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Resilience from the perspective of the illicit injection drug user : an exploratory descriptive study Shaw, Audrey Linda 2006

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RESILIENCE F R O M T H E P E R S P E C T I V E O F T H E ILLICIT INJECTION D R U G U S E R : A N E X P L O R A T O R Y DESCRIPTIVE S T U D Y  by  Audrey Linda S h a w  B . S . N . , T h e University of Victoria, 1981  T H E S I S S U B M I T T E D IN P A R T I A L F U L F I L L M E N T O F THE REQUIREMENTS FOR THE DEGREE OF M A S T E R O F S C I E N C E IN N U R S I N G in T h e Faculty of G r a d u a t e S t u d i e s (NURSING) UNIVERSITY O F BRITISH C O L U M B I A  April 2 0 0 6  © Audrey Linda S h a w 2006  ABSTRACT Illicit injection drug u s e is a daunting health and social problem that calls for a multifaceted r e s p o n s e . R e s i l i e n c e b a s e d strategies h a v e the potential to c o m p l e m e n t the current a p p r o a c h to this problem but there is a paucity of r e s e a r c h that would e n a b l e scientifically b a s e d strategies to be d e v e l o p e d . T h e p u r p o s e of this s e c o n d a r y study w a s to explore and d e s c r i b e resilience from the perspective of individuals w h o u s e illicit injection drugs. F o r the p u r p o s e s of this r e s e a r c h i n c r e a s e d resilience w a s v i e w e d a s quitting, d e c r e a s i n g a n d safer drug u s e a n d support s e e k i n g w h e r e a s d e c r e a s e d resilience w a s v i e w e d a s initial, i n c r e a s e d or unsafe drug u s e a n d r e l a p s e . T h i s qualitative study u s e d data obtained from a larger qualitative study, c o n d u c t e d in Victoria, British C o l u m b i a in 2 0 0 0 , w h o s e p u r p o s e w a s to determine b e h a v i o u r s and contexts that place the IDU at risk. U s i n g R a p i d A s s e s s m e n t R e s p o n s e a n d Evaluation methodology, data w e r e collected from three participant g r o u p s : IDU (20 f e m a l e , 21 male) s e r v i c e providers (45) a n d c o m m u n i t y leaders/policy m a k e r s (12). T h i s study is limited to the key informant interview a n d f o c u s group d a t a of the first two groups. Participants d e s c r i b e d two types of e x p e r i e n c e s that w e r e a s s o c i a t e d with a n i n c r e a s e in resilience a n d o n e type of e x p e r i e n c e that w a s a s s o c i a t e d with a d e c r e a s e in resilience. O n e type of e x p e r i e n c e a s s o c i a t e d with i n c r e a s e d resilience involved getting to the point of behavioural and attitudinal c h a n g e either by recognizing drug u s e w a s not worth the negative c o n s e q u e n c e s entailed, by getting s c a r e d of the effects of drug u s e , by recognizing an inner desire to quit or by reaching out for support. A s e c o n d type of e x p e r i e n c e a s s o c i a t e d with i n c r e a s e d resilience involved envisioning a  better non-drug using future. Participants a l s o d e s c r i b e d e x p e r i e n c e s , a s s o c i a t e d with a d e c r e a s e in resilience, w h i c h involved using illicit drugs to dull emotional pain s t e m m i n g from a b u s e , mental illness, alienation, marginalization a n d h o p e l e s s n e s s . Future r e s e a r c h using primary data is s u g g e s t e d to i n c r e a s e k n o w l e d g e of resilience in the context of t h o s e w h o u s e illicit injection drugs a n d to evaluate intervention strategies that include the fostering of protective factors in order to strengthen resilience.  iii  T A B L E OF CONTENTS Abstract  ii  T a b l e of C o n t e n t s  iv  List of T a b l e s  vi  Acknowledgements  J  Dedication C h a p t e r I Introduction S i g n i f i c a n c e of the P r o b l e m R e s p o n s e to Illicit Injection Drug U s e R e s e a r c h P r o b l e m and P u r p o s e R e s e a r c h Q u e s t i o n for this Study  vii viii 1 1 4 7 7  C h a p t e r 2 Literature R e v i e w of R e s i l i e n c e Origins of the C o n c e p t of R e s i l i e n c e R e s i l i e n c e a s a State Protective Factors Risk Factors Resilience A s A Process P s y c h o l o g i c a l M o d e l s of R e s i l i e n c e P h y s i o l o g i c a l M o d e l of R e s i l i e n c e Discrepant V i e w s O n the Conceptualization of R e s i l i e n c e Context Specificity R e s i l i e n c e R e s e a r c h In S p e c i f i c Populations R e s i l i e n c e R e s e a r c h F r o m the Nursing Literature R e s i l i e n c e and S u b s t a n c e A b u s e R e s i l i e n c e Intervention and Treatment P r o g r a m s Summary  8 8 9 9 10 12 12 14 15 16 17 18 19 21 22  Chapter 3 Methods Introduction R e s e a r c h D e s i g n F o r T h i s Study R e s e a r c h D e s i g n of Original Study D a t a Collection M e t h o d s and Description of S a m p l e K e y Informant Interviews , F o c u s G r o u p Interviews Questionnaires Demographics Drug u s e patterns Hepatitis C and HIV status Drug and alcohol treatment  24 24 24 26 26 27 27 28 28 29 29 29  IV  D a t a M a n a g e m e n t and A n a l y s i s F o r T h i s Study E n s u r i n g R i g o r In T h i s Study Ethical C o n s i d e r a t i o n s  v  30 32 33  C h a p t e r 4 Findings Introduction S o c i a l Context of Drug U s e and R e s i l i e n c e E x p e r i e n c e s A s s o c i a t e d With Increased R e s i l i e n c e Getting T o T h e Point of C h a n g e R e c o g n i z i n g it's not worth it Getting s c a r e d R e c o g n i z i n g an inner desire to quit R e a c h i n g out for support Envisioning A Better Future E x p e r i e n c e s A s s o c i a t e d With D e c r e a s e d R e s i l i e n c e Needing To DulHhe Pain Summary  35 35 36 38 39 39 41 44 45 47 48 48 51  C h a p t e r 5 D i s c u s s i o n and C o n c l u s i o n s R e s i l i e n c e In Populations In the P r o c e s s of R e c o v e r y Resilience A s A Dynamic Process R e s i l i e n c e and A T r a n s f o r m e d World V i e w Protective F a c t o r s Individual Protective F a c t o r s F a m i l y and C o m m u n i t y Protective Factors R e s i l i e n c e and Context Specificity Drug M i s u s e T o Dull Emotional P a i n Implications of the Study Limitations  52 52 53 53 54 54 56 56 57 58 60  Conclusions  61  References  63  Appendices  72  Appendix Appendix Appendix Appendix  A B C D  (Interview G u i d e - Injection Drug User) (Interview G u i d e - S e r v i c e Provider) (Protective Factors A s s o c i a t e d With R e s i l i e n c e ) (Terms)  72 75 79 80  v  LIST O F T A B L E S Table 1  List of S t u d y Participants  26  Table 2  Participant E x p e r i e n c e s A s s o c i a t e d With A C h a n g e In R e s i l i e n c e  38  vi  ACKNOWLEDGEMENTS I h a v e not b e e n a l o n e o n this journey. I offer my enduring gratitude to the m e m b e r s of my thesis committee, Drs. J o a n Bottorff (Chairperson), J o y J o h n s o n a n d Kelli Stajduhar, for sharing their k n o w l e d g e a n d providing expert g u i d a n c e . A s p e c i a l thanks to J o a n for her w i s d o m a n d support, to J o y for her thought provoking q u e s t i o n s a n d to Kelli for being the impetus for this journey by introducing m e to the exciting c h a l l e n g e s of r e s e a r c h . I w o u l d a l s o like to thank the V a n c o u v e r Island Health Authority a n d the exceptional n u r s e s a n d administrative staff of the Department of E p i d e m i o l o g y a n d D i s e a s e Control for their o n g o i n g support. T h a n k you for holding the fort while I w a s off to U B C for yet another c l a s s . Finally, I w o u l d like to thank my father, G o r d o n Scarff, my children R o b e r t a n d Emily, my sister, C a r o l a n d my d e a r friends. I a m forever grateful for your love, support and encouragement.  vii  DEDICATION  To the citizens of Victoria who use illicit injection  drugs  viii  CHAPTER 1 Introduction T h e p u r p o s e of this study w a s to explore and d e s c r i b e the c o n c e p t of resilience from the p e r s p e c t i v e of the illicit injection drug u s e r (IDU). R e s i l i e n c e is defined a s a family of loosely c o n n e c t e d p h e n o m e n a involving a d e q u a t e or better adaptation in the context of adversity ( R o i s m a n , 2005). R e s i l i e n c e is important in relation to this topic b e c a u s e illicit injection drug u s e a n d its attendant h a r m s are a daunting p r o b l e m that is the s o u r c e of great h u m a n suffering a n d l o s s of h u m a n potential a n d is threatening to o v e r w h e l m C a n a d a ' s m e d i c a l , s o c i a l a n d legal s y s t e m s . T h e current most effective a p p r o a c h to this problem is thought to be multifaceted including prevention, legal, treatment a n d harm reduction strategies. R e s i l i e n c e b a s e d strategies h a v e the potential to c o m p l e m e n t the existing a p p r o a c h but there is a paucity of r e s e a r c h o n this topic that would e n a b l e scientifically b a s e d strategies to be d e v e l o p e d a n d i m p l e m e n t e d . In this chapter, a description of the significance of the illicit injection drug u s e p r o b l e m within C a n a d a is followed by an overview of the historical r e s p o n s e to the p r o b l e m a n d the r e s e a r c h p u r p o s e a n d question. S u b s e q u e n t c h a p t e r s present the literature on resilience a s it pertains to illicit injection drug u s e , a description of the r e s e a r c h m e t h o d s a n d the findings of this study. Finally a d i s c u s s i o n of the findings a n d c o n c l u s i o n are provided. The Significance of the Problem T h e u s e of illicit injection drugs is a health a n d s o c i a l i s s u e that entails daunting h u m a n a n d financial c o s t s and c o n s e q u e n c e s for individuals, families a n d c o m m u n i t i e s in C a n a d a . B a s e d o n provincial a n d city estimates, approximately 100,000 C a n a d i a n s  1  inject illicit drugs (Health C a n a d a , 2002). Often most evident in large cities s u c h a s the downtown e a s t side of V a n c o u v e r , the problem of illicit injection drug u s e a l s o exists in smaller urban centres a n d rural a r e a s (Public Health A g e n c y of C a n a d a , 2 0 0 4 ; Stajduhar et a l . , 2004). N o r is the problem confined to o n e gender, a g e group or s o c i o e c o n o m i c stratum. T h e m a n y harms a s s o c i a t e d with injection drug u s e include o v e r d o s e and d e a t h , blood borne d i s e a s e s s u c h a s H u m a n Immune Deficiency V i r u s (HIV), A c q u i r e d Immune Deficiency S y n d r o m e (AIDS), Hepatitis C ( H C V ) , Hepatitis B ( H B V ) a n d local skin a b s c e s s e s that too frequently b e c o m e s y s t e m i c , resulting in s e r i o u s conditions s u c h a s endocarditis and osteomyelitis (Health C a n a d a , 2 0 0 2 ; C a n a d i a n F o u n d a t i o n for Drug P o l i c y , 2 0 0 5 ; United Nations, 1997; Health C a n a d a , 2 0 0 4 ; Stajduhar et a l . , 2 0 0 4 ) . Direct m e d i c a l c o s t s of treating HIV h a v e b e e n estimated at $ 1 0 0 , 0 0 0 p e r individual and t h e s e c o s t s are e x p e c t e d to i n c r e a s e a s new medications b e c o m e a v a i l a b l e that i n c r e a s e the life e x p e c t a n c y of t h o s e w h o are infected (Health C a n a d a , 2 0 0 2 ) . In addition to the cost to the health c a r e s y s t e m , injection drug u s e results in untold h u m a n suffering and loss of h u m a n potential and p l a c e s a n extraordinary burden o n the law enforcement, correctional a n d social service s y s t e m s . In the 1 9 9 0 s injection drug u s e e m e r g e d a s o n e of the primary m e a n s of HIV t r a n s m i s s i o n (Health C a n a d a , 2002). B y 1999, injection drug u s e w a s r e s p o n s i b l e for 34 percent of the new HIV c a s e s . Although this d r o p p e d to 24 percent by 2 0 0 2 , c o n c e r n regarding the injection drug u s e problem led to the initiation of 'I T r a c k ' , a n e n h a n c e d surveillance s y s t e m at selected centres a c r o s s C a n a d a . T h e p u r p o s e of this surveillance s y s t e m is to monitor the incidence of HIV and H C V a s well a s the testing  2  a n d risk b e h a v i o u r s of injection drug u s e r s (IDUs). HIV p r e v a l e n c e , a m o n g the I T r a c k study participants in the pilot p h a s e for Victoria w a s 16.0 percent, R e g i n a 1.2 percent, S u d b u r y 10 percent a n d Toronto 5.1 percent (Health C a n a d a , 2004). Injection drug u s e has b e e n identified a s a risk factor in at least half of the estimated 2 7 5 , 0 0 0 H C V c a s e s in C a n a d a (Health C a n a d a , 2 0 0 4 ) . It is e s t i m a t e d that in both V a n c o u v e r a n d Montreal there is a n 8 5 percent p r e v a l e n c e rate of H C V in the IDU population with an annual i n c i d e n c e of approximately 2 6 percent (Health C a n a d a , 2 0 0 2 ) . H C V p r e v a l e n c e rates a m o n g study participants in the pilot p h a s e of I T r a c k , a national surveillance of injection drug u s e , ranged from 79.3 percent in Victoria to 54.3 percent in Toronto (Health C a n a d a , 2004). T h e s m a l l e r urban centres of R e g i n a , P r i n c e Albert a n d C a p e Breton have estimated H C V p r e v a l e n c e rates a m o n g the IDU population of 4 6 percent, 50 percent and 4 7 percent respectively (Health C a n a d a , 2004). A p p r o x i m a t e l y o n e fourth of people w h o inject illicit drugs in C a n a d a are w o m e n a n d by 2 0 0 2 , o n e fourth of all the HIV c a s e s in C a n a d a w e r e w o m e n (Health C a n a d a , 2002). T h e major risk factors for HIV in f e m a l e s are heterosexual t r a n s m i s s i o n a n d injection drug u s e . B e t w e e n 1989 a n d 1992 the proportion of A I D S c a s e s in w o m e n that could be attributed to injection drug u s e i n c r e a s e d from 6 percent to 15 percent a n d b e t w e e n 1993 a n d 1996 the i n c r e a s e w a s from 15 percent to 2 4 percent ( C a n a d i a n F o u n d a t i o n for Drug Policy, 2005). HIV positive w o m e n h a v e the potential of transmitting the infection to their infants either at birth or by breastfeeding. A s of 1996, 116 A I D S c a s e s in C a n a d a have b e e n attributed to perinatal t r a n s m i s s i o n ( C a n a d i a n F o u n d a t i o n for Drug Policy, 2005).  3  Thirty percent of participants of a national surveillance of I D U s in C a n a d a (IT r a c k ) reported initiation of injecting at the a g e of 16 y e a r s or y o u n g e r (Health C a n a d a , 2 0 0 4 ) . Street-involved youth, youth w h o inject d r u g s a n d y o u n g m e n w h o h a v e s e x with m e n are particularly vulnerable to HIV infection (Health C a n a d a , 1994). Street life is a s s o c i a t e d with a high incidence of survival s e x a n d injection drug u s e (Health C a n a d a , 2002). HIV p r e v a l e n c e in youth varies. In a national surveillance study, in 2 0 0 1 , o n e percent of street youth tested positive for HIV (Health C a n a d a , 2 0 0 1 ) w h e r e a s , in the V a n c o u v e r Injection Drug U s e r S t u d y (1996 to 2001) 17 percent of youth tested HIV positive. T h e problem of illicit injection drug u s e h a s b e e n d o c u m e n t e d both by a C a n a d a wide s u r v e i l l a n c e s y s t e m (Health C a n a d a , 2004) a n d in locally f o c u s e d studies (Stajduhar, Poffenroth & W o n g , 2 0 0 0 ; Stajduhar et a l . , 2 0 0 4 ; V a n d u , 2 0 0 3 ) . C l e a r l y a c o m p l e x p r o b l e m extending a c r o s s all a g e , g e n d e r a n d s o c i o e c o n o m i c g r o u p s a n d involving both m e d i c a l a n d social h a r m s that entail daunting c o s t s to the health, s o c i a l a n d law enforcement s y s t e m s , illicit injection drug u s e calls for a multifaceted r e s p o n s e . Response  to Illicit Injection Drug Use  Injection drug u s e a n d its multiple attendant harms p o s e a n increasing public health p r o b l e m that has not b e e n a d d r e s s e d a d e q u a t e l y by existing a b s t i n e n c e , law e n f o r c e m e n t a n d risk b a s e d policies a n d programs (Health C a n a d a 1994, 2 0 0 1 , 2 0 0 4 ) . T h e lack of a n in-depth understanding of resilience in the context of illicit injection drug u s e h a s h a m p e r e d the d e v e l o p m e n t of resilience b a s e d strategies that h a v e the potential to c o m p l e m e n t the existing r e s p o n s e to this significant public health p r o b l e m .  4  In C a n a d a , a s in the industrialized countries of w e s t e r n E u r o p e , the r e s p o n s e to the problem of illicit injection drug u s e h a s c h a n g e d o v e r time. Prior to the 1 9 8 0 s , there w a s a l m o s t a total reliance on a b s t i n e n c e - b a s e d strategies (Tukka, 2004). A n a s s u m p t i o n of the a b s t i n e n c e paradigm is that s u b s t a n c e a b u s e is a moral/legal p r o b l e m ; law enforcement strategies w e r e relied on to d e c r e a s e the p r e v a l e n c e a n d i n c i d e n c e of drug u s e by reducing or eliminating the drug s u p p l y a n d incarcerating both t h o s e w h o sold a n d t h o s e w h o u s e d illegal s u b s t a n c e s ( M a c C o u n , 1998). A b s t i n e n c e b a s e d drug recovery a n d treatment p r o g r a m s , for the most part, w e r e r e s e r v e d for those w h o had already s u c c e s s f u l l y a b s t a i n e d , at least for a short period of time, from the u s e of illicit s u b s t a n c e s . H o w e v e r , the effectiveness of a n e x c l u s i v e l y a b s t i n e n c e b a s e d a p p r o a c h c a m e to be q u e s t i o n e d by British p h a r m a c i s t s a n d p h y s i c i a n s w h o a d v o c a t e d for the prescription of opiates to drug addicts w h o h a d not b e e n s u c c e s s f u l in, or not qualified to a c c e s s , a b s t i n e n c e b a s e d p r o g r a m s ( T u k k a , 2004). Inciardi (2004) states that by the mid 1 9 8 0 s there w a s a growing realization that a b s t i n e n c e b a s e d policies a n d programs a n d the w a r on drugs had failed to eliminate or e v e n significantly d e c r e a s e drug supply or drug u s e . In addition, the h a r m s a s s o c i a t e d with the a b s t i n e n c e a p p r o a c h , w h i c h entailed denial of a c c e s s to s e r v i c e s a n d to information a n d involved long term incarceration to t h o s e w h o w e r e a d d i c t e d to d r u g s , w e r e gaining recognition. A n alternate lens w a s n e e d e d with w h i c h to v i e w the problem. T h e roots of the philosophy of harm reduction are found in the scientific public health m o d e l , w h i c h is g r o u n d e d in humanitarianism (Tukka, 2004). H a r m reduction provided the philosophical b a s i s to o v e r c o m e the barriers of a b s t i n e n c e b a s e d policies  5  a n d p r o g r a m s that prevented those w h o w e r e actively using illicit drugs to a c c e s s information a n d s e r v i c e s ( H o d g i n s , 2005). H a r m reduction p r o g r a m s w e r e first initiated in Liverpool, A m s t e r d a m a n d s e v e r a l other E u r o p e a n cities (Tukka). A l t h o u g h h a r m reduction policies a n d programs h a v e s i n c e g a i n e d ground in m a n y C a n a d i a n a n d w e s t e r n E u r o p e a n settings, Stajduhar et a l . (2000, p. vi) state that there continue to be m i s s e d opportunities in the prevention, c a r e and treatment of p e o p l e addicted to drugs d u e to a p p r o a c h e s that f o c u s o n a n 'abstinence only' a p p r o a c h . H a r m reduction policies a n d programs f o c u s o n reducing both the risk a n d the h a r m s a s s o c i a t e d with the risk. H a r m reduction is often incorporated into a multifocused a p p r o a c h to problematic s u b s t a n c e u s e s u c h a s the four pillar a p p r o a c h r e c o m m e n d e d in C a n a d a ' s Drug Strategy (Health C a n a d a , 2002). T h e four pillars represent prevention, enforcement, treatment a n d h a r m reduction. T h i s multifocused a p p r o a c h h a s provided n e w hope for an effective a n d h u m a n e a p p r o a c h to the p r o b l e m of s u b s t a n c e m i s u s e . Innovative harm reduction strategies s u c h a s n e e d l e e x c h a n g e s , safe injection sites a n d m e t h a d o n e a n d heroin m a i n t e n a n c e p r o g r a m s h a v e m a d e significant g a i n s in reducing the h a r m s a s s o c i a t e d with illicit injection drug u s e (Health C a n a d a , 2 0 0 2 , 2 0 0 4 ; P u b l i c Health A g e n c y of C a n a d a , 2 0 0 4 , 2005). H o w e v e r , there is a growing v o i c e for the inclusion of resilience a s a n additional a n d c o m p l e m e n t a r y r e s p o n s e to significant health related problems ( J a c e l o n , 1997; J o h n s o n & W i e c h e l t , 2 0 0 4 ; T u s a i e & Dyer, 2 0 0 4 ; W e r n e r & S m i t h , 1982). R e s i l i e n c e b a s e d policies a n d programs typically f o c u s o n strengthening protective factors a n d p r o c e s s e s that are a s s o c i a t e d with s u c c e s s f u l o u t c o m e s . A s s u c h they hold the promise of b e c o m i n g a n effective c o m p o n e n t of a multifocused  6  health r e s p o n s e to illicit injection drug u s e . Y e t there are significant g a p s in our understanding of this c o n c e p t that h a m p e r the d e v e l o p m e n t of strategies to support resilience on the front lines. R e s e a r c h is n e e d e d to explore resilience in the context of illicit injection drug u s e in order to d e v e l o p effective resilience b a s e d strategies to mitigate this significant public health problem. Research  Problem  and  Purpose  T o date, very few r e s e a r c h studies h a v e b e e n c o n d u c t e d o n resilience in the context of the illicit injection drug using population. N o r e s e a r c h studies with the explicit p u r p o s e of exploring resilience from the perspective of t h o s e w h o inject illicit d r u g s w e r e f o u n d . T h e p u r p o s e of this study w a s to explore and d e s c r i b e resilience from the p e r s p e c t i v e of t h o s e individuals w h o inject illicit drugs. Research  Question  for this  Study  T h e p u r p o s e of this study w a s to explore and d e s c r i b e resilience from the perspective of the illicit injection drug user. T h e r e s e a r c h question w a s , "What are the e x p e r i e n c e s in the life of the illicit injection drug user that are a s s o c i a t e d with a c h a n g e in the d e g r e e of r e s i l i e n c e ? " S p e c i f i c objectives w e r e : 1) T o d e s c r i b e e x p e r i e n c e s that are a s s o c i a t e d with c h a n g e s in resilience a m o n g illicit injection drug u s e r s and 2) T o identify protective factors or p r o c e s s e s that are a s s o c i a t e d with a c h a n g e from a l e s s e r to a greater d e g r e e of resilience.  7  CHAPTER 2 Literature R e v i e w R e s i l i e n c e R e s i l i e n c e h a s b e e n c o n c e p t u a l i z e d a s a state and a s both a p s y c h o l o g i c a l and physiological p r o c e s s . In this section, a n overview of the origins of the c o n c e p t is followed by a d i s c u s s i o n of the psychological and then the physiological p r o c e s s m o d e l s of resilience a s they pertain to illicit injection drug u s e . T w o d i s c r e p a n t v i e w s within the conceptualization of resilience are then explored. T h i s is followed by a d i s c u s s i o n of the context d e p e n d e n t nature of resilience and the r e s e a r c h f o c u s e d on resilience in specific populations. Origins Of The Concept Of Resilience T h e term resilience originated in p h y s i c s w h e r e a resilient object w a s defined a s o n e that d o e s not break but b e n d s under stress and then springs back to its original s h a p e (Brendtro & Longhurst, 2005). T h e current interest in the c o n c e p t of resilience grew from the observation that s o m e individuals c o p e d better than w a s e x p e c t e d c o n s i d e r i n g their dire c i r c u m s t a n c e s (Tusaie & Dyer, 2004). T h e findings of long term prospective studies indicated that, e v e n for children e x p o s e d to s e v e r e a n d multiple risk factors, it w a s u n u s u a l for m o r e than 50 percent to d e v e l o p s e v e r e p r o b l e m s ( J a c e l o n , 1997; W e r n e r & S m i t h , 1982). T h i s observation led to the realization that, historically, the f o c u s of health c a r e had b e e n on symptomatology, victimization, pathology a n d risk factors a n d there existed a need to l e s s e n the e m p h a s i s on negative o u t c o m e s a n d to look at s u c c e s s f u l adaptation in spite of adversity ( J a c e l o n ; J o h n s o n & W i e c h e l t , 2 0 0 4 ; T u s a i e & Dyer).  8  Resilience  As A State  R e s i l i e n c e w a s first c o n c e p t u a l i z e d a s a state, a n d it is from this early r e s e a r c h that the main constructs of protective factors a n d risk factors w e r e d e v e l o p e d . R e l e v a n t r e s e a r c h related to e a c h of t h e s e constructs is d i s c u s s e d in this s e c t i o n . A l t h o u g h , resilience, for the most part, is no longer c o n c e p t u a l i z e d a s a state, protective a n d risk factors continue to be r e c o g n i z e d a s important constructs in the conceptualization of resilience a s a p r o c e s s . Protective  Factors  J o h n s o n a n d W i e c h e l t (2004, p. 659) state that "individuals a n d families d e m o n s t r a t e resilience w h e n they draw on inner strengths, skills a n d supports 'Protective factor' is defined a s a n y characteristic of individuals or g r o u p s that m a k e t h e m l e s s vulnerable to a risk ( J a c e l o n , 1997; J o h n s o n & Wiechelt). Rutter (1993) postulated that protective factors c a m e into play during key turning points a n d w e r e possibly only apparent in times of stress. G a r m a z y (1991) categorized protective factors a s individual, family or c o m m u n i t y a n d this organizational framework w a s adopted by other r e s e a r c h e r s (Fine, 1 9 9 1 ; W e r n e r & J o h n s o n , 2004) although the community category h a s b e e n b r o a d e n e d to include the larger sociopolitical a n d physical environment. Protective factors of the individual w e r e identified a s a high activity level, the ability to elicit a positive r e s p o n s e from others, a u t o n o m y , self-efficacy, h o p e f u l n e s s , s e n s e of p u r p o s e a n d a r e a s of talent or a c c o m p l i s h m e n t (Werner, 1989). A l s o r e c o g n i z e d w e r e cognitive factors s u c h a s reflectiveness, o p t i m i s m , intelligence, creativity, a belief s y s t e m that p r o v i d e s existential m e a n i n g , a c o h e s i v e life narrative, self-worth, a n appreciation of o n e ' s u n i q u e n e s s a n d  9  g o o d fortune (Carbonell et a l . , 2 0 0 2 ; M a s t e n , 1994; P a t t e r s o n , 2 0 0 0 ; W e r n e r & S m i t h , 1982). In addition, p h y s i c a l attractiveness in f e m a l e s ( J a c e l o n , 1997) a n d individual c o m p e t e n c i e s s u c h a s c o p i n g strategies a n d s o c i a l skills w e r e identified a s protective factors (Tusaie a n d Dyer, 2004). W e r n e r (1989) W e r n e r a n d Smith (1982) a n d G a r m a z y (1991) identified family a n d c o m m u n i t y protective factors. F a m i l y protective factors include a w a r m , supportive, s t a b l e environment, p r e s e n c e of a n attentive a n d caring parent a n d p e r c e i v e d family c o n n e c t e d n e s s . C o m m u n i t y protective factors consist of extrafamilial support from p e e r s , adults a n d role m o d e l s , s c h o o l affiliation, religious faith or c h u r c h affiliation, a c c e s s to c o m m u n i t y r e s o u r c e s , a d e q u a t e housing a n d m e d i u m to high s o c i o e c o n o m i c status. A l t h o u g h the p r e s e n c e of protective factors indicates that the individual is p r e d i s p o s e d to a more positive o u t c o m e , this is far from a s s u r e d . A protective factor a p p e a r s to h a v e varying protective properties between individuals or within o n e individual a c r o s s time ( J o h n s o n & Wiechelt, 2004). F o r instance, two individuals with the s a m e level of intelligence a n d s e n s e of p u r p o s e may not a c h i e v e the s a m e level of s u c c e s s in life a n d this level of s u c c e s s m a y vary b e t w e e n e d u c a t i o n a l , adult work a n d interpersonal relationship d o m a i n s . Risk  Factors  A risk factor is defined a s a biological, d e v e l o p m e n t a l or p s y c h o s o c i a l event that i n c r e a s e s the likelihood of a negative o u t c o m e in an individual or group ( T u s a i e & Dyer, 2004). R i s k factors are a n integral part of the c o n c e p t of resilience b e c a u s e together with vulnerability they provide the preconditions or impetus that calls protective factors  10  into play. F l a c h (1988) labelled the entry of stress into a n individual's h o m e o s t a t i c s y s t e m a s the 'bifurcation point'. T h e s e points of entry h a v e a l s o b e e n referred to a s key turning points (Rutter, 1993) a n d points of reorganization (Horowitz, 1987). T u s a i e a n d D y e r (2004) s u g g e s t the categories of anticipated a n d u n e x p e c t e d risk factors. Anticipated risk factors are exemplified by d e v e l o p m e n t a l transitions s u c h a s t h o s e involved in s c h o o l entry, d e t a c h m e n t from parents during a d o l e s c e n c e a n d childbearing. U n e x p e c t e d risk factors are events s u c h a s family disruption d u e to mental illness, addiction, legal problems or u n e m p l o y m e n t a n d environmental risk factors s u c h a s flood, drought, famine or socio-political risks s u c h a s terrorist attacks or e v e n , a s h a p p e n e d relatively recently in British C o l u m b i a , c h a n g e s in u n e m p l o y m e n t i n s u r a n c e legislation that reduce i n c o m e . R i s k factors m a y o c c u r individually, simultaneously or c o n s e c u t i v e l y a n d m a y h a v e a cumulative effect o v e r t i m e ( J o h n s o n & W i e c h e l t , 2004). A l t h o u g h a n individual e x p o s e d to a risk factor is more highly a s s o c i a t e d with a negative o u t c o m e , T u s a i e a n d D y e r (2004) caution that o u t c o m e c a n not be predicted with c o n f i d e n c e from the p r e s e n c e of a risk factor a s a risk factor is a n e c e s s a r y but not sufficient precondition for the e x p r e s s i o n of resilience. A s J o h n s o n a n d W i e c h e l t (2004) note, the list of protective factors a n d risks that resulted from r e s e a r c h to identify the characteristics of individuals that c o p e d better than w a s e x p e c t e d considering their high risk c i r c u m s t a n c e s contributed to the understanding of the c o n c e p t of resilience but a p p e a r e d to be too simplistic to a c c o u n t for the o b s e r v e d variation in resilience. H o w t h e s e protective factors a n d risk factors interacted r e m a i n e d largely unexplained a n d h a m p e r e d the u s e f u l n e s s of the c o n c e p t .  11  Resilience  As A  Process  A s a shift from c a s e studies a n d retrospective studies to prospective longitudinal studies o c c u r r e d , resilience w a s no longer v i e w e d a s a state but a s a c o m p l e x a n d d y n a m i c p r o c e s s (Tusaie & Dyer, 2004). N u m e r o u s p r o c e s s m o d e l s w e r e d e v e l o p e d in a n attempt to explain the complexity of the c o n c e p t of resilience. In this section the n u m e r o u s p s y c h o l o g i c a l p r o c e s s m o d e l s , a s well a s a physiological m o d e l of resilience, are d i s c u s s e d . Psychological  Models  Of  Resilience  In F l a c h ' s (1988) multistage cyclical model of resilience, the introduction of a risk factor disrupts the individual's h o m e o s t a s i s c a u s i n g c h a o s followed by the activation of protective factors that eventually return the s y s t e m to its former h o m e o s t a s i s . Horowitz (1987) v i e w e d resilience a s the o u t c o m e of a c o m p l e x , d y n a m i c interplay b e t w e e n certain genetic a n d non genetic characteristics of individuals or s y s t e m s a n d the b r o a d e r environment. In h e r structural behavioural m o d e l of child d e v e l o p m e n t , Horowitz p r o p o s e d a c o n c e p t of relative resilience. Horowitz's model is b a s e d o n s e v e r a l a s s u m p t i o n s . T h e first a s s u m p t i o n is that e v e r y o n e h a s s o m e m e a s u r e of resilience, just a s e v e r y o n e h a s other individual characteristics s u c h a s height a n d weight. V i e w i n g resilience through this lens, the question to a s k is not if a n individual is or is not resilient but how resilient is an individual at a point in t i m e ? A s e c o n d a s s u m p t i o n of Horowitz' is that e v e r y o n e e x p e r i e n c e s points of reorganization in their life in w h i c h their level of resilience i n c r e a s e s or d e c r e a s e s . T h e m e a s u r e of resilience would vary a n d be determined according to the context.  12  F i n e ' s (1991) m o d e l articulated two related but s e p a r a t e p r o c e s s e s within resilience. T h e first includes a n acute p h a s e w h e r e the individual's e n e r g y is directed at minimizing s t r e s s . It is in the s e c o n d , reorganization stage, that not only a return to the former h o m e o s t a s i s , but the possibility of learning from adversity a n d b e c o m i n g stronger or more efficient a s a result, is s e e n . Rutter (1993) in a m o d e l similar to H o w o w i t z (1987) p r o p o s e d a simple continuum with vulnerability at o n e e n d a n d resilience at the other. Rutter s u g g e s t e d four potential protective p r o c e s s e s . T h e first w a s reduction of the impact of the risk by altering o n e ' s e x p o s u r e or involvement with the risk. T h e s e c o n d protective p r o c e s s , similar to a harm reduction a p p r o a c h , w a s reduction of the negative chain of reaction following the introduction of the risk. T h e third w a s the promotion of s e l f - e s t e e m a n d self efficacy through s u c c e s s f u l completion of t a s k s or the d e v e l o p m e n t of support s y s t e m s a n d the fourth protective p r o c e s s w a s the o p e n i n g up of n e w opportunities or a n e w world view. O t h e r m o d e l s a p p e a r e d out of the continuing n e e d to understand the variation a n d complexity of resilience a n d all of t h e s e m o d e l s defined resilience a s a d y n a m i c p r o c e s s that w a s influenced by time, d e v e l o p m e n t a l s t a g e a n d context (Brown & K u l i g , 1996; M a s t i n , 1994; R i c h a r d s o n , Neiger, J e n s e n & K e u m p f e r , 1 9 9 0 ; T u s a i e & D y e r , 2004). T h e R e s i l i e n c e P r o c e s s M o d e l of R i c h a r d s o n et a l . p r o p o s e s a biopsychospiritual h o m e o s t a s i s that, w h e n disrupted by a risk factor, results in o n e of four o u t c o m e s 1) resilient reintegration resulting in growth, self-understanding a n d i n c r e a s e d resilience, 2) reintegration back to the former h o m e o s t a s i s , 3) reintegration with s o m e l o s s of former function or 4) dysfunctional reintegration.  13  B r o w n a n d Kulig's (1996) two level model of resilience, to be applied to either individuals or c o m m u n i t i e s , has similarities to the two p r o c e s s e s of F i n e ' s (1991) m o d e l a n d the third a n d fourth protective p r o c e s s e s s u g g e s t e d by Rutter (1993). T h e first level of B r o w n a n d K u l i g ' s m o d e l is reactive, in that the individual o r c o m m u n i t y is s e e n a s reacting to stress in order to be able to carry o n . T h e best o u t c o m e that c a n be h o p e d for at this first level is a return to the former state before the stress o c c u r r e d . T h e s e c o n d level is proactive, in which the individual or community a d a p t s or transforms s o that the o u t c o m e is a n i n c r e a s e d capacity to anticipate s t r e s s a n d to minimize or to avoid future s t r e s s o r s . B r o w n a n d Kulig clearly state what Horowitz's m o d e l (1987) implies, that the question to be a s k e d about resilience is not if a n individual or c o m m u n i t y is resilient but what are the p r o c e s s e s that m o v e the individual or c o m m u n i t y towards o r a w a y from being more o r l e s s resilient. Physiological  Model Of  Resilience  Exploration of the c o n c e p t of resilience c a n be found in the literature of the physiological a s p e c t s of stress (Tusaie & Dyer, 2004). A physiological l e n s h a s m u c h to contribute to a n understanding of resilience within the a r e a of addiction a n d s u c h treatment strategies a s m e t h a d o n e m a i n t e n a n c e programs. O n e branch of b i o m e d i c a l r e s e a r c h is currently f o c u s e d o n exploring the neurological a n d physiological factors that a c c o u n t for the intergenerational transmission of addictive b e h a v i o u r (Schuckit, 1991). Brendtro a n d Longhurst (2005) d i s c u s s resilience in terms of s p e c i f i c a r e a s of the brain that are involved in resilient behaviours. T h e y state that recent r e s e a r c h o n the physiology of the brain indicates that e v e r y o n e is resilient a n d t h o s e w h o are l e s s resilient c a n be 'rewired' by positive learning e x p e r i e n c e s . J o h n s o n a n d W i e c h e l t  14  (2004) state that resilient o u t c o m e s are more c o m m o n than originally realized a n d that negative o u t c o m e s are the a n o m a l y . H o w e v e r , there, is e v i d e n c e that o n c e adaptation s y s t e m s are c o m p r o m i s e d then negative o u t c o m e s b e c o m e more prevalent ( J o h n s o n & Weichelt) a n d this negative c y c l e c a n be s e e n in individuals, s u c h a s t h o s e w h o u s e injection d r u g s , w h o are e x p o s e d to extreme a n d s u s t a i n e d adversity. Discrepant  Views On the Conceptualization  of  Resilience  R e s i l i e n c e h a s b e e n defined in both positive a n d negative terms. W e r n e r (1989) identified resilient individuals a s t h o s e w h o met child a n d adult d e v e l o p m e n t a l milestones. O t h e r s have defined resilience in children a n d a d o l e s c e n t s by the lack of internal a n d external psychopathological s y m p t o m s or psychiatric d i s o r d e r s , u s i n g instruments s u c h a s the C h i l d B e h a v i o u r C h e c k l i s t (Carbonell et a l . , 2002). A d i s a g r e e m e n t exists between t h o s e w h o s e definition of resilience is confined to individuals w h o h a v e never s u c c u m b e d to risk factors or exhibited b e h a v i o u r s or s y m p t o m s s u c h a s mental illness, s u b s t a n c e m i s u s e , d e l i n q u e n c y or post traumatic s t r e s s s y n d r o m e (Rutter, 1 9 9 3 ; W e r n e r , 1989) a n d t h o s e w h o v i e w resilience through a broader c o n c e p t u a l lens that e n c o m p a s s e s recovery a s a s p e c i a l c a s e of resilience (Brown & K u l i g , 1996; Horowitz, 1 9 8 7 ; Miller, 2 0 0 3 ; R o i s m a n , 2 0 0 5 ) . In this latter view, resilience includes s u c c e s s f u l adaptation following a period of maladaptation or d e v e l o p m e n t a l difficulty. V i e w e d through this broader c o n c e p t u a l lens, e v e r y o n e is s e e n to h a v e s o m e level of resilience a n d the question to a s k is not is this p e r s o n resilient but what are the p r o c e s s e s that i n c r e a s e or d e c r e a s e resilience within this p e r s o n (Brown & K u l i g , 1996; Horowitz, 1987).  15  A s e c o n d controversy c o n c e r n s the o u t c o m e s of the resilient p r o c e s s . O n e opinion is that resilience is a o n e stage p r o c e s s that c o n c l u d e s with a return to the former, pre-risk state ( F l a c h , 1988). H o w e v e r , m a n y p r o c e s s m o d e l s while incorporating the first stage have s u g g e s t e d a s e c o n d stage of resilience that results in a new, improved post risk o u t c o m e in w h i c h the individual u n d e r g o e s c h a n g e c h a r a c t e r i z e d by being better e q u i p p e d than formerly to anticipate a n d r e s p o n d to risks a n d is, in fact, more resilient (Brown & K u l i g , 1 9 9 6 ; Horowitz, 1 9 8 7 ; R i c h a r d s o n et a l . , 1990; Rutter, 1998). T e b e s , Irish, V a s q u e z a n d P e r k i n s (2004) state that c o p i n g with adversity m a y result in cognitive transformation leading to e n h a n c e d adaptation a n d that this e n h a n c e d adaptation is a marker of resilience. Further r e s e a r c h is n e e d e d to a d d r e s s t h e s e a r e a s of d i s a g r e e m e n t in the c o n c e p t u a l i z a t i o n of resilience a n d to clarify h o w protective p r o c e s s e s a n d risk factors interact to i n c r e a s e or d e c r e a s e resilience within individuals. Qualitative r e s e a r c h is particularly suitable to explore a n d d e s c r i b e this immature c o n c e p t a n d m o v e it towards r e a d i n e s s for u s e on the frontlines of nursing practice. Context  Specificity  It is generally a g r e e d in the literature that resilience is context d e p e n d e n t a n d this is thought to at least partially explain the variation in resilience s e e n b e t w e e n a n d within individuals. Variation within a n individual in different d e v e l o p m e n t a l d o m a i n s is exemplified by the child raised in poverty with a n a b u s i v e family w h o s u c c e s s f u l l y a c h i e v e s adult education a n d c a r e e r g o a l s but is not able to a c h i e v e normal interpersonal relationships (Tusaie & Dyer, 2004). J o h n s o n a n d W i e c h e l t (2004) s u g g e s t that a holistic framework to view resilience should include the contexts of a g e  16  a n d d e v e l o p m e n t a l stage, family history, s o c i a l c l a s s , ethnicity, g e n d e r a n d c h a n g e overtime. Resiliency  Research  In Specific  Populations  S t u d i e s of resilience within the context of the injection drug using population w e r e not f o u n d , however, studies in a r e a s relevant to this context are d i s c u s s e d below. W e r n e r (1989) found that children w h o grow up in poverty are more vulnerable to negative health a n d d e v e l o p m e n t a l o u t c o m e s . T h e negative influence of low s o c i o e c o n o m i c status o n resilience has s i n c e b e e n r e c o g n i z e d (Ferrar & P a l m e r , 2004). Starfield, R i l e y , Wit a n d R o b e r t s o n (2002) l o o k e d specifically at the c o n n e c t i o n b e t w e e n poverty a n d lowered a d o l e s c e n t health status. Hall (1999) a n d Z e r w e k h (2000) h a v e d i s c u s s e d resilience in the context of marginalization a n d d i s e n f r a n c h i s e m e n t . T h e illicit injection drug u s i n g population is m o r e likely to live in poverty a n d suffer marginalization, d i s e n f r a n c h i s e m e n t a n d stigmatisation (Stajduhar et a l . , 2 0 0 0 , 2 0 0 4 ) . T h e V a n c o u v e r A r e a Network of Drug U s e r s ( V a n d u , 2003) h a s stated that a d e q u a t e housing is a n e c e s s a r y first step towards addiction recovery. R e s i l i e n c e h a s b e e n studied in the context of h o m e l e s s n e s s ( R e w , C h a m b e r s & Kulkarni, 2 0 0 2 ; R e w , T a y l o r - S e e h a f e r , T h o m a s & Y o c k e y , 2001) suggesting that while h o m e l e s s p e o p l e m a y p o s s e s s c o n s i d e r a b l e resilience they f a c e significant o b s t a c l e s to s u c c e s s f u l o u t c o m e s that the h o u s e d d o not f a c e . Adult resilience h a s been studied in the context of specific d i s e a s e p r o c e s s e s s u c h a s ovarian c a n c e r ( W e n z e l et a l . , 2002) a n d breast c a n c e r ( B o w e n , M o r a s c a & M e i s c h k e , 2003). A medical model of addiction v i e w s addiction a s the result of physiological problems a n d genetic propensities similar to other d i s e a s e p r o c e s s e s .  17  W h i l e this view eliminates the view of addiction a s a moral problem it d o e s not a c c o u n t for the s o c i a l a s p e c t s of the d i s e a s e . A w a r m supportive family environment h a s b e e n identified a s a protective factor contributing to resilience ( G a r m a z y , 1991). T h e resilience of families h a s b e e n studied in terms of health-promoting lifestyles (Monteith & F o r d - G i l b o e , 2002) and the relationship between family c o n n e c t e d n e s s and s e x u a l risk taking (Tuttle, L a n d a u , S t a n t o n , K i n g & Frodi, 2 0 0 4 ) . Addiction and mental health problems are often co-occurring conditions ( P u b l i c Health A g e n c y , 2005). T h e role of resilience in d e p r e s s i o n ( A d a m s , S a n d e r s & A u t h , 2 0 0 4 ; C a r b o n e l l et a l . , 2 0 0 2 ; Miller & C h a n d l e r , 2002) and in suicide ( R e w , T h o m a s , Horner, R e s n i c k & B e u h r i n g , 2001) h a s b e e n studied. K a t e r n d a h l , B u r g e a n d K e l l o g (2005) studied predictors of resilience a n d adult mental disorders in w o m e n survivors of childhood s e x u a l a b u s e . R e s i l i e n c e and post traumatic stress disorder, in the context of w a r h o s t a g e s ( S a a b , C h a a y a , Doumit & F a r h o o d , 2003) and d i s a s t e r s s u c h a s a nightclub fire (Badger, 2004) h a s a l s o b e e n the focus of r e s e a r c h studies. Illicit injection drug u s e is a s s o c i a t e d with high levels of physical a n d emotional t r a u m a both from the family of origin a n d from o n g o i n g s o u r c e s s u c h a s s e x trade work a n d marginalization. Resilience  Research  From The Nursing  Literature  Nursing h a s long b e e n interested in a n understanding of factors that protect health by promoting emotional and physical well-being and quality of life. T h e Nursing literature a d d r e s s e s a w i d e range of topics o n the p s y c h o s o c i a l a s p e c t s of resilience including family violence (Heinzer & K r i m m , 2 0 0 2 ; Martin, 2 0 0 2 ) , family relations a n d  18  s e x u a l b e h a v i o u r of y o u n g w o m e n (Tuttle et al., 2004) s u b s t a n c e a b u s e a n d s e x u a l risk taking in w o m e n (Lindenberg et a l . , 1998) post traumatic stress disorder ( M c C u l l o u g h Z a n d e r & L a r s o n , 2 0 0 4 ; S e n g , 2003) marginalization a n d d i s e n f r a n c h i s e m e n t (Hall, 1999; Z e r w e k h , 2 0 0 0 ) a n d health care inequalities ( L y n a m , 2005). Additional a r e a s , relevant to the illicit injection drug using population, a d d r e s s e d by nursing r e s e a r c h are the role of self c o n c e p t a n d the role of spirituality. S t e i n , R o e s e r a n d M a r k u s (1998) in their study of the role of self-concept in a d o l e s c e n t risk b e h a v i o u r s found that self c o n c e p t m a y be a determining c o m p o n e n t not o n l y a s a n a n t e c e d e n t to but a l s o in the continuing participation in risk b e h a v i o u r s . S o w e l l (2000) looked at the c o n n e c t i o n between spiritual activities a n d wellbeing a m o n g a group of HIV positive w o m e n . T h e s e studies s u g g e s t that a positive s e n s e of self a n d spiritual activities m a y be protective factors that contribute to resilience. Increased in-depth k n o w l e d g e of the c o n c e p t of resilience is significant to Nursing a s well a s other disciplines a s this c o n c e p t holds the promise for the d e v e l o p m e n t of practice applications d e s i g n e d to strengthen the resilience of vulnerable individuals a n d g r o u p s . Resilience  And Substance  Abuse  R e s e a r c h o n resilience in the context of s u b s t a n c e a b u s e h a s mainly f o c u s e d o n identifying the characteristics of resilient children of adults w h o m i s u s e drugs ( P i l o w s k y , Zybert & V l a h o v , 2 0 0 4 ) youth at high risk for s u b s t a n c e a b u s e (Hostetler & Kirk, 1997) a n d the role of caring adults in the lives of children of a l c o h o l i c s ( W e r n e r & J o h n s o n , 2004). A u s t i n (2004) states that the role of culture a n d the d y n a m i c s of the protective p r o c e s s e s of resilience are not fully understood a n d should be explored to allow for the d e v e l o p m e n t of effective prevention a n d treatment programs (Austin, 2 0 0 4 ) . A u s t i n ' s  19  study of drug u s e a n d violent behaviours in native H a w a i i a n s s u g g e s t e d that ethnic pride m a y be a n important protective factor against v i o l e n c e in this g r o u p . S e v e r a l studies, not d e s i g n e d specifically to look at resilience, n e v e r t h e l e s s contributed k n o w l e d g e of p o s s i b l e protective factors that m a y promote resilience. N y a m a t h i , F l a s k e r u d a n d L e a k e ' s (1977) study of HIV risk b e h a v i o u r s , mental health characteristics a n d support s y s t e m s of 2 4 0 h o m e l e s s , drug recovering w o m e n s u g g e s t e d that t h o s e at risk for d e p r e s s i o n a n d illicit injection a n d non-injection drug u s e tend to c h o s e support p e r s o n s w h o are t h e m s e l v e s at high risk for the s a m e p r o b l e m s . N y a m a t h i (2004) identified the characteristics of h o m e l e s s w o m e n w h o want to permanently quit a l c o h o l , c o c a i n e or heroin u s e . T h e characteristics of the o n e third of the 748 participants w h o wanted to quit drug u s e w e r e : recognition that their s u b s t a n c e u s e w a s a n extremely s e r i o u s problem, not a s s o c i a t i n g with other drug u s e r s , a history of hospitalization for drug u s e a n d recent s u b s t a n c e u s e treatment. T e b e s et a l . (2004) studied transformative c h a n g e in a study of 3 5 y o u n g adults w h o had e x p e r i e n c e d the death of a parent in the previous two y e a r s . T h e study findings s u g g e s t that individuals e x p o s e d to adversity m a y e x p e r i e n c e cognitive transformation, w h i c h is s e e n a s a form of e n h a n c e d adaptation a n d m a y b e a m a r k e r of resilience. C o g n i t i v e transformation is characterized by a turning point in w h i c h the individual r e c o g n i z e s that c o p i n g with adversity h a s o p e n e d up n e w opportunities a n d a s a result revaluates the e x p e r i e n c e from negative to positive or growth-promoting. T h e s e turning points m a y b e a n e x a m p l e of re-organizational points a s d e f i n e d by Horowitz (1987).  20  A r o n w i t z a n d M o r r i s o n - B e e d y (2004) looked at resilience in the context of motherd a u g h t e r c o n n e c t e d n e s s , risk taking behaviours s u c h a s s u b s t a n c e a b u s e a n d a hopeful view of the future in a population of impoverished A f r i c a n A m e r i c a n girls. T h e study results contrasted with earlier studies in that no relationship w a s found b e t w e e n c o n n e c t e d n e s s a n d resilience. T h e girls with a m o r e hopeful v i e w of the future w e r e found to be the most resilient. In s u m m a r y , although resilience h a s not b e e n a f o c u s of study within the specific context of injection drug u s e , it h a s b e e n studied in m a n y a s s o c i a t e d a r e a s . T h e negative effects of poverty, h o m e l e s s n e s s , co-occurring mental health d i s o r d e r s , history of a b u s e a n d post traumatic stress disorder on resilience a n d the s u g g e s t e d positive effects of a positive self concept, spirituality, family c o n n e c t e d n e s s a n d h o p e for the future on resilience have implications for the injection drug using population. T h e r e is a n e e d to look at all t h e s e i s s u e s specifically within the context of injection drug u s e a n d to identify t h e s e a n d other protective factors a n d p r o c e s s e s that work towards resilience in this vulnerable population. Resilience  Intervention  and Treatment  Programs  Intervention a n d treatment programs d e s i g n e d to strengthen resilience are b a s e d o n the a s s u m p t i o n that protective factors contribute in s o m e w a y to resilience. B r o w n (2001) critiqued the effectiveness of s u c h programs a s D r u g A b u s e R e s i s t a n c e E d u c a t i o n ( D . A . R . E . ) a n d Life Skills Training ( L . S . T ) a n d r e c o m m e n d e d resilienceb a s e d p r o g r a m s a s a more effective a p p r o a c h . A n e e d for resiliency b a s e d p r o g r a m s for high risk individuals a n d families has b e e n identified (Turtle et a l . , 2 0 0 4 ) both for prevention of s u b s t a n c e a b u s e (Glance—Cleavland, 2 0 0 4 ; H a r v e y & Hill, 2 0 0 4 ; K a p l a n ,  21  Turner, N o r m a n & Stillson, 1 9 9 6 ; L i n d e n b e r g et a l . , 2 0 0 2 ; R e w , 2 0 0 3 ; R i c h a r d s o n et al., 1990; S a n d a u - B e c k l e r , Devall & d e la R o s a , 2 0 0 2 ; W e r n e r , 1998) a n d for t h o s e already involved in s u b s t a n c e a b u s e (Miller, 2 0 0 3 ; R o i s m a n , 2 0 0 5 ) . J o h n s o n et a l . (1998) report on a program d e s i g n e d to i n c r e a s e family resilience a n d thereby prevent or r e d u c e alcohol a n d other drug u s e a m o n g high-risk youths. L i n d e n b e r g et a l . (2002) favourably c o m p a r e d the effectiveness of a c o m b i n e d risk a n d resilience b a s e d intervention to a health information program in reducing s e x u a l a n d s u b s t a n c e a b u s e b e h a v i o u r a m o n g y o u n g , low i n c o m e M e x i c a n A m e r i c a n w o m e n . A better understanding of resilience a m o n g illicit drug u s e r s could provide direction for n e w p r o g r a m s a n d policies. Summary T h e current interest in resilience c a m e from the n e e d to a c c o u n t for the 50 percent of individuals w h o suffer negative c i r c u m s t a n c e s yet w h o h a v e u n e x p e c t e d l y g o o d o u t c o m e s . R e s i l i e n c e , first v i e w e d a s a state, is currently c o n c e p t u a l i z e d a s a context d e p e n d e n t p r o c e s s . T h e b a s i c constructs of resilience are protective factors a n d risk factors but the d y n a m i c s of the interaction between t h e s e is, a s yet, poorly understood. J o h n s o n a n d Wiechett (2004, p.665) refer to resilience a s a "data s c a n t field", a n d r e c o m m e n d r e s e a r c h to i n c r e a s e k n o w l e d g e of the multiple interactive p r o c e s s e s of protective a n d risk factors. U n g a r (2003) identifies arbitrariness in selection of o u t c o m e v a r i a b l e s a s a problem with the r e s e a r c h in resilience a n d , in addition, states there is a significant g a p in k n o w l e d g e of the influence of s o c i a l a n d cultural context in w h i c h resilience o c c u r s . Other key a r e a s in the current thinking on resilience that  22  require further r e s e a r c h are: the role of relationships, both familial a n d extrafamilial, in the prevention of s u b s t a n c e a b u s e , protective factors that contribute to resilience in specific contexts a n d the relationship of cognitive transformation to indications of resilience ( J o h n s o n & Wiechett). In addition, there r e m a i n s d i s a g r e e m e n t c o n c e r n i n g the n u m b e r of s t a g e s within the p r o c e s s of resilience a n d if recovery c a n be v i e w e d a s a s p e c i a l c a s e of resilience. T e b e s et a l . (2004) r e c o m m e n d that future r e s e a r c h explore resilience a s it relates to recovery a m o n g specific populations including addictions, mental disorder a n d acute a n d chronic illness. Illicit injection drug u s e is a m o m e n t o u s public health problem. D u e to the significance of the problem a n d the variability of its presentation a c r o s s g e n d e r , a g e a n d g e o g r a p h i c a l contexts, studies to e n h a n c e understanding within a specific context are required to guide the public health r e s p o n s e . A m o n g the guiding principles that e m e r g e d from a study d o n e in Victoria, British C o l u m b i a , o n w h i c h this s e c o n d a r y study is b a s e d , w e r e that differing philosophical a p p r o a c h e s be included in public health strategies for injection drug u s e a n d that people with addictions must play a n integral role in the d e v e l o p m e n t of s e r v i c e s that affect t h e m (Stajduhar et a l . , 2 0 0 0 , 2 0 0 4 ) . A l t h o u g h the main philosophical a p p r o a c h e s f o c u s s e d on in the original study w e r e a b s t i n e n c e a n d harm reduction, this m a y b e e x t e n d e d to include the c o n s i d e r a t i o n of resilience b a s e d programs to c o m p l e m e n t existing s e r v i c e s b a s e d on a b s t i n e n c e a n d h a r m reduction p h i l o s o p h i e s . A l s o , studies that give a v o i c e to resilience f r o m the perspective of the illicit drug u s e r h a v e the potential of providing v a l u a b l e information to the d e v e l o p m e n t of the c o n c e p t of resilience a n d the d e s i g n of resilience b a s e d strategies within this context.  23  CHAPTER 3 Methods Introduction In this section the r e s e a r c h d e s i g n of both the original study a n d the s e c o n d a r y study that is the subject of this proposal are d e s c r i b e d : its s a m p l i n g m e t h o d , d a t a collection p r o c e d u r e s , m e a n s of ensuring rigor a n d p r o c e d u r e s for protection of h u m a n rights. T h e description of data analysis will be confined to the p r o p o s e d s e c o n d a r y study. Research Design for this Study A n exploratory descriptive a p p r o a c h to qualitative r e s e a r c h w a s the d e s i g n c h o s e n for this s e c o n d a r y study. A qualitative r e s e a r c h d e s i g n is appropriate d u e to the immaturity of the c o n c e p t of resilience ( J o h n s o n & Wiechett, 2 0 0 4 ; T e b e s et a l . , 2 0 0 4 ; U n g a r , 2003) a n d the lack of in-depth knowledge of the specific r e s e a r c h question of this study ( M o r s e & Field, 1 9 9 5 , 2004). Qualitative s e c o n d a r y a n a l y s i s is a credible method to f o c u s o n a c o n c e p t or question that a p p e a r e d to be evident but w a s not specifically explored in the original study (Hinds, V o g e l & C l a r k e - S t e f f e n , 1 9 9 7 ; T h o r n e , 1994). H i n d s et a l . (p. 4 2 0 - 4 2 1 ) provide a n a s s e s s m e n t tool to determine the fit of the s e c o n d a r y r e s e a r c h question to the data provided by the original study. U s i n g this tool the following criteria w e r e met 1) the c o n c e p t of interest w a s reflected in sufficient depth in the d a t a set, 2) it is likely the study s a m p l e could be e x p e c t e d to e x p e r i e n c e this c o n c e p t , a n d 3) the data s e t of the original study w a s of sufficient quality, c o m p l e t e n e s s and fit with the s e c o n d a r y r e s e a r c h question. T h e fourth criteria w a s partially met in that the p r o p o s e d r e s e a r c h question w a s s o m e w h a t similar to that of the primary study,  24  w h i c h is to further the understanding of injection drug u s e a n d H I V / A I D S . T h e selection of a n exploratory descriptive a p p r o a c h w a s b a s e d o n the p u r p o s e of the study, w h i c h w a s to explore a n d d e s c r i b e resilience a s it is e x p r e s s e d from the perspective of the IDU. Descriptive r e s e a r c h , a type of nonexperimental study, is d e s i g n e d to d e s c r i b e a n d d o c u m e n t a s p e c t s of a situation from the e m i c p e r s p e c t i v e a n d to s e r v e a s a possible starting point for future hypothesis generation or theory d e v e l o p m e n t . Although a n in-depth understanding is sought, s o m e t i m e s r e s e a r c h e r s c a n d o little more than d e s c r i b e existing relationships without fully c o m p r e h e n d i n g the c o m p l e x c a u s a l pathways that exist (Polit & Hungler, 1995). R a t h e r than c a u s a l relationships or s e e k i n g to explain w h y the study participants are more or l e s s resilient, the p u r p o s e of this study w a s to d e s c r i b e resilience from their perspective. T h i s study u s e d s e c o n d a r y data obtained from a larger qualitative study, c o n d u c t e d in Victoria, British C o l u m b i a in 2 0 0 0 . T h e p u r p o s e of the original study w a s to determine b e h a v i o u r s a n d contexts that place IDUs at risk for blood-borne d i s e a s e s a n d to d r a w o n this information to d e v e l o p interventions to r e d u c e the harm a s s o c i a t e d with injection drug u s e (Stajduhar et a l . , 2 0 0 0 , 2004). T h e principal investigators of the original study w e r e Kelli I. Stajduhar, R . N . , P h . D . , Clinical N u r s e S p e c i a l i s t , C a p i t a l Health R e g i o n of Victoria, B . C . a n d L i n d a Poffenroth, M.D., M S c , C o m m u n i t y M e d i c i n e , Deputy M e d i a l Health Officer & M a n a g e r D i s e a s e S u r v e i l l a n c e , C a p i t a l Health R e g i o n , Victoria, B . C . T h e co-investigator w a s E l s i e W o n g , B . S . N . , M . B . A . , Field S u r v e i l l a n c e Officer, Health C a n a d a , B C C e n t r e for D i s e a s e Control, S T D / A I D S Control. T h e project w a s funded by the Division of HIV E p i d e m i o l o g y , B u r e a u of H I V / A I D S , S T D & T B , Laboratory C e n t r e for D i s e a s e Control, Health C a n a d a , the B . C .  25  Ministry of Health a n d the Capital Health R e g i o n , Victoria, B C . Research Design of Original Study R a p i d A s s e s s m e n t R e s p o n s e and Evaluation ( R A R E ) methodology w a s the research d e s i g n c h o s e n for the original study. T h e R A R E method is d e s i g n e d to guide the d e v e l o p m e n t of prompt, community f o c u s e d interventions in r e s p o n s e to emerging d i s e a s e s and other public health problems (Stajduhar et a l . , 2000). T h e key c o m p o n e n t s of R A R E methodology are a f o c u s e d a p p r o a c h , short completion time, built-in evaluation, inclusion of community consultation a n d strong partnerships between front-line community workers a n d r e s e a r c h e r s . Data Collection Methods and Description of Sample T h e r e w e r e three groups of participants: I D U s (20 f e m a l e , 21 male) service providers a n d community leaders/policy m a k e r s (see T a b l e 1). T h i s study w a s limited to the u s e of the IDU a n d s e r v i c e provider k e y informant interview a n d f o c u s group d a t a . Table 1. List of study participants Total  K e y Informant  Focus Group  Interviews  Interviews  Injection Drug U s e r s  17  24  41  Service Providers  20  25  45  Policy M a k e r s / C o m m u n i t y L e a d e r s  12  0  12  TOTAL  49  49  98  Category  T h e three recruitment strategies u s e d w e r e nominated s a m p l i n g , targeted sampling a n d advertising. T h e focus of the s a m p l i n g strategies w a s to recruit key informants within e a c h of the three groups with in-depth k n o w l e d g e a n d e x p e r i e n c e of  26  injection drug u s e . Target s a m p l i n g w a s u s e d to find IDUs w h o w e r e u n k n o w n to the r e s e a r c h t e a m . O n c e interviewed, the IDUs w e r e a s k e d to nominate their p e e r s . Advertising c o n s i s t e d of posting notices in service delivery a r e a s that I D U s frequent. S a m p l e s i z e w a s not determined in a d v a n c e but w a s b a s e d o n saturation. All IDU participants received a $ 2 0 stipend to c o v e r e x p e n s e s incurred. D a t a collection methods included: key informant interviews, f o c u s g r o u p s , q u e s t i o n n a i r e s to obtain d e m o g r a p h i c a n d drug a n d d i s e a s e information from the IDU participants, IDU participant observation (70 hours), g e o m a p p i n g to d o c u m e n t s e r v i c e a n d risk locations a n d 15 rapid a s s e s s m e n t s u r v e y s to fill in g a p s in the d a t a . T h e field t e a m m e m b e r s , w h o included street n u r s e s a n d other frontline outreach w o r k e r s , w e r e crucial to the recruitment plan a s they w e r e able to invite p e o p l e to participate w h o m they k n e w to be currently using injection drugs a n d to have in-depth k n o w l e d g e a n d e x p e r i e n c e within the injection drug using community. Key Informant  Interviews  T h e interviews ranged from 30 to 120 minutes. P e r m i s s i o n w a s obtained to a u d i o t a p e all but o n e of the interviews a n d t h e s e w e r e transcribed in full. In addition, interviewers m a d e e x t e n s i v e notes a s s o o n after the interview a s p o s s i b l e . Interviewers w e r e instructed to k e e p the interviews f o c u s e d on the r e s e a r c h objectives a n d w e r e provided with questions to be u s e d a s a guide only (see A p p e n d i x A for Interview G u i d e - Injection drug U s e r s & A p p e n d i x B for Interview G u i d e - S e r v i c e P r o v i d e r s ) . Focus  Group  Interviews  A total of s e v e n f o c u s g r o u p s w e r e c o n d u c t e d with two participant g r o u p s a s follows: three IDU (24 participants) a n d four service provider (25 participants). T h e IDU  27  f o c u s group participants did not take part in key informant interviews. Participants for e a c h of the f o c u s g r o u p s w e r e s e l e c t e d to capture a specific l e n s o n injection d r u g u s e . F o r the injection drug u s e f o c u s g r o u p s this w a s 1) youth, 2) f e m a l e adult, a n d 3) m a l e adult a n d for the service provider f o c u s groups this w a s 1) mental health s e r v i c e providers, 2) aboriginal s e r v i c e providers, 3) p e o p l e working in c o m m u n i t y - b a s e d a n d non-profit organizations, a n d 4) police c o n s t a b l e s . T h e f o c u s g r o u p s w e r e audiotaped a n d transcribed in full. A recorder w a s present during the group s e s s i o n s to record the main t h e m e s that e m e r g e d . T h e group facilitator promoted d i s c u s s i o n c o n c e r n i n g the r e s e a r c h objectives a n d u s e d q u e s t i o n s similar to the key informant interview guide questions. Questionnaires D e m o g r a p h i c a n d drug a n d d i s e a s e related information w a s collected by a questionnaire a d a p t e d from the HIV s e r o p r e v a l e n c e study c o n d u c t e d in Victoria in the Fall of 1999. T h e questionnaire w a s administered to the IDU participants at the start of key informant interviews a n d f o c u s g r o u p s . Forty-one IDU questionnaires w e r e completed. Demographics T w e n t y - o n e of the IDU participants w e r e male a n d twenty w e r e f e m a l e ; of t h e s e 11 w e r e youth b e t w e e n the a g e s of 15 a n d 2 4 y e a r s of a g e . Ethnicity w a s identified by the participants a s White (29), Aboriginal (6) a n d M i d d l e E a s t e r n (2). F o u r participants did not identify their ethnicity. M o r e than half of the s a m p l e had not c o m p l e t e d high s c h o o l ; six h a d c o m p l e t e d high s c h o o l a n d s e v e n h a d s o m e post s e c o n d a r y e d u c a t i o n . Fifteen participants reported relatively stable housing (apartment, h o u s e , boarding  28  h o u s e ) in the past three months a n d 3 3 participants reported unstable h o u s i n g (living o n the street, squatting, hospitalization, incarceration) within the last three months. J u s t under half of all participants w e r e or had b e e n o n s o c i a l a s s i s t a n c e a n d nine participants received government disability benefits. T h e majority (34) e a r n e d most of their i n c o m e through drug d e a l i n g , panhandling a n d working in the s e x trade. O t h e r s o u r c e s of i n c o m e w e r e " s q u e e g e e i n g " a n d criminal activities s u c h a s break a n d enter. Nineteen of the 4 0 participants that r e s p o n d e d to the question had previously w o r k e d in the s e x trade (14 w o m e n , 5 men) a n d s e v e n of t h e s e participants w e r e currently working in the s e x trade (6 f e m a l e , 1 male). O n a v e r a g e , the participants reported s p e n d i n g from $ 1 0 0 to $ 2 0 0 per d a y o n their drug habit. Drug use  patterns.  A g e of first injection ranged from l e s s than 15 y e a r s for eight participants a n d l e s s than 20 y e a r s for 27 participants (13 f e m a l e a n d 14 male). T h e drug of c h o i c e w a s heroin (4) c o c a i n e (6) a n d both heroin a n d c o c a i n e (25). T h e r e w e r e no g e n d e r differences in drug c h o i c e . O f the 4 0 participants w h o r e s p o n d e d to the question of s h a r i n g injecting equipment, 2 9 h a d s h a r e d with another p e r s o n (16 f e m a l e , 13 male). Hepatitis  C and HIV  status.  Thirty-six participants stated they had tested for H C V (19 f e m a l e , 17 male) a n d of t h e s e 19 (11 f e m a l e , 8 males) self-identified a s H C V positive. Thirty-six (18 f e m a l e , 18 male) participants a l s o stated they had tested for HIV a n d of t h o s e tested 9 (7 f e m a l e s , 2 m a l e s ) self-identified a s HIV positive. Drug and alcohol  treatment.  N i n e t e e n had a c c e s s e d a drug a n d alcohol treatment program in the 12 m o n t h s  29  p r e c e d i n g the study. Approximately 12 had tried but b e e n u n s u c c e s s f u l in a c c e s s i n g a drug a n d a l c o h o l treatment program mainly d u e to long wait times. Data Management  and Analysis  for this  Study  In this s e c t i o n , the analytic framework for this study, Horowitz's construct of reorganizational points (1987) a n d analytic t e c h n i q u e s related to g r o u n d e d theory a n d other data m a n a g e m e n t tools will be d i s c u s s e d . F o r the p u r p o s e of this study, relevant data s e g m e n t s w e r e identified a n d retrieved from the IDU a n d service provider data of the original study. Horowitz's construct of re-organizational points (1987) that c o r r e s p o n d to a c h a n g e in the d e g r e e of resilience w a s u s e d a s a n analytic framework. T h i s is a particularly suitable framework to guide but not limit the a n a l y s i s of the data of this s e c o n d a r y study a s it is a c o m p o n e n t of a p r o c e s s model that a c k n o w l e d g e s the d y n a m i c a n d c o m p l e x nature of resilience. Horowitz b a s e d his model on the a s s u m p t i o n that e v e r y o n e h a s s o m e " d e g r e e " of resilience that varies o v e r t i m e (p. 151). R e s i l i e n c e is v i e w e d o n a continuum in w h i c h the individual that is relatively invulnerable to adversity is s a i d to h a v e "strong resilience" w h e r e a s the individual that is relatively vulnerable to adversity is referred to a s having "low resilience". T h o s e w h o h a v e exhibited negative b e h a v i o u r s a n d o u t c o m e s , s u c h a s the illicit IDU, may be said to h a v e s o m e level of resilience a n d that this level of resilience m a y vary o v e r t i m e . E x a m p l e s of p o s s i b l e re-organizational points in the life of a n illicit IDU m a y be e x p e r i e n c e s related to surviving a n o v e r d o s e , having o n e ' s children r e m o v e d by social s e r v i c e s or connecting with a n e w support person O t h e r resilience m o d e l s a n d studies d i s c u s s e d in the literature review contribute  30  to an understanding of resilience a n d w e r e u s e d in the a n a l y s i s of the IDU a n d s e r v i c e provider data. F o r e x a m p l e , protective factors identified by G a r m e z y (1991) a n d W e r n e r a n d S m i t h (1982) a n d instances of cognitive transformation a s d e s c r i b e d by T e b e s et al. (2004) w e r e sought. In addition, the r e s e a r c h e r u s e d k n o w l e d g e g a i n e d both a s a frontline nurse working with illicit IDUs a n d a s a n interviewer a n d f o c u s group facilitator for s o m e of the s e r v i c e providers in the original study. D a t a a n a l y s i s t e c h n i q u e s u s e d in grounded theory r e s e a r c h , s u c h a s constant c o m p a r i s o n a n d o p e n coding (Morse & Field, 1995) w e r e u s e d . Immersion in the data w a s a c h i e v e d by careful a n d multiple readings. All data s e g m e n t s w e r e r e v i e w e d lineby-line, potential "rich points", data that a p p e a r e d to be e s p e c i a l l y relevant to resilience, w e r e highlighted a n d first level c o d e s that e m e r g e d w e r e noted. D a t a w a s c o m p a r e d a n d contrasted both within a n d a c r o s s individual interviews. In addition, particular attention w a s paid to repetitions, potential inconsistencies or contradictions, a n d surprising or u n u s u a l l a n g u a g e or information within a n individual interview a n d a c r o s s interviews. " M e m o i n g " w a s u s e d to i n c r e a s e the conceptual level of the a n a l y s i s by capturing the i d e a s a n d insights of the researcher. S e l e c t i v e coding w a s a c c o m p l i s h e d by identifying the relationships between the first level c o d e s that allowed t h e m to be sorted or c o n d e n s e d into more abstract categories. In the final p h a s e of a n a l y s i s e a c h category w a s further a n a l y s e d to allow identification of the major t h e m e s . Microsoft W o r d 2 0 0 3 w a s u s e d to cut a n d paste data into individual word d o c u m e n t s for e a s e of sorting. Interviews a n d all d o c u m e n t s containing data w e r e stored in either a c o m p u t e r with p a s s w o r d a c c e s s or in a locked file cabinet. T h e  31  r e s e a r c h e r u s e d a diary to d o c u m e n t personal bias a n d the d e c i s i o n - m a k i n g trail a n d c o n s u l t e d with her thesis committee a n d the principal investigators of the original study on the reliability a n d validity of the p r o c e s s a n d findings. In the final p h a s e of the a n a l y s i s , the r e s e a r c h e r returned to the data to c h e c k that the major t h e m e s that had e m e r g e d w e r e true to individual interviews. Ensuring  Rigor in this Study  T h e r e are a range of criteria to e n s u r e rigor in qualitative r e s e a r c h . T h e four criteria that w e r e u s e d in this study to guide the c o n d u c t of this r e s e a r c h project w e r e : credibility, transferability or applicability, dependability or c o n s i s t e n c y a n d confirmability or neutrality ( M o r s e & Field, 1995). Credibility refers to the level of c o n f i d e n c e in the truth of the findings a n d w a s a d d r e s s e d in this study by: supporting a n a l y s i s a n d interpretation with direct q u o t e s from the d a t a ; triangulation of data s o u r c e s (IDUs a n d s e r v i c e providers); a n d drawing on the r e s e a r c h e r ' s clinical e x p e r i e n c e in providing health c a r e s e r v i c e s to the injection drug using population. Transferability or applicability refers to whether the findings c a n be applied to other contexts. T h e unique characteristics of the small s a m p l e s i z e w e r e d e s c r i b e d to allow others to determine the applicability of the findings to individuals in similar c i r c u m s t a n c e s . T h e findings m a y have limited transferability to other injection drug using populations. H o w e v e r , the insights from this study provide important directions for future r e s e a r c h on resilience a s it relates to illicit injection drug u s e . Dependability or c o n s i s t e n c y is u s e d to evaluate whether the study findings could be duplicated or similar in similar contexts. Although a n audit frail of q u e s t i o n s , d e c i s i o n s , insights a n d  32  p e r s o n a l b i a s e s a n d a s s u m p t i o n s w a s kept, it is noted by M o r s e a n d Field (1995) that qualitative r e s e a r c h f o c u s e s on the u n i q u e n e s s of h u m a n e x p e r i e n c e a n d that variation, not repetition, is to be e x p e c t e d . Confirmability, or neutrality, is c o n c e r n e d with f r e e d o m from, or at m i n i m u m a w a r e n e s s of, b i a s e s a n d a s s u m p t i o n s a n d maintaining r e s e a r c h objectivity. A p e r s o n a l diary w a s kept to d o c u m e n t a n d i n c r e a s e a w a r e n e s s of the r e s e a r c h e r ' s b i a s e s a n d a s s u m p t i o n s . In addition, all possible explanations of the data w e r e e x p l o r e d a n d negative c a s e s w e r e sought. Ethical  Considerations  T h e original study w a s a p p r o v e d by the Capital Health R e g i o n (Victoria, British C o l u m b i a ) R e s e a r c h R e v i e w a n d Ethical A p p r o v a l C o m m i t t e e a n d informed c o n s e n t w a s obtained f r o m all participants. T h e s i g n e d c o n s e n t stipulated that the typed transcripts a n d notes obtained in the study would be retained for educational a n d future r e s e a r c h p u r p o s e s with the understanding that a n y additional r e s e a r c h projects that u s e the transcriptions w o u l d be a p p r o v e d by the appropriate r e s e a r c h a n d ethics c o m m i t t e e s . A p p r o v a l of the University of British C o l u m b i a R e s e a r c h R e v i e w a n d Ethical A p p r o v a l C o m m i t t e e w a s obtained for this study. Participants w e r e g i v e n written information s u m m a r i z i n g the p u r p o s e of the study a n d informing t h e m that their participation w a s voluntary a n d that they c o u l d withdraw from the study at a n y time without suffering a n y negative c o n s e q u e n c e s . T h e n a m e s a n d contact n u m b e r s of the principal investigators w e r e a l s o g i v e n to participants for a n y future q u e s t i o n s or complaints. A numerical coding s y s t e m w a s u s e d to protect the identity of participants. All interviews, except o n e w h e r e p e r m i s s i o n w a s d e n i e d , w e r e  33  a u d i o t a p e d a n d transcribed in full with all identifiers r e m o v e d . A u d i o t a p e s w e r e d e s t r o y e d on completion of the original study a n d transcripts kept in a c o m p u t e r with p a s s w o r d or in a locked storage cabinet. In this study, interviews a n d all d o c u m e n t s containing d a t a or other confidential information w e r e stored in the s a m e s e c u r e d manner.  Chapter 4 Findings Introduction T h e p u r p o s e of this study w a s to gain a better understanding of resilience from the perspective of t h o s e w h o u s e illicit injection drugs. T o contextualize the findings, this c h a p t e r begins with a description of the conditions in w h i c h the participants w h o u s e d illicit injection drugs lived. U n l e s s otherwise indicated, "participants" refers to the illicit injection drug u s e r group. Next, the e x p e r i e n c e s of t h e s e participants that a r e a s s o c i a t e d with a c h a n g e in the level of their resilience are d i s c u s s e d . T h e s e r v i c e provider data e x t e n d s the understanding of t h e s e e x p e r i e n c e s , m a n y of w h i c h h a v e b e e n d i s c u s s e d in a different context in earlier publications b a s e d o n this d a t a (Stajduhar et a l . , 2 0 0 1 , 2004). In this study, Horowitz's (1987) conceptualization of resilience a s a relative a n d d y n a m i c p r o c e s s provided a lens with w h i c h to frame the a n a l y s i s . T h e participants s p o k e of e x p e r i e n c e s in their lives that involved behavioural a n d attitudinal c h a n g e s around their drug u s e . Participant's descriptions of c h a n g e s in their lives that influenced drug u s e w e r e u s e d a s a starting point for the a n a l y s i s . B e h a v i o u r a l a n d attitudinal c h a n g e s related to quitting drug u s e , d e c r e a s i n g drug u s e , safer drug u s e a n d support s e e k i n g w e r e v i e w e d a s s i g n s of increasing resilience, while behavioural a n d attitudinal c h a n g e s related to the initiation of drug u s e , i n c r e a s e d drug u s e , u n s a f e d r u g u s e a n d r e l a p s e w e r e interpreted a s signs of d e c r e a s i n g resilience.  35  Social Context  of Drug Use and  Resilience  T h e s o c i a l environment, including poverty, stigmatization a n d marginalization, in which the participants lived h a s b e e n d e s c r i b e d in previous publications (Stajduhar et al., 2 0 0 1 , 2 0 0 4 ) . H o w e v e r , a brief overview is n e c e s s a r y to put the findings of this study into context. T h e participants of this study lived in Victoria, British C o l u m b i a a s m a l l , urban, s e a s i d e city with a mild climate a n d a population, including outlying a r e a s , of approximately 3 2 5 , 0 0 0 . T h e illicit injection drug using population of G r e a t e r V i c t o r i a , at the time of the study, w a s estimated to b e 1 5 0 0 to 2 0 0 0 (Capital Health R e g i o n , 2 0 0 0 ) . In the original study the participants reported that their lives centred o n maintaining their drug habit. T h e a v e r a g e daily drug cost of their addiction r a n g e d from $ 1 0 0 to $ 2 0 0 . Nine of the 41 participants received g o v e r n m e n t disability benefits a n d l e s s than half received s o c i a l a s s i s t a n c e benefits. P a n h a n d l i n g a n d criminal activity s u c h a s petty theft, s e x trade work and drug dealing w e r e reported a s major s o u r c e s of i n c o m e . T h e daily c y c l e of a c c u m u l a t i n g e n o u g h m o n e y to p a y for their d r u g s , c o n n e c t i n g with a drug d e a l e r and purchasing a n d using drugs e x h a u s t e d most of the financial, p h y s i c a l a n d emotional r e s o u r c e s of the participants. B a s i c n e e d s of shelter, nutrition, m e d i c a l c a r e a n d meaningful h u m a n contact with family a n d friends w e r e , for the most part, unmet d u e to the unrelenting c y c l e of addiction. A s almost all of their financial r e s o u r c e s went towards p u r c h a s i n g illicit d r u g s , most of the participants lived in conditions of poverty. In the three months prior to the study, 3 3 of the 41 participants reported living in unstable h o u s i n g s u c h a s shelters, s q u a t s a n d friend's apartments. Living on the street for intermittent periods w a s a l s o c o m m o n . S e r v i c e providers s p o k e of the underlying i s s u e s of addiction s u c h a s  36  poverty, u n d e r - h o u s i n g , unemployment, malnutrition, lack of e d u c a t i o n a n d job skills a n d psychiatric illness a n d other m e d i c a l p r o b l e m s . A l t h o u g h o v e r half of the participants reported s p e n d i n g most of their time in the downtown a r e a , illicit injection drug u s e w a s reported to o c c u r in multiple locations throughout G r e a t e r Victoria. A particular c o n c e r n w a s drug u s e in public a r e a s s u c h a s parks, a l l e y s a n d public w a s h r o o m s (Stajduhar et a l . , 2000). T h e interview, o b s e r v a t i o n a n d g e o m a p p i n g data of the primary study all s u g g e s t e d that there w e r e too few s e r v i c e s for t h o s e w h o u s e d illicit injection drugs a n d that t h o s e s e r v i c e s that did exist had s e r i o u s a c c e s s barriers d u e to location, waiting lists a n d a b s t i n e n c e b a s e d p r o g r a m s (Stajduhar et a l . , 2 0 0 0 ) . F o r e x a m p l e , 12 of the 41 participants reported that in the 12 months prior to the study they had tried to a c c e s s detoxification s e r v i c e s but w e r e u n a b l e to d u e to long waiting lists. In addition, the participants reported that they w e r e frequently treated in a judgemental manner, both generally in the c o m m u n i t y a n d specifically w h e n they sought health c a r e a n d that this often had the effect of precipitating additional drug u s e a n d d e c r e a s i n g healthcare s e e k i n g behaviour. A s o n e long term drug u s e r stated, " a s s o o n a s ... s o m e people ... find out I u s e d r u g s , a n IV u s e r . . . they treat m e like I'm a different p e r s o n , like I'm shit". T h e participants of this study lived in poverty, w e r e alienated a n d m a r g i n a l i z e d from main s t r e a m society a n d lacked a c c e s s to the b a s i c health determinants, including health c a r e , while they attempted to d e a l with a powerful addiction. A n appreciation of t h e s e difficult c i r c u m s t a n c e s is e s s e n t i a l to understanding the e x p e r i e n c e s they describe.  37  Participants d e s c r i b e d two types of e x p e r i e n c e s that w e r e a s s o c i a t e d with a n i n c r e a s e in resilience and o n e type of e x p e r i e n c e that w a s a s s o c i a t e d with a d e c r e a s e in resilience (see T a b l e 2). T a b l e 2.  Participant e x p e r i e n c e s a s s o c i a t e d with a c h a n g e in resilience Getting to the Point of C h a n g e  Participant E x p e r i e n c e s A s s o c i a t e d With Increased R e s i l i e n c e  •  recognizing its not worth it  •  getting s c a r e d  •  recognizing a n inner d e s i r e to quit  Envisioning a better future Participant E x p e r i e n c e s A s s o c i a t e d With  N e e d i n g to dull the pain  Decreased Resilience  All of the participants d e s c r i b e d experiencing at least o n e type of t h e s e e x p e r i e n c e s a n d most participants d e s c r i b e d experiencing more than o n e type.  Experiences  Associated  With Increased  Resilience  In this s e c t i o n , a d i s c u s s i o n of the findings f o c u s e s o n the w a y s in w h i c h the participants constructed their e x p e r i e n c e s that led to a b s t i n e n c e from drug u s e , d e c r e a s e d drug u s e , safer drug u s e or support s e e k i n g . M a n y of the participants a l s o reported attitudinal c h a n g e s in that they w e r e "seriously trying to quit" "or felt " n o w it's time to get c l e a n " . F r o m a harm reduction perspective, the participants reporting t h e s e e x p e r i e n c e s had m a d e positive c h a n g e . Getting to a point of c h a n g e w a s the first step for s o m e participants, a s o n e f e m a l e participant e x p l a i n e d , "I'm just to the point w h e r e I want to get m o r e things going on in my life, more positive things". T h e e x p e r i e n c e s a s s o c i a t e d with positive c h a n g e  38  a n d the w a y s in which they helped the participants begin to re-organize their lives are d e s c r i b e d below.  Getting  To The Point of  Change  A s s e v e r a l participants reconstructed their e x p e r i e n c e s , they d e s c r i b e d a variety of situations that got them to the point of evaluating their lifestyle a n d r e c o g n i z i n g that they could no longer continue to u s e drugs in the w a y that they had b e e n . Motivated by t h e s e self revelations individuals b e g a n to take s t e p s to a d d r e s s their drug m i s u s e . T h e participants d e s c r i b e d e x p e r i e n c e s that "got them to the point" of m a k i n g c h a n g e s in their lives including, " R e c o g n i z i n g It's Not Worth It", "Getting S c a r e d " , " R e c o g n i z i n g a n Inner D e s i r e T o Quit" a n d " R e a c h i n g Out F o r Support". Recognizing  it's not worth it.  S o m e of the participants recalled c o m i n g to the point w h e r e they had to admit to t h e m s e l v e s that their drug u s e w a s just not worth it. Participants d e s c r i b e d c o n s c i o u s l y weighing the negative a s p e c t s of maintaining a drug habit a n d the benefits drug u s e brought to their lives. T h e r e w a s c o n s i d e r a b l e variation in what w a s c o n s i d e r e d too high a cost a n d the length of time the d e c i s i o n - m a k i n g p r o c e s s took. H o w e v e r , d r a w i n g o n past e x p e r i e n c e s , t h e s e participants c a m e to the c o n c l u s i o n that s o m e c o s t s a s s o c i a t e d with continued drug u s e w e r e too high a price to pay. In particular, the participants drew attention to the personal c o s t s of jail time, the h a r d s h i p s of street life, a p p r e h e n s i o n of o n e ' s children and remorse for harm d o n e to others. It w a s not u n u s u a l for a n individual participant to report that they h a d m o r e than o n e of t h e s e experiences.  39  O n e m a l e participant, w h o had continued to u s e injection d r u g s while i n c a r c e r a t e d , reported that four months before he w a s d u e to be r e l e a s e d from the correctional facility w h e r e he w a s completing his s e c o n d , four-year term for drug trafficking he b e g a n to think about his future. H e realized that if he kept using a n d dealing d r u g s he would probably h a v e to f a c e another prison term a n d , c o n c l u d i n g that this w a s too high a price to pay, he found the motivation to quit all illicit drug related activity. At the time of the interview this participant had b e e n out of prison for three y e a r s a n d w a s o n a m e t h a d o n e program. H e had o n e relapse o n e y e a r after his r e l e a s e from prison but h a d not u s e d a n y illicit d r u g s for the two y e a r s p r e v i o u s to the interview. T h e o n g o i n g n e e d for financial r e s o u r c e s to pay for the next "fix" drove m a n y of the participants into situations that e x p o s e d t h e m to physical a n d emotional h a r d s h i p s . After 12 y e a r s of living for the 'high' that drugs could give her, o n e f e m a l e participant c o n s i d e r e d the risks a s s o c i a t e d with panhandling a n d s e x trade work to support her habit a n d c a m e to realize that "it w a s n ' t worth it". A l t h o u g h after m a k i n g the d e c i s i o n to quit, s h e had s e v e r a l r e l a p s e s into c o c a i n e u s e , at the time of the interview, this participant proudly reported that s h e had not u s e d c o c a i n e for three y e a r s . H o w e v e r , recognizing that the costs of continued drug u s e outweighed the benefits d r u g s provided did not a l w a y s result in long-term a b s t i n e n c e . A n o t h e r f e m a l e participant, w h o s e re-evaluation of the c o s t s of her drug habit w a s precipitated by having her children a p p r e h e n d e d by S o c i a l S e r v i c e s , d e s c r i b e d d e c i d i n g to quit d r u g s then suffering repeated r e l a p s e s . S h e did, however, explain that losing her children initiated a s e r i e s of attempts to quit drug u s e a n d her drug habit w a s n e v e r a s out of control a s  40  before this point in her life. At the time of the interview, this participant reported that it had taken her three y e a r s to get to the point w h e r e s h e mainly s m o k e d a n d rarely injected c o c a i n e . S h e had not regained custody of her children. All of the participants s p o k e of the p e r s o n a l "costs" a s s o c i a t e d with drug u s e but only o n e , w h o stated he had b e e n involved in selling d r u g s , e x p r e s s e d r e m o r s e for the harm d o n e to others. This m a l e participant, w h o had originally sought support at a n inner city a g e n c y a n d then b e c a m e a volunteer there, reported that s e e i n g the plight of his former d r u g - s e e k i n g c u s t o m e r s w a s a constant reminder of the harm he had d o n e to others a n d helped him continue to abstain from illicit drug u s e . S p e a k i n g of how those w h o u s e illicit injection drugs c o m e to a point in their lives w h e r e they start to re-evaluate their drug u s e , a s e r v i c e provider d e s c r i b e d two factors that a p p e a r to be important 1) witnessing the negative c o n s e q u e n c e s of d r u g u s e in others, a n d 2) b e c o m i n g tired of dealing with the personal c o n s e q u e n c e s of drug u s e . T h e time l a p s e between initial drug u s e a n d b e c o m i n g ready to re-evaluate the c o n s e q u e n c e s varied for m a n y of the participants. M o s t of the participants that h a d m a d e positive c h a n g e s had u s e d drugs for o v e r ten y e a r s before they r e a c h e d this point, h o w e v e r , two of the f e m a l e participants, a g e d 16 a n d 19 at the time of the study, u s e d d r u g s for only two y e a r s before they r e a c h e d the point w h e r e they w e r e ready to s e e k treatment. Getting  scared.  M a n y of the participants d e s c r i b e d e x p e r i e n c e s of a c h i e v i n g a b s t i n e n c e , d e c r e a s e d drug u s e , safer drug u s e a n d support s e e k i n g that a p p e a r e d to b e motivated by getting s c a r e d . T h e r e w a s c o n s i d e r a b l e variation in the frightening e x p e r i e n c e s that  41  the participants d e s c r i b e d a n d most of them reported having multiple fears that included being afraid of d a n g e r o u s drugs a n d drug c o m b i n a t i o n s , negative c o n s e q u e n c e s of drug u s e to their health, including d e a t h , negative c o n s e q u e n c e s of drug u s e to their physical a p p e a r a n c e , m e m o r y "blackouts" a n d r e l a p s e . T h e s e f e a r s a p p e a r e d to be important catalysts in finding the strength to m o v e toward m o r e positive health b e h a v i o u r s . S o m e t i m e s e x p e r i e n c e s of fear w e r e u n e x p e c t e d . O n e f e m a l e participant reported that s h e b e c a m e fearful for her health w h e n s h e looked in a mirror a n d s a w her facial a c n e a n d how m u c h weight s h e had lost. H e r fears w e r e reinforced by s e e i n g the s c a b s , a b s c e s s e s , a c n e a n d weight l o s s of her drug using friends. Motivated by t h e s e fears this f e m a l e participant, with a history of three y e a r s of h e a v y injection c o c a i n e u s e , greatly r e d u c e d the amount of c o c a i n e s h e u s e d a n d a l s o c h a n g e d from injecting to mainly s m o k i n g . F r o m a harm reduction perspective r e d u c e d drug u s e a n d s m o k i n g the s a m e s u b s t a n c e instead of injecting it is s e e n a s a positive c h a n g e . T h e fear of relapsing a n d the loss of g a i n s a l r e a d y m a d e in o v e r c o m i n g the addiction a p p e a r e d to a l s o b e a s s o c i a t e d with positive c h a n g e for s o m e participants. O n e f e m a l e participant w h o had m a d e strong gains in stabilizing her life reported that being frightened of relapsing strengthened her resolve to stay a w a y from injection drug use: I k n o w it wouldn't take m u c h . If you d o start u s i n g , then you'll start craving it a n d that s c a r e s m e . . . t h e thought will c r o s s my mind ... A n d I just think " N o . " It's not worth it... I don't want to let myself d o w n .  42  S o m e t i m e s the w a r n i n g s of friends of the participant raised additional f e a r s . O n e f e m a l e participant w h o w a s already fearful about weight l o s s a n d losing her apartment reported that her friends kept telling her s h e w a s going to die if s h e kept o n injecting drugs. F e a r of d y i n g , a d d e d to her other fears, motivated her to enter a detoxification facility. S o m e of the participants reported fearing for others a s well a s t h e m s e l v e s . F o r e x a m p l e , o n e m a l e participant, w h o w a s on a m e t h a d o n e program but e x p e r i e n c i n g r e l a p s e s , reported that he w a s extremely fearful for the health of his wife, w h o a l s o u s e d illicit d r u g s , a n d that this had motivated him to begin the p r o c e s s of quitting drug u s e . S u p p o r t s e e k i n g behaviour w a s a l s o a s s o c i a t e d with being frightened. O n e f e m a l e participant, w h o w a s not injecting drugs at the time of the study interview, d e s c r i b e d being extremely frightened after friends told her s h e had b e e n m i s s i n g for a n u m b e r of d a y s a n d realizing s h e h a d no m e m o r y of w h e r e s h e h a d b e e n or what s h e h a d b e e n d o i n g . T h i s participant w a s motivated by this e x p e r i e n c e to m o v e to a different city w h e r e s h e had friends w h o did not u s e drugs a n d s e e k community supports a s well a s m e d i c a l help for h o m e detoxification. D a t a from the s e r v i c e provider interviews supported the participant reports that being s c a r e d often precipitated support s e e k i n g . T h e s e r v i c e providers s a i d that their clients frequently reported that they had sought support s e r v i c e s b e c a u s e they b e c a m e d e s p e r a t e l y frightened d u e to losing or s p e n d i n g all their m o n e y , pawning or selling all their p o s s e s s i o n s or b e c a u s e they had legal c h a r g e s p e n d i n g . O n e s e r v i c e provider talked about using the fear for personal safety to attract youth into treatment stating, "The biggest carrot is often safety, just plain safety. Their lives are very  43  perilous, very u n s a f e , a n d s o m e t i m e s if you c a n just offer a s a f e p l a c e a w a y from the predators a n d the streets, they'll g r a b onto that." Recognizing  an inner desire to quit.  S o m e of the participants w e r e c o n v i n c e d that a g e n u i n e "inner" d e s i r e to quit drug u s e must be present before they are able to benefit from external support or influences. O n e participant w h o had b e e n through a drug treatment p r o g r a m three times with no apparent effect but w h o eventually had greatly r e d u c e d her drug u s e a n d stabilized her life, apparently without outside support, stated that nothing could h a v e b e e n d o n e differently that would h a v e helped her control her drug u s e s o o n e r : B e c a u s e it's all o n the inside ... A n d w h e n I did finally quit I didn't n e e d to g o to t r e a t m e n t . . . w h e n you want to quit you'll d o it. A n d if you don't want to quit I don't c a r e w h e r e they s e n d you a n d for how long you're not going to quit. It all c o m e s from inside. A n o t h e r participant w h o highlighted the importance of the d e c i s i o n to quit indicated that for her this involved deciding that s h e n e e d e d to stop a n d that s h e w o u l d be " O K " if s h e did stop. T h e fear of not being able to c o p e with life after quitting drug u s e h a s b e e n d i s c u s s e d in an earlier publication b a s e d o n this data (Stajduhar, et a l . , 2000). T h e participants reported that w h e n they quit d r u g s they had to f a c e the r e a s o n s they started using in the first place a s well a s the harm they had d o n e to t h e m s e l v e s a n d to others during their drug u s e . Although the data for this category w a s limited, s o m e of the participants strongly believed that the p e r s o n a l d e c i s i o n to quit drug u s e w a s a key point in being able to s u c c e s s f u l l y follow through o n the d e c i s i o n to quit.  44  Reaching  out for  support.  T h e realization of s o m e of the participants that they n e e d e d help to d e a l with their addiction w a s another mark of beginning to making positive c h a n g e s that reflected i n c r e a s e d resilience. T h i s realization led individuals to s e e k support from m a n y s o u r c e s including c o m m u n i t y a g e n c i e s , medical s e r v i c e s , street n u r s e s , inpatient a n d outpatient detoxification s e r v i c e s , treatment, recovery a n d m e t h a d o n e p r o g r a m s , s u p p o r t e d h o u s i n g a n d counselling a n d psychiatric s e r v i c e s . In contrast, the participants w h o w e r e not at a point in their lives w h e r e they w e r e contemplating positive c h a n g e t e n d e d not to s e e k support for e v e n their b a s i c medical n e e d s : M y w h o l e time is locked up getting coin together. I've got a lot of health i s s u e s myself that n e e d to be dealt with a n d I can't just get around to it right n o w a n d I can't s e e it getting a n y better until I c a n kick [drugs]. F o r t h o s e participants w h o sought support, being treated a s a v a l u a b l e h u m a n b e c a m e a catalyst for c h a n g e . R e l a t i o n s h i p s of trust, in particular, w e r e attributed great v a l u e by the participants. T h e y d e s c r i b e d s p e c i a l individuals w h o they felt they could turn to b e c a u s e that person k n e w t h e m well, w a s non-judgemental, a n d w o u l d g o to great lengths to help them on a n o n g o i n g b a s i s . T h e s e kinds of relationships s o m e t i m e s g r e w out of contacts with their medical practitioner, other times it w a s their m e t h a d o n e doctor or an outreach nurse or a staff m e m b e r at a c o m m u n i t y a g e n c y . M a n y of the participants sought community supports that had a spiritual c o m p o n e n t but it is not c l e a r from the data that it w a s the spiritual c o m p o n e n t that attracted or h e l p e d them or the non-spiritual supportive s e r v i c e s that w e r e offered.  45  T h e r e w e r e no apparent a c c e s s barriers to t h o s e w h o did not h a v e similar beliefs or did not want to b e involved in religious o r spiritual activities. A w a r m supportive family environment a n d a n interested a n d involved parent are reported in the literature to be protective factors that bolster resilience ( G a r m e z y , 1 9 9 1 ; W e r n e r & J o h n s o n , 2004). F a m i l y support w a s mentioned m u c h l e s s frequently by the study participants than community support w a s , however, s o m e participants reported that they did a c c e s s family support. A t e e n a g e participant d e s c r i b e d the positive effect the continued involvement of her family in her life had stating, " F o r m e the difference b e t w e e n using a n d not using is having them [her family] in my life." S e r v i c e providers a g r e e d that family support w a s very important a n d that family m e m b e r s often provided the r e s o u r c e s , e n e r g y a n d motivation to d e a l with the addiction a n d that, generally, youth w h o could maintain contact with their family w e r e better off than youth w h o did not h a v e contact with their family. T h e importance of family w a s illustrated by o n e adult f e m a l e participant w h o did not h a v e family support w h e n s h e first d e c i d e d to abstain from drug u s e . T h i s participant knew s h e n e e d e d s o m e thing to c a r e for a n d constructed a p s e u d o family situation for herself, "I got myself a kitten, a n d clung to her ... s h e w a s my r e a s o n for staying c l e a n , b e c a u s e if I started using a g a i n I w o u l d e n d up losing her." T h e w a y s of "getting to the point" of m a k i n g c h a n g e that h a v e b e e n d i s c u s s e d d e s c r i b e how s o m e of the participants constructed their ability to m a r s h a l the strength a n d help they n e e d e d to begin the long road to abstaining or s a f e r drug u s e . O t h e r participants d e s c r i b e d wanting more, not only to control or e s c a p e their addiction but a l s o to realize a better future.  46  Envisioning  A Better  Future  A n o t h e r w a y that s o m e participants constructed their e x p e r i e n c e s that a p p e a r e d to be a s s o c i a t e d with a n i n c r e a s e in resilience w a s reflected in the category of " E n v i s i o n i n g A Better Future". A s o n e male participant stated, "I f u c k e d up for 3 0 y e a r s of my life ... let's try a n d m a k e the next 30 better than the last 30." T w o f e m a l e participants w e r e a b l e to articulate a specific future g o a l , w h i c h w a s finishing high s c h o o l . Both of t h e s e participants had started drug u s e in their mid t e e n s a n d after being involved for only a few y e a r s had taken significant s t e p s to either stop or a l m o s t stop their drug u s e . O n e of t h e s e participants d e s c r i b e d her vision of b e i n g a n o u t r e a c h w o r k e r after completing high s c h o o l . Other participants, while apparently lacking specific g o a l s , e x p r e s s e d a g e n e r a l vision of a different, more positive life. A s o n e participant stated, "I want to get m o r e things g o i n g o n in m y life, m o r e positive things." Unlike the conceptualization of cognitive transformation d e s c r i b e d by T e b e s et al. (2004), the participants in this study continued to s e e their past e x p e r i e n c e s a s negative. H o w e v e r , for s o m e of the participants wanting m o r e from life a p p e a r e d to b e a s s o c i a t e d with arriving at a n e w a c c e p t a n c e of self. O n e m a l e participant, o n m e t h a d o n e at the time of the interview, stated he w a n t e d to c h a n g e his life a r o u n d a n d that, " T h e r e isn't a d a y that I've w o k e n up a n d s a i d , O h I'm h a p p y that I'm a n addict. T h e fact is that I a m a n addict. S o I h a v e to d e a l with that". T h e s e r v i c e provider data supported the view that having a vision of the future a n d g o a l s to work t o w a r d s w a s a s s o c i a t e d with positive behavioural c h a n g e in the injection drug using population. T h e y e n c o u r a g e d their clients e v e n while still actively using drugs to find a vision of the future a n d g o a l s to work towards. O n e s e r v i c e  47  provider d e s c r i b e d the s u c c e s s e s a c h i e v e d in e n h a n c i n g work r e a d i n e s s a n d selfe s t e e m by having individuals still actively involved in their addiction volunteer to work in a n inner city lunch program. S o m e of the participants d e s c r i b e d attitudinal a n d behavioural c h a n g e s that involved n e w h o p e for a different a n d better future, a n e w vision of t h e m s e l v e s a s n o n drug u s e r s a n d for a few, specific g o a l s for the future. T h e s e c h a n g e s m a y be v i e w e d a s similar to the transformative c h a n g e s d e s c r i b e d by T e b e s et a l . (2004) a n d be s e e n a s indicative of a n i n c r e a s e in resilience. Experiences  Associated  With Decreased  Resilience  A l t h o u g h most participants d e s c r i b e d e x p e r i e n c e s a s s o c i a t e d with both i n c r e a s e s a n d d e c r e a s e s in resilience, a few participants d e s c r i b e d only e x p e r i e n c e s a s s o c i a t e d with d e c r e a s e s in resilience. T h e s e participants w e r e f o c u s e d o n the m a n y types of pain in their past a n d current life a n d their attempts to dull or e s c a p e the pain of their e x i s t e n c e . Their feelings of h o p e l e s s n e s s w e r e a chief characteristic of their stories. T h e s e e x p e r i e n c e s w e r e captured under the category " N e e d i n g T o Dull T h e Pain". Needing  To Dull The Pain  E x p e r i e n c e s of pain a p p e a r e d to i n c r e a s e the vulnerability of s o m e participants to initiation of drug u s e , continued drug u s e , u n s a f e drug u s e practices a n d r e l a p s e . A l t h o u g h there w e r e m a n y s o u r c e s of physical pain a s s o c i a t e d with injection drug u s e (systemic infections, local a b s c e s s e s , e x p o s u r e to inclement weather, beatings) the primary s o u r c e of pain d e s c r i b e d by participants w a s emotional, including feeling h o p e l e s s that their lives w o u l d e v e r improve.  48  T h e emotional pain d e s c r i b e d by the participants a r o s e from a variety of traumatic e x p e r i e n c e s . O n e major s o u r c e reported by participants w a s a history of childhood s e x u a l a b u s e . S o m e of the participants told horrific stories of long-term a b u s e a n d being introduced into the s e x trade a n d the drug world by their parents. A n o t h e r s o u r c e of pain that e m e r g e d from the data w a s untreated mental health p r o b l e m s . T h e s e r v i c e providers reported that a large n u m b e r of their clients w e r e particularly vulnerable to addiction d u e to mental health i s s u e s , including d e p r e s s i o n a n d foetal a l c o h o l s y n d r o m e . F e e l i n g s of alienation from both family a n d c o m m u n i t y w e r e a l s o a frequently reported s o u r c e of emotional pain. A lack of h o p e that their lives could improve p e r m e a t e d the stories of t h e s e participants. T h e participants reported using illicit drugs in order to dull the emotional pain of past a n d o n g o i n g p h y s i c a l , emotional a n d s e x u a l a b u s e a s well a s the feeling of n e v e r belonging or being a part of any community. Unfortunately, using illicit d r u g s to e a s e the pain a p p e a r e d to lead the participants into street life a n d s e x trade work a n d a n escalating n e e d to self-medicate. In fact, a s o n e s e r v i c e provider d e s c r i b e d , it a p p e a r e d to m a k e their lives w o r s e : T h e y just want to feel loved a n d they want to feel a part of a n d they want to feel like they're g o o d e n o u g h for s o m e t h i n g . S o , I think to gain that feeling they will put t h e m s e l v e s at risk in other w a y s ... to feel g o o d ... they will give s o m e t h i n g up a n d that could be their safety, that could be being s o l o a d e d that they just don't c a r e . They'll d o another hit with s o m e b o d y ' s n e e d l e o r they'll s l e e p with s o m e b o d y or whatever.  49  A n o t h e r s o u r c e of pain w a s the emotional trauma that o c c u r r e d while i n c a r c e r a t e d . M a n y of the participants had s e r v e d s e n t e n c e s in correctional facilities. A s e r v i c e provider stated that m a n y of the inmates d o not h a v e the c o p i n g m e c h a n i s m s to deal with this trauma a n d s o they, "go into prison, never d o n e heroin before, but w h e n they c o m e out they're addicted". S o m e of the participants s p o k e of controlling their drug u s e at a minimal level for e x t e n d e d periods of time or quitting drug u s e completely until a n u n e x p e c t e d a d v e r s e event, s u c h a s a d e p r e s s i o n or incarceration, o c c u r r e d . Without a d e q u a t e c o p i n g skills, t h e s e e v e n t s left t h e m vulnerable to drug u s e . O n e f e m a l e participant e x p l a i n e d that s h e would be more likely to relapse if "life is going d o w n , it's shitty [and] y o u h a v e no w h e r e to live or nothing's h a p p e n i n g " . A n o t h e r f e m a l e participant s a i d that s h e returned to drugs w h e n her boyfriend went to jail. E v e n long-term a b s t i n e n c e c o u l d be u n d e r m i n e d by a n a d v e r s e event, a s w a s the c a s e with o n e m a l e participant w h o w a s drug free for five y e a r s before relapsing after taking pain medication for a b a c k injury. T h e s e r v i c e providers stated that b e c o m i n g addicted w a s a s s o c i a t e d with both the addictive quality of the drug u s e d and a lack of personal r e s o u r c e s a n d s u p p o r t s to k e e p the drug u s e under control. M a n y service providers postulated that the pain of low s e l f - e s t e e m w a s the k e y i s s u e that i n c r e a s e d vulnerability to addiction. O n e s e r v i c e provider e x p l a i n e d : If y o u don't feel very g o o d about yourself, you just don't bother taking c a r e of yourself. If you don't believe you d e s e r v e to take c a r e of yourself. T h e r e ' s no p u r p o s e for tomorrow. It doesn't matter. It can't get a n y w o r s e .  50  Summary T h e primary aim of this s e c o n d a r y study w a s to d e s c r i b e resilience from the perspective of t h o s e w h o u s e illicit injection drugs. Interviews with individuals w h o u s e d illicit injection drugs s e r v e d a s a primary s o u r c e , and w h e r e a p p l i c a b l e , interview d a t a from s e r v i c e providers w a s u s e d to c o m p l e m e n t data obtained from the IDU interviews. T w o t y p e s of participant e x p e r i e n c e s w e r e a s s o c i a t e d with a n i n c r e a s e in resilience, "Getting T o T h e Point" a n d "Envisioning A Better Future". T h e participants reported e x p e r i e n c e s of getting to the point of making positive c h a n g e in the following w a y s , " R e c o g n i z i n g It's Not Worth It", "Getting S c a r e d " , R e c o g n i z i n g A n Inner D e s i r e T o Quit" and " R e a c h i n g Out F o r Support". " N e e d i n g T o Dull the P a i n " of both the past a n d the present and a n a b s e n c e of hope for the future w a s a s s o c i a t e d with a d e c r e a s e in resilience. T h e first two types of e x p e r i e n c e s w e r e a s s o c i a t e d with support s e e k i n g a n d quitting, d e c r e a s i n g and safer drug u s e while the third type of e x p e r i e n c e w a s a s s o c i a t e d with initial drug u s e , continued drug u s e , unsafe drug u s e a n d r e l a p s e . B y c o n c e p t u a l i z i n g t h e s e efforts a s part of the p r o c e s s of increasing or d e c r e a s i n g resilience, a n a l y s i s of the data resulted in i n c r e a s e d k n o w l e d g e of the participants' e x p e r i e n c e s that could be linked to c h a n g e s in resilience.  51  CHAPTER 5 Discussion T o my k n o w l e d g e this w a s the first study to explore resilience from the perspective of individuals w h o inject illicit drugs. K e y findings included w a y s that individuals constructed their e x p e r i e n c e s that led t h e m to marshalling the strength a n d help they n e e d e d to begin the long road to quitting, reducing a n d safer drug u s e . In contrast, at other times in their lives, the n e e d to a d d r e s s the pain they e x p e r i e n c e d a p p e a r e d to i n c r e a s e vulnerability to continued or i n c r e a s e d u s e of d r u g s , a n d deter individuals from considering any other option. B y c o n c e p t u a l i z i n g t h e s e efforts a s part of the p r o c e s s of increasing or d e c r e a s i n g resilience, the findings of this study extend the w a y s in w h i c h f r a m e w o r k s of resilience have b e e n applied to this population. In this chapter, I d i s c u s s the findings a n d limitations of the study a n d the implications for future research. Resilience  In Populations  In the Process  of  Recovery-  There are discrepant v i e w s in the literature c o n c e r n i n g e v i d e n c e of resilience in populations experiencing problems s u c h a s addiction or mental illness (Brown & Kulig, 1996; Miller, 2 0 0 3 ; R o i s m a n , 2 0 0 5 ; Rutter, 1993; W e r n e r , 1989). T h e findings of this study lend support to the claim that resilience c a n be d e m o n s t r a t e d in populations w h o are in the p r o c e s s of recovery (Brown & Kulig; Miller; R o i s m a n ) . All of the participants in the study s p o k e of e x p e r i e n c e s in their lives that involved behavioural a n d attitudinal c h a n g e s c o n c e r n i n g their drug u s e that w a s c o n c e p t u a l i z e d a s c h a n g e s in resilience. R e s i l i e n c e w a s d e m o n s t r a t e d in spite of their struggle with addiction a n d the difficult  52  c i r c u m s t a n c e s , including poverty, marginalization, u n d e r - h o u s i n g , u n e m p l o y m e n t , illness, d i s e a s e a n d barriers to health c a r e that characterized their e x i s t e n c e . Resilience  As A Dynamic  Process  S t u d y findings extend our understanding of resilience a s a relative a n d d y n a m i c p r o c e s s a s c o n c e p t u a l i z e d by Horowitz (1987). T h e c o n c e p t of multiple points of c h a n g e in a n individual's level of resilience is included in s e v e r a l of the p r o c e s s m o d e l s of resilience. Horowitz included the c o n c e p t of "points of reorganization", Rutter (1993) d e s c r i b e d "key turning points" a n d F l a c h (1988) referred to 'bifurcation points'. T h e findings from this study s u g g e s t that there are multiple w a y s that behavioural a n d attitudinal c h a n g e s m a y influence resiliency. M a n y of the participants s p o k e of h o w they got to the point of making positive c h a n g e s in their lives that h e l p e d t h e m a b s t a i n or d e c r e a s e their drug u s e , begin to p a y attention to their health, o r e n g a g e in h a r m reduction strategies, w h e r e a s at other times individuals talked of difficult times that m a r k e d c h a n g e s that i n c r e a s e d their vulnerability to continued drug u s e . T h e s e findings s u g g e s t that it m a y be important to identify individuals w h o are ready to m a k e c h a n g e s in their lives a n d tailor s e r v i c e s to either support their efforts to m a k e positive c h a n g e or d e c r e a s e their vulnerability to making negative c h a n g e by providing alternatives to a d d r e s s e x p e r i e n c e s of pain. Resilience  and A Transformed  World  View  Participant reports of non-drug related future g o a l s a n d plans w a s c o n c e p t u a l i z e d a s a n indicator of a transformed world view that w a s indicative of i n c r e a s e d resilience. W h i l e m a n y of the participants e x p r e s s e d the d e s i r e to quit drug u s e only a few reported future plans a n d g o a l s that involved a life free of addiction.  53  T h e s e findings are similar to the construct d e v e l o p e d by T e b e s et a l . (2004) in w h i c h transformation is v i e w e d a s a turning point, marking a n altered world view w h e r e i n n e w opportunities are r e c o g n i z e d . Unlike the construct of T e b e s et a l . , the participants did not reconstruct their past e x p e r i e n c e s a s positive a n d growth-promoting. H o w e v e r , participants a p p e a r e d to gain a n e w a c c e p t a n c e of t h e m s e l v e s a n d a n e w s e n s e of their self worth in spite of past mistakes. S e v e r a l of the multi-stage p r o c e s s m o d e l s of resilience include a s t a g e that h a s similarities to t h e s e e x p e r i e n c e s of a transformed world view. T h e model of R i c h a r d s o n et a l . (1990) includes a s t a g e c h a r a c t e r i z e d by growth of self-understanding resulting in i n c r e a s e d resilience. Rutter's (1993) m o d e l includes a third s t a g e of resilience involving a n i n c r e a s e in s e l f - e s t e e m a n d self-efficacy while his fourth stage is c h a r a c t e r i z e d by the o p e n i n g up of n e w opportunities or a n e w world v i e w that is indicative of the highest level of resilience. B r o w n a n d K u l i g ' s (1996) model includes a s e c o n d , proactive s t a g e involving positive adaptation a n d transformation a s indicators of not only bouncing back to the former s t a g e of resilience but b e c o m i n g e v e n more resilient than before. Protective  Factors  T h e findings of this study s u g g e s t that s o m e of the protective factors identified a s related to resilience in other populations m a y a l s o be related to resilience in the illicit injection drug using population. D i s c u s s i o n of protective factors will be divided into the c a t e g o r i e s of individual, family a n d community a s p r o p o s e d by G a r m e z y (1991). Individual Protective  Factors  Twenty-eight protective factors w e r e identified in a review of the literature o n resilience (Carbonell et a l . , 2 0 0 2 ; F i n e , 1 9 9 1 ; G a r m a z y , 1 9 9 1 ; J a c e l o n , 1 9 9 7 ; M a s t e n ,  54  1994; P a t t e r s o n , 2 0 0 0 ; T u s a i e a n d Dyer, 2 0 0 4 ; W e r n e r , 1989; W e r n e r & J o h n s o n , 2 0 0 4 ; W e r n e r & S m i t h , 1982). In this study 15 of the 2 8 protective factors e m e r g e d from the stories of participants a s being related to e x p e r i e n c e s that w e r e a s s o c i a t e d with positive c h a n g e ( s e e A p p e n d i x C ) . T h e remaining factors m a y not h a v e b e e n r e p r e s e n t e d by the participants in the study for a variety of r e a s o n s . T h i s m a y be partially d u e to the s i z e of the s a m p l e but p e r h a p s more importantly the fact that this w a s a s e c o n d a r y a n a l y s i s a n d specific questions about individual protective factors w e r e not a s k e d . It is a l s o possible the remaining protective factors hold l e s s r e l e v a n c e to explaining resiliency a m o n g t h o s e w h o inject illicit d r u g s . T h e Individual protective factors of a s e n s e of self worth, a s e n s e of p u r p o s e , h o p e f u l n e s s a n d optimism characterized the stories of t h o s e participants w h o w e r e d e c r e a s i n g their drug u s e or e n g a g i n g in harm reduction practices. In the literature o n resilience a positive s e n s e of self (Carbonell et a l . , 2 0 0 2 ; M a s t e n , 1994; P a t t e r s o n , 2 0 0 0 ; S o w e l l et a l . , 2 0 0 0 ; S t e i n et a l . , 1998; W e r n e r , 1 9 8 9 ; W e r n e r & S m i t h , 1982) h o p e a n d a s e n s e of p u r p o s e (Werner) a n d optimism (Carbonell et a l . ; M a s t e n ; P a t t e r s o n ; W e r n e r & Smith) are identified a s significant to resilience in a d o l e s c e n t s with d e p r e s s i o n , w o m e n w h o h a v e b e e n d i a g n o s e d with HIV, high risk children in y o u n g adulthood, adult children of a l c o h o l i c s a n d families. T w o additional individual protective factors, identified in the literature by T u s a i e a n d D y e r (2004) that e m e r g e d f r o m the d a t a of this study w e r e c o p i n g strategies a n d social skills. Barriers to health c a r e s e r v i c e s created by the lack of t h e s e factors w e r e often apparent a n d a p p e a r e d to be related to another protective factor identified by W e r n e r (1989) the ability to elicit a  55  positive r e s p o n s e from others. Findings from this study support previous r e s e a r c h that t h e s e protective factors a r e related to resilience. Family and Community  Protective  Factors  A l t h o u g h in this study family protective factors w e r e m u c h l e s s evident than c o m m u n i t y protective factors, findings s u g g e s t that both are important a s p r o p o s e d by G a r m e z y (1991) a n d W e r n e r (1989) a n d W e r n e r a n d Smith (1982). R e a s o n s for the lack of data on family protective factors in this study m a y be related to the study d e s i g n a n d the characteristics of the s u b s t a n c e a b u s i n g population itself w h i c h tend to be alienated from family. N e v e r t h e l e s s , the importance of community or extrafamilial support s u g g e s t e d by G a r m e z y a n d W e r n e r a s well a s Monteith a n d F o r d - G i l b o e , (2002) a n d Tuttle et a l . (2004) w a s s u g g e s t e d in this study by the high v a l u e s o m e participants p l a c e d o n relationships of trust with s e r v i c e providers a n d h o w t h e s e relationships w e r e related to positive c h a n g e . M a r s h a n d D a l e (2005) s u g g e s t that feeling cut off from the rewards afforded by s c h o o l , work, p e r s o n a l relationships a n d other more conventional s o u r c e s of support a p p e a r to i n c r e a s e vulnerability to s u b s t a n c e m i s u s e . T h e findings of this study illustrate the importance of a c c e s s to community r e s o u r c e s a s s u g g e s t e d by W e r n e r (1989) a n d G a r m e z y (1991) a s well a s the negative c o n s e q u e n c e s of barriers to community resources. Resilience  and Context  Specificity  T h e findings of this study provide a n important beginning to extending u n d e r s t a n d i n g of the context specificity of protective factors a s d e s c r i b e d by J o h n s o n a n d W i e c h e l t (2004) w h o stated that resilience should be v i e w e d using a holistic  56  framework that includes the contexts of a g e a n d d e v e l o p m e n t a l s t a g e , family history, social c l a s s , ethnicity, g e n d e r a n d c h a n g e o v e r time. F o r e x a m p l e , a n a g g r e s s i v e a p p e a r a n c e a n d m a n n e r in the illicit drug using community m a y elicit the positive r e s p o n s e of being left u n m o l e s t e d w h e r e a s in the non-drug community it m a y elicit a negative r e s p o n s e creating barriers to s e r v i c e . Alternately, s o m e of the creativity a n d adaptability d e v e l o p e d to survive life o n the street m a y b e transferred to n o n - d r u g settings. T h e findings support the r e c o m m e n d a t i o n of J o h n s o n a n d W i e c h e l t to e x p l o r e protective factors in specific contexts. Drug Misuse  To Dull Emotional  Pain  T h e findings s u g g e s t that m a n y participants u s e illicit d r u g s to dull their emotional pain. A l t h o u g h participants reported both physical a n d emotional p a i n , the emotional pain c a u s e d by past a n d current s e x u a l , p h y s i c a l a n d emotional a b u s e , mental health problems a n d alienation a n d marginalization a p p e a r e d to play a larger role. T h e s e findings lend support to previous studies on the relationship of s u b s t a n c e m i s u s e to family v i o l e n c e ( H e i n z e r & K r i m m , 2 0 0 2 ; Martin, 2 0 0 2 ) , s e x u a l a b u s e ( B r e m s , J o h n s o n , N e a l & F r e e m a n , 2004) mental health problems ( A d a m s et a l . , 2 0 0 4 ; C a r b o n e l l et a l . , 2 0 0 2 ; Miller & C h a n d l e r , 2 0 0 2 ; P u b l i c Health A g e n c y , 2 0 0 5 ) a n d marginalization a n d alienation (van V o o r h i s , 1 9 9 8 ; Z e r w e k h , 2 0 0 0 ) . Further, the findings support Hall's (1999) belief in the reality of pain for the marginalized in the p o s t m o d e r n world in w h i c h marginalized populations, s u c h a s t h o s e w h o u s e illicit d r u g s , are without p o w e r or v o i c e . T h e findings of this study extend understanding of the negative effects of the s o c i o e c o n o m i c a s p e c t s of addiction that are not within the control of the individual.  57  U n d e r - h o u s i n g , u n e m p l o y m e n t , malnutrition a n d lack of e d u c a t i o n a n d job skills are c o m m o n i s s u e s of p e o p l e w h o live in poverty a n d are marginalized (Ferrar & P a l m e r , 2 0 0 4 ; R e w et a l . , 2 0 0 2 ; V a n d u , 2003). T h e findings indicate t h e s e i s s u e s not only c o exist with addiction but support R o o m ' s (2005) contention that alienation, marginalization a n d poverty i n c r e a s e vulnerability to s u b s t a n c e m i s u s e a n d n e e d to be factored into health care strategies. H o p e is r e c o g n i z e d a s a protective factor in the literature o n resilience (Aronwitz & M o r r i s o n - B e e d y , 2 0 0 4 ; W e r n e r , 1989), but the findings of this study indicate that m a n y of the participants felt trapped in their addiction with little opportunity of e s c a p e . T h e lives of m a n y of the participants in this study w e r e c h a r a c t e r i z e d by illness, d i s e a s e a n d encountering barriers to community r e s o u r c e s that a d v e r s e l y affected their c a p a c i t y for positive adaptation to life's c h a l l e n g e s . In addition they l a c k e d the v o i c e to h a v e their e x p e r i e n c e s heard and the power to provide input into political, s o c i a l a n d health c a r e policy d e c i s i o n s that c o n c e r n e d their welfare. Implications  of the  Study  T h e r e are implications for r e s e a r c h a n d for education a n d practice interventions. Additional r e s e a r c h is warranted to i n c r e a s e k n o w l e d g e of the c o n c e p t of resilience in the injection drug using population a n d to determine if protective factors, identified a s significant to resilience in the general population, are related to resilience in the injection drug using population. T h e findings of this s e c o n d a r y a n a l y s i s d e m o n s t r a t e the potential for a primary study f o c u s i n g specifically o n resilience from the p e r s p e c t i v e of t h o s e individuals w h o inject illicit s u b s t a n c e s . A s a starting point, r e s e a r c h e r s could  58  e x a m i n e e x p e r i e n c e s related to getting to the point of positive c h a n g e that a p p e a r to be important from the perspective of individuals w h o inject illicit drug including 1) o b s e r v i n g the harmful effects of illicit drug u s e o n self a n d o n others, 2) fear of the negative c o n s e q u e n c e s of drug u s e , 3) support s e e k i n g , a n d 4) envisioning a better future for oneself. Additionally, b a s e d on the findings of this study there is likely to be benefit in studying in greater depth the negative effects o n resilience including 1) drug m i s u s e for the p u r p o s e of dulling emotional pain, 2) lack of individual a n d family protective factors, 3) barriers to c o m m u n i t y protective factors a n d the health determinants, a n d 4) s o c i o e c o n o m i c status a n d a s s o c i a t e d feelings resulting from alienation, marginalization a n d h o p e l e s s n e s s . B e c a u s e resilience is context d e p e n d e n t ( J o h n s o n a n d W i e c h e l t (2004); T u s a i e & Dyer, 2 0 0 4 ) s a m p l i n g f r a m e s for future studies should be d e s i g n e d to e n a b l e a n a l y s e s of influencing factors o n resilience s u c h a s s e x , a g e , d e v e l o p m e n t a l s t a g e , family history, s o c i o e c o n o m i c status, ethnicity, a g e of first drug u s e a n d time s i n c e first drug u s e . S t u d y s a m p l e s should a l s o include t h o s e w h o h a v e a b s t a i n e d from d r u g s for a lengthy period of time to determine what protective factors a n d p r o c e s s e s c h a r a c t e r i z e this group. Further r e s e a r c h is a l s o indicated to i n c r e a s e k n o w l e d g e of the e f f e c t i v e n e s s of e d u c a t i o n a n d intervention strategies that include fostering of protective factors in t h o s e that are involved in s u b s t a n c e a b u s e . All protective factors identified in the literature s h o u l d be included in future r e s e a r c h , however, the findings of this study indicate the n e e d for future r e s e a r c h on coping m e c h a n i s m s , s o c i a l skills, self e s t e e m , the ability to elicit a positive r e s p o n s e from others, s e n s e of p u r p o s e , a r e a s of a c c o m p l i s h m e n t ,  59  d e c r e a s i n g feelings of alienation from family a n d community a n d facilitating a positive world view. Further r e s e a r c h is indicated to evaluate the effectiveness of e d u c a t i o n a l interventions that include a resilience c o m p o n e n t . P r o g r a m s that c o m b i n e risk a n d resilience b a s e d interventions h a v e b e e n favourably c o m p a r e d to t h o s e that are limited to health information programs that f o c u s exclusively o n risk ( B r o w n , 2 0 0 1 ; L i n d e n b e r g et a l . , 2002). In this study the participants s p o k e of their e x p e r i e n c e s of building protective factors s u c h a s a s e n s e of p u r p o s e a n d of self-worth, h o p e f u l n e s s , s o c i a l skills, c o p i n g strategies a n d a r e a s of talent a n d a c c o m p l i s h m e n t through job training, volunteer a n d recreational activities that provided e x p e r i e n c e s for the drug u s e r outside the drug using community. Limitations T h e major limitation of s e c o n d a r y studies is that the original study w a s not d e s i g n e d to collect information on the s e c o n d a r y r e s e a r c h question (Hinds et a l . , 1997). H o w e v e r , the interview guide of the original study contained q u e s t i o n s that f o c u s e d on protective b e h a v i o u r s relevant to resilience a n d the study participants w e r e , for the most part, given the opportunity to "tell their story". T h e principal r e s e a r c h e r of this study took part in the original study a s a m e m b e r of the a n a l y s i s t e a m a n d a s a n interviewer for s o m e of the key informant service provider interviews a n d a facilitator for two of the s e r v i c e provider f o c u s groups. T h i s is both a potential strength b e c a u s e the r e s e a r c h e r h a s s p e c i a l k n o w l e d g e of the original study that m a y result in meaningful insights a n d a potential limitation a s the r e s e a r c h e r m a y be b i a s e d by her previous experience.  60  O t h e r p o s s i b l e limitations are c o n n e c t e d to the original study. T h e s a m p l e s i z e w a s relatively small a n d it is a c c e p t e d that no a g e o r culture specific c o m p a r i s o n s c o u l d be m a d e . H o w e v e r , d e m o g r a p h i c a n d drug a n d d i s e a s e related information collected via t h e questionnaire w e r e u s e d to d e s c r i b e the s a m p l e a n d to contextualize findings. T h e subject matter of the interviews w a s directly related to b e h a v i o u r s that are illegal a n d possibly involved feelings of s h a m e a n d e m b a r r a s s m e n t . In addition, most of the interviewers w e r e relatively i n e x p e r i e n c e d . T h e influence of t h e s e factors o n the data collected w a s minimized in s e v e r a l w a y s . Efforts w e r e m a d e to e n h a n c e participant comfort with interviews b y using interviewers w h o w e r e a l r e a d y k n o w n a n d trusted, ensuring that information w a s kept confidential a n d removing all identifiers from the transcripts. Interviewers w e r e provided with extensive training e m p h a s i z i n g t h e i m p o r t a n c e of a respectful, non-judgemental attitude. Conclusions Illicit injection drug u s e is a daunting health a n d s o c i a l p r o b l e m that calls for a multifaceted r e s p o n s e . R e s i l i e n c e - b a s e d strategies are p r o p o s e d a s a n important adjunct to the current a b s t i n e n c e , law enforcement a n d risk b a s e d policies a n d interventions that h a v e b e e n d e v e l o p e d to a d d r e s s this issue. T h i s study h a s b e e n the first to explore resilience in the context of injection drug u s e a n d supports t h e contention that resilience is a d y n a m i c p r o c e s s that c a n b e d e m o n s t r a t e d in t h o s e w h o are in the p r o c e s s of recovery from addiction. M a n y of the protective factors identified in the literature a s a s s o c i a t e d with resilience in other populations c a n a l s o b e d e m o n s t r a t e d in the context of injection drug u s e . T h e s e protective factors include h o p e , o p t i m i s m , a s e n s e of p u r p o s e a n d self-worth, c o p i n g strategies, s o c i a l skills, the  61  ability to elicit a positive r e s p o n s e from others, a r e a s of a c c o m p l i s h m e n t a n d a c c e s s to family a n d community support. D e c r e a s e d resilience w a s a s s o c i a t e d with using illicit drugs to dull the emotional pain c a u s e d by p h y s i c a l , s e x u a l a n d emotional a b u s e , mental illness, marginalization, alienation, h o p e l e s s n e s s a n d a lack of individual, family a n d c o m m u n i t y protective factors. A s the findings of this study indicate that the participants w h o u s e d injection drugs lived in a d v e r s e s o c i o e c o n o m i c conditions a n d e x p e r i e n c e d marginalization a n d barriers to health s e r v i c e s , the c o p i n g strategies fostered by r e s i l i e n c e - b a s e d interventions should include a d v o c a c y skills a n d other m e a n s of gaining a v o i c e to h a v e their e x p e r i e n c e s h e a r d a n d to influence the s o c i a l , political, e c o n o m i c a n d health c a r e policy d e c i s i o n s that effect their lives. Future r e s e a r c h using primary data is implicated to i n c r e a s e k n o w l e d g e of resilience in the context of injection drug u s e a n d to evaluate intervention strategies that foster protective factors for the p u r p o s e of strengthening resilience in this vulnerable population.  62  REFERENCES A d a m s , K. B., S a n d e r s , S . , & A u t h , E . A . (2004). 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Retrieved J u n e 4 , 2 0 0 5 , from http://search.epnet.com/login.aspx?direct=true&db=aph&an=10324278  P i l o w s k y , D. J . , Zybert, P. A . , & V l a h o v , D. (2004). Resilient children of injection drug u s e r s . Journal of the American Academy of Child & Adolescent Psychiatry, 43, 1372-1379. Polit, D. F., & Hungler, B. (1995). Nursing  research.  N e w Y o r k : Lippincott.  P u b l i c Health A g e n c y of C a n a d a . (2004). H I V / A I D S a m o n g injecting drug u s e r s in C a n a d a . R e t r i e v e d O c t o b e r 8, 2 0 0 5 , from http://www.phac-aspc.gc.ca/publicat /epiu - a e p i / e p i _ u p d a t e _ m a y _ 0 4 / 1 1 _ e . h t m l P u b l i c Health A g e n c y of C a n a d a . (2005). H a r m reduction a n d injection drug u s e : A n international comparative study of contextual factors influencing the d e v e l o p m e n t a n d implementation of relevant policies a n d p r o g r a m s . R e t r i e v e d O c t o b e r 5, 2 0 0 5 , from http://www.phac-aspc.gc.ca/hepc/hepatitis c/pdf/harm reduction_ e/intro.html R e w , L. (2003). A theory of taking c a r e of o n e s e l f g r o u n d e d in e x p e r i e n c e s of h o m e l e s s youth. Nursing Research, 52, 2 3 4 - 2 4 1 . Retrieved J u n e 4 , 2 0 0 5 , from http://search.epnet.com/login.aspx?direct=true&db=aph&an=10324278 R e w , L , C h a m b e r s , K., & Kulkarni, S . (2002). P l a n n i n g a s e x u a l health promotion intervention with h o m e l e s s a d o l e s c e n t s . Nursing Research, 51, 1 6 8 - 1 7 4 . R e t r i e v e d J u n e 9, 2 0 0 5 , from http://gateway.ut.ovid.com/gw1/ovidweb.cgi R e w , L , T a y l o r - S e e h a f e r , M . , T h o m a s N. Y . , & Y o c k e y , R. D. (2001). C o r r e l a t e s of resilience in h o m e l e s s a d o l e s c e n t s . Journal of Nursing Scholarship, 33, 3 3 - 4 0 . 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S t i g m a , s o c i a l inequality a n d alcohol a n d drug u s e . Drug and Review, 24, 1 4 3 - 1 5 5 . Retrieved J u n e 9, 2 0 0 5 , from http://search.epnet.com/login.aspx?direct=true&db=aph&an=17835341 Rutter, M . (1993). R e s i l i e n c e : S o m e conceptual considerations. Journal Health,14, 6 9 0 - 6 9 6 .  of  Alcohol  Adolescent  S a a b , B. R., C h a a y a , M . , Doumit, M . , & F a r h o o d , L. (2003). Predictors of p s y c h o l o g i c a l distress in L e b a n e s e h o s t a g e s of war. Social Science and Medicine, 57, 1 2 4 9 1257. Retrieved S e p t e m b e r 2 5 , 2 0 0 5 , from http://www.sciencedirect.com/science? ob=Mlmg& i m a g e k e v = B 6 V B F 47T893R-7S a n d a u - B e c k l e r , P . A . , D e v a l l , E . , & d e la R o s a , I. A . (2002). Strengthening family resilience: Prevention a n d treatment for high-risk s u b s t a n c e - a f f e c t e d families. Journal of Individual Psychology, 58, 3 0 5 - 3 3 3 . Retrieved S e p t e m b e r 10, 2 0 0 5 , from http://weblinks2.epnet.com/externalframe.asp?tb=1& ua=bo+B%5F+shn+1+db+ aphjnh S c h u c k i t , M . (1991). A longitudinal study of children of a l c o h o l i c s . In G a l a n t e r , Begleiter, (Ed.), Recent developments in alcoholism: Children of alcoholics 5-19). N e w Y o r k : P l e n u m P r e s s .  (pp.  S e n g , J . (2003). A c k n o w l e d g i n g posttraumatic stress effects o n health: A nursing intervention m o d e l . Clinical Nurse Specialist, 17, 3 4 - 4 1 . Retrieved J u n e 4 , 2 0 0 5 , from http://gateway.ut.ovid.com/gw1/ovidweb.cgi S o w e l l , R., M o n e y h a m , L , H e n n e s s y , M . , Guillory, J . , D e m i , A . , & S e a l s , B. (2000). Spiritual activities a s a r e s i s t a n c e r e s o u r c e for w o m e n with h u m a n i m m u n o d e f i c i e n c y virus. Nursing Research, 49, 7 3 - 8 2 . Retrieved J u n e 9, 2 0 0 4 , from http://gateway.ut.ovid.com/gw1/ovidweb.cgi Stajduhar, K. I., Poffenroth, L., & W o n g , E . (2000). Missed opportunities: Putting a face on injection drug use and HIV/AIDS. Victoria: C a p i t a l Health R e g i o n . Stajduhar, K. I., Poffenroth, L , W o n g , E . , A r c h i b a l d , C . P . , S u t h e r l a n d , D., & R e k a r t , M . (2004). M i s s e d opportunities: Injection drug u s e a n d H I V / A I D S in Victoria, C a n a d a . International Journal of Drug Policy, 15, 171-181. Retrieved September 25, 2005, from http://www.sciencedirect.com/science? ob=Mlmg& i m a g e k e v = B 6 V J X 4BVP9GF-6Starfield, B., R i l e y , A . W . , Witt, W . P . , & R o b e r t s o n , J . (2002). S o c i a l c l a s s gradients in health during a d o l e s c e n c e . Journal of Epidemiology and Community Health, 56,  69  3 5 4 - 6 1 . Retrieved S e p t e m b e r 10, 2 0 0 5 , from http://iech.bmiiournals.eom/content/vol56/issue5/#RESEARCH  REPORTS  S t e i n , K., R o e s e r , R., & M a r k u s , H. (1998). S e l f - s c h e m a s a n d p o s s i b l e s e l v e s a s predictors a n d o u t c o m e s of risky behaviours in a d o l e s c e n t s . Nursing Research, 47, 9 6 - 1 0 6 . Retrieved J u n e 9, 2 0 0 5 , from http://gateway.ut.ovid.com/gw1/ovidweb.cgi T e b e s , J . K., Irish, J . T . , V a s q u e z , M . J . P . , & P e r k i n s , D. V . (2004). C o g n i t i v e transformation a s a marker of resilience. Substance Use & Misuse, 39, 7 6 9 - 7 8 8 . Retrieved J u n e 9, 2 0 0 5 , from http://search.epnet.com/login.aspx?direct=true&db=aph&an=13176164 T h o r n e , S . (1994). S e c o n d a r y a n a l y s i s in qualitative r e s e a r c h : Issues a n d implications. In J . M . M o r s e (Ed.), Critical research methods (pp. 263-279). L o n d o n : S a g e . T u k k a , T. (2004). T h e harm-reduction s c h o o l of thought: T h r e e fractions. Drug Problems, 31, 381 - 3 9 9 .  Contemporary  T u s a i e , K., & Dyer, J . (2004). R e s i l i e n c e : A historical review of the construct. Nursing Practice, 18, 3-10. Retrieved J u n e 4 , 2 0 0 5 , from http://search.epnet.com/login.aspx?direct=true&db=aph&an=11871554  Holistic  Tuttle, J . , L a n d a u , J . , S t a n t o n , M . D., K i n g , K. U., & F r o d i , A . (2004). Intergenerational family relations a n d s e x u a l risk behaviour in y o u n g w o m e n . American Journal of Maternal Child Nursing, 29, 56-6. Retrieved J u n e 4 , 2 0 0 5 , from http://gateway.ut.ovid.com/gw1/ovidweb.cgi United Nations. (1997). International Narcotic Control B o a r d ( I N C B ) A n n u a l Report. R e t r i e v e d S e p t e m b e r 10, 2 0 0 5 , from http://www.incb.org/incb/index.html U n g e r , M . (2003). Methodological a n d contextual c h a l l e n g e s r e s e a r c h i n g childhood resilience: A n international collaboration to d e v e l o p a mixed method d e s i g n to investigate health-related p h e n o m e n a in at-risk child populations. S u m m a r y R e p o r t on Y e a r O n e Activities a n d the first Halifax T e a m M e e t i n g . R e t r i e v e d S e p t 2 5 , 2 0 0 5 , from http://66.102.7.104/search?g=cache:XuiKII n r Q A J : w w w . r e s i l i e n c e p r o j e c t . o r g / c m p documents/documents/resilience report.pdf+childhood+resilience+Halifax&hl =en V a n d u . (2003). V a n c o u v e r a r e a network of drug u s e r s : H o u s i n g action committee. R e t r i e v e d O c t o b e r 5, 2 0 0 5 , from http://www.vandu.org/vhacgroup.html v a n V o o r h i s , R. (1998). Culturally relevant practice: A framework for t e a c h i n g the p s y c h o s o c i a l d y n a m i c s of o p p r e s s i o n . Journal of Social Work Education, 34, 1 2 1 - 1 2 4 . Retrieved J u n e 9, 2 0 0 5 , from  70  http://search.epnet.com/login.aspx?direct=true&db=aph&an W e n z e l , L. B., Donnelly, J . P., Fowler, J . M . , H a b b a l , R., Taylor, T. H., A z i z , N., & C e l l a , D. (2002). R e s i l i e n c e , reflection, a n d residual stress in ovarian c a n c e r survivorship: A g y n a e c o l o g i c o n c o l o g y group study. Psycho-Oncology, 11, 1 4 2 153. Retrieved J u n e 9, 2 0 0 5 , from http://www3.interscience.wiley.com/cgi-bin/fulltext/91015521/PDFSTART W e r n e r , E . (1989). High-risk children in y o u n g adulthood: A longitudinal study from birth to 3 2 y e a r s . American Journal of Orthopsychiatry, 59, 7 2 - 8 1 . W e r n e r , E . , & J o h n s o n , J . (2004). T h e role of caring adults in the lives of children of a l c o h o l i c s . Substance Use & Misuse, 39, 6 9 9 - 7 2 0 . Retrieved J u n e 19, 2 0 0 5 , from http://www.metapress.com/(iknp3p45if5ebgmvwpimar55)/app/home/contribution. asp?referrer=parent&backto=issue,3,10;iournal,17,50;linkingpublicationresults,1: 107866,1 W e r n e r , E . , & S m i t h , R. (1982). Vulnerable but invincible: A longitudinal resilient children and youth. N e w Y o r k : M c G r a w - H i l l .  study of  Z e r w e k h , J . V . (2000). C a r i n g o n the ragged e d g e : Nursing p e r s o n s w h o are d i s e n f r a n c h i s e d . Advances in Nursing Science, 22, 4 7 - 6 1 . R e t r i e v e d J u n e 4 , 2 0 0 5 , from http://search.epnet.com/login.aspx?direct=true&db=aph&an=6682248  71  APPENDICES APPENDIX A Interview G u i d e - Injection Drug U s e r Note: T h e s e q u e s t i o n s are to be u s e d a s a  guide only.  Introductory Questions 1. C a n you tell m e a little bit about yourself? Elaborating Q u e s t i o n s •  W h e r e are y o u f r o m ?  •  W h a t is your b a c k g r o u n d ?  I would like you to talk a little bit about drug activity.  Context questions 1. W h e r e are the "hot spots" for drug activity? Elaborating Q u e s t i o n s •  W h a t is h a p p e n i n g there?  • W h y is this a r e a a "hot s p o t " ? • W h e n are people there (time of d a y , w h i c h d a y s of the w e e k ) ? • H o w do people find out this is a "hot spot"? • D o e s being in this a r e a i n c r e a s e p e o p l e ' s c h a n c e of getting H I V ? If s o , how c o m e ? • W h a t would m a k e o n e place l e s s risky than another p l a c e ? • A r e there p l a c e s in this a r e a w h e r e you think s e r v i c e s could/should be set u p ? 2. W h o do y o u think are the people most at risk? • • • • • • •  W h a t m a k e s t h e m most at risk? W h e r e are they from? (e.g. D o they live in Victoria? D o they c o m e from a n o t h e r municipality/city? D o they m o v e between a r e a s ? ) W h e n do you usually shoot up (time of d a y , etc.)? W h e r e d o y o u usually shoot u p ? (e.g. own h o m e , bar, park, etc.) W h e n you shoot up, how do you do it (e.g. a l o n e , with a partner, etc.)? C a n y o u demonstrate to me or d e s c r i b e to me how you shoot u p ? W h a t do you think led you to begin injecting d r u g s ?  I a m now going to a s k you s o m e questions about the risks a s s o c i a t e d with injection drug u s e . If you don't feel comfortable a n s w e r i n g s o m e of t h e s e q u e s t i o n s , p l e a s e don't  72  hesitate to let m e know.  Risk/Consequences Questions 1. W h a t drugs do y o u c o m m o n l y inject? • • • •  W h y these drugs? W h e r e d o y o u get t h e m from? A r e there other drugs that y o u u s e b e s i d e s that o n e s that y o u inject? If s o , what a r e they? T o what extent is alcohol a n i s s u e ?  2. W h a t kinds of things d o y o u o r others do that p l a c e y o u at risk (e.g. sharing needles)? Elaborating Q u e s t i o n s • • • • • • •  W h a t a r e s o m e of the r e a s o n s that y o u or others p l a c e t h e m s e l v e s at risk? W h e r e d o y o u get your n e e d l e s (rigs) from? W h a t d o y o u d o with your n e e d l e s (rigs) w h e n y o u a r e finished with t h e m ? H o w often do you re-use your n e e d l e s (rigs)? H o w d o y o u c l e a n your n e e d l e s (rigs)? If y o u don't a l w a y s c l e a n your n e e d l e s (rigs), what is the r e a s o n for this? W h a t w o u l d y o u s a y to s o m e o n e w h o is injecting drugs for the first t i m e ?  3. H o w d o e s w h e r e you "hang out" influence whether y o u put yourself at risk? • • • •  H o w d o the p e o p l e y o u h a n g out with influence your risk b e h a v i o u r s ? A r e there s o m e g r o u p s that have higher levels of risk behaviour (e.g. youth, Aboriginal p e o p l e , etc.)? Is s o , w h i c h g r o u p s a n d w h y ? A r e there times w h e n the risks a r e greater than o t h e r s ? If s o , w h y ? W h a t n e e d s to h a p p e n to help reduce the risks?  4. W h a t d o y o u know about h o w HIV is transmitted? 5. W h a t kinds of things d o y o u do to protect yourself from being infected? I just want to finish off the interview by a s k i n g y o u s o m e questions about your e x p e r i e n c e with health c a r e s e r v i c e s .  Intervention Questions 1. W h a t kinds of s e r v i c e s d o y o u u s e ? (e.g. S O S , Detox, etc.)?  73  Elaborating Q u e s t i o n s • • • •  T o what extent are they working? A r e there a n y g a p s in the s e r v i c e s or interventions? If s o , what are t h e y ? W h a t is your e x p e r i e n c e in getting into a n d using prevention, treatment a n d c a r e services? H o w w o u l d you d e s c r i b e your relationship with health c a r e providers (e.g. doctors, n u r s e s , e m e r g e n c y department, etc.)?  2.  If y o u c o u l d c h a n g e a n y health s e r v i c e s a v a i l a b l e to injection drug u s e r s , what would this "wish list" look like?  3.  W h a t kinds of things get in the w a y of putting s e r v i c e s in p l a c e for injection drug users? Elaborating Q u e s t i o n s  • •  W h a t a d v i c e could you give for o v e r c o m i n g t h e s e o b s t a c l e s ? D o y o u h a v e anything to a d d that w e haven't talked about or a n y q u e s t i o n s for m e ?  Closing Statement I w o u l d like to thank you again for taking the time to participate in this study. Y o u r input is v a l u e d a n d integral for the well-being of our community a n d will help provide us with important information to d e v e l o p a plan to help injection drug u s e r s .  GIVE PARTICIPANT ENVELOPE WITH $20 INSIDE. HAVE THEM OPEN THE ENVELOPE AND THEN SIGN THE WAIVER THAT THEY HAVE RECEIVED THE MONEY. IF THERE ARE ANY FOLLOW UP CONCERNS AT ALL PLEASE REFER THEM TO THE STREET NURSES.  74  Appendix B  Interview G u i d e - S e r v i c e P r o v i d e r Note:  T h e s e questions are to be u s e d a s a g u i d e only.  Introductory Question 1. A s a w a y to b e g i n , I w o n d e r if you could tell m e a little about the s e r v i c e s y o u r organization provides for injection drug u s e r s ? Elaborating Questions • • •  W h o are the clients you primarily s e r v e (e.g. youth, adults, etc.)? W h a t d o you know about t h e s e clients (e.g. whether they inject d r u g s ) ? W h a t d o you know about the s e r v i c e s that t h e s e clients u s e (e.g. a c c e s s to m e t h a d o n e or other harm reduction s e r v i c e s , alcohol a n d drug s e r v i c e s , m e d i c a l c a r e , etc.)?  Context Questions 1. W h e r e are the "hot s p o t s " for drug activity? (If the p e r s o n is willing, y o u m a y provide a m a p to t h e m a n d a s k t h e m to m a p it out) Elaborating Questions • • • • •  W h a t is h a p p e n i n g there? W h y is this a r e a a "hot spot"? W h e n are people there? (time of d a y , which d a y s of the w e e k ) H o w d o p e o p l e find out that this is a "hot spot"? H o w d o e s being in t h e s e a r e a s i n c r e a s e people's c h a n c e s of getting HIV infection?  • •  W h a t m a k e s o n e place l e s s risky than others? H o w d o e s this setting (hot spot) influence risk b e h a v i o u r ?  •  A r e there p l a c e s in this setting w h e r e s e r v i c e s could/should be set u p ?  2. W h o are the people most at risk? Elaborating Questions •  W h a t m a k e s t h e m most at risk?  •  W h e r e are they from (e.g. D o they live in Victoria? D o they c o m e from a n o t h e r municipality/city? D o they m o v e between a r e a s ? ) ? W h e n are they c o m m o n l y partaking in risk behaviours (time of d a y , etc.)? W h e r e d o p e o p l e usually shoot up (e.g. o w n h o m e , bar, park, etc.)? W h e n people shoot up, how d o they d o it (e.g. a l o n e , with a partner, etc.)?  • • •  75  •  W h y d o y o u think people start injecting d r u g s ?  3.  W h a t kinds of things might help people to inject more s a f e l y ?  I a m n o w going to a s k you s o m e questions about the risks a s s o c i a t e d with injection drug u s e . If you don't feel comfortable a n s w e r i n g s o m e of t h e s e q u e s t i o n s p l e a s e don't hesitate to let m e know.  Risk/Consequences Questions 1. W h a t d r u g s are c o m m o n l y being injected? Elaborating  Questions  •  W h y are t h e s e d r u g s c o m m o n l y injected?  • •  W h e r e d o p e o p l e get them from? A r e there other drugs b e s i d e s injection drugs that are being u s e d by p e o p l e ? If s o , what are t h e y ? T o what extent is alcohol a n i s s u e ?  •  2. W h a t kinds of things are people doing specifically that p l a c e t h e m at risk? Elaborating  Questions  •  W h a t are s o m e of the r e a s o n s w h y people put t h e m s e l v e s at risk?  • • • • •  W h e r e d o p e o p l e get their n e e d l e s from? W h a t d o you think people do with their n e e d l e s o n c e they are u s e d ? H o w often d o y o u think p e o p l e r e - u s e their n e e d l e s ? H o w often d o you think people c l e a n their n e e d l e s ? If p e o p l e don't u s e c l e a n n e e d l e s , w h y is this s o ?  3. T o what extent d o s o c i a l settings influence the risk b e h a v i o u r s of injection drug users? Elaborating • • • •  Questions  H o w d o s o c i a l norms influence risk b e h a v i o u r s ? D o particular g r o u p s have higher levels of risk b e h a v i o u r ? If s o , w h i c h g r o u p s a n d why? A r e there times w h e n the risks are greater than o t h e r s ? If s o , w h y ? W h a t n e e d s to h a p p e n to help reduce the risks?  4. W h a t level of k n o w l e d g e d o you think people h a v e in g e n e r a l about HIV transmission? 5.  W h a t do people do specifically to protect t h e m s e l v e s from being infected?  76  Elaborating Questions • •  H o w d o p e o p l e protect t h e m s e l v e s from h a r m ? H o w d o they take care of t h e m s e l v e s ?  I just want to finish off the interview by a s k i n g y o u s o m e questions about your k n o w l e d g e of the health s e r v i c e s available for injection drug u s e r s . Intervention Questions 1. B e s i d e s s e r v i c e s that your organization provides, what e l s e is available to s e r v e injection drug u s e r s ? Elaborating Questions • • • •  T o what extent a r e they a d e q u a t e a n d effective? A r e there a n y g a p s in the s e r v i c e s or interventions? If s o , what a r e t h e y ? W h a t d o y o u think injection drug u s e r s ' e x p e r i e n c e s a r e in a c c e s s i n g a n d utilizing prevention, treatment a n d care s e r v i c e s ? H o w w o u l d you d e s c r i b e the relationship that most injection drug u s e r s h a v e with health s e r v i c e providers?  2. If y o u could c h a n g e or e x p a n d a n y health s e r v i c e s available to injection drug u s e r s , what w o u l d this look like? Elaborating Questions • •  If y o u could c h a n g e t h e m , what would y o u d o ? If y o u could e x p a n d t h e m , what would y o u d o ?  3.  W h a t n e w interventions a r e n e e d e d to help injection drug u s e r s ?  4.  W h a t a r e the o b s t a c l e s to implementing interventions? Elaborating Questions  •  W h a t a d v i c e could y o u give for o v e r c o m i n g t h e s e o b s t a c l e s ?  5.  D o y o u h a v e anything to a d d that w e haven't talked about o r a n y q u e s t i o n s for m e ?  A s a last q u e s t i o n , I w o n d e r e d whether your organization h a d a n y statistics that might help u s with o u r s t u d y ? If s o , a r e y o u willing to s h a r e t h o s e with u s ? (IF Y E S , P L E A S E GIVE T H E M DR. P O F F E N R O T H ' S C A R D T O CONTACT).  77  CLOSING STATEMENT I w o u l d like to thank you a g a i n for taking the time to participate in this study. Y o u r input is v a l u e d a n d integral for the well-being of our c o m m u n i t y a n d will help provide u s with important information to d e v e l o p a plan to help injection drug u s e r s .  78  Appendix C  Protective F a c t o r s A s s o c i a t e d With R e s i l i e n c e Analysis For this Study Indicates A Role In Resilience*  Protective Factors Identified In the Literature 1 2  Individual protective factors. high activity level the ability to elicit a positive r e s p o n s e from others,  3  autonomy  4  adaptability  5  self-efficacy  6  hopefulness  7  s e n s e of p u r p o s e  8  a r e a s of talent or a c c o m p l i s h m e n t  9  reflectiveness  10  optimism  11  intelligence  12  creativity  13  a belief s y s t e m that provides existential m e a n i n g  14  a cohesive-life narrative  15  a s e n s e of self-worth  iw-  *  * * ^  * *  "  *  a n appreciation of o n e ' s u n i q u e n e s s a n d g o o d fortune  17  c o p i n g strategies  18  s o c i a l skills  19  f e m a l e only - physical attractiveness  20  Family protective factors. a w a r m supportiye^stable environment  21  p r e s e n c e of a n attentive a n d caring parent  22  p e r c e i v e d family c o n n e c t e d n e s s  23  Community protective factors. extrafamilial support from p e e r s , adults, role m o d e l s  24  s c h o o l affiliation  25  religious faith or church affiliation  26  a c c e s s to community r e s o u r c e s  27  a d e q u a t e housing  28  m e d i u m to high s o c i o e c o n o m i c status  * *  * * * *  79  Appendix D  Terms A b s t i n e n c e B a s e d A p p r o a c h to S u b s t a n c e A b u s e T h e s e are a l c o h o l a n d drug treatment strategies with a n a c c e s s criterion of a b s t i n e n c e . Pertaining to law enforcement, this a p p r o a c h is d e s i g n e d to d e c r e a s e the p r e v a l e n c e a n d i n c i d e n c e of drug u s e by reducing or eliminating the drug supply a n d incarcerating both t h o s e w h o sell and t h o s e w h o u s e illegal s u b s t a n c e s . G e o Mapping T h i s is a d a t a collection technique for the p u r p o s e of drawing pictorial representations of events and/or activities a n d their locations. T h i s technique is often u s e d in conjunction with participant observation. Harm Reduction T h i s is both a philosophical a p p r o a c h a n d a frontline strategy that f o c u s e s on reduction of harm that is a s s o c i a t e d with a risk s u c h a s illicit drug u s e . Low Threshold T h i s is a term that is u s e d in the literature, usually in reference to harm reduction strategies, to denote e a s e of accessibility by clients to s e r v i c e s . T h i s is in contrast to a b s t i n e n c e b a s e d policies a n d practices that require a b s t i n e n c e for eligibility to a c c e s s a service. Protective F a c t o r s T h i s is a key construct in resilience u s e d to denote characteristics of individuals, families or c o m m u n i t i e s that result in d e c r e a s e d vulnerability to a risk. Protective P r o c e s s e s Within resilience p r o c e s s m o d e l s , this is a poorly understood context d e p e n d e n t interaction between protective factors a n d risk factors w h o s e o u t c o m e is a d e c r e a s e d vulnerability to risk. Protective p r o c e s s e s are thought to vary o v e r time within o n e individual a n d a l s o b e t w e e n individuals. Rapid Assessment Surveys T h i s is a d a t a gathering technique in the form of a questionnaire consisting of a s m a l l n u m b e r of questions (e.g. three to five) that are d e s i g n e d to fill in g a p s in r e s e a r c h d a t a . Re-organizational Points T h i s is a term borrowed from S y s t e m s T h e o r y that refers to turning points that m a y be e n c o u n t e r e d in a n individual's life that act a s a n impetus to c h a n g e . Risk F a c t o r s T h i s is a biological, d e v e l o p m e n t a l or p s y c h o s o c i a l event that i n c r e a s e s the likelihood of a negative o u t c o m e in a n individual or group.  

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