȱ ȱ ȱ 1.58ȱȱ(1.11ȱ––ȱ2.27)ȱ ȱ ȱ 0.66ȱȱ(0.52ȱ––ȱ0.84)ȱ ȱ ȱ 0.93ȱȱ(0.72ȱ––ȱ1.19)ȱ ȱ  pȬvalueȱ <0.001  <0.001 0.570  <0.001  0.016  <ȱ0.001  <ȱ0.001  <ȱ0.001  0.001  <0.001  0.006  0.012  <0.001  0.558  Note:ȱ aȱSocializingȱinȱtheȱopenȱdrugȱsceneȱwasȱdefinedȱasȱlivingȱinȱorȱfrequentingȱVancouver’’sȱdrugȱuseȱ epicentreȱandȱspendingȱonȱaverageȱthreeȱorȱmoreȱhoursȱonȱtheȱstreetȱeachȱdayȱsocializing.;ȱ bȱ ORȱ=ȱOddsȱ Ratio,ȱ ȱCIȱ=ȱConfidenceȱInterval;ȱ cȱ IQR=ȱInterȱQuartileȱRange;ȱ dȱ Denotesȱactivitiesȱorȱsituationsȱreferringȱtoȱ previousȱ6ȱmonths.ȱ ȱ  97  ȱ  ȱ  Tableȱ 5.2ȱ Univariateȱ analysisȱ ofȱ housingȱ statusȱ andȱ socializingȱ inȱ Vancouver’’sȱ openȱdrugȱsceneȱamongȱinjectionȱdrugȱusersȱ ȱ  Socializesȱinȱopenȱdrugȱsceneȱa ȱ Univariateȱ  Characteristicȱ HousingȱStatus ȱ StableȱHousingȱ RoomȱinȱHotelȱ(SRO)ȱ Shelterȱ NoȱFixedȱAddress/Street TreatmentȱRecovery*ȱȱ Jailȱ(Prison)**ȱ Other*ȱ ȱc  Yesȱn=ȱ477,ȱ  Noȱn=ȱ644,ȱ  nȱ(%)ȱ  nȱ(%)ȱ  ȱ 78ȱ(22)ȱ 225ȱ(48)ȱ 19ȱ(48)ȱ 146ȱ(66)ȱ 5ȱ(29)ȱ 0ȱ(0)ȱ 4ȱ(22)ȱ  ȱ 273ȱ(78)ȱ 245ȱ(52)ȱ 21ȱ(52)ȱ 75ȱ(34)ȱ 12ȱ(71)ȱ 4ȱ(100)ȱ 14ȱ(82)ȱ  ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ  ORbȱȱ(95%ȱCI)ȱ ȱ ȬȱReferenceȬȱ 3.21ȱȱ(2.36ȱ––ȱ4.38)ȱ 3.17ȱȱ(1.62ȱ––ȱ6.19)ȱ 6.81ȱȱ(4.68ȱ––ȱ9.92)ȱ 1.46ȱȱ(0.39ȱ––ȱ4.61)ȱ 0.67ȱȱ(0.00ȱ––ȱ5.40)ȱ 1.00ȱȱ(0.23ȱ––ȱ3.31)ȱ  pȬvalueȱ  <0.001ȱ <0.001ȱ <0.001ȱ 0.552ȱ 0.738ȱ 1.000ȱ  Note:ȱaȱSocializingȱinȱtheȱopenȱdrugȱsceneȱwasȱdefinedȱasȱlivingȱinȱorȱfrequentingȱVancouver’’sȱdrugȱ useȱepicenterȱandȱspendingȱonȱaverageȱthreeȱorȱmoreȱhoursȱonȱtheȱstreetȱeachȱdayȱsocializing.;ȱbORȱ =ȱOddsȱRatio,ȱȱCIȱ=ȱConfidenceȱInterval;ȱcȱDenotesȱcurrentȱstatus.ȱ *pȬvalueȱandȱ95%ȱCIȱreportedȱfromȱFisher’’sȱExactȱTestȱasȱ25%ȱofȱcellsȱhadȱexpectedȱcountsȱlessȱthanȱ5. **ȱExactȱlogisticȱmodelȱusedȱdueȱtoȱpresenceȱofȱzeroȱcell.ȱ ȱ  ȱ Tableȱ 5.3ȱ Multivariateȱ logisticȱ regressionȱ analysisȱ ofȱ primaryȱ andȱ secondaryȱ factorsȱ associatedȱ withȱ socializingaȱ inȱ Vancouver’’sȱ openȱ drugȱ sceneȱamongȱinjectionȱdrugȱusersȱ(n=1121)ȱ Adjustedȱ (95%ȱConfidenceȱInterval)ȱ OddsȱRatioȱ LimitedȱPrivateȱSpaceȱbȱ 2.33ȱ ȱ(1.68ȱ––ȱ3.24)ȱ AboriginalȱAncestryȱȱ 1.59ȱ ȱ(1.21ȱ––ȱ2.09)ȱ ȱb 1.79ȱ ȱ(1.34ȱ––ȱ2.39)ȱ DailyȱCrackȱUse ȱ 1.80ȱ ȱ(1.36ȱ––ȱ2.38)ȱ BingeȱDrugȱUseȱbȱ ȱb DrugȱDealing ȱ 1.62ȱ ȱ(1.19ȱ––ȱ2.20)ȱ ȱb 0.63ȱ ȱ(0.49ȱ––ȱ0.82)ȱ AnyȱAddictionȱTreatment ȱ Characteristicȱ  pȬvalue <0.001 <0.001 <0.001 <0.001 0.002 <0.001  Note:ȱaȱSocializingȱwasȱdefinedȱasȱlivingȱinȱorȱfrequentingȱVancouver’’sȱdrugȱuseȱepicenterȱ andȱspendingȱonȱaverageȱthreeȱorȱmoreȱhoursȱonȱtheȱstreetȱeachȱdayȱsocializing.;ȱbȱ Denotesȱ activitiesȱorȱsituationsȱreferringȱtoȱpreviousȱ6ȱmonths.ȱ *Finalȱmodelȱadjustedȱforȱtheȱmonthȱthatȱtheȱinterviewȱwasȱconducted ȱ  ȱ  ȱ  98  ȱ  Tableȱ 5.4ȱ Univariateȱ analysesȱ ofȱ injectionȱ drugȱ usersȱ thatȱ haveȱ limitedȱ accessȱ toȱ privateȱ spaceȱ andȱ engageȱ inȱ socializingaȱ inȱ Vancouver’’sȱ openȱ drugȱsceneȱstratifiedȱbyȱwillingnessȱtoȱrelocateȱ(n=392)ȱ ȱ  Willingȱtoȱrelocateȱsocializingȱȱ  Characteristicȱ  ȱ Univariateȱȱ  Yesȱn=256,nȱ(%) Noȱn=136,ȱnȱ(%) ȱ ORbȱȱ(95%ȱCI)ȱ  HoursȱSocializingȱ ȱ Ageȱ(perȱyearȱolder)ȱ FemaleȱGenderȱȱ yYesȱ Noȱ AboriginalȱAncestryȱȱ Yesȱ Noȱ DailyȱCocaineȱInjectionȱcȱ Yesȱ Noȱ DailyȱHeroinȱInjectionȱcȱ Yesȱ Noȱ DailyȱCrackȱUseȱcȱ Yesȱ Noȱ BingeȱDrugȱUseȱcȱ Yesȱ Noȱ Overdoseȱ(nonȬfatal)ȱcȱ Yesȱ Noȱ EncountersȱwithȱPoliceȱeȱ Yesȱ Noȱ VictimȱofȱViolenceȱcȱ Yesȱ Noȱ SyringeȱSharing*ȱcȱ Yesȱ Noȱ SexȱTradeȱcȱ Yesȱ Noȱ DrugȱDealingȱcȱ Yesȱ Noȱ Employmentȱcȱ Yesȱ Noȱ RecentȱIncarcerationȱcȱ Yesȱ Noȱ AnyȱAddictionȱTreatmentȱcȱ Yesȱ Noȱ MultipleȱSexȱPartnersȱcȱ Yesȱ Noȱ HIVȱPositiveȱȱ Yesȱ Noȱ c,ȱd  8ȱ 43ȱ ȱ 96ȱ 160ȱ ȱ 104ȱ 152ȱ ȱ 23ȱ 233ȱ ȱ 85ȱ 171ȱ ȱ 157ȱ 99ȱ ȱ 130ȱ 126ȱ ȱ 17ȱ 239ȱ ȱ 97ȱ 159ȱ ȱ 63ȱ 193ȱ ȱ 7ȱ 249ȱ ȱ 44ȱ 212ȱ ȱ 111ȱ 145ȱ ȱ 44ȱ 212ȱ ȱ 48ȱ 208ȱ ȱ 122ȱ 134ȱ ȱ 52ȱ 204ȱ ȱ 77ȱ 177ȱ  (4Ȭ12)ȱ (36Ȭ48)ȱ ȱ (37)ȱ (63)ȱ ȱ (41)ȱ (59)ȱ ȱ ȱȱ(9)ȱ (91)ȱ ȱ (33)ȱ (67)ȱ ȱ (61)ȱ (39)ȱ ȱ (51)ȱ (49)ȱ ȱ ȱȱ(7)ȱ (93)ȱ ȱ (38)ȱ (62)ȱ ȱ (25)ȱ (75)ȱ ȱ ȱȱ(3)ȱ (97)ȱ ȱ (17)ȱ (83)ȱ ȱ (43)ȱ (57)ȱ ȱ (17)ȱ (83)ȱ ȱ (19)ȱ (81)ȱ ȱ (48)ȱ (52)ȱ ȱ (20)ȱ (80)ȱ ȱ (30)ȱ (70)ȱ  6ȱ ȱ(4Ȭ12)ȱ 46ȱ ȱ(40Ȭ50)ȱ ȱ 51 (37)ȱ 85 (63)ȱ ȱ 54 (40)ȱ 82 (60)ȱ ȱ 20 (15)ȱ 116 (85)ȱ ȱ 21 (15)ȱ 115 (85)ȱ ȱ 71 (52)ȱ 65 (48)ȱ ȱ 64 (47)ȱ 72 (53)ȱ ȱ 6 ȱȱ(4)ȱ 130 (96)ȱ ȱ 33 (24)ȱ 103 (76)ȱ ȱ 19 (14)ȱ 117 (86)ȱ ȱ 3 ȱȱ(2)ȱ 133 (98)ȱ ȱ 18 (13)ȱ 118 (87)ȱ ȱ 47 (35)ȱ 89 (65)ȱ ȱ 18 (13)ȱ 118 (87)ȱ ȱ 16 (12)ȱ 120 (88)ȱ ȱ 72 (53)ȱ 64 (47)ȱ ȱ 24 (18)ȱ 112 (82)ȱ ȱ 48 (36)ȱ 87 (64)ȱ  ȱ 1.05ȱ(1.01ȱ––ȱ1.09)ȱ ȱ 0.97ȱ(0.95ȱ––ȱ0.99)ȱ ȱ ȱ ȱ 1.00ȱ(0.65ȱ––ȱ1.54)ȱ ȱ ȱ ȱ ȱ ȱ 1.04ȱ(0.68ȱ––ȱ1.59)ȱ ȱ ȱ ȱ ȱ ȱ 0.57ȱ(0.30ȱ––ȱ1.09)ȱ ȱ ȱ ȱ ȱ ȱ 2.72ȱ(1.60ȱ––ȱ4.64)ȱ ȱ ȱ ȱ ȱ ȱ 1.45ȱ(0.95ȱ––ȱ2.21)ȱ ȱ ȱ ȱ ȱ ȱ 1.16ȱ(0.77ȱ––ȱ1.76)ȱ ȱ ȱ ȱ ȱ ȱ 1.54ȱ(0.59ȱ––ȱ4.00)ȱ ȱ ȱ ȱ ȱ ȱ 1.90ȱ(1.19ȱ––ȱ3.04)ȱ ȱ ȱ ȱ ȱ ȱ 2.01ȱ(1.15ȱ––ȱ3.53)ȱ ȱ ȱ ȱ ȱ ȱ ȱȱ1.25ȱ(0.28ȱ––ȱ7.59)ȱ ȱ ȱ ȱ ȱ ȱ 1.36ȱ(0.75ȱ––ȱ2.46)ȱ ȱ ȱ ȱ ȱ ȱ 1.45ȱ(0.94ȱ––ȱ2.23)ȱ ȱ ȱ ȱ ȱ ȱ 1.36ȱ(0.75ȱ––ȱ2.46)ȱ ȱ ȱ ȱ ȱ ȱ 1.73ȱ(0.94ȱ––ȱ3.18)ȱ ȱ ȱ ȱ ȱ ȱ 0.81ȱ(0.53ȱ––ȱ1.23)ȱ ȱ ȱ ȱ ȱ ȱ 1.19ȱ(0.70ȱ––ȱ2.03)ȱ ȱ ȱ ȱ ȱ ȱ 0.79ȱ(0.51ȱ––ȱ1.23)ȱ ȱ ȱ  pȬvalueȱ 0.025ȱ 0.013ȱ ȱ 1.000ȱ ȱ ȱ 0.860ȱ ȱ ȱ 0.085ȱ ȱ ȱ <0.001ȱ ȱ ȱ 0.081ȱ ȱ ȱ 0.483ȱ ȱ ȱ 0.371ȱ ȱ ȱ 0.006ȱ ȱ ȱ 0.014ȱ ȱ ȱ 1.000ȱ ȱ ȱ 0.307ȱ ȱ ȱ 0.091ȱ ȱ ȱ 0.307ȱ ȱ ȱ 0.075ȱ ȱ ȱ 0.319ȱ ȱ ȱ 0.525ȱ ȱ ȱ 0.292ȱ ȱ  ȱ  Note:ȱ ȱSocializingȱwasȱdefinedȱasȱspendingȱonȱave.ȱ3+ȱhrsȱonȱtheȱstreetȱeachȱday;ȱ ORȱ=ȱ Oddsȱ Ratio,ȱ CI=Confidenceȱ Interval;ȱ cȱ Denotesȱ activitiesȱ orȱ situationsȱ referringȱ toȱ previousȱ 6ȱ months;ȱ dȱ ‘‘Hoursȱ Socializing’’ȱ wasȱ definedȱ asȱ aȱ continuousȱ variableȱ &ȱ measuredȱperȱadditionalȱhr;ȱeȱDenotesȱactivitiesȱorȱsituationsȱreferringȱtoȱpreviousȱmonth.ȱ *pȬvalueȱ andȱ 95%ȱ CIȱ reportedȱ fromȱ Fisher’’sȱ Exactȱ Testȱ asȱ 25%ȱ ofȱ cellsȱ hadȱ expectedȱ countsȱlessȱthanȱ5.ȱ a  bȱ  ȱ  99  ȱ  Tableȱ 5.5ȱ Univariateȱ analysisȱ ofȱ housingȱ statusȱ andȱ willingnessȱ toȱ relocateȱ amongȱ injectionȱdrugȱusersȱ  Willingȱtoȱrelocateȱ socializingȱ Yesȱn=256,ȱ n(%)ȱ ȱc HousingȱStatus ȱ ȱ StableȱHousingȱ 14ȱ(35)ȱ RoomȱinȱHotelȱ(SRO)ȱ 106ȱ(56)ȱ Shelter*ȱ 13ȱ(76)ȱ NoȱFixedȱAddress/Street 117ȱ(85)ȱ TreatmentȱRecovery**ȱȱ 4(100)ȱ Jailȱ ȬȱȱȱȬȱ Other*ȱ 2ȱ(67)ȱ Characteristicȱ  Noȱn=ȱ136,ȱ n(%)ȱ ȱ 26ȱ(65)ȱ 84ȱ(44)ȱ 4ȱ(24)ȱ 21ȱ(15)ȱ 0ȱ(0)ȱ ȬȱȱȱȬȱ 1ȱ(33)ȱ  ȱ  Univariateȱ ORbȱȱ(95%ȱCI)ȱ  ȱ ȱ ȱ ȬȱReferenceȬȱ ȱ 2.34ȱȱ(1.15ȱ––ȱȱ4.77)ȱ ȱ 6.04ȱȱ(1.45ȱ––29.37)ȱ ȱ 10.35ȱȱ(4.67––ȱ23.00)ȱ ȱ 8.95ȱ(1.05ȱ––ȱȱinfinity) ȱ ȱ ȱ 3.71ȱȱ(0.31ȱ––ȱ44.66)ȱ  pȬvalue  0.017 0.008 <0.001 0.045 0.545  Note:ȱ ȱSocializingȱinȱtheȱopenȱdrugȱsceneȱwasȱdefinedȱasȱlivingȱinȱorȱfrequentingȱVancouver’’sȱ drugȱ useȱ epicenterȱ andȱ spendingȱ onȱ averageȱ threeȱ orȱ moreȱ hoursȱ onȱ theȱ streetȱ eachȱ dayȱ socializing.;ȱbORȱ=ȱOddsȱRatio,ȱȱCIȱ=ȱConfidenceȱInterval;ȱcȱDenotesȱcurrentȱstatus.ȱ **pȬvalueȱandȱ95%ȱCIȱreportedȱfromȱFisher’’sȱExactȱTestȱasȱ25%ȱofȱcellsȱhadȱexpectedȱcountsȱ lessȱthanȱ5.**ȱExactȱlogisticȱmodelȱusedȱdueȱtoȱpresenceȱofȱzeroȱcell.ȱ a  ȱ  ȱ Tableȱ 5.6ȱ Multivariateȱ logisticȱ regressionȱ analysisȱ ofȱ factorsȱ associatedȱ withȱ willingnessȱtoȱrelocateȱsocializingȱactivityaȱamongȱinjectionȱdrugȱusersȱ(n=392)ȱ Characteristicȱ HoursȱSocializingȱȱb,ȱcȱ Ageȱ(perȱyearȱolder)ȱ DailyȱHeroinȱInjectionȱbȱ EncountersȱwithȱPoliceȱdȱ VictimȱofȱViolenceȱbȱ  Adjustedȱ (95%ȱConfidenceȱInterval)ȱ OddsȱRatio 1.02 ȱ(0.98ȱ––ȱ1.07)ȱ 0.98 ȱ(0.96ȱ––ȱ1.01)ȱ 2.27 ȱ(1.28ȱ––ȱ3.88)ȱ 1.47 ȱ(0.90ȱ––ȱ2.40)ȱ 1.81 ȱ(1.02ȱ––ȱ3.23)ȱ  pȬvalue 0.266 0.167 0.005 0.124 0.044  Note:ȱaȱSocializingȱinȱtheȱopenȱdrugȱsceneȱwasȱdefinedȱasȱlivingȱinȱorȱfrequentingȱVancouver’’sȱ drugȱ useȱ epicenterȱ andȱ spendingȱ onȱ averageȱ threeȱ orȱ moreȱ hoursȱ onȱ theȱ streetȱ eachȱ dayȱ socializing;ȱbȱDenotesȱactivitiesȱorȱsituationsȱreferringȱtoȱpreviousȱ6ȱmonths;ȱcȱ‘‘HoursȱSocializing’’ȱ wasȱdefinedȱasȱaȱcontinuousȱvariableȱandȱmeasuredȱperȱadditionalȱhour;ȱ dȱ Denotesȱactivitiesȱorȱ situationsȱreferringȱtoȱpreviousȱmonth.ȱ  ȱ  ȱ  ȱ  100  ȱ  Figureȱ5.1ȱHousingȱstatusȱamongȱinjectionȱdrugȱusersȱ Housing Status SRO 41%  Shelter/Hostel 4%  NFA/Street 20%  Treatment RecoveryHouse 2% StableHousing 31%  Other 2%  Jail 0%  ȱ  Note:ȱSROȱ––‘‘SingleȱRoomȱOccupancy’’ȱdefinedȱasȱaȱsingleȱroomȱinȱaȱhotelȱ  Figureȱ 5.2ȱ Distributionȱ ofȱ injectionȱ drugȱ usersȱ byȱ housingȱ statusȱ andȱ accessȱtoȱprivateȱspaceȱ 450  399  400 350 300 250 200  219  199 152  150  71  100  39  50  1  12 5  2  3 1  15 3  Ot he r  l Ja i  ou se ec ov er yH  en tR  NF A/ St re et  ste l  Limited Private Space, n=839 Adequate Private Space, n=282  Tr ea tm  SR O  Sh elt er /H o  St ab l  eH ou sin g  0  Note:ȱSROȱ––‘‘SingleȱRoomȱOccupancy’’ȱdefinedȱasȱaȱsingleȱroomȱinȱaȱhotelȱ  ȱ  ȱ ȱ  101  ȱ  CHAPTER 6: ȱ OPPORTUNITIESȱFORȱREDUCINGȱENGAGEMENTȱINȱ DISORDERLYȱINCOMEȱGENERATIONȱACTIVITIESȱAMONGȱ PEOPLEȱWHOȱINJECTȱILLICITȱDRUGS 5ȱ  6.1 Introductionȱ Thereȱ areȱ manyȱ establishedȱ linksȱ betweenȱ chronicȱ illicitȱ drugȱ useȱ andȱ engagementȱinȱillegalȱincomeȱgenerationȱactivities.171,ȱ264Ȭ269ȱȱPeopleȱwhoȱuseȱillicitȱdrugsȱ andȱ areȱ strugglingȱ withȱ addictionȱ areȱ oftenȱ unableȱ toȱ acquireȱ andȱ sustainȱ formalȱ employment,ȱ andȱ yetȱ theȱ highȱ costsȱ associatedȱ withȱ obtainingȱ illicitȱ drugsȱ requiresȱ individualsȱ toȱ findȱ meansȱ ofȱ generatingȱ income.33,ȱ 170Ȭ174ȱ Givenȱ theseȱ constraints,ȱ theȱ incomeȱgenerationȱopportunitiesȱavailableȱtoȱillicitȱdrugȱusersȱfrequentlyȱinvolveȱillegalȱ activityȱandȱareȱoftenȱassociatedȱwithȱstreetȱdisorder.7,ȱ171ȱForȱexample,ȱcommonȱincomeȱ generationȱ strategiesȱ includeȱ streetȬbasedȱ sexȱ work,ȱ drugȱ dealing,ȱ panhandlingȱ andȱ recycling/salvaging/vendingȱwhichȱoftenȱtakeȱplaceȱonȱpublicȱstreetsȱandȱareȱgenerallyȱ consideredȱ toȱ beȱ undesirableȱ behavioursȱ fromȱ aȱ communityȱ perspective.4,ȱ  7Ȭ10  ȱ ȱ Inȱ  Vancouver,ȱ Canadaȱ theseȱ typesȱ ofȱ disorderlyȱ incomeȱ generationȱ activitiesȱ areȱ aȱ wellȱ describedȱ featureȱ ofȱ theȱ city’’sȱ drugȱ useȱ epicentreȱ knownȱ asȱ theȱ Downtownȱ Eastsideȱ [DTES].4,ȱ7,ȱ10ȱ  ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 5  Aȱversionȱofȱthisȱchapterȱhasȱbeenȱsubmittedȱforȱpublicationȱas:ȱDeBeck,ȱK.,ȱWood,ȱE.,ȱ Qi,ȱJ.,ȱMcArthur,ȱD.,ȱMontaner,ȱJ.,ȱKerr,ȱT.ȱOpportunitiesȱforȱreducingȱengagementȱinȱ streetȱbasedȱincomeȱgenerationȱactivitiesȱamongȱpeopleȱwhoȱinjectȱillicitȱdrugs. ȱ  102  ȱ  Toȱ date,ȱ policyȱ responsesȱ toȱ addressȱ problemsȱ associatedȱ withȱ illicitȱ drugȱ use,ȱ includingȱ streetȱ disorderȱ resultingȱ fromȱ theȱ incomeȱ generationȱ activitiesȱ ofȱ illicitȱ drugȱ users,ȱtypicallyȱrelyȱonȱlawȱenforcementȱtoȱdeterȱandȱmanageȱundesirableȱbehaviours.57,ȱ 198,ȱ 200,ȱ 212,ȱ 270  ȱȱHowever,ȱitȱhasȱbeenȱdocumentedȱthatȱinȱmanyȱinstancesȱlawȱenforcementȱ  initiativesȱseekingȱtoȱreduceȱstreetȱdisorderȱresultȱinȱdisplacingȱdisorderlyȱbehaviourȱtoȱ surroundingȱ neighbourhoods,ȱ whichȱ mayȱ negativelyȱ impactȱ communitiesȱ and/orȱ separateȱ vulnerableȱ drugȱ usersȱ fromȱ familiarȱ healthȱ andȱ socialȱ services.62,ȱ 64,ȱ 69,ȱ 249ȱ Aȱ growingȱbodyȱofȱhealthȱresearchȱsuggestsȱthatȱinterventionsȱthatȱtargetȱtheȱbehaviourȱofȱ individuals,ȱ suchȱ asȱ lawȱ enforcement,ȱ mayȱ beȱ ineffectiveȱ andȱ inadvertentlyȱ produceȱ harm,ȱ asȱ theyȱ failȱ toȱ recognizeȱ andȱ addressȱ theȱ roleȱ thatȱ socialȱ andȱ structuralȱ factorsȱ playȱinȱshapingȱbehaviour.73,ȱ74,ȱ76,ȱ197ȱIndeed,ȱinterventionsȱthatȱareȱlikelyȱtoȱhaveȱaȱmoreȱ lastingȱ andȱ positiveȱ influenceȱ areȱ onesȱ thatȱ seekȱ toȱ alterȱ theȱ socialȱ andȱ structuralȱ environmentȱ surroundingȱ drugȱ usersȱ asȱ aȱ meansȱ ofȱ changingȱ behaviour.75,ȱ 77,ȱ 78ȱ Inȱ theȱ contextȱ ofȱ disorderlyȱ incomeȱ generationȱ activities,ȱ oneȱ potentialȱ approachȱ toȱ reducingȱ streetȱ disorderȱ isȱ toȱ changeȱ theȱ structuralȱ environmentȱ surroundingȱ individualsȱ whoȱ useȱdrugsȱbyȱcreatingȱsanctionedȱlowȬthresholdȱemploymentȱopportunities.ȱȱ Inȱ Vancouver,ȱ Canadaȱ thereȱ areȱ aȱ smallȱ numberȱ ofȱ existingȱ lowȬthresholdȱ employmentȱ opportunitiesȱ availableȱ toȱ individualsȱ whoȱ activelyȱ useȱ illicitȱ drugs.ȱ Forȱ example,ȱ inȱ theȱ DTESȱ ofȱ Vancouverȱ aȱ communityȱ caféȱ andȱ cateringȱ socialȱ enterpriseȱ companyȱ providesȱ anȱ estimatedȱ nineȱ lowȬthresholdȱ employmentȱ positions,176,ȱ 177ȱ anȱ organizationȱ thatȱ processesȱ recyclableȱ containersȱ providesȱ roughlyȱ 33ȱ lowȬthresholdȱ ȱ  103  ȱ  positions,178,ȱ 179ȱ aȱ localȱ drugȱ usersȱ groupȱ providesȱ aȱ smallȱ numberȱ ofȱ stipendsȱ forȱ volunteerȱ workȱ undertakenȱ byȱ theirȱ members271Ȭ273ȱ andȱ aȱ photoȱ calendarȱ projectȱ initiatedȱ byȱ aȱ socialȱ justiceȱ organizationȱ offersȱ aȱ programȱ forȱ residentsȱ ofȱ theȱ DTESȱ toȱ becomeȱ vendorsȱ andȱ sellȱ calendarsȱ andȱ books.180Ȭ182ȱ Despiteȱ theȱ existenceȱ ofȱ theseȱ opportunities,ȱtheȱnumberȱofȱlowȬthresholdȱemploymentȱpositionsȱisȱlimitedȱandȱthereȱ isȱlittleȱinformationȱavailableȱtoȱdetermineȱwhetherȱthereȱisȱaȱsignificantȱdemandȱforȱthisȱ typeȱofȱworkȱamongȱindividualsȱwhoȱcurrentlyȱengageȱinȱdisorderlyȱincomeȱgenerationȱ activities.ȱȱ Therefore,ȱweȱsoughtȱtoȱcharacterizeȱtheȱprevalenceȱandȱcorrelatesȱofȱengagingȱinȱ disorderlyȱ incomeȱ generationȱ activitiesȱ amongȱ aȱ communityȱ recruitedȱ cohortȱ ofȱ injectionȱdrugȱusersȱ(IDU)ȱinȱVancouver.ȱWeȱalsoȱsoughtȱtoȱidentifyȱaȱsubȬpopulationȱofȱ IDUȱwhoȱwouldȱbeȱwillingȱtoȱ ceaseȱengagingȱinȱtheseȱactivitiesȱifȱotherȱlowȬthresholdȱ workȱopportunitiesȱwereȱmadeȱavailableȱtoȱthem.ȱȱ  6.2 Methodsȱ Dataȱ forȱ thisȱ studyȱ wereȱ obtainedȱ fromȱ theȱ Vancouverȱ Injectionȱ Drugȱ Usersȱ Studyȱ (VIDUS).ȱ Forȱ aȱ fullȱ descriptionȱ ofȱ theȱ studyȱ pleaseȱ referȱ toȱ sectionȱ 1.4ȱ ofȱ thisȱ thesis.ȱTheȱpresentȱanalysesȱareȱrestrictedȱtoȱVIDUSȱparticipantsȱseenȱforȱstudyȱfollowȬ upȱduringȱtheȱperiodȱofȱNovemberȱ2008ȱtoȱJulyȱ2009ȱasȱtheȱmeasureȱforȱourȱoutcomeȱofȱ interestȱwasȱavailableȱonlyȱforȱthisȱperiod.ȱIfȱindividualsȱwereȱseenȱforȱmultipleȱstudyȱ followȬupȱvisitsȱduringȱthisȱstudyȱperiod,ȱonlyȱdataȱfromȱtheirȱfirstȱvisitȱwereȱused.ȱ ȱ  104  ȱ  Allȱ participantsȱ seenȱ duringȱ ourȱ studyȱ periodȱ wereȱ askedȱ toȱ identifyȱ allȱ theirȱ incomeȱsourcesȱsinceȱtheirȱlastȱstudyȱvisitȱandȱtoȱestimateȱtheȱaverageȱnumberȱofȱhoursȱ perȱweekȱtheyȱspentȱengagedȱinȱeachȱincomeȱgenerationȱactivity.ȱCategoriesȱofȱincomeȱ sourcesȱ includedȱ recyclingȱ (includesȱ salvagingȱ recyclableȱ materialsȱ andȱ unsanctionedȱ streetȱ vending),ȱ panhandling,ȱ squeegeeing,ȱ sexȱ tradeȱ workȱ andȱ drugȱ dealing.ȱ Otherȱ categoriesȱofȱincomeȱsourcesȱincludedȱwelfareȱ(includingȱdisability,ȱpensionsȱandȱotherȱ formsȱ ofȱ governmentȱ transfers),ȱ familyȱ andȱ friends,ȱ regularȱ job,ȱ temporaryȱ workȱ (includingȱunderȱtheȱtableȱemployment)ȱandȱcriminalȱactivityȱ(categoryȱencompassesȱaȱ rangeȱofȱcriminalȱactivitiesȱincludingȱtheft,ȱbreakȱandȱentry,ȱrobberyȱandȱfraud).ȱȱ Inȱ ourȱ primaryȱ analysisȱ theȱ outcomeȱ ofȱ interestȱ wasȱ engagingȱ inȱ ‘‘disorderlyȱ incomeȱgenerationȱactivities’’ȱdefinedȱasȱreportingȱanyȱofȱtheȱfollowingȱincomeȱsources:ȱ recycling,ȱ squeegeeing,ȱ panhandling,ȱ sellingȱ drugsȱ andȱ exchangingȱ sexȱ forȱ money.ȱ Althoughȱ weȱ wereȱ unableȱ toȱ confirmȱ thatȱ allȱ reportedȱ drugȱ dealingȱ andȱ sexȱ workȱ activitiesȱ occurredȱ inȱ publicȱ settings,ȱ aȱ previousȱ studyȱ amongȱ VIDUSȱ participantsȱ foundȱ thatȱ bothȱ activitiesȱ areȱ independentlyȱ associatedȱ withȱ spendingȱ timeȱ inȱ Vancouver’’sȱopenȱdrugȱsceneȱsuggestingȱthatȱtheseȱactivitiesȱareȱlargelyȱstreetȬbased.247ȱ Toȱ characterizeȱ factorsȱ associatedȱ withȱ engagementȱ inȱ disorderlyȱ incomeȱ generationȱ activities,ȱ weȱ aȱ prioriȱselectedȱ aȱrangeȱ ofȱ socioȬdemographicȱ andȱ behaviouralȱ variablesȱ thatȱweȱhypothesizedȱmightȱbeȱassociatedȱwithȱourȱoutcomeȱofȱinterest.ȱTheseȱincluded:ȱ ageȱ(perȱyearȱolder);ȱdailyȱexpenditureȱonȱdrugsȱ(perȱadditionalȱ$10);ȱgenderȱ(femaleȱvs.ȱ male);ȱAboriginalȱancestryȱ(yesȱvs.ȱno);ȱunstableȱhousing,ȱdefinedȱasȱcurrentlyȱlivingȱinȱ ȱ  105  ȱ  aȱsingleȱoccupancyȱroomȱinȱaȱhotel,ȱaȱtreatmentȱorȱrecoveryȱhouse,ȱjail,ȱshelterȱorȱhostel,ȱ orȱhavingȱnoȱfixedȱaddressȱforȱtheȱlastȱsixȱmonthsȱ(yesȱvs.ȱno);ȱhighȱschoolȱeducation,ȱ definedȱasȱcompletingȱhighȱschoolȱorȱobtainingȱequivalentȱdiplomaȱ(yesȱvs.ȱno);ȱhavingȱ regularȱ employment,ȱ definedȱ asȱ havingȱ aȱ regularȱ orȱ temporaryȱ jobȱ (yesȱ vs.ȱ no);ȱ dailyȱ cocaineȱ injectionȱ (yesȱ vs.ȱ no);ȱ dailyȱ heroinȱ injectionȱ (yesȱ vs.ȱ no);ȱ dailyȱ crackȱ cocaineȱ smokingȱ (yesȱ vs.ȱ no);ȱ nonȬfatalȱ overdoseȱ (yesȱ vs.ȱ no),ȱ bingeȱ drugȱ use,ȱ definedȱ asȱ aȱ periodȱofȱusingȱdrugsȱmoreȱoftenȱthanȱusualȱ(yesȱvs.ȱno);ȱencountersȱwithȱpoliceȱinȱtheȱ lastȱ month,ȱ definedȱ asȱ beingȱ questioned,ȱ searchedȱ orȱ stoppedȱ byȱ policeȱ (yesȱ vs.ȱ no);ȱ beingȱaȱvictimȱofȱviolenceȱ(yesȱvs.ȱno);ȱsyringeȱsharing,ȱdefinedȱasȱborrowingȱorȱlendingȱ syringesȱalreadyȱusedȱbyȱsomeoneȱelseȱtoȱinjectȱdrugsȱ(yesȱvs.ȱno);ȱusingȱinjectionȱdrugsȱ inȱ publicȱ locations,ȱ suchȱ asȱ cityȱ streets,ȱ parksȱ andȱ alleysȱ (yesȱ vs.ȱ no);ȱ engagingȱ inȱ anyȱ unprotectedȱ sexȱ (yesȱ vs.ȱ no);ȱ beingȱ recentlyȱ incarceratedȱ (yesȱ vs.ȱ no);ȱ andȱ currentȱ enrolmentȱ inȱ methadoneȱ treatmentȱ (yesȱ vs.ȱ no).ȱ Unlessȱ otherwiseȱ stated,ȱ allȱ drugȱ useȱ andȱbehaviouralȱvariablesȱreferȱtoȱtheȱpreviousȱsixȱmonthȱperiod.ȱȱ Inȱ subȬanalysis,ȱ weȱ soughtȱ toȱ assessȱ andȱ identifyȱ predictorsȱ ofȱ willingnessȱ toȱ ceaseȱengagementȱinȱdisorderlyȱincomeȱgenerationȱactivitiesȱifȱalternativeȱlowȬthresholdȱ optionsȱwereȱmadeȱavailable.ȱToȱmeasureȱwillingnessȱtoȱceaseȱengagementȱinȱdisorderȱ incomeȱ generationȱ activitiesȱ weȱ askedȱ participants:ȱ ““Ifȱ youȱ wereȱ offeredȱ casualȱ workȱ thatȱdidȱnotȱinterfereȱwithȱyourȱwelfare,ȱwouldȱyouȱtakeȱit?””ȱandȱ““Ifȱyes,ȱareȱthereȱanyȱ incomeȱ sourcesȱ inȱ theȱ lastȱ 30ȱ daysȱ thatȱ youȱ wouldȱ eliminate?””ȱ Participantsȱ wereȱ thenȱ askedȱ toȱ indicateȱ whichȱ sourcesȱ ofȱ incomeȱ theyȱ wouldȱ forgo.ȱ Variablesȱ ofȱ interestȱ forȱ ȱ  106  ȱ  secondaryȱ analysisȱ includedȱ allȱ variablesȱ fromȱ theȱ primaryȱ analysis,ȱ inȱ additionȱ toȱ engagementȱ inȱ specificȱ disorderlyȱ incomeȱ generationȱ activities,ȱ includingȱ recycling,ȱ panhandling,ȱ squeegeeing,ȱ drugȱ dealingȱ andȱ sexȱ work.ȱ Asȱ inȱ theȱ primaryȱ analysis,ȱ unlessȱotherwiseȱstated,ȱallȱdrugȱuseȱandȱbehaviouralȱvariablesȱreferȱtoȱtheȱpreviousȱsixȱ monthȱperiod.ȱȱ Forȱ bothȱ ourȱ primaryȱ andȱ secondaryȱ analyses,ȱ weȱ usedȱ univariateȱ andȱ multivariateȱstatisticsȱtoȱdetermineȱfactorsȱassociatedȱwithȱourȱoutcomesȱofȱinterest.ȱInȱ univariateȱanalysisȱcategoricalȱexplanatoryȱvariablesȱwereȱanalyzedȱusingȱPearson’’sȱchiȬ squareȱ testȱ andȱ continuousȱ variablesȱ wereȱ analyzedȱ usingȱ theȱ MannȬWhitneyȱ test.ȱ Fisher’’sȱexactȱtestȱwasȱusedȱwhenȱoneȱorȱmoreȱofȱtheȱcellȱcountsȱwasȱlessȱthanȱorȱequalȱ toȱfive.ȱToȱevaluateȱfactorsȱindependentlyȱassociatedȱwithȱourȱoutcomesȱofȱinterest,ȱallȱ variablesȱ thatȱ wereȱ associatedȱ withȱ theȱ dependentȱ variableȱ atȱ pȱ <ȱ 0.05ȱ inȱ univariateȱ analysesȱ wereȱ enteredȱ intoȱ theȱ respectiveȱ multivariateȱ logisticȱ regressionȱ models.ȱ Allȱ statisticalȱ analysesȱ wereȱ performedȱ usingȱ SASȱ softwareȱ versionȱ 9.1ȱ (SAS,ȱ Cary,ȱ NC).ȱȱ AllȱpȬvaluesȱareȱtwoȱsided.ȱ  6.3 Resultsȱ Duringȱ theȱ studyȱ periodȱ aȱ totalȱ ofȱ 874ȱ participantsȱ completedȱ followȬupȱ visits,ȱ includingȱ 310ȱ (35%)ȱ womenȱ andȱ 312ȱ (36%)ȱ personsȱ whoȱ identifiedȱ asȱ beingȱ ofȱ Aboriginalȱ ancestry.ȱ Theȱ medianȱ ageȱ ofȱ participantsȱ wasȱ 45ȱ yearsȱ (interquartileȱ rangeȱ [IQR]ȱ=ȱ39Ȭ51).ȱAmongȱourȱsampleȱofȱ874ȱIDUȱaȱtotalȱofȱ418ȱ(48%)ȱreportedȱengagingȱinȱ ȱ  107  ȱ  disorderlyȱincomeȱgenerationȱactivities.ȱTheȱmedianȱnumberȱofȱdisorderlyȱactivitiesȱthatȱ participantsȱ engagedȱ inȱ wasȱ 1ȱ (IQRȱ =ȱ 1Ȭ1).ȱ Asȱ displayedȱ inȱ Tableȱ 6.1,ȱ drugȱ dealingȱ (n=220,ȱ 25%)ȱ andȱ recyclingȱ (n=165,ȱ 19%)ȱ wereȱ theȱ mostȱ commonȱ typesȱ ofȱ disorderlyȱ incomeȱ generationȱ activity,ȱ andȱ theȱ medianȱ numberȱ ofȱ hoursȱ spentȱ engagedȱ inȱ disorderlyȱincomeȱgenerationȱactivitiesȱeachȱweekȱwasȱhighestȱforȱdrugȱdealingȱ(20ȱhrsȱ perȱweek,ȱIQRȱ=ȱ6Ȭ40).ȱTheȱcharacteristicsȱofȱtheȱstudyȱsampleȱstratifiedȱbyȱengagementȱ inȱdisorderlyȱincomeȱgenerationȱactivitiesȱareȱpresentedȱinȱTableȱ6.2.ȱȱ Amongȱ individualsȱ whoȱ reportedȱ engagingȱ inȱ disorderlyȱ incomeȱ generationȱ activities,ȱ 198ȱ (47%)ȱ indicatedȱ theyȱ wouldȱ ceaseȱ engagingȱ inȱ thisȱ activityȱ ifȱ theyȱ hadȱ accessȱtoȱlowȬthresholdȱemployment.ȱAsȱshownȱinȱTableȱ6.1,ȱamongȱthoseȱwhoȱreportedȱ incomeȱ fromȱ sexȱ tradeȱ work,ȱ 51ȱ (63%)ȱ indicatedȱ theyȱ wouldȱ noȱ longerȱ engageȱ inȱ sexȱ tradeȱ workȱ ifȱ theyȱ hadȱ accessȱ toȱ lowȬthresholdȱ employment.ȱ Further,ȱ 97ȱ (44%)ȱȱ respondentsȱ whoȱ reportedȱ incomeȱ fromȱ drugȱ dealing,ȱ 21ȱ (37%)ȱ respondentsȱ whoȱ reportedȱengagingȱinȱpanhandlingȱandȱ48ȱ(29%)ȱrespondentsȱwhoȱengagedȱinȱrecyclingȱ reportedȱthatȱtheyȱwouldȱrefrainȱfromȱengagingȱinȱthoseȱdisorderlyȱincomeȱgenerationȱ activitiesȱifȱtheyȱhadȱaccessȱtoȱcausalȱemploymentȱopportunities.ȱ Theȱ univariateȱ analysesȱ ofȱ behaviouralȱ andȱ socioȬdemographicȱ variablesȱ associatedȱwithȱengagingȱinȱdisorderlyȱincomeȱgenerationȱactivitiesȱareȱalsoȱpresentedȱ inȱTableȱ6.2,ȱwhileȱtheȱresultsȱofȱtheȱmultivariateȱlogisticȱregressionȱanalysisȱofȱfactorsȱ associatedȱwithȱengagingȱinȱdisorderlyȱincomeȱgenerationȱactivitiesȱareȱshownȱinȱTableȱ  ȱ  108  ȱ  6.3.ȱ Factorsȱ thatȱ remainedȱ independentlyȱ associatedȱ withȱ ourȱ outcomeȱ ofȱ interestȱ included:ȱ regularȱ employmentȱ (adjustedȱ oddsȱ ratioȱ [AOR]ȱ =ȱ 0.48,ȱ 95%CI:ȱ 0.32Ȭ0.71);ȱ dailyȱ cocaineȱ injectionȱ (AORȱ =ȱ 1.98,ȱ 95%CI:ȱ 1.05Ȭ3.76);ȱ dailyȱ crackȱ cocaineȱ smokingȱ (AORȱ =ȱ 3.11,ȱ 95%CI:ȱ 2.17Ȭ4.45);ȱ bingeȱ drugȱ useȱ (AORȱ =ȱ 1.55,ȱ 95%CI:ȱ 1.12Ȭ2.14),ȱ encountersȱwithȱpoliceȱ(AORȱ=ȱ2.45,ȱ95%CI:ȱ1.61Ȭ3.72);ȱbeingȱaȱvictimȱofȱviolenceȱ(AORȱ =ȱ 1.68,ȱ 95%CI:ȱ 1.06Ȭ2.68);ȱ syringeȱ sharingȱ (AORȱ =ȱ 4.50,ȱ 95%CI:ȱ 1.44Ȭ14.09);ȱ andȱ publicȱ injectingȱ(AORȱ=ȱ2.03,ȱ95%CI:ȱ1.28Ȭ3.23).ȱ Forȱ ourȱ secondaryȱ analysis,ȱ theȱ univariateȱ resultsȱ ofȱ factorsȱ associatedȱ withȱ willingnessȱ toȱ ceaseȱengagingȱ inȱ disorderlyȱ incomeȱ generationȱ activitiesȱ areȱ presentedȱ inȱ Tableȱ 6.4ȱ andȱ theȱ resultsȱ ofȱ theȱ multivariateȱ logisticȱ regressionȱ analysisȱ ofȱ factorsȱ associatedȱwithȱwillingnessȱtoȱceaseȱengagingȱinȱdisorderlyȱincomeȱgenerationȱactivitiesȱ areȱ shownȱ inȱ Tableȱ 6.5.ȱ Factorsȱ thatȱ remainedȱ independentlyȱ associatedȱ withȱ ourȱ outcomeȱ ofȱ interestȱ included:ȱ sexȱ workȱ (AORȱ =ȱ 2.54,ȱ 95%CI:ȱ 1.32Ȭ4.88),ȱ drugȱ dealingȱ (AORȱ =ȱ 1.86,ȱ 95%CI:ȱ 1.13Ȭ3.06),ȱ bingeȱ drugȱ useȱ (AORȱ =ȱ 1.56,ȱ 95%CI:ȱ 1.03Ȭ2.37),ȱ andȱ incarcerationȱ(AORȱ=ȱ1.88,ȱ95%CI:ȱ1.04Ȭ3.42).ȱ  6.4 Discussionȱ Amongȱ ourȱ sampleȱ ofȱ 874ȱ IDU,ȱ weȱ foundȱ thatȱ 48%ȱ reportedȱ engagingȱ inȱ aȱ disorderlyȱ incomeȱ generationȱ activityȱ inȱ theȱ lastȱ sixȱ months.ȱ Theȱ mostȱ commonȱ activitiesȱ reportedȱ wereȱ drugȱ dealingȱ andȱ recyclingȱ (whichȱ includedȱ salvagingȱ andȱ unsanctionedȱstreetȱvending).ȱInȱaȱmultivariateȱanalysisȱpeopleȱwhoȱreportedȱengagingȱ ȱ  109  ȱ  inȱdisorderlyȱincomeȱgenerationȱactivitiesȱwereȱmoreȱlikelyȱtoȱsmokeȱcrackȱcocaineȱonȱaȱ dailyȱbasisȱandȱinjectȱcocaineȱonȱaȱdailyȱbasis.ȱThisȱpopulationȱwasȱalsoȱmoreȱlikelyȱtoȱ engageȱ inȱ bingeȱ drugȱ use,ȱ haveȱ encountersȱ withȱ police,ȱ beȱ aȱ victimȱ ofȱ violence,ȱ shareȱ usedȱ syringesȱ andȱ injectȱ drugsȱ inȱ publicȱ areas.ȱ Conversely,ȱ individualsȱ withȱ regularȱ employmentȱ wereȱ significantlyȱ lessȱ likelyȱ toȱ reportȱ engagingȱ inȱ disorderlyȱ incomeȱ generationȱactivities.ȱWeȱalsoȱfoundȱthatȱamongȱindividualsȱwhoȱengagedȱinȱdisorderlyȱ incomeȱgenerationȱactivities,ȱ47%ȱreportedȱthatȱtheyȱwouldȱbeȱwillingȱtoȱstopȱengagingȱ inȱtheseȱdisorderlyȱactivitiesȱifȱtheyȱwereȱofferedȱotherȱopportunitiesȱforȱlowȬthresholdȱ employment.ȱ Individualsȱ engagedȱ inȱ sexȱ work,ȱ drugȱ dealing,ȱ bingeȱ drugȱ use,ȱ orȱ whoȱ wereȱ recentlyȱ incarcerated,ȱ wereȱ mostȱ interestedȱ inȱ ceasingȱ theirȱ engagementȱ inȱ disorderlyȱincomeȱgenerationȱactivities.ȱȱ Theseȱ findingsȱ supportȱ theȱ conclusionsȱ ofȱ previousȱ studiesȱ indicatingȱ thatȱ disorderlyȱincomeȱgenerationȱactivitiesȱareȱcommonȱamongȱillicitȱdrugȱusers.33,ȱ 171,ȱ 265,ȱ 268ȱ Theȱ significantȱ associationsȱ betweenȱ engagingȱ inȱ disorderlyȱ incomeȱ generationȱ activitiesȱ andȱ dailyȱ crackȱ cocaineȱ smokingȱ andȱ dailyȱ cocaineȱ injectingȱ areȱ consistentȱ withȱaȱgrowingȱnumberȱofȱstudiesȱlinkingȱfrequentȱcocaineȱuseȱwithȱaȱgreaterȱlikelihoodȱ ofȱengagingȱinȱriskyȱbehaviours30Ȭ32ȱandȱillegalȱactivities.7,ȱ 33ȱȱTheseȱassociationsȱsuggestȱ thatȱtheȱcompulsiveȱdrugȱacquisitionȱbehavioursȱassociatedȱwithȱcocaineȱaddictionȱmayȱ perpetuateȱ theȱ needȱ toȱ generateȱ incomeȱ throughȱ prohibitedȱ means.ȱ Inȱ particular,ȱ theȱ relativelyȱ shortȱ halfȬlifeȱ ofȱ cocaineȱ comparedȱ withȱ opioidsȱ orȱ methamphetamineȱ mayȱ contributeȱ toȱ anȱ increasedȱ frequencyȱ ofȱ drugȱ useȱ andȱ pressureȱ toȱ purchaseȱ largerȱ ȱ  110  ȱ  quantitiesȱ ofȱ drugs.274ȱ Inȱ addition,ȱ theȱ negativeȱ psychiatricȱ effectsȱ ofȱ highȱ intensityȱ cocaineȱ useȱ mayȱ haveȱ destabilizingȱ influencesȱ thatȱ presentȱ barriersȱ toȱ engagingȱ inȱ formalȱ employment.33ȱ Indeed,ȱ previousȱ researchȱ foundȱ thatȱ frequentȱ crackȱ cocaineȱ smokingȱ wasȱ negativelyȱ associatedȱ withȱ attainingȱ formalȱ employmentȱ amongȱ IDUȱ inȱ ourȱstudyȱsetting.173ȱȱ Ourȱfindingsȱfurtherȱindicateȱthatȱindividualsȱwhoȱengageȱinȱdisorderlyȱincomeȱ generationȱactivitiesȱareȱaȱvulnerableȱpopulationȱatȱriskȱforȱmultipleȱnegativeȱhealthȱandȱ socialȱoutcomes.ȱManyȱofȱtheȱbehavioursȱassociatedȱwithȱdisorderlyȱincomeȱgenerationȱ activities,ȱincludingȱdailyȱcocaineȱinjection,ȱdailyȱcrackȱcocaineȱsmoking,ȱbingeȱdrugȱuseȱ andȱ syringeȱ sharing,ȱ haveȱ allȱ beenȱ independentlyȱ linkedȱ withȱ increasedȱ riskȱ ofȱ HIVȱ infectionȱinȱthisȱsetting.27,ȱ275,ȱ276ȱȱTheseȱfindingsȱunderscoreȱtheȱimportanceȱofȱidentifyingȱ interventionsȱtoȱreduceȱengagementȱinȱdisorderlyȱincomeȱgenerationȱactivities,ȱandȱourȱ studyȱfindingsȱfurtherȱsuggestȱthatȱthereȱisȱconsiderableȱwillingnessȱamongȱmanyȱIDUȱ toȱceaseȱengagingȱinȱtheseȱactivitiesȱifȱtheyȱwereȱprovidedȱwithȱopportunitiesȱforȱlowȬ thresholdȱemployment.ȱThisȱfindingȱisȱconsistentȱwithȱcurrentȱliteratureȱinȱtheȱdrugȱuseȱ fieldȱ thatȱ emphasizesȱ theȱ importanceȱ thatȱ structuralȱ factors,ȱ suchȱ asȱ employmentȱ opportunities,ȱ playȱ inȱ shapingȱ behaviour,ȱ andȱ supportsȱ assertionsȱ thatȱ interventionsȱ thatȱ changeȱ theȱ environmentȱ ofȱ drugȱ usersȱ canȱ reduceȱ theirȱ engagementȱ inȱ riskyȱ behaviour.75,ȱ77,ȱ78ȱȱ  ȱ  111  ȱ  Itȱ isȱ noteworthyȱ thatȱ inȱ ourȱ studyȱ participationȱ inȱ sexȱ workȱ wasȱ theȱ strongestȱ independentȱ predictorȱ ofȱ willingnessȱ toȱ takeȱ lowȬthresholdȱ employment.ȱ Givenȱ theȱ physicalȱ dangersȱ andȱ healthȱ risksȱ associatedȱ withȱ sexȱ work,ȱ itȱ isȱ understandableȱ thatȱ participantȱengagedȱinȱsexȱworkȱwereȱmostȱlikelyȱtoȱbeȱwillingȱtoȱceaseȱengagingȱinȱthisȱ behaviourȱ ifȱ givenȱ otherȱ optionsȱ toȱ earnȱ income.10,ȱ 60ȱ Inȱ additionȱ toȱ theȱ inherentȱ risksȱ associatedȱ withȱ sexȱ work,ȱ numerousȱ studiesȱ haveȱ alsoȱ linkedȱ prohibitiveȱ sexȬworkȱ legislationȱ withȱ increasingȱ theȱ vulnerabilityȱ ofȱ sexȱ workersȱ andȱ underminingȱ theirȱ abilityȱ toȱ protectȱ theirȱ healthȱ andȱ physicalȱ security.57Ȭ59,ȱ 64ȱ Althoughȱ theȱ intentionȱ ofȱ prohibitiveȱ sexȬworkȱ legislationȱ isȱ toȱ deterȱ engagementȱ inȱ theȱ activity,ȱ itȱ appearsȱ thatȱ theȱlawsȱthatȱareȱimplementedȱtoȱreduceȱtheȱharmsȱofȱsexȱworkȱareȱactuallyȱincreasingȱ risks.ȱ Theȱ strongȱ demandȱ forȱ lowȬthresholdȱ employmentȱ foundȱ inȱ theȱ currentȱ studyȱ amongȱ individualsȱ engagedȱ inȱ sexȱ worksȱ suggestsȱ thatȱ thereȱ areȱ importantȱ opportunitiesȱ toȱ reduceȱ theȱ prevalenceȱ ofȱ thisȱ activityȱ throughȱ meansȱ thatȱ doȱ notȱ criminalizeȱsexȱworkersȱandȱcarryȱtheȱunanticipatedȱnegativeȱconsequencesȱofȱcriminalȱ justiceȱinterventions.ȱItȱisȱimportantȱtoȱnote,ȱhowever,ȱthatȱtheȱincomeȱearnedȱthroughȱ sexȱ workȱ isȱ oftenȱ muchȱ greaterȱ thanȱ throughȱ otherȱ incomeȱ generationȱ opportunities.ȱ Despiteȱ theȱ potentialȱ forȱ sexȱ workersȱ toȱ reduceȱ theirȱ engagementȱ inȱ sexȱ workȱ ifȱ alternativeȱ lowȬthresholdȱ employmentȱ opportunitiesȱwhereȱmadeȱavailable,ȱitȱ isȱlikelyȱ thatȱtheȱincentivesȱwillȱnotȱbeȱsufficientȱforȱsomeȱsexȱworkers.ȱInȱadditionȱtoȱsupportingȱ theȱdevelopmentȱofȱlowȬthresholdȱemploymentȱopportunities,ȱamendingȱlawsȱthatȱlimitȱ  ȱ  112  ȱ  theȱ abilityȱ ofȱ sexȱ workersȱ toȱ protectȱ theirȱ healthȱ andȱ physicalȱ safetyȱ shouldȱ beȱ simultaneouslyȱconsideredȱandȱpursued.ȱ IDUȱwhoȱengagedȱinȱdrugȱdealingȱwereȱalsoȱsignificantlyȱmoreȱwillingȱtoȱceaseȱ thisȱ incomeȱ generationȱ activityȱ ifȱ theyȱ wereȱ givenȱ alternativeȱ opportunitiesȱ forȱ lowȬ thresholdȱ employment.ȱ Thisȱ findingȱ shouldȱ beȱ ofȱ particularȱ interestȱ toȱ policyȬmakersȱ givenȱ theȱ highȱ costsȱ ofȱ drugȱ lawȱ enforcementȱ whichȱ attemptȱ toȱ deterȱ illicitȱ drugȱ productionȱandȱdistributionȱwithȱtheȱthreatȱofȱincarcerationȱandȱlegalȱpenaltiesȱwhich,ȱ toȱdate,ȱhaveȱbeenȱlimitedȱinȱtheirȱabilityȱtoȱpreventȱengagementȱinȱdrugȱdealingȱamongȱ IDUȱandȱotherȱsegmentsȱofȱtheȱgeneralȱpopulation.200,ȱ277,ȱ278ȱȱ Itȱ isȱ clearȱ fromȱ theȱ highȱ ratesȱ ofȱ engagementȱ inȱ disorderlyȱ incomeȱ generationȱ activitiesȱ reportedȱ inȱ ourȱ studyȱ thatȱ currentȱ directȱ andȱ indirectȱ prohibitionsȱ againstȱ behavioursȱ suchȱ asȱ drugȱ dealingȱ andȱ sexȱ workȱ areȱ notȱ successfullyȱ deterringȱ orȱ preventingȱ engagementȱ inȱ theseȱ activities.ȱ However,ȱ itȱ isȱ interestingȱ toȱ noteȱ thatȱ sexȱ workȱandȱdrugȱdealing,ȱasȱwellȱasȱrecentȱincarceration,ȱwereȱallȱsignificantlyȱassociatedȱ withȱ willingnessȱ toȱ ceaseȱ engagementȱ inȱ disorderlyȱ incomeȱ generationȱ activities.ȱ Thisȱ mayȱ suggestȱ thatȱ theȱ deterrentȱ influenceȱ ofȱ prohibitionsȱ againstȱ drugȱ dealingȱ andȱ sexȱ workȱ couldȱ beȱ successfulȱ inȱ situationsȱ whereȱ IDUȱ wereȱ givenȱ opportunitiesȱ toȱ chooseȱ otherȱ lessȱ riskyȱ incomeȱ generationȱ opportunities.ȱ Unfortunately,ȱ itȱ currentlyȱ appearsȱ thatȱlessȱriskyȱincomeȱgenerationȱopportunitiesȱavailableȱtoȱmostȱIDUȱremainȱlimited.170,ȱ 173,ȱ174  ȱȱȱȱ  ȱ  113  ȱ  Aȱ keyȱ implicationȱ ofȱ thisȱ studyȱ isȱ thatȱ creatingȱ lowȬthresholdȱ employmentȱ opportunitiesȱandȱsupportingȱexistingȱinitiativesȱthatȱcurrentlyȱprovideȱtheseȱpositionsȱ hasȱ potentialȱ toȱ reduceȱ bothȱ streetȱ disorderȱ andȱ healthȱ risksȱ currentlyȱ facedȱ byȱ individualsȱ whoȱ engageȱ inȱ disorderlyȱ incomeȱ generationȱ activities.ȱ ȱ Modelsȱ ofȱ lowȬ thresholdȱemploymentȱforȱactiveȱillicitȱdrugȱusersȱalreadyȱexistȱinȱourȱstudyȱsettingȱandȱ elsewhere;176,ȱ 177,ȱ 179,ȱ182,ȱ273ȱhowever,ȱourȱstudyȱsuggestsȱthatȱincreasingȱtheirȱcapacityȱandȱ availabilityȱhasȱpotentialȱtoȱreduceȱbothȱindividualȬȱandȱcommunityȬlevelȱharms.ȱ Thereȱareȱaȱnumberȱofȱlimitationsȱwithȱthisȱstudy.ȱFirstly,ȱVIDUSȱisȱnotȱaȱrandomȱ sampleȱofȱinjectionȱdrugȱusersȱandȱthereforeȱtheseȱfindingsȱmayȱnotȱgeneralizeȱtoȱotherȱ drugȱusingȱpopulations.ȱHowever,ȱtheȱassociationȱbetweenȱcrackȱcocaineȱsmokingȱandȱ streetȬbasedȱ incomeȱ generationȱ suggestsȱ thatȱ ourȱ findingsȱ areȱ likelyȱ notȱ specificȱ toȱ injectionȱ drugȱ useȱ andȱ mayȱ beȱ relevantȱ forȱ crackȱ cocaineȱ smokersȱ thatȱ doȱ notȱ haveȱ aȱ historyȱ ofȱ injecting.ȱ Secondly,ȱ thereȱ areȱ limitationsȱ withȱ combiningȱ differentȱ streetȬ basedȱ disorderlyȱ incomeȱ generationȱ activitiesȱ intoȱ oneȱ categoryȱ asȱ eachȱ ofȱ theseȱ activitiesȱisȱuniqueȱandȱlikelyȱattractsȱdifferentȱpopulations.ȱItȱisȱevidentȱfromȱtheȱsubȬ analysisȱ presentedȱ hereinȱ thatȱ thereȱ areȱ uniqueȱ characteristicsȱ amongȱ eachȱ group.ȱ Althoughȱitȱisȱcrudeȱtoȱcombineȱtheseȱveryȱdifferentȱactivities,ȱfromȱaȱpolicyȱperspectiveȱ itȱisȱmeaningfulȱtoȱprovideȱaȱpictureȱofȱtheȱnetȱfactorsȱassociatedȱwithȱtheseȱactivities,ȱasȱ wellȱasȱdirectionȱasȱtoȱwhetherȱaȱpotentialȱpolicyȱinterventionȱwillȱlikelyȱhaveȱanȱoverallȱ beneficialȱ impactȱ despiteȱ theȱ differencesȱ amongȱ activities.ȱ Whileȱ itȱ wouldȱ haveȱ beenȱ idealȱtoȱsupplementȱourȱprimaryȱanalysisȱwithȱadditionalȱmodelsȱthatȱconsideredȱeachȱ ȱ  114  ȱ  individualȱ incomeȱ generationȱ activityȱ separately,ȱ lowȱ eventȱ countsȱ precludedȱ theseȱ additionalȱcomparisons.ȱAȱthirdȱlimitationȱisȱthatȱmanyȱofȱourȱmeasuresȱreliedȱonȱselfȬ reportedȱinformationȱconcerningȱbehavioursȱthatȱareȱillegalȱand/orȱstigmatized,ȱsuchȱasȱ drugȱ dealing,ȱ sexȱ workȱ andȱ syringeȱ sharing,ȱ andȱ areȱ thereforeȱ vulnerableȱ toȱ socialȱ desirableȱ responding.ȱ Inȱ thisȱ presentȱ study,ȱ thisȱ couldȱ haveȱ resultedȱ inȱ anȱ underȬ reportingȱofȱengagementȱinȱdisorderlyȱincomeȱgenerationȱactivitiesȱandȱassociatedȱrisksȱ resultingȱinȱconservativeȱestimatesȱofȱtheȱprevalenceȱofȱtheseȱactivitiesȱandȱrisks.ȱThereȱ areȱ otherȱ limitationsȱ withȱ ourȱ measuresȱ ofȱ streetȬbasedȱ incomeȱ generationȱ activities.ȱ Specifically,ȱ theȱ amountȱ ofȱ moneyȱ earnedȱ throughȱ streetȬbasedȱ disorderlyȱ incomeȱ generationȱ activitiesȱ doesȱ notȱ accountȱ forȱ ‘‘inȬkind’’ȱ transactionsȱ orȱ nonȬmonetaryȱ contributionsȱ(i.e.,ȱexchangingȱsexȱforȱdrugs,ȱbeingȱpaidȱinȱdrugsȱratherȱthanȱmoneyȱforȱ drugȱ dealing,ȱ orȱ receivingȱ foodȱ whenȱ panhandling).ȱ Thisȱ couldȱ haveȱ alsoȱ ledȱ toȱ anȱ underȬreportingȱ ofȱ engagementȱ inȱ streetȬbasedȱ disorderlyȱ incomeȱ generation.ȱ Lastly,ȱ ourȱ studyȱ reliedȱ onȱ willingnessȱ responsesȱ whichȱ doȱ notȱ representȱ actualȱ behaviourȱ change.ȱ Thereȱ areȱ potentiallyȱ aȱ hostȱ ofȱ externalȱ factorsȱ thatȱ mightȱ influenceȱ incomeȱ generationȱbehaviours,ȱsomeȱofȱwhichȱmayȱinvolveȱcomplexȱsocialȱnetworksȱandȱpowerȱ relations.ȱTherefore,ȱtheȱprovisionȱofȱlowȬthresholdȱemploymentȱcanȱnotȱbeȱexpectedȱtoȱ automaticallyȱ translateȱ intoȱ aȱ reductionȱ ofȱ streetȬbasedȱ incomeȱ generationȱ amongȱ allȱ participantsȱ thatȱ indicatedȱ aȱ willingnessȱ toȱ changeȱ theirȱ behaviour.ȱ However,ȱ itȱ isȱ importantȱ toȱ noteȱ thatȱ previousȱ analysesȱ evaluatingȱ theȱ validityȱ ofȱ reportingȱ willingnessȱtoȱuseȱaȱsupervisedȱinjectionȱfacilityȱonȱsubsequentȱratesȱofȱuseȱamongȱillicitȱ ȱ  115  ȱ  injectionȱ drugȱ usersȱ foundȱ thatȱ willingnessȱ measuresȱ wereȱ reasonablyȱ accurateȱ predictorsȱofȱlaterȱbehaviourȱamongȱIDU.263ȱ Inȱ summary,ȱ weȱ foundȱ thatȱ 48%ȱ ofȱ ourȱ sampleȱ ofȱ IDUȱ recentlyȱ engagedȱ inȱ disorderlyȱincomeȱgenerationȱactivities,ȱandȱtheseȱbehavioursȱwereȱassociatedȱwithȱhighȱ intensityȱstimulantȱdrugȱuseȱandȱvariousȱmarkersȱofȱrisk.ȱHowever,ȱweȱalsoȱfoundȱthatȱ aȱ highȱ percentageȱ ofȱ IDUȱ reportedȱ beingȱ willingȱ toȱ ceaseȱ engagementȱ inȱ disorderlyȱ incomeȱ generationȱ activitiesȱ ifȱ theyȱ hadȱ optionsȱ forȱ lowȬthresholdȱ employment.ȱ Theseȱ findingsȱindicateȱthatȱlowȬthresholdȱemploymentȱmayȱofferȱimportantȱopportunitiesȱtoȱ reduceȱdrugȬrelatedȱstreetȱdisorderȱandȱassociatedȱharms.ȱȱȱ  ȱ  116  ȱ  Tableȱ6.1ȱParticipationȱinȱdisorderlyȱincomeȱgenerationȱactivitiesȱamongȱinjectionȱ drugȱusersȱ(lastȱ30ȱdays)ȱ(n=874)ȱ  IncomeȱSourceȱ ȱȱȱ Recyclingȱ Panhandlingȱ Squeegeeingȱ DrugȱDealingȱ SexȱWorkȱ  Nȱ(%)ȱwouldȱ Medianȱhrsȱperȱweekȱ Nȱ(%)ȱreportingȱ ceaseȱtoȱengageȱinȱ activityȱ engagedȱinȱactivity*ȱ(IQR)ȱ activity**ȱ ȱ  ȱ  165ȱ 57ȱ 5ȱ 220ȱ 81ȱ  (19)ȱ (7)ȱ (1)ȱ (25)ȱ (9)ȱ  ȱ  ȱ  14 14 5 20 9  (8Ȭ30)ȱ (4.5Ȭ40)ȱ (2Ȭ10)ȱ (6Ȭ40)ȱ (3Ȭ21)ȱ  ȱ  ȱ  48ȱ 21ȱ 0ȱ 97ȱ 51ȱ  (29)ȱ (37)ȱ (0)ȱ (44)ȱ (63)ȱ  *ȱRefersȱtoȱnumberȱofȱhoursȱspentȱdoingȱtheȱactivityȱinȱtheȱaverageȱweek;ȱ**Indicatesȱparticipantsȱ thatȱwouldȱceaseȱtoȱengageȱinȱtheȱactivityȱifȱtheyȱhadȱotherȱopportunitiesȱforȱlowȬthresholdȱ employment.ȱ  ȱ  ȱ  117  ȱ  Tableȱ 6.2ȱ Univariateȱ analysesȱ ofȱ factorsȱ associatedȱ withȱ engagingȱ inȱ disorderlyȱ incomeȱgenerationȱactivitiesȱamongȱinjectionȱdrugȱusersȱ(n=874)ȱ ȱ  Disorderlyȱincomeȱgenerationȱa ȱ  Yesȱn=ȱ418,ȱnȱ(%)Noȱn=ȱ456,ȱnȱ(%)ȱ Characteristicȱ Ageȱȱ ȱ ȱ 46ȱ(41Ȭ51)ȱcȱ Perȱyearȱolderȱ 43ȱ(38Ȭ50)ȱcȱ ȱ ȱ DailyȱExpenditureȱonȱDrugsȱ Perȱadditionalȱ$10ȱ 50ȱ(30Ȭ100)ȱcȱ 30ȱ(10Ȭ60)ȱcȱ FemaleȱGenderȱȱ ȱ ȱ Yesȱ 165ȱ(39)ȱ 145ȱ(32)ȱ Noȱ 253ȱ(61)ȱ 311ȱ(68)ȱ ȱ ȱ AboriginalȱAncestryȱȱ Yesȱ 152ȱ(36)ȱ 160ȱ(35)ȱ Noȱ 266ȱ(64)ȱ 296ȱ(65)ȱ ȱ ȱ UnstableȱHousingȱ(current)ȱȱ Yesȱ 110ȱ(26)ȱ 58ȱ(13)ȱ Noȱ 308ȱ(74)ȱ 398ȱ(87)ȱ ȱ ȱ HighȱSchoolȱEducationȱȱ Yesȱ 199ȱ(48)ȱ 248ȱ(54)ȱ 208ȱ(46)ȱ Noȱ 219ȱ(52)ȱ ȱ ȱ RegularȱEmploymentȱdȱ Yesȱ 55ȱ(13)ȱ 137ȱ(30)ȱ 319ȱ(70)ȱ Noȱ 363ȱ(87)ȱ ȱ ȱ DailyȱCocaineȱInjectionȱdȱ Yesȱ 49ȱ(12)ȱ 18ȱȱȱ(4)ȱ Noȱ 369ȱ(88)ȱ 438ȱ(96)ȱ ȱ ȱ DailyȱHeroinȱInjectionȱdȱ Yesȱ 110ȱ(26)ȱ 43ȱȱȱ(9)ȱ Noȱ 308ȱ(74)ȱ 413ȱ(91)ȱ DailyȱCrackȱSmokingȱdȱ ȱ ȱ Yesȱ 213ȱ(51)ȱ 74ȱ(16)ȱȱȱȱ Noȱ 205ȱ(49)ȱ 382ȱ(84)ȱ ȱ ȱ Overdoseȱ(nonȬfatal)ȱdȱ Yesȱ 20ȱȱȱ(5)ȱ 7ȱȱȱ(2)ȱ Noȱ 398ȱ(95)ȱ 449ȱ(98)ȱ ȱ ȱ BingeȱDrugȱUsedȱ Yesȱ 230ȱ(55)ȱ 150ȱ(33)ȱ 306ȱ(67)ȱ Noȱ 188ȱ(45)ȱ ȱ ȱ EncountersȱwithȱPoliceȱdȱ Yesȱ 129ȱ(31)ȱ 50ȱ(11)ȱ Noȱ 289ȱ(69)ȱ 406ȱ(89)ȱ ȱ ȱ VictimȱofȱViolenceȱdȱ Yesȱ 84ȱ(20)ȱ 42ȱ(9)ȱ Noȱ 334ȱ(80)ȱ 414ȱ(91)ȱ ȱ ȱ SyringeȱSharingȱdȱ Yesȱ 28ȱȱȱ(7)ȱ 4ȱȱȱ(1)ȱ Noȱ 390ȱ(93)ȱ 452ȱ(99)ȱ ȱ ȱ PublicȱInjectingȱdȱ Yesȱ 148ȱ(35)ȱ 52ȱ(11)ȱȱȱȱ Noȱ 270ȱ(65)ȱ 404ȱ(89)ȱ ȱ ȱ UnprotectedȱSexȱdȱ Yesȱ 113ȱ(27)ȱ 98ȱ(21)ȱ 358ȱ(79)ȱ Noȱ 305ȱ(73)ȱ ȱ ȱ RecentȱIncarcerationȱdȱ Yesȱ 65ȱ(16)ȱ 30ȱȱȱ(7)ȱ 426ȱ(93)ȱ Noȱ 353ȱ(84)ȱ ȱ ȱ MethadoneȱTreatmentȱ(current)ȱ Yesȱ 188ȱ(45)ȱ 218ȱ(48)ȱ Noȱ 230ȱ(55) 238ȱ(52)  ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ  ORbȱȱ(95%ȱCI)ȱ pȬvalueȱ ȱ 0.97ȱ(0.95ȱ––ȱ0.98)ȱ <0.001ȱ ȱ 1.05ȱȱ(1.03ȱ––ȱ1.07)ȱ <0.001ȱ ȱ 1.40ȱ(1.06ȱ––ȱ1.85)ȱ 0.018ȱ ȱ ȱ 1.06ȱ(0.80ȱ––ȱ1.39)ȱ 0.694ȱ ȱ ȱ 2.45ȱ(1.73ȱ––ȱ3.48)ȱ <0.001ȱ ȱ ȱ 0.76ȱȱ(0.58ȱ––ȱ0.99)ȱ 0.045ȱ ȱ ȱ 0.35ȱȱ(0.25ȱ––ȱ0.50)ȱ <0.001ȱ ȱ ȱ 3.23ȱ(1.85ȱ––ȱ5.64)ȱ <0.001ȱ ȱ ȱ 3.43ȱ(2.34ȱ––ȱ5.03)ȱ <ȱ0.001ȱ ȱ ȱ 5.36ȱ(3.92ȱ––ȱ7.34)ȱ <ȱ0.001ȱ ȱ ȱ 3.22ȱ(1.35ȱ––ȱ7.70)ȱ 0.006ȱ ȱ ȱ 2.50ȱ(1.90ȱ––ȱ3.28)ȱ <ȱ0.001ȱ ȱ ȱ 3.62ȱ(2.53ȱ––ȱ5.19)ȱ <ȱ0.001ȱ ȱ ȱ 2.48ȱ(1.66ȱ––ȱ3.69)ȱ <ȱ0.001ȱ ȱ ȱ 8.11ȱ(2.82ȱ––ȱ23.33) <ȱ0.001ȱ ȱ ȱ 4.26ȱ(3.00ȱ––ȱ6.05)ȱ <ȱ0.001ȱ ȱ ȱ 1.35ȱ(0.99ȱ––ȱ1.85)ȱ 0.056ȱ ȱ ȱ 2.61ȱ(1.66ȱ––ȱ4.12)ȱ <ȱ0.001ȱ ȱ ȱ 0.89ȱȱ(0.68ȱ––ȱ1.16)ȱ 0.402ȱ ȱ ȱ  Note:ȱ aȱDisorderlyȱincomeȱgenerationȱincludes:ȱrecycling,ȱsqueegeeing,ȱpanhandling,ȱsellingȱdrugsȱandȱ engagingȱinȱsexȱwork;ȱ bȱ ORȱ=ȱOddsȱRatio,ȱ ȱCIȱ=ȱConfidenceȱInterval;ȱ cȱ MedianȱandȱInterquartileȱRange;ȱ dȱ Denotesȱactivitiesȱorȱsituationsȱreferringȱtoȱpreviousȱsixȱmonths.ȱ ȱ  118  ȱ  Tableȱ6.3ȱMultivariateȱlogisticȱregressionȱanalysisȱofȱfactorsȱassociatedȱ withȱ participationȱ inȱ disorderlyȱ incomeȱ generationȱ activitiesȱ aȱ amongȱ injectionȱdrugȱusersȱ(n=874)ȱ Adjustedȱ (95%ȱ Oddsȱ Confidenceȱ pȬvalueȱ Characteristicȱ Ratioȱ Interval)ȱ OlderȱAgeȱȱ 1.00ȱ ȱ(0.98ȱ––ȱ1.02)ȱ 0.799ȱ FemaleȱGenderȱȱ 1.12ȱ ȱ(0.79ȱ––ȱ1.57)ȱ 0.526ȱ ȱ UnstableȱHousingȱ(current) ȱ 0.96ȱ ȱ(0.61ȱ––ȱ1.52)ȱ 0.864ȱ ȱb RegularȱEmployment ȱ 0.48ȱ ȱ(0.32ȱ––ȱ0.71)ȱ <ȱ0.001ȱ ȱ HighȱSchoolȱEducation ȱ 0.89ȱ ȱ(0.65ȱ––ȱ1.22)ȱ 0.474ȱ ȱb DailyȱExpenditureȱonȱDrugs 1.01ȱ ȱ(1.00ȱ––ȱ1.03)ȱ 0.121ȱ ȱb 1.98ȱ ȱ(1.05ȱ––ȱ3.76)ȱ 0.036ȱ DailyȱCocaineȱInject ȱ ȱb DailyȱHeroinȱInject ȱ 1.40ȱ ȱ(0.86ȱ––ȱ2.26)ȱ 0.175ȱ ȱb DailyȱCrackȱSmoking ȱ 3.11ȱ ȱ(2.17ȱ––ȱ4.45)ȱ <ȱ0.001ȱ ȱb Overdoseȱ(nonȬfatal) ȱ 1.83ȱ ȱ(0.67ȱ––ȱ5.01)ȱ 0.239ȱ ȱb BingeȱDrugȱUse ȱ 1.55ȱ ȱ(1.12ȱ––ȱ2.14)ȱ 0.008ȱ ȱb EncountersȱwithȱPolice ȱ 2.45ȱ ȱ(1.61ȱ––ȱ3.72)ȱ <ȱ0.001ȱ ȱb VictimȱofȱViolence ȱ 1.68ȱ ȱ(1.06ȱ––ȱ2.68)ȱ 0.028ȱ ȱb SyringeȱSharingȱ *ȱ 4.50ȱ ȱ(1.44ȱ––ȱ14.09)ȱ 0.010ȱ ȱb PublicȱInjection ȱ 2.03ȱ ȱ(1.28ȱ––ȱ3.23)ȱ 0.003ȱ ȱb Incarcerationȱ ȱ 1.10ȱ ȱ(0.63ȱ––ȱ1.91)ȱ 0.740ȱ Note:ȱ aȱ Disorderlyȱ incomeȱ generationȱ activitiesȱ include:ȱ recycling,ȱ squeegeeing,ȱ panhandling,ȱ sellingȱ drugs,ȱ andȱ engagingȱ inȱ sexȱ work.;ȱ bȱ Denotesȱ activitiesȱ orȱ situationsȱreferringȱtoȱpreviousȱ6ȱmonths.ȱ *pȬvalueȱandȱ95%ȱCIȱreportedȱfromȱFisher’’sȱExactȱTestȱasȱ25%ȱofȱcellsȱhadȱexpectedȱ countsȱlessȱthanȱ5.ȱ  ȱ  ȱ  119  ȱ  Tableȱ6.4ȱUnivariateȱanalysesȱofȱfactorsȱassociatedȱwithȱwillingnessȱtoȱ ceaseȱ engagingȱ inȱ disorderlyȱ incomeȱ generationȱ activitiesȱ amongȱ injectionȱdrugȱusersȱ(n=418)ȱ ȱ Characteristicȱ Ageȱȱ Perȱyearȱolderȱ DailyȱExpenditureȱonȱ Drugsȱ Perȱadditionalȱ$10ȱ FemaleȱGenderȱȱ Yesȱ Noȱ AboriginalȱAncestryȱȱ Yesȱ Noȱ UnstableȱHousingȱ(current)ȱȱ Yesȱ Noȱ HighȱSchoolȱEducationȱȱ Yesȱ Noȱ RegularȱEmploymentȱdȱ Yesȱ Noȱ SexȱWorkȱdȱ Yesȱ Noȱ DrugȱDealingȱdȱ Yesȱ Noȱ Recyclingȱȱdȱ Yesȱ Noȱ Panhandlingȱdȱ Yesȱ Noȱ DailyȱCocaineȱInjectionȱdȱ Yesȱ Noȱ DailyȱHeroinȱInjectionȱdȱ Yesȱ Noȱ DailyȱCrackȱSmokingȱdȱ Yesȱ Noȱ Overdoseȱ(nonȬfatal)ȱdȱ Yesȱ Noȱ BingeȱDrugȱUsedȱ Yesȱ Noȱ EncountersȱwithȱPoliceȱdȱ Yesȱ Noȱ VictimȱofȱViolenceȱdȱ Yesȱ Noȱ SyringeȱSharingȱdȱ Yesȱ Noȱ PublicȱInjectingȱdȱ Yesȱ Noȱ UnprotectedȱSexȱdȱ Yesȱ Noȱ RecentȱIncarcerationȱdȱ Yesȱ  Noȱ  Willingȱtoȱceaseȱengagingȱinȱ disorderlyȱincomeȱgenerationȱaȱ Yesȱn=ȱ198,ȱnȱ(%)ȱ Noȱn=ȱ220,ȱnȱ(%)ȱ ȱ ȱ 43ȱ(37Ȭ49)ȱ 44ȱ(38Ȭ51)ȱ  MethadoneȱTreatmentȱ(current)ȱ Yesȱ Noȱ  ȱ ȱ ȱ ȱ  ORbȱȱ(95%ȱCI)ȱ ȱ 0.98ȱ(0.96ȱ––ȱ1.00)ȱ ȱ  pȬvalueȱ ȱ 0.006ȱ ȱ  ȱ  ȱ  ȱ  60ȱ(30Ȭ100)ȱcȱ ȱ 88ȱ(44)ȱ 110ȱ(56)ȱ ȱ 81ȱ(41)ȱ 117ȱ(59)ȱ ȱ 63ȱ(32)ȱ 135ȱ(68)ȱ ȱ 86ȱ(43)ȱ 112ȱ(57)ȱ ȱ 23ȱ(12)ȱ 175ȱ(88)ȱ ȱ 52ȱ(26)ȱ 146ȱ(74)ȱ ȱ 122ȱ(62)ȱ 76ȱ(38)ȱ ȱ 67ȱ(34)ȱ 131ȱ(66)ȱ ȱ 27ȱ(14)ȱ 171ȱ(86)ȱ ȱ 24ȱ(12)ȱ 174ȱ(88)ȱ ȱ 61ȱ(31)ȱ 137ȱ(69)ȱ ȱ 108ȱ(55)ȱ 90ȱ(45)ȱ ȱ 11ȱȱȱ(6)ȱ 187ȱ(94)ȱ ȱ 125ȱ(63)ȱ 73ȱ(37)ȱ ȱ 69ȱ(35)ȱ 129ȱ(65)ȱ ȱ 42ȱ(21)ȱ 156ȱ(79)ȱ ȱ 14ȱȱȱ(7)ȱ 184ȱ(93)ȱ ȱ 81ȱ(41)ȱ 117ȱ(59)ȱ ȱ 59ȱ(30)ȱ 139ȱ(70)ȱ ȱ 43ȱ(22)ȱ  50ȱ(20Ȭ100)ȱcȱ ȱ 77ȱ(35)ȱ 143ȱ(65)ȱ ȱ 71ȱ(32)ȱ 149ȱ(68)ȱ ȱ 47ȱ(21)ȱ 173ȱ(79)ȱ ȱ 113ȱ(51)ȱ 107ȱ(49)ȱ ȱ 39ȱ(18)ȱ 181ȱ(82)ȱ ȱ 29ȱ(13)ȱȱȱȱ 191ȱ(87)ȱ ȱ 98ȱ(45)ȱȱȱȱ 122ȱ(55)ȱ ȱ 98ȱ(45)ȱȱȱȱ 122ȱ(55)ȱ ȱ 30ȱ(14)ȱȱȱȱ 190ȱ(86)ȱ ȱ 25ȱ(11)ȱ 195ȱ(89)ȱ ȱ 49ȱ(22)ȱ 171ȱ(78)ȱ ȱ 105ȱ(48)ȱȱȱȱ 115ȱ(52)ȱ ȱ 9ȱȱȱ(4)ȱ 221ȱ(96)ȱ ȱ 105ȱ(48)ȱ 115ȱ(52)ȱ ȱ 60ȱ(27)ȱ 160ȱ(73)ȱ ȱ 42ȱ(19)ȱ 178ȱ(81)ȱ ȱ 14ȱȱȱ(6)ȱ 206ȱ(94)ȱ ȱ 67ȱ(30)ȱȱȱȱ 153ȱ(70)ȱ ȱ 54ȱ(25)ȱ 166ȱ(75)ȱ ȱ 22ȱ(10)ȱ  ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ  1.01ȱȱ(1.00ȱ––ȱ1.03)ȱ ȱ 1.49ȱ(1.00ȱ––ȱ2.20)ȱ ȱ ȱ 1.45ȱ(0.97ȱ––ȱ2.17)ȱ ȱ ȱ 0.73ȱ(0.49ȱ––ȱ1.07)ȱ ȱ ȱ 0.76ȱȱ(0.58ȱ––ȱ0.99)ȱ ȱ ȱ 0.61ȱȱ(0.35ȱ––ȱ1.06)ȱ ȱ ȱ 2.34ȱ(1.42ȱ––ȱ3.88)ȱ ȱ ȱ 2.00ȱ(1.35ȱ––ȱ2.95)ȱ ȱ ȱ 0.64ȱ(0.43ȱ––ȱ0.95)ȱ ȱ ȱ 1.00ȱ(0.57ȱ––ȱ1.75)ȱ ȱ ȱ 1.08ȱ(0.59ȱ––ȱ1.95)ȱ ȱ ȱ 1.55ȱ(1.00ȱ––ȱ2.41)ȱ ȱ ȱ 1.31ȱ(0.89ȱ––ȱ1.93)ȱ ȱ ȱ 1.38ȱ(0.56ȱ––ȱ3.40)ȱ ȱ ȱ 1.88ȱ(1.27ȱ––ȱ2.77)ȱ ȱ ȱ 1.43ȱ(0.94ȱ––ȱ2.16)ȱ ȱ ȱ 1.14ȱ(0.71ȱ––ȱ1.84)ȱ ȱ ȱ 1.12ȱ(0.52ȱ––ȱ2.41)ȱ ȱ ȱ 1.58ȱ(1.06ȱ––ȱ2.37)ȱ ȱ ȱ 1.30ȱ(0.85ȱ––ȱ2.01)ȱ ȱ ȱ 2.50ȱ(1.43ȱ––ȱ4.35)ȱ  0.073ȱ ȱ 0.049ȱ ȱ ȱ 0.067ȱ ȱ ȱ 0.105ȱ ȱ ȱ 0.045ȱ ȱ ȱ 0.079ȱ ȱ ȱ <0.001ȱ ȱ ȱ <0.001ȱ ȱ ȱ ȱ0.025ȱ ȱ ȱ ȱ1.000ȱ ȱ ȱ ȱ0.810ȱ ȱ ȱ 0.048ȱ ȱ ȱ ȱ0.164ȱ ȱ ȱ 0.484ȱ ȱ ȱ ȱ0.002ȱ ȱ ȱ ȱ0.094ȱ ȱ ȱ ȱ0.589ȱ ȱ ȱ 0.773ȱ ȱ ȱ 0.026ȱ ȱ ȱ 0.227ȱ ȱ ȱ 0.001ȱ  ȱ 103ȱ(52)ȱ 95ȱ(48)ȱ  ȱ 95ȱ(43)ȱ 125ȱ(57)ȱ  ȱ ȱ ȱ  ȱ 1.43ȱ(0.97ȱ––ȱ2.10)ȱ ȱ  ȱ 0.071ȱ ȱ  155ȱ(78)ȱ  198ȱ(90)ȱ  ȱ  ȱ  ȱ  Note:ȱ aȱ Disorderlyȱ incomeȱ generationȱ includes:ȱ recycling,ȱ squeegeeing,ȱ panhandling,ȱ sellingȱ drugsȱ andȱ sexȱ work;ȱ bȱ ORȱ =ȱ Oddsȱ Ratio,ȱ ȱ CIȱ =ȱ Confidenceȱ Interval;ȱ cȱ Medianȱ andȱ InterȱQuartileȱRange;ȱdȱDenotesȱactivitiesȱorȱsituationsȱreferringȱtoȱpreviousȱ6ȱmonths.ȱ ȱ  120  ȱ  Tableȱ6.5ȱ Multivariateȱlogisticȱregressionȱanalysisȱofȱfactorsȱassociatedȱwithȱ willingnessȱ toȱ ceaseȱ engagingȱ inȱ disorderlyȱ incomeȱ generationȱ amongȱ injectionȱdrugȱusersȱ(n=418)ȱ  Characteristicȱ FemaleȱGenderȱȱ UnstableȱHousingȱbȱ SexȱWorkȱdȱ DrugȱDealingȱdȱ Recyclingȱȱdȱ DailyȱHeroinȱInjectȱbȱ BingeȱDrugȱUseȱbȱ PublicȱInjectionȱbȱ Incarcerationȱbȱ  Adjustedȱ OddsȱRatioȱ 1.00ȱ 1.35ȱ 2.54ȱ 1.86ȱ 1.25ȱ 1.05ȱ 1.56ȱ 1.09ȱ 1.88ȱ  (95%ȱConfidenceȱ Interval)ȱ ȱ(0.60ȱ––ȱ1.67)ȱ ȱ(0.80ȱ––ȱ2.28)ȱ ȱ(1.32ȱ––ȱ4.88)ȱ ȱ(1.13ȱ––ȱ3.06)ȱ ȱ(0.74ȱ––ȱ2.09)ȱ ȱ(0.63ȱ––ȱ1.74)ȱ ȱ(1.03ȱ––ȱ2.37)ȱ ȱ(0.66ȱ––ȱ1.80)ȱ ȱ(1.04ȱ––ȱ3.42)ȱ  pȬvalueȱ 0.998ȱ 0.263ȱ 0.005ȱ 0.014ȱ 0.405ȱ 0.864ȱ ȱ0.036ȱ 0.748ȱ 0.037ȱ  Note:ȱ aȱ Disorderlyȱ incomeȱ generationȱ includes:ȱ recycling,ȱ squeegeeing,ȱ panhandling,ȱ sellingȱ drugs,ȱ andȱ engagingȱ inȱ sexȱ work.;ȱ bȱ Denotesȱ activitiesȱ orȱ situationsȱreferringȱtoȱpreviousȱ6ȱmonths.ȱ ȱ ȱ ȱ ȱ ȱ ȱ  ȱ  121  ȱ  CHAPTER 7: ȱ PUBLICȱCRACKȱCOCAINEȱUSEȱANDȱWILLINGNESSȱTOȱUSEȱAȱ SUPERVISEDȱINHALATIONȱFACILITY:ȱIMPLICATIONSȱFORȱ STREETȱDISORDER 6ȱ  7.1 Introductionȱ Theȱ useȱ ofȱ illicitȱ drugsȱ inȱ publicȱ settings,ȱ includingȱ street,ȱ alleysȱ andȱ parksȱ isȱ bothȱ aȱ publicȱ healthȱ andȱ publicȱ orderȱ concernȱ inȱ manyȱ urbanȱ areas.6,ȱ 42,ȱ 91ȱ Toȱ date,ȱ theȱ useȱ ofȱ injectionȱ drugsȱ inȱ publicȱ settingsȱ hasȱ receivedȱ theȱ mostȱ attentionȱ fromȱ policyȬ makersȱandȱpublicȱhealthȱresearchers.5,ȱ42ȱPublicȱinjectingȱisȱknownȱtoȱpresentȱproblemsȱ forȱ citizensȱ whoȱ resideȱ inȱ orȱ aroundȱ areasȱ whereȱ publicȱ drugȱ useȱ isȱ prevalent,ȱ andȱ scientificȱ studiesȱ haveȱ documentedȱ thatȱ usingȱ injectionȱ drugsȱ inȱ publicȱ settingsȱ canȱ discourageȱsaferȱinjectingȱpracticesȱresultingȱinȱmanyȱpublicȱhealthȱproblems,ȱincludingȱ increasedȱriskȱforȱdrugȱoverdoseȱeventsȱandȱHIVȱandȱotherȱbloodȬborneȱinfections.61Ȭ64,ȱ83ȱ Asȱ aȱ result,ȱ someȱ citiesȱ haveȱ implementedȱ supervisedȱ injectionȱ facilitiesȱ whichȱ aimȱ toȱ provideȱ anȱ alternativeȱ injectingȱ environmentȱ thatȱ reducesȱ bothȱ theȱ healthȱ risksȱ associatedȱwithȱinjectionȱdrugȱ useȱandȱtheȱstreetȱ disorderȱitȱcanȱ generate.20,ȱ 150,ȱ 151,ȱ 153,ȱ 154ȱ Whileȱ supervisedȱ injectionȱ facilitiesȱ haveȱ beenȱ notedȱ toȱ haveȱ measurableȱ successȱ inȱ achievingȱ theseȱ publicȱ healthȱ andȱ publicȱ orderȱ objectives,ȱ theȱ useȱ ofȱ inhalableȱ drugs,ȱ  ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ 6  ȱAȱversionȱofȱthisȱchapterȱhasȱbeenȱsubmittedȱforȱpublicationȱas:ȱDeBeck,ȱK.,ȱBuxton,ȱJ.,ȱ Kerr,ȱT.,ȱQi,ȱJ.,ȱMontaner,ȱJ.,ȱWood,ȱE.ȱPublicȱcrackȱuseȱandȱwillingnessȱtoȱuseȱaȱ supervisedȱinhalationȱfacility:ȱImplicationsȱforȱstreetȱdisorder.ȱ ȱ  122  ȱ  particularlyȱ crackȱ cocaineȱ smoking,ȱ hasȱ beenȱ growingȱ inȱ popularityȱ inȱ manyȱ streetȬ basedȱdrugȱscenesȱacrossȱCanada.26,ȱ27,ȱ29ȱIndeed,ȱtheȱpopularityȱofȱcrackȱcocaineȱandȱeaseȱ ofȱ administrationȱ throughȱ smokingȱ hasȱ madeȱ publicȱ crackȱ cocaineȱ useȱ aȱ commonȱ featureȱ ofȱ theȱ streetsȱ inȱ Vancouver’’sȱ drugȱ useȱ epicentre,ȱ knownȱ asȱ theȱ Downtownȱ Eastside.279ȱ Publicȱ crackȱ cocaineȱ smokingȱ isȱ posingȱ aȱ growingȱ burdenȱ forȱ lawȱ enforcementȱagenciesȱresponsibleȱforȱmaintainingȱpublicȱorder.280ȱInȱaddition,ȱtheȱhealthȱ andȱ socialȱ harmsȱ associatedȱ withȱ crackȱ cocaineȱ smokingȱ areȱ extensive.ȱ Comparedȱ toȱ otherȱ drugȱ userȱ populations,ȱ crackȱ cocaineȱ usersȱ areȱ moreȱ likelyȱ toȱ engageȱ inȱ riskyȱ behaviours30Ȭ32ȱ andȱ illegalȱ activities7,ȱ 33ȱ andȱ toȱ experienceȱ homelessness29ȱ andȱ healthȱ problems,29,ȱ34Ȭ37ȱyetȱareȱlessȱlikelyȱtoȱaccessȱhealthȱandȱsocialȱservices.38ȱȱItȱhasȱalsoȱbeenȱ recentlyȱdocumentedȱthatȱdailyȱcrackȱcocaineȱsmokersȱareȱatȱaȱfourȬfoldȱgreaterȱriskȱofȱ contractingȱHIVȱcomparedȱtoȱtheirȱdrugȱusingȱpeersȱwhoȱsmokeȱcrackȱcocaineȱlessȱoftenȱ orȱnotȱatȱall.27ȱ Givenȱtheȱdramaticȱriseȱinȱcrackȱcocaineȱsmokingȱandȱtheȱpublicȱorderȱandȱpublicȱ healthȱ concernsȱ associatedȱ withȱ it,ȱ theȱ needȱ forȱ targetedȱ interventionsȱ forȱ peopleȱ whoȱ smokeȱ crackȱ cocaineȱ isȱ unambiguous.ȱ Oneȱ potentialȱ interventionȱ thatȱ isȱ receivingȱ increasingȱ attentionȱ fromȱ publicȱ healthȱ officials,ȱ healthȱ researchersȱ andȱ localȱ communityȱ groupsȱ isȱ supervisedȱ drugȱ consumptionȱ facilitiesȱ similarȱ toȱ Vancouver’’sȱ supervisedȱ injectionȱ siteȱ butȱ thatȱ accommodateȱ crackȱ cocaineȱ smoking.27,ȱ 281Ȭ285ȱ Theȱ Canadianȱ Institutesȱ ofȱ Healthȱ Researchȱ recentlyȱ approvedȱ fundingȱ toȱ conductȱ aȱ randomizedȱ controlȱ trialȱ toȱ evaluateȱ theȱ impactȱ ofȱ aȱ supervisedȱ inhalationȱ facilityȱ onȱ ȱ  123  ȱ  accessȱ toȱ medicalȱ andȱ socialȱ services,ȱ particularlyȱ addictionȱ treatment,ȱ amongȱ VancouverȬbasedȱ crackȱ cocaineȱ smokers.286ȱ Previousȱ studiesȱ haveȱ assessedȱ generalȱ willingnessȱ amongȱ localȱ drugȱ usersȱ toȱ useȱ aȱ supervisedȱ inhalationȱ facility;287,ȱ  ȱ  288  however,ȱtheseȱstudiesȱwereȱnotȱprimarilyȱconcernedȱwithȱstreetȱdisorderȱandȱthereforeȱ didȱ notȱ considerȱ theȱ specificȱ risksȱ associatedȱ withȱ smokingȱ crackȱ cocaineȱ inȱ publicȱ areas,ȱnorȱ didȱtheyȱassessȱwillingnessȱtoȱ useȱanȱinhalationȱfacilityȱamongȱpublicȱcrackȱ cocaineȱsmokersȱexclusively.ȱThereforeȱ weȱconductedȱ aȱ studyȱ focusedȱ onȱpublicȱcrackȱ cocaineȱ smokersȱ toȱ identifyȱ factorsȱ associatedȱ withȱ thisȱ practice.ȱ Weȱ alsoȱ soughtȱ toȱ assessȱ willingnessȱ toȱ useȱ anȱ inhalationȱ facilityȱ amongȱ individualsȱ whoȱ smokeȱ crackȱ cocaineȱinȱpublicȱareasȱtoȱdetermineȱtheȱpotentialȱimpactȱaȱsupervisedȱinhalationȱfacilityȱ mightȱhaveȱonȱstreetȱdisorderȱinȱVancouver,ȱCanada.ȱ  7.2 Methodsȱ Dataȱ forȱ thisȱ studyȱ wereȱ obtainedȱ fromȱ theȱ Vancouverȱ Injectionȱ Drugȱ Usersȱ Studyȱ (VIDUS).ȱ Forȱ aȱ fullȱ descriptionȱ ofȱ theȱ studyȱ pleaseȱ referȱ toȱ sectionȱ 1.4ȱ ofȱ thisȱ thesis.ȱTheȱpresentȱanalysesȱareȱrestrictedȱtoȱVIDUSȱparticipantsȱwhoȱreportedȱsmokingȱ crackȱcocaineȱinȱtheȱlastȱsixȱmonths,ȱandȱwereȱseenȱforȱstudyȱfollowȬupȱvisitsȱduringȱtheȱ periodȱofȱNovemberȱ2008ȱandȱJuneȱ2009ȱasȱmeasuresȱforȱoneȱofȱourȱoutcomesȱofȱinterestȱ areȱavailableȱonlyȱforȱthisȱsampleȱperiod.ȱȱ Inȱ ourȱ firstȱ analysisȱ amongȱ crackȱ cocaineȱ smokers,ȱ theȱ outcomeȱ ofȱ interestȱ wasȱ usingȱ drugsȱ (nonȬinjection)ȱ inȱ publicȱ areasȱ inȱ theȱ lastȱ sixȱ months.ȱ Asȱ inȱ previousȱ ȱ  124  ȱ  analyses,ȱpublicȱareasȱincludedȱcityȱstreets,ȱparks,ȱpublicȱwashrooms,ȱparkingȱlots,ȱclubsȱ orȱ barsȱ andȱ abandonedȱ buildings.3ȱ Toȱ characterizeȱ ourȱ outcomeȱ ofȱ interestȱ weȱ aȱ prioriȱ selectedȱ aȱ rangeȱ ofȱ socioȬdemographicȱ andȱ behaviouralȱ variablesȱ weȱ hypothesizedȱ mightȱ beȱ associatedȱ withȱ smokingȱ crackȱ cocaineȱ inȱ publicȱ areas.ȱ Theseȱ included:ȱ ageȱ (perȱ yearȱ older);ȱ genderȱ (femaleȱ vs.ȱ male);ȱ Aboriginalȱ Ancestryȱ (yesȱ vs.ȱ no);ȱ limitedȱ accessȱ toȱ privateȱ space,ȱ definedȱ asȱ answeringȱ ““no””ȱ toȱ theȱ question:ȱ ““Doȱ youȱ haveȱ aȱ privateȱindoorȱspaceȱforȱsocializingȱwithȱfriendsȱandȱacquaintances?””ȱorȱreportingȱthatȱ theȱ numberȱ ofȱ guestsȱ theyȱ wereȱ allowedȱ toȱ haveȱ inȱ theirȱ residenceȱ atȱ oneȱ timeȱ wasȱ restrictedȱ toȱ lessȱ thanȱ three289ȱ (yesȱ vs.ȱ no);ȱ dailyȱ cocaineȱ injectionȱ (yesȱ vs.ȱ no);ȱ dailyȱ heroinȱ injectionȱ (yesȱ vs.ȱ no);ȱ dailyȱ crackȱ cocaineȱ smokingȱ (yesȱ vs.ȱ no);ȱ nonȬfatalȱ overdose,ȱselfȱidentifiedȱbyȱparticipantsȱ(yesȱvs.ȱno),ȱencountersȱwithȱpoliceȱinȱtheȱlastȱ month,ȱdefinedȱasȱbeingȱquestioned,ȱsearchedȱorȱstoppedȱbyȱpoliceȱ(yesȱvs.ȱno);ȱbeingȱaȱ victimȱ ofȱ violenceȱ definedȱ asȱ beingȱ physicallyȱ assaultedȱ (yesȱ vs.ȱ no);ȱ sexȱ tradeȱ involvement,ȱdefinedȱasȱexchangingȱsexȱforȱmoney,ȱshelter,ȱdrugsȱorȱotherȱcommoditiesȱ (yesȱvs.ȱno);ȱandȱparticipationȱinȱdrugȱdealingȱ(yesȱvs.ȱno).ȱUnlessȱotherwiseȱstated,ȱallȱ drugȱuseȱandȱbehaviouralȱvariablesȱreferȱtoȱtheȱpreviousȱsixȱmonthȱperiod.ȱȱ Inȱaȱsecondȱanalysis,ȱweȱsoughtȱtoȱassessȱandȱidentifyȱpredictorsȱofȱwillingnessȱtoȱ useȱaȱsupervisedȱinhalationȱroom.ȱBecauseȱweȱwereȱparticularlyȱconcernedȱwithȱpublicȱ drugȱ use,ȱ weȱ restrictedȱ ourȱ sampleȱ toȱ crackȱ cocaineȱ smokersȱ thatȱ reportedȱ recentlyȱ usingȱnonȬinjectionȱdrugsȱinȱpublicȱareas.ȱToȱmeasureȱwillingnessȱweȱaskedȱparticipantsȱ  ȱ  125  ȱ  ““Ifȱ thereȱ wasȱ aȱ safeȱ placeȱ toȱ smokeȱ yourȱ drugsȱ (ventilatedȱ inhalationȱ room),ȱ closeȱ toȱ whereȱyouȱbuyȱorȱuse,ȱwouldȱyouȱuseȱit?””ȱȱ Variablesȱofȱinterestȱforȱourȱsecondȱanalysisȱwereȱalsoȱselectedȱaȱprioriȱbasedȱonȱ factorsȱ weȱ hypothesizedȱ mightȱ beȱ associatedȱ withȱ willingnessȱ toȱ useȱ anȱ inhalationȱ room.ȱ Theseȱ included:ȱ ageȱ (perȱ yearȱ older);ȱ genderȱ (femaleȱ vs.ȱ male);ȱ Aboriginalȱ Ancestryȱ (yesȱ vs.ȱ no);ȱ limitedȱ accessȱ toȱ privateȱ space,ȱ asȱ definedȱ above,ȱ (yesȱ vs.ȱ no);ȱ drugȱ sceneȱ exposure,ȱ definedȱ asȱ spendingȱ anȱ averageȱ ofȱ sevenȱ orȱ moreȱ hoursȱ onȱ theȱ streetȱeachȱdayȱinȱVancouver’’sȱdrugȱuseȱepicentreȱinȱtheȱpreviousȱsixȱmonths247ȱ(yesȱvs.ȱ no);ȱmostȱdrugȱuseȱinȱpublicȱareas,ȱdefinedȱbasedȱonȱreportsȱthatȱpublicȱlocationsȱwereȱ whereȱ theyȱ mostȱ frequentlyȱusedȱdrugsȱ (yesȱ vs.ȱno);ȱ dailyȱcrackȱ cocaineȱsmokingȱ (yesȱ vs.ȱno);ȱriskyȱpipeȱsharing,ȱdefinedȱasȱreportingȱsharingȱaȱcrackȱpipeȱorȱmouthpieceȱinȱ theȱ sameȱ sixȱ monthȱ periodȱ asȱ havingȱ burnsȱ orȱ soresȱ onȱ theirȱ mouthȱ (yesȱ vs.ȱ no);ȱ encountersȱwithȱpoliceȱinȱtheȱlastȱmonthȱ(yesȱvs.ȱno);ȱandȱbeingȱaȱvictimȱofȱviolenceȱ(yesȱ vs.ȱno).ȱAsȱabove,ȱunlessȱotherwiseȱstated,ȱallȱdrugȱuseȱandȱbehaviouralȱvariablesȱreferȱ toȱtheȱpreviousȱsixȱmonthȱperiod.ȱȱ Forȱ bothȱ ofȱ ourȱ firstȱ andȱ secondȱ analyses,ȱ weȱ usedȱ univariateȱ andȱ multivariateȱ statisticsȱ toȱ determineȱ factorsȱ associatedȱ withȱ ourȱ outcomesȱ ofȱ interest.ȱ Inȱ univariateȱ analysisȱcategoricalȱexplanatoryȱvariablesȱwereȱanalyzedȱusingȱPearson’’sȱchiȬsquareȱtestȱ andȱ continuousȱ variablesȱ wereȱ analyzedȱ usingȱ theȱ Wilcoxonȱ rankȱ sumȱ test.ȱ Fisher’’sȱ exactȱtestȱwasȱusedȱwhenȱoneȱorȱmoreȱofȱtheȱcellȱcountsȱwasȱlessȱthanȱorȱequalȱtoȱfive.ȱ  ȱ  126  ȱ  Toȱevaluateȱfactorsȱindependentlyȱassociatedȱwithȱourȱoutcomesȱofȱinterest,ȱallȱvariablesȱ thatȱ wereȱ pȱ<ȱ 0.05ȱinȱ univariateȱ analysesȱwereȱ enteredȱintoȱ theȱrespectiveȱ multivariateȱ regressionȱmodels.ȱAllȱstatisticalȱanalysesȱwereȱperformedȱusingȱSASȱsoftwareȱversionȱ 9.1ȱ(SAS,ȱCary,ȱNC).ȱȱAllȱpȬvaluesȱareȱtwoȱsided.ȱ  7.3 Resultsȱ Duringȱ theȱ studyȱ periodȱ 623ȱ participantsȱ wereȱ seenȱ forȱ studyȱ followȬupȱ visitsȱ andȱ reportedȱ smokingȱ crackȱ cocaineȱ inȱ theȱ lastȱ sixȱ months.ȱ Theseȱ includedȱ 249ȱ (40%)ȱ womenȱandȱ231ȱ(37%)ȱpersonsȱwhoȱidentifiedȱasȱAboriginal.ȱAmongȱourȱsampleȱofȱ623ȱ crackȱcocaineȱsmokers,ȱaȱtotalȱofȱ382ȱ(61%)ȱreportedȱusingȱinȱpublicȱareasȱinȱtheȱlastȱsixȱ months.ȱ ȱ Theȱ characteristicsȱ ofȱ theȱ studyȱ sampleȱ stratifiedȱ byȱ publicȱ drugȱ useȱ areȱ presentedȱ inȱ Tableȱ 7.1,ȱ andȱ theȱ univariateȱ analysesȱ ofȱ behaviouralȱ andȱ socioȬ demographicȱ variablesȱ associatedȱ withȱ publicȱ drugȱ useȱ amongȱ crackȱ cocaineȱ smokersȱ areȱpresentedȱinȱTableȱ7.2.ȱTheȱresultsȱofȱtheȱmultivariateȱlogisticȱregressionȱforȱfactorsȱ associatedȱwithȱpublicȱdrugȱuseȱamongȱcrackȱcocaineȱsmokersȱareȱalsoȱshownȱinȱTableȱ 7.2.ȱ Factorsȱ thatȱ remainedȱ independentlyȱ associatedȱ withȱ ourȱ outcomeȱ ofȱ interestȱ included:ȱ dailyȱ heroinȱ injectionȱ (adjustedȱ oddsȱ ratioȱ [AOR]ȱ =ȱ 1.95,ȱ 95%CI:ȱ 1.17Ȭ3.27),ȱ dailyȱ crackȱ cocaineȱ smokingȱ (AORȱ =ȱ 2.17,ȱ 95%CI:ȱ 1.49Ȭ3.14),ȱ encountersȱ withȱ policeȱ (AORȱ=ȱ1.69,ȱ95%CI:ȱ1.07Ȭ2.68)ȱandȱdrugȱdealingȱ(AORȱ=ȱ1.61,ȱ95%CI:ȱ1.06Ȭ2.47).ȱ Forȱ ourȱ secondȱ analysis,ȱ theȱ demographicȱ andȱ behaviouralȱ characteristicsȱ ofȱ publicȱ crackȱ cocaineȱ smokersȱ stratifiedȱ byȱ willingnessȱ toȱ useȱ aȱ supervisedȱ inhalationȱ ȱ  127  ȱ  roomȱ areȱ presentedȱ inȱ Tableȱ 7.3ȱ andȱ theȱ univariateȱ resultsȱ ofȱ factorsȱ associatedȱ withȱ willingnessȱtoȱuseȱaȱsupervisedȱinhalationȱroomȱareȱpresentedȱinȱTableȱ7.4.ȱTheȱresultsȱ ofȱ theȱ multivariateȱ logisticȱ regressionȱ forȱ factorsȱ associatedȱ withȱ willingnessȱ toȱ useȱ aȱ supervisedȱ inhalationȱ roomȱ areȱ alsoȱ shownȱ inȱ Tableȱ 7.4.ȱ Factorsȱ thatȱ remainedȱ independentlyȱ associatedȱ withȱ willingnessȱ included:ȱ femaleȱ genderȱ (AORȱ =ȱ 2.11,ȱ 95%ȱ CI:ȱ1.26Ȭ3.55),ȱriskyȱpipeȱsharingȱ(AORȱ=ȱ5.50,ȱ95%ȱCI:ȱ1.63Ȭ18.56)ȱandȱrecentȱencountersȱ withȱpoliceȱ(AORȱ=ȱ2.09,ȱ95%ȱCI:ȱ1.20Ȭ3.65).ȱ  7.4 Discussionȱ Weȱ foundȱ thatȱ theȱ majorityȱ ofȱ crackȱ cocaineȱ smokersȱ inȱ ourȱ studyȱ reportedȱ havingȱusedȱdrugsȱinȱpublicȱareasȱatȱsomeȱpointȱinȱtheȱlastȱsixȱmonths.ȱThisȱgroupȱwasȱ moreȱlikelyȱtoȱbeȱhigherȬintensityȱdrugȱusersȱwithȱrespectȱtoȱheroinȱinjectionȱandȱcrackȱ cocaineȱsmoking,ȱhaveȱencountersȱwithȱtheȱpoliceȱandȱbeȱinvolvedȱinȱdrugȱdealing.ȱOfȱ theseȱ publicȱ crackȱ cocaineȱ smokers,ȱ 71%ȱ reportedȱ beingȱ willingȱ toȱ useȱ aȱ supervisedȱ inhalationȱ roomȱ ifȱ oneȱ wasȱ available.ȱ Individualsȱ whoȱ reportedȱ beingȱ willingȱ wereȱ moreȱ likelyȱ toȱ beȱ female,ȱ engageȱ inȱ riskyȱ pipeȱ sharingȱ andȱ haveȱ encountersȱ withȱ theȱ police.ȱ Theȱ profileȱ ofȱ publicȱ crackȱ cocaineȱ smokersȱ asȱ higherȬintensityȱ drugȱ usersȱ whoȱ haveȱ interactionsȱ withȱ theȱ criminalȱ justiceȱ systemȱ isȱ reflectiveȱ ofȱ previousȱ findingsȱ describingȱpublicȱinjectionȱdrugȱuserȱpopulations.5,ȱ 6,ȱ 290ȱOurȱfindingȱthatȱ71%ȱofȱpublicȱ crackȱ cocaineȱ smokersȱ areȱ willingȱ toȱ useȱ anȱ inhalationȱ facilityȱ alsoȱ supportsȱ previousȱ ȱ  128  ȱ  willingnessȱ estimatesȱ conductedȱ amongȱ theȱ generalȱ populationȱ ofȱ VancouverȬbasedȱ illicitȱ drugȱ usersȱ andȱ suggestsȱ thatȱ anȱ interventionȱ ofȱ thisȱ natureȱ willȱ likelyȱ reachȱ theȱ targetȱpopulation.288ȱTheȱhighȱdegreeȱofȱwillingnessȱthatȱthisȱstudyȱfoundȱamongȱpublicȱ crackȱ cocaineȱ smokersȱ toȱ useȱ anȱ inhalationȱ facilityȱ suggestsȱ that,ȱ likeȱ supervisedȱ injectionȱ facilities,ȱ theseȱ interventionsȱ areȱ likelyȱ toȱ successfullyȱ encourageȱ publicȱ drugȱ usersȱtoȱrelocateȱtoȱindoorȱvenues.ȱȱ Interestingly,ȱ oneȱ ofȱ theȱ commonȱ featuresȱ amongȱ bothȱ publicȱ crackȱ cocaineȱ smokersȱ andȱ thoseȱ whoȱ areȱ willingȱ toȱ useȱ aȱ supervisedȱ inhalationȱ facilityȱ isȱ theirȱ elevatedȱlikelihoodȱofȱrecentlyȱhavingȱencountersȱwithȱlawȱenforcement.ȱThisȱsuggestsȱ thatȱpublicȱcrackȱcocaineȱsmokersȱwhoȱareȱtheȱsubjectȱofȱlawȱenforcementȱattentionȱareȱ veryȱ willingȱ toȱ relocateȱ toȱ alternativeȱ offȬstreetȱ andȱ healthȬfocussedȱ environmentsȱ ifȱ theyȱ wereȱ madeȱ available.ȱ Indeed,ȱ ourȱ dataȱ indicateȱ thatȱ 81%ȱ ofȱ publicȱ crackȱ cocaineȱ smokersȱ whoȱ haveȱhadȱaȱ recentȱ encounterȱ withȱ policeȱareȱwillingȱtoȱ useȱaȱ supervisedȱ inhalationȱfacility.ȱȱ Aȱkeyȱimplicationȱofȱtheseȱfindingsȱisȱthatȱthereȱisȱaȱlargeȱdemandȱforȱsupervisedȱ inhalationȱ roomsȱ amongȱ individualsȱ thatȱ areȱ potentiallyȱ keyȱ contributorsȱ toȱ drugȬ relatedȱ streetȱ disorder.ȱ Theȱ associationȱ betweenȱ publicȱ crackȱ cocaineȱ smokingȱ andȱ encountersȱ withȱ policeȱ suggestsȱ thatȱ interventionsȱ ofȱ thisȱ natureȱ areȱ likelyȱ toȱ targetȱ aȱ criticalȱ subȬpopulationȱ ofȱ drugȱ usersȱ andȱ couldȱ beȱ aȱ valuableȱ toolȱ forȱ policeȱ inȱ theȱ managementȱ ofȱ streetȱ disorder.ȱ ȱ Previousȱ studiesȱ haveȱ foundȱ thatȱ Vancouverȱ policeȱ  ȱ  129  ȱ  regularlyȱ referȱ publicȱ injectionȱ drugȱ usersȱ toȱ theȱ localȱ supervisedȱ injectionȱ facility.291ȱ Sinceȱ ourȱ analysisȱ indicatesȱ thatȱ localȱ policeȱ areȱ alreadyȱ frequentlyȱ interactingȱ withȱ publicȱcrackȱcocaineȱsmokers,ȱtheȱestablishmentȱofȱaȱsupervisedȱinhalationȱfacilityȱcouldȱ provideȱ aȱ uniqueȱ opportunityȱ forȱ policeȱ toȱ directȱ thisȱ vulnerableȱ groupȱ toȱ aȱ lowȬ thresholdȱ serviceȱ whereȱ theyȱ willȱ haveȱ opportunitiesȱ toȱ beȱ linkedȱ withȱ appropriateȱ healthȱandȱsocialȱservices.ȱȱ Thisȱstudyȱhasȱaȱnumberȱofȱlimitations.ȱFirstly,ȱVIDUSȱisȱaȱcommunityȱrecruitedȱ nonȬrandomizedȱ sampleȱ andȱ thereforeȱ ourȱ findingsȱ mayȱ notȱ beȱ generalizableȱ toȱ otherȱ settings.ȱ Ifȱ supervisedȱ inhalationȱ facilitiesȱ areȱ beingȱ consideredȱ inȱ otherȱ settings,ȱ willingnessȱstudiesȱshouldȱbeȱconductedȱamongȱtheȱlocalȱtargetȱpopulationsȱandȱshouldȱ notȱrelyȱonȱtheȱfindingsȱemergingȱfromȱourȱsetting.ȱTheȱgeneralizabilityȱofȱourȱfindingsȱ isȱalsoȱlimitedȱbyȱourȱstudyȱsampleȱwhichȱwasȱrestrictedȱtoȱindividualsȱwithȱaȱhistoryȱofȱ injectionȱdrugȱuse.ȱCrackȱcocaineȱsmokersȱwhoȱdidȱnotȱhaveȱaȱhistoryȱofȱinjectionȱdrugȱ useȱwereȱnotȱeligibleȱforȱourȱstudy.ȱGivenȱtheȱharmsȱassociatedȱwithȱinjectionȱdrugȱuseȱ weȱ anticipateȱ thatȱ ifȱ aȱ selectionȱ effectȱ wereȱ presentȱ itȱ wouldȱ likelyȱ biasȱ ourȱ sampleȱ towardsȱhighȱriskȱdrugȱusers,ȱsuggestingȱthatȱthisȱgroupȱwouldȱbeȱanȱappropriateȱtargetȱ populationȱforȱpublicȱhealthȱintervention.ȱȱWeȱshouldȱalsoȱnoteȱthatȱamongȱourȱstudyȱ sampleȱ dailyȱ crackȱ cocaineȱ smokingȱ wasȱ significantlyȱ moreȱ commonȱ thanȱ dailyȱ injecting,ȱsuggestingȱthatȱ despiteȱ theȱrequirementȱofȱ aȱhistoryȱofȱ injecting,ȱ ourȱ sampleȱ representsȱ aȱ primarilyȱ crackȱ cocaineȱ smokingȱ population.ȱ Secondly,ȱ someȱ ofȱ ourȱ measuresȱ reliedȱ onȱ selfȬreportȱ andȱ couldȱ beȱ vulnerableȱ toȱ sociallyȱ desirableȱ reporting.ȱ ȱ  130  ȱ  Thisȱ wouldȱ haveȱ likelyȱ beenȱ ofȱ mostȱ relevanceȱ toȱ ourȱ measureȱ ofȱ willingness,ȱ sinceȱ respondentsȱ mightȱ perceiveȱ aȱ pressureȱ toȱ reportȱ beingȱ willingȱ toȱ engageȱ withȱ lowȬ thresholdȱservicesȱofȱthisȱnatureȱgivenȱtheȱwidespreadȱactivismȱamongȱlocalȱdrugȱusersȱ inȱourȱstudyȱsettingȱtoȱimplementȱsupervisedȱdrugȱconsumptionȱfacilities.284ȱWhileȱitȱisȱ possibleȱ thatȱ someȱ respondentsȱ mayȱ overȬreportȱ willingness,ȱ aȱ previousȱ studyȱ comparingȱ measuresȱ ofȱ willingnessȱ toȱ useȱ aȱ supervisedȱ injectionȱ facilityȱ beforeȱ itȱ wasȱ establishedȱ withȱ laterȱ reportsȱ ofȱ actualȱ attendanceȱ afterȱ anȱ injectionȱ facilityȱ wasȱ establishedȱ suggestsȱ thatȱ willingnessȱ measuresȱ areȱ goodȱ predictorsȱ ofȱ laterȱ behaviourȱ amongȱ thisȱ population.263ȱ Lastly,ȱ sociallyȱ desirableȱ reportingȱ couldȱ haveȱ influencedȱ reportsȱ ofȱ stigmatizedȱ behaviour,ȱ suchȱ asȱ publicȱ drugȱ use,ȱ leadingȱ toȱ anȱ underestimationȱ ofȱpublicȱ crackȱcocaineȱsmoking.ȱIfȱsocialȱdesirabilityȱ wasȱ anȱ issueȱ inȱ ourȱstudyȱweȱsuspectȱourȱfindingȱwouldȱbeȱaȱconservativeȱindicationȱofȱtheȱprevalenceȱ ofȱandȱharmsȱassociatedȱwithȱpublicȱdrugȱuseȱamongȱcrackȱcocaineȱsmokers.ȱȱȱ Inȱ summary,ȱ ourȱ studyȱ foundȱ thatȱ locally,ȱ publicȱ crackȱ cocaineȱ smokingȱ isȱ aȱ commonȱ practiceȱthatȱ isȱalsoȱ associatedȱwithȱ recentȱencountersȱwithȱpolice.ȱWeȱfoundȱ thatȱ theȱ majorityȱ ofȱ publicȱ crackȱ cocaineȱ smokersȱ wereȱ willingȱ toȱ useȱ anȱ inhalationȱ facilityȱ ifȱ oneȱ wereȱ available.ȱ Furthermore,ȱ publicȱ crackȱ cocaineȱ smokersȱ whoȱ hadȱ recentȱencountersȱwithȱpoliceȱwereȱevenȱmoreȱlikelyȱtoȱbeȱwillingȱtoȱuseȱanȱinhalationȱ room,ȱsuggestingȱthatȱsupervisedȱinhalationȱfacilitiesȱmayȱofferȱuniqueȱopportunitiesȱtoȱ decreaseȱoneȱcomponentȱofȱdrugȬrelatedȱstreetȱdisorderȱandȱreduceȱtheȱburdenȱonȱlocalȱ lawȱenforcementȱagencies.ȱȱ ȱ  131  ȱ  Tableȱ 7.1ȱ Characteristicsȱ ofȱ crackȱ cocaineȱ smokersȱ stratifiedȱ byȱpublicȱdrugȱuseȱ(n=623)ȱ ȱ  Publicȱdrugȱuseȱaȱ  Characteristicȱ  Yesȱn=ȱ382,ȱnȱ(%)ȱ  Noȱn=ȱ241,ȱnȱ(%)ȱ  Ageȱpreȱyearȱolderȱȱ ȱ ȱ c (Median,ȱIQR)ȱ ȱ 43ȱ(37Ȭ49)ȱ 46ȱ(40Ȭ50)ȱ ȱ ȱ FemaleȱGenderȱȱ Yesȱ 145ȱ(38)ȱ 104ȱ(43)ȱ Noȱ 237ȱ(62)ȱ 137ȱ(57)ȱ ȱ ȱ AboriginalȱAncestryȱȱ Yesȱ 137ȱ(36)ȱ 94ȱ(39)ȱ Noȱ 245ȱ(64)ȱ 147ȱ(61)ȱ d ȱ ȱ LimitedȱAccessȱtoȱPrivateȱSpaceȱ ȱ Yesȱ 316ȱ(83)ȱ 169ȱ(70)ȱ Noȱ 66ȱ(17)ȱ 72ȱ(30)ȱ ȱ ȱ DailyȱCocaineȱInjectionȱdȱ Yesȱ 39ȱ(10)ȱ 9ȱ(4)ȱ Noȱ 343ȱ(90)ȱ 232ȱ(96)ȱ ȱd ȱ ȱ DailyȱHeroinȱInjection ȱ Yesȱ 107(28)ȱ 25ȱ(10)ȱ Noȱ 275ȱ(72)ȱ 216ȱ(90)ȱ ȱd ȱ ȱ DailyȱCrackȱSmoking ȱ Yesȱ 220ȱ(58)ȱ 72ȱ(30)ȱȱȱȱ Noȱ 162ȱ(42)ȱ 169ȱ(70)ȱ ȱ ȱ Overdoseȱ(nonȬfatal)dȱ Yesȱ 18ȱ(5)ȱ 3ȱ(1)ȱ Noȱ 364ȱ(95)ȱ 238ȱ(99)ȱ ȱe ȱ ȱ Encountersȱwithȱpolice ȱ Yesȱ 114ȱ(30)ȱ 35ȱ(15)ȱ Noȱ 268ȱ(70)ȱ 206ȱ(85)ȱ ȱd ȱ ȱ VictimȱofȱViolence ȱ Yesȱ 77ȱ(20)ȱ 30ȱ(12)ȱ Noȱ 305ȱ(80)ȱ 211ȱ(88)ȱ ȱ ȱ SexȱTradeȱdȱ Yesȱ 60ȱ(16)ȱ 19ȱ(8)ȱ Noȱ 322ȱ(84)ȱ 222ȱ(92)ȱ ȱd ȱ ȱ DrugȱDealing ȱ Yesȱ 150ȱ(39)ȱ 46ȱ(19)ȱ Noȱ 232ȱ(61)ȱ 195ȱ(81)ȱ a Note:ȱ ȱPublicȱlocationsȱinclude:ȱcityȱstreets,ȱparks,ȱpublicȱwashrooms,ȱ parkingȱlots,ȱclubsȱorȱbars,ȱandȱabandonȱbuildings;ȱcȱIQR=ȱInterȱQuartileȱ Range;ȱdȱDenotesȱactivitiesȱorȱsituationsȱreferringȱtoȱpreviousȱ6ȱmonths;ȱeȱ Denotesȱactivitiesȱorȱsituationsȱreferringȱtoȱpreviousȱȱmonth.ȱ  ȱ  132  ȱ  Tableȱ 7.2ȱ Univariateȱ andȱ multivariateȱ analysesȱ ofȱ factorsȱ associatedȱ withȱ publicȱ drugȱuseȱamongȱcrackȱcocaineȱsmokersȱaȱȱ(n=623)ȱ ȱ  Univariateȱȱ  ȱȱȱ  ORbȱȱ(95%ȱCI)ȱ  Characteristicȱ OlderȱAgeȱȱ Perȱyearȱolderȱ Genderȱȱ Femaleȱvs.ȱMaleȱ AboriginalȱAncestryȱȱ Yesȱvs.ȱNoȱ LimitedȱAccessȱtoȱPrivateȱSpaceȱeȱ Yesȱvs.ȱNoȱ DailyȱCocaineȱInjectionȱeȱ Yesȱvs.ȱNoȱ DailyȱHeroinȱInjectionȱeȱ Yesȱvs.ȱNoȱ  ȱ <0.001ȱ ȱ 0.197ȱ  ȱ 0.98ȱȱ(0.96ȱ––ȱ1.00)ȱ ȱ ȱ  ȱ 0.87ȱȱ(0.63ȱ––ȱ1.22)ȱ  ȱ 0.429ȱ  ȱ ȱ  ȱ 2.04ȱȱ(1.39ȱ––ȱ2.99)ȱ  ȱ <0.001ȱ  1.49ȱ(0.99ȱ––ȱ2.26)ȱ  ȱ  ȱ  2.93ȱȱ(1.39ȱ––ȱ6.17)ȱ ȱ 3.36ȱȱ(2.10ȱ––ȱ5.38)ȱ ȱ  Overdoseȱ(nonȬfatal)* ȱ Yesȱvs.ȱNoȱ  3.92ȱȱ(1.13ȱ––ȱ20.98)ȱ  EncountersȱwithȱPolice ȱ Yesȱvs.ȱNoȱ VictimȱofȱViolenceȱeȱ Yesȱvs.ȱNoȱ  ȱ  ȱ  ȱ 0.058ȱ ȱ  ȱ  ȱ 1.95ȱ(1.17ȱ––ȱ3.27)ȱ  ȱ 0.011ȱ  <ȱ0.001ȱ <ȱ0.001ȱ 0.020ȱ <0.001ȱ ȱ  1.78ȱȱ(1.12ȱ––ȱ2.80)ȱ  ȱ ȱ  0.190ȱ  ȱ  2.50ȱȱ(1.64ȱ––ȱ3.81)ȱ  ȱ  ȱ 0.065ȱ ȱ ȱ  1.70ȱ(0.77ȱ––ȱ3.75)ȱ  ȱ  ȱ  ȱ  pȬvalueȱ  0.003ȱ  ȱ  3.19ȱȱ(2.26ȱ––ȱ4.49)ȱ  ȱd  AORȱ(95%ȱCI)ȱ  ȱ 0.96ȱȱ(0.94ȱ––ȱ0.98)ȱ ȱ 0.81ȱȱ(0.58ȱ––ȱ1.12)ȱ  DailyȱCrackȱCocaineȱSmokingȱeȱ Yesȱvs.ȱNoȱ ȱe  pȬvalueȱ  Multivariateȱ  0.013ȱ  ȱ 2.17ȱ(1.49ȱ––ȱ3.14)ȱ ȱ 2.04ȱ(0.55ȱ––ȱ7.61)ȱ ȱ 1.69ȱ(1.07ȱ––ȱ2.68)ȱ ȱ 1.52ȱ(0.92ȱ––ȱ2.51)ȱ  ȱ <.001ȱ ȱ 0.288ȱ ȱ 0.025ȱ ȱ 0.100ȱ  SexȱTradeȱ ȱ ȱ ȱ ȱ ȱ 2.18ȱȱ(1.26ȱ––ȱ3.75)ȱ 0.004ȱ Yesȱvs.ȱNoȱ 1.30ȱ(0.72ȱ––ȱ2.38)ȱ 0.386ȱ ȱ ȱ DrugȱDealingȱeȱ ȱ ȱ 2.74ȱȱ(1.87ȱ––ȱ4.01)ȱ <0.001ȱ 1.61ȱ(1.06ȱ––ȱ2.47)ȱ 0.027ȱ Yesȱvs.ȱNoȱ Note:ȱaȱPublicȱareasȱincluded:ȱcityȱstreets,ȱparks,ȱpublicȱwashrooms,ȱparkingȱlots,ȱclubsȱorȱbars,ȱandȱ abandonȱbuildings;ȱbORȱ=ȱOddsȱRatio,ȱȱCIȱ=ȱConfidenceȱInterval;ȱAORȱ=ȱAdjustedȱOddsȱRatio;ȱ eDenotesȱactivitiesȱorȱsituationsȱreferringȱtoȱpreviousȱ6ȱmonths;ȱdȱDenotesȱactivitiesȱorȱsituationsȱ referringȱtoȱpreviousȱmonth.ȱȱ *pȬvalueȱandȱ95%ȱCIȱreportedȱfromȱFisher’’sȱExactȱTestȱasȱ25%ȱofȱcellsȱhadȱexpectedȱcountsȱlessȱthanȱ 5.ȱ eȱ  ȱ      ȱ ȱ ȱ  133  ȱ  Tableȱ7.3ȱCharacteristicsȱofȱcrackȱcocaineȱsmokersȱwhoȱuseȱdrugsȱinȱ publicȱstratifiedȱbyȱwillingnessȱtoȱuseȱaȱsupervisedȱinhalationȱroomȱ (n=382)ȱ ȱ  WillingȱtoȱuseȱSIRȱaȱ  Characteristicȱ  Yesȱn=ȱ271,ȱnȱ(%)ȱ  Noȱn=ȱ111,ȱnȱ(%)ȱ  Ageȱpreȱyearȱolderȱȱ ȱ ȱ c 43ȱ(37Ȭ49)ȱ 44ȱ(37Ȭ48)ȱ (Median,ȱIQR)ȱ ȱ ȱ ȱ FemaleȱGenderȱȱ Yesȱ 117ȱ(43)ȱ 28ȱ(25)ȱ Noȱ 154ȱ(57)ȱ 83ȱ(75)ȱ ȱ ȱ AboriginalȱAncestryȱȱ Yesȱ 108ȱ(40)ȱ 29ȱ(26)ȱ Noȱ 163ȱ(60)ȱ 82ȱ(74)ȱ ȱe ȱ ȱ LimitedȱAccessȱtoȱPrivateȱSpace ȱ Yesȱ 230ȱ(85)ȱ 86ȱ(77)ȱ Noȱ 41ȱ(15)ȱ 25ȱ(23)ȱ ȱe,ȱf ȱ ȱ DrugȱSceneȱExposure ȱ Yesȱ 157ȱ(58)ȱ 49ȱ(44)ȱ Noȱ 114ȱ(42)ȱ 62ȱ(56)ȱ MostȱDrugȱUseȱinȱPublicȱAreasȱeȱ ȱ ȱ Yesȱ 140ȱ(52)ȱ 43ȱ(39)ȱ Noȱ 131ȱ(48)ȱ 68ȱ(61)ȱ ȱe DailyȱCrackȱCocaineȱSmoking ȱ ȱ ȱ Yesȱ 164ȱ(61)ȱ 56ȱ(50)ȱȱȱȱ Noȱ 107ȱ(39)ȱ 55ȱ(50)ȱ ȱe RiskyȱPipeȱSharing ȱ ȱ ȱ Yesȱ 38ȱ(14)ȱ 3ȱ(3)ȱ Noȱ 233ȱ(86)ȱ 108ȱ(97)ȱ EncountersȱwithȱPoliceȱdȱ ȱ ȱ Yesȱ 92ȱ(34)ȱ 22ȱ(20)ȱ Noȱ 179ȱ(66)ȱ 89ȱ(80)ȱ ȱ ȱ VictimȱofȱViolenceȱeȱ Yesȱ 53ȱ(20)ȱ 24ȱ(22)ȱ Noȱ 218ȱ(80)ȱ 87ȱ(78)ȱ cȱ dȱ Note:ȱ IQR=ȱInterȱQuartileȱRange;ȱ Denotesȱactivitiesȱorȱsituationsȱreferringȱ toȱpreviousȱ6ȱmonths;ȱeȱDenotesȱactivitiesȱorȱsituationsȱreferringȱtoȱpreviousȱȱ month;ȱfȱDrugȱsceneȱexposureȱwasȱdefinedȱasȱspendingȱanȱaverageȱofȱ7ȱorȱ moreȱhoursȱonȱtheȱstreetȱeachȱdayȱinȱVancouver’’sȱdrugȱuseȱepicenterȱinȱtheȱ      ȱ  134  ȱ  Tableȱ7.4ȱUnivariateȱandȱmultivariateȱanalysesȱofȱfactorsȱassociatedȱwithȱwillingnessȱ toȱuseȱaȱsupervisedȱinhalationȱroomȱamongȱparticipantsȱthatȱsmokeȱcrackȱcocaineȱandȱ useȱdrugsȱinȱpublicȱlocationsȱaȱȱ(n=382)ȱ ȱ  Univariateȱȱ  ȱȱȱ  ORaȱȱ(95%ȱCI)ȱ  Characteristicȱ OlderȱAgeȱȱ Perȱyearȱolderȱ Genderȱȱ Femaleȱvs.ȱMaleȱ AboriginalȱAncestryȱȱ Yesȱvs.ȱNoȱ LimitedȱAccessȱtoȱPrivateȱSpaceȱeȱ Yesȱvs.ȱNoȱ DrugȱSceneȱExposureȱeȱ Yesȱvs.ȱNoȱ MostȱDrugȱUseȱinȱPublicȱAreasȱ ȱ Yesȱvs.ȱNoȱ e  DailyȱCrackȱCocaineȱSmoking ȱ Yesȱvs.ȱNoȱ ȱe  BingeȱDrugȱUseȱeȱ Yesȱ RiskyȱPipeȱSharing*ȱeȱ Yesȱvs.ȱNoȱ  pȬvalueȱ  ȱ 0.446ȱ ȱ 0.001ȱ  ȱ ȱ ȱ 2.11ȱȱ(1.26ȱ––ȱ3.55)ȱ  ȱ ȱ ȱ 0.005ȱ  ȱ 1.87ȱȱ(1.15ȱ––ȱ3.05)ȱ  ȱ 0.011ȱ  ȱ 1.61ȱȱ(0.96ȱ––ȱ2.72)ȱ  ȱ 0.072ȱ  ȱ  ȱ  ȱ  ȱ  1.63ȱȱ(0.94ȱ––ȱ2.84)ȱ  0.083ȱ  ȱ  ȱ  ȱ 1.74ȱ(1.12ȱ––ȱ2.72)ȱ  ȱ 0.014ȱ  ȱ  ȱ  ȱ  ȱ  1.69ȱȱ(1.08ȱ––ȱ2.65)ȱ ȱ  0.022ȱ  1.40ȱ(0.86ȱ––ȱ2.28)ȱ  0.181ȱ  ȱ  ȱ  1.39ȱȱ(0.85ȱ––ȱ2.28)ȱ  0.187ȱ  ȱ  ȱ  ȱ  0.071ȱ  ȱ  ȱ  ȱ  ȱ  ȱ  ȱ  ȱ  ȱ  ȱ  ȱ  ȱ  ȱ  ȱ  ȱ  1.51ȱȱ(0.96ȱ––ȱ2.35)ȱ  ȱ 2.08ȱȱ(1.22ȱ––ȱ3.53)ȱ ȱ  VictimȱofȱViolence ȱ Yesȱvs.ȱNoȱ ȱe  AORbȱ(95%ȱCI)ȱ  pȬvalueȱ  ȱ 1.01ȱȱ(0.98ȱ––ȱ1.04)ȱ ȱ 2.25ȱȱ(1.38ȱ––ȱ3.68)ȱ  5.87ȱ(1.79ȱ––ȱ30.29)ȱ  EncountersȱwithȱPoliceȱdȱ Yesȱvs.ȱNoȱ  Multivariateȱ  0.88ȱȱ(0.51ȱ––ȱ1.52)ȱ  <ȱ0.001ȱ  5.50ȱ(1.63ȱ––ȱ18.56)ȱ  0.006ȱ  ȱ  ȱ 2.09ȱȱ(1.20ȱ––ȱ3.65)ȱ  ȱ 0.010ȱ  0.006ȱ ȱ  ȱ  0.648ȱ  ȱ  ȱ ȱ  Note:ȱ ORȱ=ȱOddsȱRatio, ȱCIȱ=ȱConfidenceȱInterval;ȱ AORȱ=ȱAdjustedȱOddsȱRatio; Denotesȱactivitiesȱ orȱsituationsȱreferringȱtoȱpreviousȱ6ȱmonths;ȱdȱDenotesȱactivitiesȱorȱsituationsȱreferringȱtoȱpreviousȱ month.ȱ*pȬvalueȱandȱ95%ȱCIȱreportedȱfromȱFisher’’sȱExactȱTestȱasȱ25%ȱofȱcellsȱhadȱexpectedȱcountsȱ lessȱthanȱ5.ȱ a  ȱ  b  ȱe  ȱ ȱ ȱ ȱ ȱ ȱ ȱȱ  ȱ  135  ȱ  CHAPTER 8: ȱ CONCLUSIONSȱ  8.1 Summaryȱofȱfindingsȱ ThisȱthesisȱbeganȱwithȱanȱoverviewȱofȱtheȱproblemsȱassociatedȱwithȱdrugȬrelatedȱ streetȱ disorderȱ andȱ aȱ reviewȱ ofȱ literatureȱ onȱ theȱ impactsȱ ofȱ currentȱ policyȬapproachesȱ thatȱ haveȱ beenȱ implementedȱ toȱ addressȱ thisȱ issue.ȱ Theȱ resultsȱ ofȱ theȱ literatureȱ reviewȱ suggestȱ thatȱ lawȱ enforcementȱ basedȱ approachesȱ whichȱ aimȱ toȱ addressȱ streetȱ disorderȱ areȱ associatedȱ withȱ manyȱ unintendedȱ harmfulȱ consequencesȱ andȱ areȱ limitedȱ inȱ theirȱ effectivenessȱtoȱsustainablyȱreduceȱstreetȱdisorder.ȱTheȱreviewȱalsoȱsuggestedȱthatȱthereȱ areȱ aȱ numberȱ ofȱ interventionsȱ withȱ promisingȱ signsȱ ofȱ effectivenessȱ inȱ reducingȱ engagementȱ inȱ drugȬrelatedȱ streetȱ disorder.ȱ Theseȱ includeȱ lowȬthresholdȱ employmentȱ programs,ȱsupervisedȱinjectionȱfacilitiesȱandȱaddictionȱtreatmentȱprograms.ȱInȱaddition,ȱ theȱ reviewȱ highlightedȱ promisingȱ underexploredȱ interventionsȱ suchȱ asȱ lowȬthresholdȱ supportiveȱhousingȱandȱsupervisedȱinhalationȱfacilitiesȱforȱpeopleȱwhoȱsmokeȱdrugs.ȱItȱ concludedȱ thatȱ furtherȱ researchȱ shouldȱ beȱ directedȱ towardsȱ identifyingȱ innovativeȱ interventionsȱ toȱ addressȱ streetȱ disorderȱ asȱ wellȱ asȱ assessingȱ theȱ impactȱ thatȱ underexploredȱpublicȱ healthȱbasedȱinterventionsȱmightȱ haveȱonȱreducingȱengagementȱ inȱstreetȱdisorder.ȱ Theȱ centralȱ aimsȱ ofȱ thisȱ thesisȱ wereȱ toȱ identifyȱ factorsȱ thatȱ contributeȱ toȱ drugȬ relatedȱ streetȱ disorder,ȱ exploreȱ theȱ impactsȱ ofȱ drugȬrelatedȱ streetȱ disorderȱ andȱ assessȱ ȱ  136  ȱ  potentialȱ policyȱ responsesȱ toȱ thisȱ problem.ȱ Theȱ firstȱ dataȬdrivenȱ chapter,ȱ Chapterȱ 3,ȱ describedȱtheȱhealthȱandȱsocialȱimpactsȱofȱexposureȱtoȱdrugȬrelatedȱstreetȱdisorderȱandȱ assessedȱwhetherȱexposureȱposedȱpublicȱhealthȱrisks.ȱItȱfoundȱthatȱdrugȱsceneȱexposureȱ wasȱ associatedȱ inȱ aȱ doseȬdependentȱ fashionȱ withȱ multipleȱ markersȱ ofȱ vulnerabilityȱ toȱ harmȱandȱadverseȱhealthȱoutcomes,ȱincludingȱbeingȱunstablyȱhoused,ȱbeingȱaȱvictimȱofȱ violence,ȱhavingȱencountersȱwithȱpoliceȱandȱparticipatingȱinȱdrugȱdealing.ȱDrugȱsceneȱ exposureȱ wasȱ alsoȱ associatedȱ withȱ higherȬintensityȱ drugȱ use,ȱ specifically,ȱ greaterȱ likelihoodȱ ofȱ injectingȱ cocaineȱ andȱ heroinȱ onȱ aȱ dailyȱ basisȱ andȱ smokingȱ crackȱ cocaineȱ daily.ȱ Theȱ analysisȱ furtherȱ foundȱ thatȱ employmentȱ andȱ addictionȱ treatmentȱ wereȱ associatedȱ withȱ decreasedȱ drugȱ sceneȱ exposure.ȱ Theseȱ findingsȱ supportedȱ theȱ explorationȱofȱpolicyȱinterventionsȱinȱtheȱareasȱofȱhousingȱandȱemployment.ȱ Toȱ provideȱ aȱ basisȱ forȱ exploringȱ theȱ potentialȱ impactsȱ ofȱ differentȱ policyȱ interventionsȱ toȱ addressȱ drugȬrelatedȱ streetȱ disorder,ȱ Chapterȱ 4ȱ soughtȱ toȱ assessȱ whetherȱ willingnessȱ measuresȱ couldȱ beȱ effectiveȱ toolsȱ forȱ planningȱ publicȱ healthȱ interventionsȱ forȱ injectionȱ drugȱ userȱ populations.ȱ Afterȱ comparingȱ priorȱ measuresȱ forȱ willingnessȱ toȱ useȱ aȱ supervisedȱ injectionȱ facilityȱ withȱ laterȱ attendanceȱ atȱ theȱ facilityȱ onceȱ itȱ wasȱ established,ȱ thisȱ analysisȱ foundȱ thatȱ initialȱ willingnessȱ toȱ useȱ aȱ SIFȱ wasȱ independentlyȱ associatedȱ withȱ subsequentȱ attendanceȱ atȱ Vancouver’’sȱ SIF,ȱ evenȱ afterȱ adjustingȱforȱotherȱdeterminantsȱofȱwillingness.ȱThisȱsuggestsȱthatȱwillingnessȱmeasuresȱ areȱ reasonablyȱ validȱ toolsȱ forȱ predictingȱ engagementȱ withȱ publicȱ healthȱ programsȱ amongȱlocalȱIDU.ȱȱ ȱ  137  ȱ  Afterȱ establishingȱ thatȱ willingnessȱ measuresȱ wereȱ appropriateȱ toolsȱ toȱ assessȱ aȱ population’’sȱ potentialȱ engagementȱ withȱ specificȱ publicȱ healthȱ interventions,ȱ theȱ relationshipȱbetweenȱaccessȱtoȱprivateȱspaceȱandȱtimeȱspentȱsocializingȱinȱtheȱopenȱdrugȱ sceneȱ wasȱ thenȱ examined.ȱ Thisȱ wasȱ theȱ firstȱ analysisȱ toȱ considerȱ whetherȱ aȱ particularȱ interventionȱ (increasingȱ accessȱ toȱ privateȱ space)ȱ mightȱ haveȱ anȱ influenceȱ onȱ streetȱ disorder.ȱItȱalsoȱsoughtȱtoȱidentifyȱfactorsȱthatȱmightȱcontributeȱtoȱstreetȱdisorder.ȱThisȱ studyȱ foundȱ thatȱ havingȱ limitedȱ privateȱ spaceȱ wasȱ significantlyȱ associatedȱ withȱ spendingȱanȱaverageȱofȱthreeȱorȱmoreȱhoursȱperȱdayȱsocializingȱinȱtheȱopenȱdrugȱsceneȱ amongȱ localȱ IDU.ȱ Thisȱ associationȱ persistedȱ afterȱ adjustmentȱ forȱ aȱ rangeȱ ofȱ potentialȱ confoundingȱ factors,ȱ suggestingȱ thatȱ limitedȱ accessȱ toȱ privateȱ spaceȱ mayȱ beȱ contributingȱ toȱ oneȱ aspectȱ ofȱ drugȬrelatedȱ streetȱ disorder.ȱ ȱ Theȱ majority,ȱ 65%ȱ ofȱ thoseȱ whoȱ hadȱ limitedȱ accessȱ toȱ privateȱ spaceȱ andȱ spendȱ significantȱ timeȱ socializingȱ inȱ theȱ openȱdrugȱ scene,ȱreportedȱthatȱtheyȱwouldȱ beȱwillingȱ toȱ relocateȱawayȱfromȱ theȱopenȱ drugȱsceneȱifȱtheyȱwereȱprovidedȱwithȱprivateȱspaceȱforȱsocializing.ȱWhenȱcomparedȱtoȱ IDUȱwhoȱlivedȱinȱstableȱhousing,ȱstudyȱparticipantsȱwhoȱlivedȱinȱSROs,ȱsheltersȱorȱhadȱ noȱfixedȱaddressȱwereȱsignificantlyȱmoreȱlikelyȱtoȱsocializeȱinȱtheȱopenȱdrugȱsceneȱandȱ wereȱsignificantlyȱmoreȱlikelyȱtoȱbeȱwillingȱtoȱrelocate.ȱȱ Followingȱ theȱ analysisȱ ofȱ willingnessȱ toȱ relocateȱ socializing,ȱ theȱ nextȱ areaȱ ofȱ studyȱassessedȱengagementȱinȱstreetȬbasedȱdisorderlyȱincomeȱgenerationȱactivitiesȱandȱ examinedȱtheȱrelationshipȱbetweenȱprovidingȱlowȬthresholdȱemploymentȱopportunitiesȱ andȱengagingȱinȱdisorderlyȱincomeȱgenerationȱactivities.ȱThisȱstudyȱfoundȱthatȱ48%ȱofȱ ȱ  138  ȱ  localȱ IDUȱ reportedȱ engagingȱ inȱ aȱ disorderlyȱ incomeȱ generationȱ activityȱ inȱ theȱ lastȱ sixȱ months.ȱTheȱmostȱcommonȱactivitiesȱreportedȱwereȱdrugȱdealingȱandȱrecyclingȱ(whichȱ includedȱsalvagingȱandȱunsanctionedȱstreetȱvending).ȱInȱaȱmultivariateȱanalysisȱpeopleȱ whoȱ reportedȱ engagingȱ inȱ disorderlyȱ incomeȱ generationȱ activitiesȱ wereȱ moreȱ likelyȱ toȱ smokeȱcrackȱcocaineȱonȱaȱdailyȱbasisȱandȱinjectȱcocaineȱonȱaȱdailyȱbasis.ȱThisȱpopulationȱ wasȱ alsoȱ moreȱ likelyȱ toȱ engageȱ inȱ bingeȱ drugȱ use,ȱ haveȱ encountersȱ withȱ police,ȱ beȱ aȱ victimȱ ofȱ violence,ȱ shareȱ usedȱ syringesȱ andȱ injectȱ drugsȱ inȱ publicȱ areas.ȱ Conversely,ȱ individualsȱ withȱ regularȱ employmentȱ wereȱ significantlyȱ lessȱ likelyȱ toȱ reportȱ engagingȱ inȱdisorderlyȱincomeȱgenerationȱactivities.ȱTheȱstudyȱalsoȱfoundȱthatȱamongȱindividualsȱ whoȱengagedȱinȱdisorderlyȱincomeȱgenerationȱactivities,ȱ47%ȱreportedȱthatȱtheyȱwouldȱ beȱ willingȱ toȱ stopȱ engagingȱ inȱ theseȱ activitiesȱ ifȱ theyȱwereȱ offeredȱ otherȱ opportunitiesȱ forȱ lowȬthresholdȱ employment.ȱ Individualsȱ engagedȱ inȱ sexȱ work,ȱ drugȱ dealing,ȱ bingeȱ drugȱ use,ȱ orȱ whoȱ wereȱ recentlyȱ incarceratedȱ wereȱ mostȱ interestedȱ inȱ ceasingȱ theirȱ engagementȱinȱdisorderlyȱincomeȱgenerationȱactivities.ȱȱ Theȱnextȱandȱfinalȱanalysisȱsoughtȱtoȱcharacterizeȱpublicȱcrackȱcocaineȱsmokingȱ andȱ assessȱ whetherȱ aȱ supervisedȱ inhalationȱ facilityȱ hadȱ potentialȱ toȱ addressȱ streetȱ disorderȱ byȱ reducingȱ theȱ prevalenceȱ ofȱ thisȱ behaviour.ȱ Itȱ foundȱ thatȱ theȱ majorityȱ ofȱ crackȱcocaineȱsmokersȱreportedȱhavingȱsmokedȱdrugsȱinȱpublicȱareasȱatȱsomeȱpointȱinȱ theȱlastȱsixȱmonths.ȱThisȱgroupȱwasȱmoreȱlikelyȱtoȱincludeȱhigherȱintensityȱdrugȱusersȱ withȱ respectȱ toȱ heroinȱ injectionȱ andȱ crackȱ cocaineȱ smoking,ȱ haveȱ encountersȱ withȱ theȱ policeȱandȱbeȱinvolvedȱinȱdrugȱdealing.ȱAmongȱtheseȱpublicȱcrackȱcocaineȱsmokers,ȱ71%ȱ ȱ  139  ȱ  reportedȱ beingȱ willingȱ toȱ useȱ aȱ supervisedȱ inhalationȱ roomȱ ifȱ oneȱ wasȱ available.ȱ Individualsȱwhoȱreportedȱbeingȱwillingȱwereȱmoreȱlikelyȱtoȱbeȱfemale,ȱengageȱinȱriskyȱ pipeȱsharingȱandȱhaveȱencountersȱwithȱtheȱpolice.ȱ  8.2 UniqueȱContributionsȱȱ Thisȱ thesisȱ makesȱ aȱ numberȱ ofȱ uniqueȱ contributionsȱ thatȱ haveȱ implicationsȱ forȱ framingȱ andȱ respondingȱ toȱ drugȬrelatedȱ streetȱ disorder.ȱ Theȱ literatureȱ reviewȱ ofȱ theȱ impactsȱofȱpolicyȱresponsesȱtoȱaddressȱdrugȬrelatedȱstreetȱdisorderȱisȱtheȱfirstȱofȱitsȱkindȱ toȱ summarizeȱ theȱ impactsȱ ofȱ policiesȱ inȱ thisȱ area.ȱ Byȱ identifyingȱ theȱ lackȱ ofȱ scientificȱ evidenceȱ inȱ supportȱ ofȱ currentȱ approachesȱ toȱ drugȬrelatedȱ streetȱ disorder,ȱ thisȱ reviewȱ underscoresȱtheȱneedȱtoȱidentifyȱalternativeȱpolicyȱinterventionsȱandȱguidedȱtheȱcurrentȱ thesisȱstudies.ȱȱȱȱȱ Anotherȱuniqueȱcontributionȱofȱthisȱthesisȱisȱtheȱdemonstrationȱthatȱexposureȱtoȱ drugȬrelatedȱ streetȱ disorderȱ isȱ associatedȱ inȱ aȱ doseȬdependentȱ fashionȱ withȱ higherȬ intensityȱaddictionȱandȱmarkersȱofȱvulnerabilityȱtoȱadverseȱhealthȱoutcomes.ȱAlthoughȱ previousȱ studiesȱ haveȱ assessedȱ harmsȱ associatedȱ withȱ activitiesȱ thatȱ generateȱ streetȱ disorder,4,ȱ7,ȱ10,ȱ57,ȱ61ȱthisȱisȱtheȱfirstȱtoȱsuggestȱthatȱexposureȱindependentȱofȱengagementȱinȱ specificȱactivitiesȱisȱaȱsourceȱofȱharmȱforȱstreetȬbasedȱdrugȱusers.ȱTheseȱfindingȱprovideȱ evidenceȱthatȱdrugȬrelatedȱstreetȱdisorderȱisȱnotȱjustȱaȱpublicȱorderȱconcernȱbutȱshouldȱ beȱconsideredȱaȱpublicȱhealthȱthreatȱandȱaddressedȱasȱsuch.ȱȱȱ  ȱ  140  ȱ  Theȱ thirdȱ uniqueȱ contributionȱ ofȱ thisȱ thesisȱ isȱ theȱ findingȱ thatȱ willingnessȱ measuresȱ areȱ reasonablyȱ goodȱ toolsȱ forȱ predictingȱ engagementȱ withȱ publicȱ healthȱ interventionsȱ amongȱ localȱ IDUȱ populations.ȱ Despiteȱ theȱ commonȱ useȱ ofȱ willingnessȱ measuresȱ toȱ assessȱ theȱ feasibilityȱ ofȱ publicȱ healthȱ interventionsȱ amongȱ drugȱ usingȱ populations,193,ȱ 222,ȱ 225Ȭ230ȱ itȱ appearsȱ thatȱ noȱ studyȱ hasȱ assessedȱ whetherȱ theyȱ areȱ validȱ measurementȱ tools.ȱ Thisȱ studyȱ makesȱ aȱ criticalȱ contributionȱ toȱ theȱ overallȱ thesisȱ asȱ itȱ providesȱ aȱ justificationȱ forȱ theȱ useȱ ofȱ willingnessȱ measuresȱ toȱ exploreȱ potentialȱ interventionsȱtoȱaddressȱdrugȬrelatedȱstreetȱdisorder.ȱȱ Whenȱtakenȱtogether,ȱtheȱstudiesȱinȱthisȱthesisȱrepresentȱaȱuniqueȱexplorationȱofȱ theȱ factorsȱ thatȱ contributeȱ toȱ drugȬrelatedȱ streetȱ disorder,ȱ dangersȱ associatedȱ withȱ theȱ phenomenonȱandȱpotentialȱpolicyȱresponses.ȱByȱprovidingȱanȱ inȬdepthȱunderstandingȱ ofȱ theȱ experiencesȱ ofȱ streetȬinvolvedȱ drugȱ usersȱ andȱ tailoringȱ potentialȱ policyȱ interventionsȱtoȱconsiderȱandȱaddressȱtheȱmotivationsȱandȱcurrentȱcircumstancesȱofȱthisȱ population,ȱ theȱ policyȱ developmentȱ approachȱ inȱ thisȱ thesisȱ isȱ distinctȱ andȱ somethingȱ that,ȱtoȱdate,ȱhasȱnotȱbeenȱwidelyȱemployed.ȱȱMoreȱspecifically,ȱthisȱthesisȱisȱtheȱfirstȱofȱ itsȱkindȱtoȱconsiderȱandȱfindȱanȱassociationȱbetweenȱlimitedȱaccessȱtoȱprivateȱspaceȱandȱ socializingȱinȱtheȱopenȱdrugȱscene,ȱandȱitȱisȱalsoȱtheȱfirstȱstudyȱtoȱdemonstrateȱthatȱthereȱ isȱ aȱ highȱ levelȱ ofȱ willingnessȱ amongȱ localȱ IDUȱ toȱ relocateȱ toȱ indoorȱ locationsȱ ifȱ theyȱ wereȱ givenȱ accessȱ toȱ moreȱ privateȱ indoorȱ space.ȱ Increasingȱ assessȱ toȱ privateȱ indoorȱ spaceȱ throughȱ theȱ provisionȱ ofȱ lowȬthresholdȱ supportiveȱ housingȱ withȱ safeguardsȱ toȱ  ȱ  141  ȱ  manageȱbehavioursȱassociatedȱ withȱactiveȱdrugȱ useȱisȱ aȱnovelȱapproachȱtoȱpotentiallyȱ reduceȱengagementȱinȱactivitiesȱthatȱgenerateȱstreetȱdisorder.ȱȱ Similarly,ȱthisȱthesisȱmakesȱaȱuniqueȱcontributionȱbyȱassessingȱdemandȱforȱlowȬ thresholdȱ employmentȱ asȱ aȱ meansȱ toȱ reduceȱ engagementȱ inȱ streetȬbasedȱ disorderlyȱ incomeȱ generationȱ activities.ȱ Givenȱ thatȱ roughlyȱ halfȱ ofȱ theȱ sampleȱ whoȱ engagedȱ inȱ disorderlyȱ incomeȱ generationȱ wereȱ willingȱ toȱ ceaseȱ ifȱ givenȱ otherȱ incomeȱ generationȱ opportunities,ȱ thisȱ workȱ demonstratesȱ thatȱ thereȱ isȱ considerableȱ demandȱ forȱ lowȬ thresholdȱ employmentȱ andȱ increasingȱ theseȱ opportunitiesȱ hasȱ potentialȱ toȱ reduceȱ engagementȱinȱdrugȬrelatedȱstreetȱdisorder.ȱȱ Lastly,ȱthisȱthesisȱisȱtheȱfirstȱknownȱstudyȱtoȱexamineȱtheȱspecificȱrisksȱassociatedȱ withȱ smokingȱ crackȱ cocaineȱ inȱ publicȱ areasȱ andȱ toȱ assessȱ willingnessȱ toȱ useȱ anȱ inhalationȱfacilityȱamongȱpublicȱcrackȱcocaineȱsmokersȱexclusively.ȱNotably,ȱoneȱofȱtheȱ commonȱ featuresȱ thisȱ studyȱ identifiedȱ amongȱ bothȱ publicȱ crackȱ cocaineȱ smokersȱ andȱ thoseȱ whoȱ wereȱ willingȱ toȱ useȱ aȱ supervisedȱ inhalationȱ facilityȱ wasȱ theirȱ elevatedȱ likelihoodȱ ofȱ recentlyȱ havingȱ encountersȱ withȱ lawȱ enforcement.ȱ Thisȱ findingȱ indicatesȱ thatȱ aȱ supervisedȱ inhalationȱ facilityȱ mayȱ beȱ anȱ importantȱ toolȱ forȱ policeȱ inȱ theȱ managementȱofȱstreetȱdisorder.ȱȱȱ  8.3 RecommendationsȱandȱImplicationsȱ Theȱ findingsȱ ofȱ thisȱ thesisȱ highlightȱ thatȱ social,ȱ structuralȱ andȱ environmentalȱ factorsȱplayȱaȱcentralȱroleȱinȱshapingȱtheȱbehaviourȱofȱpeopleȱwhoȱuseȱillicitȱdrugsȱandȱ ȱ  142  ȱ  areȱpotentiallyȱcriticalȱleversȱforȱpolicyȱinterventions.ȱThisȱreinforcesȱtheȱviewȱthatȱstreetȱ disorderȱ shouldȱ beȱ seenȱ inȱ theȱ contextȱ ofȱ currentȱ political,ȱ economicȱ andȱ socialȱ conditionsȱ andȱ shouldȱ notȱ beȱ solelyȱ constructedȱ asȱ theȱ productȱ ofȱ theȱ individualȱ behaviourȱ ofȱ streetȬinvolvedȱ people.ȱ Currentȱ policyȱ approachesȱ thatȱ placeȱ primaryȱ responsibilityȱonȱindividualȬlevelȱfactorsȱwithoutȱconsideringȱtheȱinfluenceȱthatȱsocial,ȱ structuralȱandȱenvironmentalȱfactorsȱhaveȱinȱgeneratingȱstreetȱdisorderȱwillȱcontinueȱtoȱ beȱ inadequateȱ responsesȱ thatȱ failȱ toȱ meetȱ theirȱ policyȱ objectivesȱ andȱ willȱ continueȱ toȱ simultaneouslyȱundermineȱtheȱhealthȱofȱvulnerableȱpopulations.ȱConversely,ȱthisȱthesisȱ contributesȱtoȱaȱgrowingȱbodyȱofȱresearchȱwhichȱindicatesȱthatȱinterventionsȱthatȱalterȱ theȱ structureȱ ofȱ streetȬbasedȱ drugȱ scenesȱ haveȱ concreteȱ potentialȱ toȱ reduceȱ riskȱ behaviours.ȱThisȱhasȱbothȱmicroȱandȱmacroȱlevelȱimplications.ȱ  8.3.1 MicroȱLevelȱRecommendationsȱandȱImplicationsȱ Theȱ studiesȱ presentedȱ inȱ thisȱ thesisȱ illustrateȱ thatȱ structuralȱ factors,ȱ includingȱ havingȱ limitedȱ accessȱ toȱ privateȱ spaceȱ andȱ aȱ lackȱ ofȱ incomeȱ generationȱ opportunities,ȱ areȱ closelyȱ connectedȱ withȱ streetȱ disorder.ȱ Byȱ addressingȱ aspectsȱ ofȱ theseȱ structuralȱ conditions,ȱ thisȱ thesisȱ hasȱ identifiedȱ threeȱ interventionsȱ thatȱ haveȱ potentialȱ toȱ successfullyȱ engageȱ aȱ largeȱ proportionȱ ofȱ streetȬbasedȱ drugȱ usersȱ andȱ createȱ environmentsȱthatȱenableȱthemȱtoȱreduceȱtheirȱengagementȱinȱbehavioursȱthatȱgenerateȱ drugȬrelatedȱ streetȱ disorder.ȱ Specifically,ȱ studyȱ findingsȱ provideȱ compellingȱ evidenceȱ thatȱinvestingȱin:ȱa)ȱlowȬthresholdȱsupportiveȱhousing,ȱb)ȱtheȱcreationȱofȱlowȬthresholdȱ employmentȱopportunities,ȱandȱc)ȱtheȱestablishmentȱofȱmedicallyȱsupervisedȱinhalationȱ ȱ  143  ȱ  facilitiesȱcanȱinfluenceȱtheȱstructureȱofȱstreetȬbasedȱdrugȱscenesȱandȱsupportȱindividualsȱ toȱ modifyȱ theirȱ behaviourȱ inȱ waysȱ thatȱ reduceȱ engagementȱ inȱ streetȱ disorder.ȱ Supportingȱ andȱ pursuingȱ theseȱ policyȱ interventionsȱ representsȱ aȱ significantȱ paradigmȱ changeȱ forȱ policyȬmakersȱ inȱ thisȱ areaȱ asȱ itȱ involvesȱ movingȱ awayȱ fromȱ punitiveȱ lawȱ enforcementȱ basedȱ approachesȱ thatȱ attributeȱ chiefȱ responsibilityȱ forȱ streetȱ disorderȱ toȱ individuals.ȱ Itȱisȱimportantȱtoȱnoteȱthatȱtheȱbenefitsȱofȱtheȱinterventionsȱexploredȱinȱthisȱthesisȱ areȱnotȱrestrictedȱtoȱtheȱsimpleȱreductionȱofȱdrugȬrelatedȱstreetȱdisorderȱbutȱalsoȱincludeȱ importantȱhealthȱbenefitsȱforȱvulnerableȱdrugȱuserȱpopulations.ȱThereȱisȱaȱvastȱscientificȱ literatureȱdocumentingȱtheȱmanyȱadvantagesȱthatȱsupportiveȱhousingȱoffersȱvulnerableȱ populations.251,ȱ 252,ȱ 254,ȱ 261,ȱ 262ȱEmploymentȱisȱsimilarlyȱlinkedȱwithȱaȱbroadȱrangeȱofȱsocialȱ andȱ healthȱ benefits,170,ȱ  172,ȱ 173  ȱ andȱ theȱ opportunitiesȱ supervisedȱ drugȱ consumptionȱ  facilitiesȱ createȱ forȱ healthȱ careȱ providersȱ toȱ engageȱ withȱ highȱ riskȱ drugȱ usingȱ populationsȱandȱlinkȱthemȱwithȱhealthȱandȱsocialȱservicesȱareȱalsoȱwellȱdocumented.21ȱ Basedȱonȱtheȱfindingsȱofȱthisȱthesisȱandȱexistingȱpublicȱhealthȱresearch,ȱitȱisȱevidentȱthatȱ theȱ foundationȱ ofȱ ourȱ approachȱ toȱ drugȬrelatedȱ streetȱ disorderȱ shouldȱ involveȱ implementingȱ interventionsȱ thatȱ bothȱ promoteȱ publicȱ healthȱ objectivesȱ andȱ supportȱ aȱ reductionȱ inȱ drugȬrelatedȱ streetȱ disorderȱ byȱ alteringȱ structuralȱ factorsȱ thatȱ shapeȱ theȱ behaviourȱofȱstreetȬbasedȱdrugȱusers.ȱȱ  ȱ  144  ȱ  8.3.2 MacroȱLevelȱRecommendationsȱandȱImplicationsȱ Atȱ theȱ macroȱ level,ȱ thisȱ thesisȱ isȱ consistentȱ withȱ theȱ growingȱ recognitionȱ ofȱ theȱ needȱforȱaȱparadigmȱshiftȱinȱallȱareasȱofȱillicitȱdrugȱpolicy.292Ȭ296ȱTheȱevidenceȱlinkingȱtheȱ criminalizationȱ ofȱ illicitȱ drugȱ usersȱ withȱ theȱ HIVȱ epidemicȱ andȱ aȱ wideȱ rangeȱ ofȱ otherȱ devastatingȱhealthȱandȱsocialȱharmsȱisȱnowȱexpansive.71,ȱ113,ȱ292,ȱ296,ȱ297ȱRecognizingȱthatȱlawȱ enforcementȱapproachesȱhaveȱfailedȱtoȱcontrolȱproblematicȱdrugȱuseȱandȱareȱcurrentlyȱ resultingȱinȱsubstantialȱharms,ȱleadingȱscientistsȱinȱtheȱareasȱofȱpublicȱhealthȱandȱpublicȱ policyȱ haveȱ comeȱ togetherȱ andȱ formedȱ aȱ consensusȱ statementȱ onȱ theȱ needȱ toȱ moveȱ awayȱfromȱtheȱcriminalizationȱofȱillicitȱdrugȱusers.293ȱThisȱpositionȱisȱarticulatedȱinȱtheȱ ViennaȱDeclaration,ȱwhichȱwasȱtheȱofficialȱdeclarationȱofȱtheȱInternationalȱAIDSȱSocietyȱ Conferenceȱ inȱ 2010,ȱ andȱ supportsȱ aȱ policyȱ refocusȱ towardsȱ theȱ adoptionȱ ofȱ scienceȬ basedȱdrugȱpoliciesȱthatȱdoȱnotȱundermineȱpublicȱhealth.298ȱThisȱpolicyȱreorientationȱisȱ analogousȱ toȱ whatȱ willȱ beȱ requiredȱ toȱ successfullyȱ respondȱ toȱ drugȬrelatedȱ streetȱ disorder.ȱȱ Aȱ policyȱ reorientationȱ towardsȱ evidenceȬbasedȱ interventions,ȱ whetherȱ itȱ beȱ specificȱ toȱ drugȬrelatedȱ streetȱ disorderȱ orȱ drugȱ policyȱ moreȱ generally,ȱ willȱ requireȱ extensiveȱpolicyȱmonitoringȱandȱevaluationȱandȱsignificantȱchangesȱinȱtheȱallocationȱofȱ drugȱ policyȱ funding.ȱ Drugȱ policyȱ fundingȱ mustȱ beȱ directedȱ towardsȱ evidenceȬbasedȱ policiesȱwhileȱinterventionsȱthatȱhaveȱbeenȱshownȱtoȱbeȱharmfulȱandȱineffectiveȱshouldȱ noȱlongerȱreceiveȱpublicȱsupport.ȱȱMoreȱspecifically,ȱconsiderationȱmustȱbeȱgivenȱtoȱtheȱ individual,ȱ communityȱ andȱ globalȬlevelȱ impactsȱ ofȱ policyȱ interventions,ȱ andȱ theȱ ȱ  145  ȱ  potentialȱ harmsȱ andȱ unintendedȱ consequencesȱ ofȱ policyȱ decisionsȱ mustȱ beȱ integratedȱ intoȱ theȱ evaluationȱ ofȱ policiesȱ andȱ centralȱ inȱ fundingȱ allocationȱ decisions.ȱ Makingȱ publicȱ healthȱ aȱ cornerstoneȱ ofȱ drugȱ policyȱ developmentȱ andȱ evaluationȱ mayȱ helpȱ toȱ ensureȱthatȱseriousȱnegativeȱpublicȱhealthȱimpactsȱareȱnotȱoverlooked.ȱȱ  8.4 FutureȱResearchȱ Theȱ managementȱ ofȱ drugȬrelatedȱ streetȱ disorderȱ willȱ benefitȱ fromȱ furtherȱ researchȱ inȱ aȱ numberȱ ofȱ areas.ȱ Firstly,ȱ althoughȱ thisȱ thesisȱ providesȱ compellingȱ evidenceȱtoȱpursueȱthreeȱtypesȱofȱpolicyȱinterventions,ȱestablishingȱanȱevidenceȬbaseȱforȱ otherȱ underexploredȱ innovativeȱ interventionsȱ thatȱ meetȱ bothȱ publicȱ healthȱ andȱ publicȱ orderȱ objectivesȱ wouldȱ beȱ beneficial.ȱ Theȱ riskȱ environmentȱ frameworkȱ suggestsȱ thatȱ thereȱareȱpolicyȱleversȱinȱtheȱphysical,ȱsocial,ȱeconomicȱandȱpolicyȱenvironmentsȱatȱbothȱ theȱmicroȱandȱmacroȱlevel.ȱIdentifyingȱandȱevaluatingȱtheȱimpactȱofȱinterventionsȱinȱallȱ theseȱ areasȱ onȱ drugȬrelatedȱ streetȱ disorderȱ wouldȱ increaseȱ theȱ potentialȱ policyȱ toolsȱ availableȱ toȱ respondȱ toȱ streetȱ disorderȱ andȱ improveȱ outcomesȱ inȱ thisȱ area.ȱ Atȱ theȱ physicalȱ microȬenvironmentalȱ level,ȱ randomizedȱ controlȱ trialsȱ offerȱ importantȱ opportunitiesȱ toȱ evaluateȱ theȱ impactsȱ ofȱ novelȱ housingȱ interventions,ȱ asȱ doȱ observationalȱ studiesȱ ofȱ theȱ impactȱ ofȱ supervisedȱ drugȱ consumptionȱ facilitiesȱ onȱ aȱ rangeȱ ofȱ outcomes,ȱ includingȱ drugȬrelatedȱ streetȱ disorder.ȱ Atȱ theȱ socialȱ microȬ environmentalȱlevelȱthereȱareȱopportunitiesȱtoȱimplementȱandȱevaluateȱtheȱpotentialȱforȱ peerȬbasedȱ interventionsȱ toȱ supportȱ reductionsȱ inȱ engagementȱ inȱ drugȬrelatedȱ streetȱ  ȱ  146  ȱ  disorder.ȱ Creatingȱ trainingȱ programsȱ forȱ policeȱ toȱ educateȱ themȱ aboutȱ theȱ harmfulȱ impactsȱ associatedȱ withȱ lawȱ enforcementȱ basedȱ approachesȱ isȱ anotherȱ typeȱ ofȱ socialȱ microȬenvironmentalȱ interventionȱ thatȱ mightȱ haveȱ anȱ impactȱ onȱ drugȬrelatedȱ streetȱ disorderȱ andȱ shouldȱ beȱ theȱ subjectȱ ofȱ furtherȱ processȱ andȱ outcomeȱ evaluation.ȱ Atȱ theȱ macroȱlevel,ȱsocialȱinterventionsȱthatȱwarrantȱexplorationȱincludeȱusingȱtheȱmediaȱandȱ socialȱ marketingȱ toȱ educateȱ theȱ publicȱ aboutȱ factorsȱ thatȱ contributeȱ toȱ drugȬrelatedȱ streetȱdisorderȱandȱtheȱimportanceȱofȱimplementedȱresponsesȱthatȱaddressȱbothȱpublicȱ healthȱandȱpublicȱorderȱobjectives.ȱȱ Furtherȱstudiesȱcouldȱalsoȱbeȱconductedȱtoȱevaluateȱtheȱpotentialȱforȱpolicyȱlevelȱ macroȬenvironmentalȱ interventionsȱ toȱ addressȱ drugȬrelatedȱ streetȱ disorder.ȱ Inȱ particular,ȱ studyingȱ howȱ reformingȱ lawsȱ andȱ policiesȱ thatȱ governȱ drugȱ useȱ mightȱ impactȱ drugȬrelatedȱ streetȱ disorderȱ andȱ associatedȱ harmsȱ appearsȱ toȱ beȱ aȱ particularlyȱ importantȱareaȱforȱfurtherȱresearch.ȱSimilarly,ȱecologicalȱstudiesȱexaminingȱassociationsȱ betweenȱdrugȱpolicyȱfundingȱallocationȱandȱdrugȱpolicyȱoutcomesȱwouldȱcontributeȱtoȱ ourȱunderstandingȱofȱhowȱweȱmightȱbetterȱmanageȱdrugȬrelatedȱstreetȱdisorder.ȱ Anotherȱ importantȱ areaȱ ofȱ furtherȱ researchȱ isȱ toȱ identifyȱ complementaryȱ interventionsȱ andȱ theȱ potentialȱ forȱ synergiesȱ amongȱ multipleȱ interventionsȱ toȱ addressȱ streetȱ disorder.ȱ Forȱ instance,ȱ integratingȱ microȱ andȱ macroȱ levelȱ interventionsȱ orȱ combiningȱ multipleȱ interventionsȱ inȱ anyȱ oneȱ levelȱ orȱ areaȱ mayȱ createȱ aȱ multiplicativeȱ effectȱ thatȱ couldȱ maximizeȱ theȱ impactsȱ ofȱ policyȱ responses.ȱ Itȱ wouldȱ beȱ equallyȱ  ȱ  147  ȱ  importantȱ toȱ determineȱ ifȱ certainȱ conditionsȱ areȱ requiredȱ inȱ orderȱ forȱ someȱ typesȱ ofȱ interventionsȱ toȱ beȱ effective.ȱ Forȱ instance,ȱ initiatingȱ policeȱ andȱ publicȱ healthȱ partnershipsȱ thatȱ educateȱ policeȱ aboutȱ theȱ dynamicsȱ ofȱ streetȱ disorderȱ andȱ theȱ healthȱ harmsȱresultingȱfromȱpolicingȱpracticesȱinȱthisȱareaȱmayȱcreateȱaȱdesireȱamongȱpoliceȱtoȱ changeȱhowȱtheyȱrespondȱtoȱindividualsȱwhoȱareȱgeneratingȱstreetȱdisorder.ȱHowever,ȱ ifȱ alternativeȱ mechanismsȱ toȱ manageȱ streetȱ disorderȱ areȱ notȱ simultaneouslyȱ implementedȱ policeȱ mayȱ beȱ unableȱ toȱ modifyȱ theirȱ practices.ȱ Similarly,ȱ establishingȱ aȱ supervisedȱ inhalationȱ facilityȱ mayȱ provideȱ alternativeȱ locationsȱ forȱ streetȬbasedȱ drugȱ usersȱtoȱconsumeȱdrugs;ȱhowever,ȱifȱlocalȱpoliceȱareȱnotȱsupportiveȱofȱtheȱintervention,ȱ streetȬbasedȱdrugȱusersȱmayȱnotȱfeelȱsafeȱvisitingȱtheȱfacilityȱandȱtheȱpotentialȱbenefitsȱ ofȱ theȱ interventionȱ couldȱ beȱ lost.ȱ Conversely,ȱ ifȱ aȱ supervisedȱ inhalationȱ facilityȱ wasȱ implementedȱinȱconjunctionȱwithȱeffortsȱtoȱbuildȱpoliceȱandȱpublicȱhealthȱpartnerships,ȱ theȱ twoȱ interventionsȱ couldȱ complementȱ andȱ supportȱ eachȱ otherȱ andȱ theirȱ combinedȱ benefitsȱ couldȱ beȱ largerȱ thanȱ theirȱ individualȱ contributions.ȱ Identifyingȱ whereȱ theseȱ complementaryȱrelationshipsȱbetweenȱinterventionsȱexistȱandȱfactorsȱthatȱareȱrequiredȱ toȱsupportȱpotentialȱinterventionsȱisȱaȱkeyȱareaȱforȱfutureȱresearchȱ ȱInȱ addition,ȱ onceȱ additionalȱ interventionsȱ areȱ identified,ȱ furtherȱ researchȱ toȱ developȱ andȱ evaluateȱ theȱ impactsȱ ofȱ differentȱ interventionȱ modelsȱ onȱ specificȱ subȬ populationsȱofȱillicitȱdrugȱusersȱ(e.g.,ȱfemaleȱdrugȱusersȱandȱAboriginalȱpeopleȱwhoȱuseȱ drugs)ȱ couldȱ helpȱ tailorȱ interventionsȱ toȱ meetȱ theȱ needsȱ ofȱ particularlyȱ vulnerableȱ streetȬinvolvedȱdrugȱusersȱandȱshouldȱbeȱanotherȱareaȱforȱfutureȱresearch.ȱȱȱ ȱ  148  ȱ  8.5 Conclusionsȱ Thisȱ thesisȱ hasȱ shownȱ thatȱ drugȬrelatedȱ streetȱ disorderȱ isȱ aȱ seriousȱ policyȱ problemȱ withȱ publicȱ healthȱ implicationsȱ forȱ streetȬbasedȱ drugȱ users.ȱ Researchȱ toȱ dateȱ indicatesȱthatȱcurrentȱ policyȱresponsesȱ toȱ streetȱdisorderȱhaveȱ beenȱdominatedȱbyȱ lawȱ enforcementȱbasedȱapproachesȱthatȱareȱassociatedȱwithȱaȱrangeȱofȱnegativeȱunintendedȱ consequences.270ȱ Theȱ evidenceȱ emergingȱ fromȱ thisȱ thesisȱ suggestsȱ thatȱ thereȱ isȱ aȱ highȱ degreeȱ ofȱ willingnessȱ amongȱ localȱ IDUȱ toȱ reduceȱ engagementȱ inȱ drugȬrelatedȱ streetȱ disorderȱ ifȱ givenȱ otherȱ optionsȱ inȱ theȱ areasȱ ofȱ housing,ȱ employmentȱ andȱ drugȱ consumptionȱlocations.ȱSpecifically,ȱ65%ȱofȱparticipantsȱthatȱreportedȱsocializingȱinȱtheȱ openȱdrugȱsceneȱwereȱwillingȱtoȱrelocateȱifȱgivenȱaccessȱtoȱmoreȱprivateȱspace;ȱ47%ȱofȱ participantsȱ whoȱ engagedȱ inȱ disorderlyȱ incomeȱ generationȱ activitiesȱ wereȱ willingȱ toȱ forgoȱthoseȱincomeȱsourcesȱifȱgivenȱlowȬthresholdȱemployment;ȱandȱ71%ȱofȱparticipantsȱ whoȱ reportedȱ smokingȱ crackȱ cocaineȱ inȱ publicȱ areasȱ wereȱ willingȱ toȱ useȱ aȱ supervisedȱ inhalationȱ facility.ȱ Togetherȱ theseȱ findingsȱ provideȱ strongȱ evidenceȱ toȱ suggestȱ thatȱ structuralȱ andȱ environmentalȱ interventions,ȱ consistentȱ withȱ theȱ riskȱ environmentȱ framework,ȱ couldȱ haveȱ aȱ significantȱ positiveȱ impactȱ onȱ theȱ reductionȱ ofȱ drugȬrelatedȱ streetȱdisorder.ȱȱȱ Inȱsum,ȱstreetȱdisorderȱremainsȱaȱsignificantȱandȱunderȬaddressedȱproblemȱwithȱ farȬreachingȱ implicationsȱ forȱ publicȱ healthȱ andȱ publicȱ order.ȱ However,ȱ theȱ dataȱ presentedȱhereinȱrevealȱthatȱnovelȱsolutionsȱthatȱsimultaneouslyȱaddressȱpublicȱhealthȱ andȱ publicȱ orderȱ challengesȱ arisingȱ fromȱ streetȱ disorderȱ areȱ withinȱ reach.ȱ Ifȱ decisiveȱ ȱ  149  ȱ  effortsȱ areȱ madeȱ byȱ policyȬmakersȱ toȱ shiftȱ theȱ focusȱ ofȱ ourȱ approachȱ toȱ drugȬrelatedȱ streetȱ disorderȱ towardsȱ theseȱ evidenceȬbasedȱ interventionsȱ weȱ canȱ expectȱ toȱ seeȱ significantȱ improvementsȱ inȱ theȱ healthȱ andȱ socialȱ conditionsȱ ofȱ streetȬinvolvedȱ drugȱ users,ȱasȱwellȱasȱmeaningfulȱandȱlastingȱreductionsȱinȱdrugȬrelatedȱstreetȱdisorder.ȱ .ȱ  ȱ  150  ȱ  REFERENCESȱ ȱ 1.ȱSampsonȱRJ,ȱRaudenbushȱSW.ȱSystematicȱsocialȱobservationȱofȱpublicȱspaces:ȱAȱnewȱ 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