Open Collections

UBC Theses and Dissertations

UBC Theses Logo

UBC Theses and Dissertations

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

Your browser doesn't seem to have a PDF viewer, please download the PDF to view this item.

Item Metadata

Download

Media
831-ubc_2006-0303.pdf [ 3.82MB ]
Metadata
JSON: 831-1.0092575.json
JSON-LD: 831-1.0092575-ld.json
RDF/XML (Pretty): 831-1.0092575-rdf.xml
RDF/JSON: 831-1.0092575-rdf.json
Turtle: 831-1.0092575-turtle.txt
N-Triples: 831-1.0092575-rdf-ntriples.txt
Original Record: 831-1.0092575-source.json
Full Text
831-1.0092575-fulltext.txt
Citation
831-1.0092575.ris

Full Text

RESILIENCE FROM THE PERSPECTIVE OF THE ILLICIT INJECTION DRUG USER: AN E X P L O R A T O R Y DESCRIPTIVE STUDY by Audrey L inda S h a w B . S . N . , The University of Victor ia, 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 T H E R E Q U I R E M E N T S F O R T H E D E G R E E O F M A S T E R O F S C I E N C E IN N U R S I N G in The Faculty of Graduate Studies ( N U R S I N G ) U N I V E R S I T Y O F BRIT ISH C O L U M B I A April 2006 © Audrey L inda S h a w 2006 ABSTRACT Illicit injection drug use is a daunting health and socia l problem that cal ls for a multi faceted response. Res i l ience based strategies have the potential to complement the current approach to this problem but there is a paucity of research that would enable scientif ically based strategies to be deve loped. The purpose of this secondary study w a s to explore and descr ibe resi l ience from the perspect ive of individuals who use illicit injection drugs. For the purposes of this research increased resi l ience w a s v iewed as quitting, decreas ing and safer drug use and support seek ing whereas dec reased resi l ience was v iewed as initial, increased or unsafe drug use and re lapse. Th is qualitative study used data obtained from a larger qualitative study, conducted in Victor ia, British Co lumb ia in 2000, whose purpose was to determine behaviours and contexts that place the IDU at risk. Us ing Rap id A s s e s s m e n t R e s p o n s e and Evaluat ion methodology, data were col lected from three participant groups: IDU (20 female, 21 male) serv ice providers (45) and communi ty leaders/pol icy makers (12). This study is limited to the key informant interview and focus group data of the first two groups. Part ic ipants descr ibed two types of exper iences that were assoc ia ted with an increase in resi l ience and one type of exper ience that was assoc ia ted with a dec rease in resi l ience. O n e type of exper ience assoc ia ted with increased resi l ience involved getting to the point of behavioural and attitudinal change either by recogniz ing drug use was not worth the negative consequences entai led, by getting scared of the effects of drug use , by recognizing an inner desire to quit or by reaching out for support. A second type of exper ience assoc ia ted with increased resi l ience involved envis ioning a better non-drug using future. Part icipants a lso descr ibed exper iences, assoc ia ted with a dec rease in resi l ience, which involved using illicit drugs to dull emotional pain s temming from abuse , mental i l lness, al ienation, marginalization and hope lessness . Future research using primary data is suggested to increase knowledge of resi l ience in the context of those who use illicit injection drugs and to evaluate intervention strategies that include the fostering of protective factors in order to strengthen resi l ience. i i i T A B L E OF CONTENTS Abstract ii Tab le of Contents iv List of Tab les vi Acknowledgements J vii Dedicat ion viii Chapter I Introduction 1 Signi f icance of the Prob lem 1 R e s p o n s e to Illicit Injection Drug U s e 4 R e s e a r c h Prob lem and Purpose 7 R e s e a r c h Quest ion for this Study 7 Chapter 2 Literature Rev iew of Resi l ience 8 Origins of the Concept of Res i l ience 8 Res i l ience as a State 9 Protect ive Factors 9 R isk Factors 10 Res i l ience A s A P rocess 12 Psycho log ica l Mode ls of Res i l ience 12 Physio logica l Mode l of Res i l ience 14 Discrepant V iews O n the Conceptual izat ion of Res i l ience 15 Context Specif ici ty 16 Res i l ience Research In Speci f ic Populat ions 17 Res i l ience Resea rch From the Nursing Literature 18 Res i l ience and Subs tance A b u s e 19 Res i l ience Intervention and Treatment Programs 21 Summary 22 Chapter 3 Methods 24 Introduction 24 R e s e a r c h Design For This Study 24 R e s e a r c h Design of Original Study 26 Data Col lect ion Methods and Descript ion of S a m p l e 26 Key Informant Interviews , 27 Focus Group Interviews 27 Quest ionnai res 28 Demograph ics 28 Drug use patterns 29 Hepatit is C and HIV status 29 Drug and alcohol treatment 29 IV Data Management and Ana lys is For This Study 30 Ensur ing Rigor In This Study 32 Ethical Considerat ions 33 Chapter 4 Findings 35 Introduction 35 Soc ia l Context of Drug U s e and Res i l ience 36 Exper iences Assoc ia ted With Increased Res i l ience 38 Gett ing To The Point of C h a n g e 39 Recogniz ing it's not worth it 39 Gett ing scared 41 Recogniz ing an inner desire to quit 44 Reach ing out for support 45 Envis ioning A Better Future 47 Exper iences Assoc ia ted With Decreased Res i l ience 48 Needing To Du lHhe Pa in 48 Summary 51 Chapter 5 D iscuss ion and Conc lus ions 52 v Res i l ience In Populat ions In the P rocess of Recovery 52 Res i l ience A s A Dynamic P rocess 53 Res i l ience and A Transformed World V iew 53 Protect ive Factors 54 Individual Protective Factors 54 Fami ly and Communi ty Protective Factors 56 Res i l ience and Context Specif icity 56 Drug M isuse To Dull Emotional Pa in 57 Implications of the Study 58 Limitations 60 Conc lus ions 61 Re fe rences 63 Append i ces 72 Append ix A (Interview Gu ide - Injection Drug User) 72 Append ix B (Interview Gu ide - Serv ice Provider) 75 Append ix C (Protective Factors Assoc ia ted With Resi l ience) 79 Append ix D (Terms) 80 v LIST OF T A B L E S Table 1 List of Study Part icipants 26 Tab le 2 Part icipant Exper iences Assoc ia ted With A C h a n g e In Res i l ience 38 vi A C K N O W L E D G E M E N T S I have not been alone on this journey. I offer my enduring gratitude to the members of my thesis committee, Drs. Joan Bottorff (Chairperson), J o y Johnson and Kell i Stajduhar, for sharing their knowledge and providing expert gu idance. A spec ia l thanks to Joan for her w isdom and support, to Joy for her thought provoking quest ions and to Kell i for being the impetus for this journey by introducing me to the excit ing cha l lenges of research. I would a lso like to thank the Vancouver Island Health Authority and the except ional nurses and administrative staff of the Department of Ep idemio logy and D i sease Control for their ongoing support. Thank you for holding the fort while I w a s off to U B C for yet another c lass . Final ly, I would like to thank my father, Gordon Scarff, my chi ldren Robert and Emily, my sister, Caro l and my dear fr iends. I am forever grateful for your love, support and encouragement . vii DEDICATION To the citizens of Victoria who use illicit injection drugs viii C H A P T E R 1 Introduction The purpose of this study w a s to explore and descr ibe the concept of resi l ience from the perspect ive of the illicit injection drug user (IDU). Res i l ience is def ined as a family of loosely connected phenomena involving adequate or better adaptat ion in the context of adversi ty (Ro isman, 2005). Res i l ience is important in relation to this topic because illicit injection drug use and its attendant harms are a daunting problem that is the source of great human suffering and loss of human potential and is threatening to overwhelm C a n a d a ' s medica l , socia l and legal sys tems. The current most effective approach to this problem is thought to be multifaceted including prevention, legal , treatment and harm reduction strategies. Res i l ience based strategies have the potential to complement the exist ing approach but there is a paucity of research on this topic that would enable scientif ically based strategies to be developed and implemented. In this chapter, a descript ion of the signif icance of the illicit injection drug use problem within C a n a d a is fol lowed by an overview of the historical response to the problem and the research purpose and quest ion. Subsequent chapters present the literature on resi l ience as it pertains to illicit injection drug use , a descript ion of the research methods and the f indings of this study. Finally a d iscuss ion of the f indings and conclus ion are provided. The Significance of the Problem The use of illicit injection drugs is a health and socia l issue that entails daunt ing human and f inancial costs and consequences for individuals, famil ies and communi t ies in C a n a d a . B a s e d on provincial and city est imates, 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 such as the downtown east s ide of Vancouver , the problem of illicit injection drug use a lso exists in smal ler urban centres and rural a reas (Publ ic Health A g e n c y of C a n a d a , 2004; Stajduhar et a l . , 2004). Nor is the problem confined to one gender, age group or soc ioeconomic stratum. The many harms assoc ia ted with injection drug use include overdose and death, blood borne d i seases such as Human Immune Def ic iency Vi rus (HIV), Acqu i red Immune Def ic iency Syndrome (AIDS), Hepatit is C (HCV) , Hepatit is B (HBV) and local skin a b s c e s s e s that too frequently become systemic, resulting in ser ious condit ions such as endocardit is and osteomyeli t is (Health C a n a d a , 2002; Canad ian Foundat ion for Drug Pol icy, 2005; United Nat ions, 1997; Health C a n a d a , 2004; Stajduhar et a l . , 2004). Direct medica l costs of treating HIV have been est imated at $100,000 per individual and these costs are expected to increase as new medicat ions become avai lable that increase the life expectancy of those who are infected (Health C a n a d a , 2002). In addition to the cost to the health care sys tem, injection drug use results in untold human suffering and loss of human potential and p laces an extraordinary burden on the law enforcement, correctional and socia l service sys tems. In the 1990s injection drug use emerged as one of the primary means of HIV t ransmission (Health C a n a d a , 2002). By 1999, injection drug use was responsib le for 34 percent of the new HIV c a s e s . Al though this dropped to 24 percent by 2002 , concern regarding the injection drug use problem led to the initiation of 'I Track ' , an enhanced survei l lance sys tem at selected centres across C a n a d a . The purpose of this survei l lance sys tem is to monitor the incidence of HIV and H C V as well as the testing 2 and risk behaviours of injection drug users (IDUs). HIV prevalence, among the I Track study participants in the pilot phase for Victoria was 16.0 percent, Reg ina 1.2 percent, Sudbury 10 percent and Toronto 5.1 percent (Health C a n a d a , 2004). Injection drug use has been identified as a risk factor in at least half of the est imated 275,000 H C V c a s e s in C a n a d a (Health C a n a d a , 2004). It is est imated that in both Vancouve r and Montreal there is an 85 percent prevalence rate of H C V in the IDU population with an annual incidence of approximately 26 percent (Health C a n a d a , 2002). H C V prevalence rates among study participants in the pilot phase of I Track, a national survei l lance of injection drug use, ranged from 79.3 percent in Victor ia to 54.3 percent in Toronto (Health C a n a d a , 2004). The smal ler urban centres of Reg ina , Pr ince Albert and C a p e Breton have est imated H C V prevalence rates among the IDU population of 46 percent, 50 percent and 47 percent respectively (Health C a n a d a , 2004). Approximately one fourth of people who inject illicit drugs in C a n a d a are w o m e n and by 2002, one fourth of all the HIV c a s e s in C a n a d a were w o m e n (Health C a n a d a , 2002). The major risk factors for HIV in females are heterosexual t ransmiss ion and injection drug use . Between 1989 and 1992 the proportion of A I D S c a s e s in women that could be attributed to injection drug use increased from 6 percent to 15 percent and between 1993 and 1996 the increase was from 15 percent to 24 percent (Canad ian Foundat ion for Drug Pol icy, 2005). HIV positive women have 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 been attributed to perinatal t ransmission (Canad ian Foundat ion for Drug Pol icy, 2005). 3 Thirty percent of participants of a national survei l lance of IDUs in C a n a d a (I-Track) reported initiation of injecting at the age of 16 years or younger (Health C a n a d a , 2004) . Street- involved youth, youth who inject drugs and young men who have sex with men are particularly vulnerable to HIV infection (Health C a n a d a , 1994). Street life is assoc ia ted with a high incidence of survival sex and injection drug use (Health C a n a d a , 2002). HIV prevalence in youth var ies. In a national survei l lance study, in 2001 , one percent of street youth tested positive for HIV (Health C a n a d a , 2001) whereas , in the Vancouve r Injection Drug User Study (1996 to 2001) 17 percent of youth tested HIV positive. The problem of illicit injection drug use has been documented both by a C a n a d a wide survei l lance system (Health C a n a d a , 2004) and in locally focused studies (Stajduhar, Poffenroth & W o n g , 2000; Stajduhar et a l . , 2004; V a n d u , 2003). Clear ly a complex problem extending across all age, gender and soc ioeconomic groups and involving both medical and social harms that entail daunting costs to the health, socia l and law enforcement sys tems, illicit injection drug use cal ls for a multifaceted response. Response to Illicit Injection Drug Use Injection drug use and its multiple attendant harms pose an increasing public health problem that has not been addressed adequately by existing abst inence, law enforcement and risk based pol icies and programs (Health C a n a d a 1994, 2001 , 2004). The lack of an in-depth understanding of resi l ience in the context of illicit injection drug use has hampered the development of resi l ience based strategies that have the potential to complement the existing response to this significant public health problem. 4 In C a n a d a , as in the industrialized countries of western Europe, the response to the problem of illicit injection drug use has changed over time. Prior to the 1980s, there was almost a total rel iance on abst inence-based strategies (Tukka, 2004). A n assumpt ion of the abst inence paradigm is that substance abuse is a moral/ legal problem; law enforcement strategies were relied on to dec rease the prevalence and inc idence of drug use by reducing or eliminating the drug supply and incarcerat ing both those who sold and those who used illegal subs tances ( M a c C o u n , 1998). Abs t inence based drug recovery and treatment programs, for the most part, were reserved for those who had already successfu l ly absta ined, at least for a short period of t ime, from the use of illicit subs tances. However , the ef fect iveness of an exclusively abst inence based approach came to be quest ioned by Brit ish pharmacists and phys ic ians who advocated for the prescription of opiates to drug addicts who had not been success fu l in, or not qualif ied to a c c e s s , abst inence based programs (Tukka, 2004). Inciardi (2004) states that by the mid 1980s there was a growing real ization that abst inence based policies and programs and the war on drugs had failed to el iminate or even significantly dec rease drug supply or drug use. In addit ion, the harms assoc ia ted with the abst inence approach, which entailed denial of a c c e s s to serv ices and to information and involved long term incarceration to those who were addicted to drugs, were gaining recognit ion. A n alternate lens was needed with which to v iew the problem. The roots of the phi losophy of harm reduction are found in the scientif ic publ ic health model , which is grounded in humanitar ianism (Tukka, 2004). Harm reduction provided the phi losophical basis to overcome the barriers of abst inence based pol ic ies 5 and programs that prevented those who were actively using illicit drugs to a c c e s s information and serv ices (Hodgins, 2005). Harm reduction programs were first initiated in Liverpool , Amste rdam and several other European cities (Tukka). Al though harm reduction pol icies and programs have s ince gained ground in many Canad ian and western European sett ings, Stajduhar et a l . (2000, p. vi) state that there continue to be missed opportunit ies in the prevention, care and treatment of people addicted to drugs due to approaches that focus on an 'abst inence only' approach. Harm reduction policies and programs focus on reducing both the risk and the harms assoc ia ted with the risk. Harm reduction is often incorporated into a mult i focused approach to problematic substance use such as the four pillar approach recommended in C a n a d a ' s Drug Strategy (Health C a n a d a , 2002). The four pillars represent prevent ion, enforcement, treatment and harm reduction. This mult i focused approach has provided new hope for an effective and humane approach to the problem of subs tance misuse. Innovative harm reduction strategies such as needle exchanges , safe injection sites and methadone and heroin maintenance programs have made significant gains in reducing the harms assoc ia ted with illicit injection drug use (Health C a n a d a , 2002 , 2004; Publ ic Health A g e n c y of C a n a d a , 2004, 2005). However , there is a growing voice for the inclusion of resi l ience as an additional and complementary response to significant health related problems (Jace lon, 1997; Johnson & Wiechel t , 2004; Tusa ie & Dyer, 2004; Werner & Smith, 1982). Res i l ience based pol icies and programs typically focus on strengthening protective factors and p rocesses that are assoc ia ted with successfu l ou tcomes. A s such they hold the promise of becoming an effective component of a mult i focused 6 health response to illicit injection drug use. Yet there are significant gaps in our understanding of this concept that hamper the development of strategies to support resi l ience on the front l ines. Resea rch is needed to explore resi l ience in the context of illicit injection drug use in order to develop effective resi l ience based strategies to mitigate this significant public health problem. Research Problem and Purpose To date, very few research studies have been conducted on resi l ience in the context of the illicit injection drug using population. No research studies with the explicit purpose of exploring resi l ience from the perspect ive of those who inject illicit drugs were found. The purpose of this study was to explore and descr ibe resi l ience from the perspect ive of those individuals who inject illicit drugs. Research Question for this Study The purpose of this study was to explore and descr ibe resi l ience from the perspect ive of the illicit injection drug user. The research quest ion was , "What are the exper iences in the life of the illicit injection drug user that are assoc ia ted with a change in the degree of res i l ience?" Spec i f i c object ives were: 1) To descr ibe exper iences that are assoc ia ted with changes in resi l ience among illicit injection drug users and 2) To identify protective factors or p rocesses that are assoc ia ted with a change from a lesser to a greater degree of resi l ience. 7 C H A P T E R 2 Literature Rev iew Res i l ience Res i l ience has been conceptual ized as a state and as both a psycholog ica l and physiological p rocess . In this sect ion, an overview of the origins of the concept is fol lowed by a d iscuss ion of the psychological and then the physiological p rocess models of resi l ience as they pertain to illicit injection drug use . Two d iscrepant v iews within the conceptual izat ion of resi l ience are then explored. Th is is fol lowed by a d iscuss ion of the context dependent nature of resi l ience and the research focused on resi l ience in speci f ic populations. Origins Of The Concept Of Resilience The term resi l ience originated in physics where a resilient object was def ined as one that does not break but bends under stress and then spr ings back to its original shape (Brendtro & Longhurst, 2005). The current interest in the concept of resi l ience grew from the observat ion that some individuals coped better than w a s expected consider ing their dire c i rcumstances (Tusaie & Dyer, 2004). The f indings of long term prospect ive studies indicated that, even for children exposed to severe and multiple risk factors, it w a s unusual for more than 50 percent to deve lop severe problems (Jace lon , 1997; Werner & Smith, 1982). This observat ion led to the realization that, historically, the focus of health care had been on symptomatology, vict imization, pathology and risk factors and there existed a need to lessen the emphas is on negative ou tcomes and to look at success fu l adaptation in spite of adversity (Jace lon; Johnson & Wiechel t , 2004; Tusa ie & Dyer). 8 Resilience As A State Res i l i ence w a s first conceptual ized as a state, and it is from this ear ly research that the main constructs of protective factors and risk factors were deve loped. Relevant research related to each of these constructs is d i scussed in this sect ion. A l though, resi l ience, for the most part, is no longer conceptual ized as a state, protective and risk factors continue to be recognized as important constructs in the conceptual izat ion of resi l ience as a process. Protective Factors Johnson and Wiechel t (2004, p. 659) state that "individuals and famil ies demonstrate resi l ience when they draw on inner strengths, skil ls and supports 'Protect ive factor' is def ined as any characterist ic of individuals or groups that make them less vulnerable to a risk (Jacelon, 1997; Johnson & Wiechelt) . Rutter (1993) postulated that protective factors came into play during key turning points and were possibly only apparent in t imes of stress. G a r m a z y (1991) categor ized protective factors as individual, family or community and this organizat ional framework was adopted by other researchers (Fine, 1991; Werner & Johnson , 2004) although the community category has been broadened to include the larger sociopoli t ical and physical environment. Protect ive factors of the individual were identified as a high activity level, the ability to elicit a posit ive response from others, autonomy, self-eff icacy, hopefulness, sense of purpose and a reas of talent or accompl ishment (Werner, 1989). A l so recognized were cognit ive factors such as ref lect iveness, opt imism, intel l igence, creativity, a belief sys tem that provides existential meaning, a cohes ive life narrative, self-worth, an appreciat ion of one 's un iqueness and 9 good fortune (Carbonel l et a l . , 2002; Masten , 1994; Pat terson, 2000; Werner & Smi th , 1982). In addit ion, physical attract iveness in females (Jace lon, 1997) and individual competenc ies such as coping strategies and socia l skil ls were identified as protective factors (Tusaie and Dyer, 2004). Werner (1989) Werner and Smith (1982) and G a r m a z y (1991) identified family and community protective factors. Fami ly protective factors include a warm, support ive, stable environment, p resence of an attentive and caring parent and perce ived family connec tedness . Communi ty protective factors consist of extrafamilial support from peers, adults and role models , school affiliation, religious faith or church affiliation, a c c e s s to community resources, adequate housing and medium to high soc ioeconomic status. Al though the p resence of protective factors indicates that the individual is pred isposed to a more positive outcome, this is far from assured . A protective factor appears to have varying protective properties between individuals or within one individual ac ross time (Johnson & Wiechelt , 2004). For instance, two individuals with the s a m e level of intell igence and sense of purpose may not ach ieve the s a m e level of s u c c e s s in life and this level of s u c c e s s may vary between educat ional , adult work and interpersonal relationship domains. Risk Factors A risk factor is defined as a biological, developmental or psychosoc ia l event that increases the l ikelihood of a negative outcome in an individual or group (Tusaie & Dyer, 2004). R isk factors are an integral part of the concept of resi l ience because together with vulnerabil ity they provide the precondit ions or impetus that cal ls protective factors 10 into play. F lach (1988) label led the entry of stress into an individual's homeostat ic sys tem as the 'bifurcation point'. These points of entry have a lso been referred to as key turning points (Rutter, 1993) and points of reorganization (Horowitz, 1987). Tusa ie and Dyer (2004) suggest the categories of anticipated and unexpected risk factors. Anticipated risk factors are exemplif ied by developmental transit ions such as those involved in school entry, detachment from parents during ado lescence and chi ldbear ing. Unexpected risk factors are events such as family disruption due to mental i l lness, addict ion, legal problems or unemployment and environmental risk factors such as f lood, drought, famine or socio-polit ical risks such as terrorist attacks or even , as happened relatively recently in British Co lumb ia , changes in unemployment insurance legislation that reduce income. Risk factors may occur individually, s imultaneously or consecut ively and may have a cumulat ive effect ove r t ime (Johnson & Wiechel t , 2004). Al though an individual exposed to a risk factor is more highly assoc ia ted with a negative outcome, Tusa ie and Dyer (2004) caution that outcome can not be predicted with conf idence from the p resence of a risk factor as a risk factor is a necessary but not sufficient precondit ion for the express ion of resi l ience. A s Johnson and Wiechel t (2004) note, the list of protective factors and r isks that resulted from research to identify the characterist ics of individuals that coped better than w a s expected consider ing their high risk c i rcumstances contributed to the understanding of the concept of resi l ience but appeared to be too simplist ic to account for the observed variation in resi l ience. How these protective factors and risk factors interacted remained largely unexplained and hampered the usefu lness of the concept . 11 Resilience As A Process A s a shift from c a s e studies and retrospective studies to prospect ive longitudinal studies occur red, resi l ience was no longer v iewed as a state but as a complex and dynamic process (Tusaie & Dyer, 2004). Numerous process models were deve loped in an attempt to explain the complexity of the concept of resi l ience. In this sect ion the numerous psychological p rocess models, as well as a physiological model of resi l ience, are d i scussed . Psychological Models Of Resilience In F lach 's (1988) multistage cycl ical model of resi l ience, the introduction of a risk factor disrupts the individual's homeostas is causing chaos fol lowed by the activation of protective factors that eventually return the system to its former homeostas is . Horowitz (1987) v iewed resi l ience as the outcome of a complex, dynamic interplay between certain genet ic and non genet ic characterist ics of individuals or sys tems and the broader environment. In her structural behavioural model of child development , Horowitz proposed a concept of relative resi l ience. Horowitz 's model is based on severa l assumpt ions. The first assumpt ion is that everyone has some measure of resi l ience, just as everyone has other individual characterist ics such as height and weight. V iewing resi l ience through this lens, the question to ask is not if an individual is or is not resilient but how resilient is an individual at a point in t ime? A second assumpt ion of Horowitz' is that everyone exper iences points of reorganizat ion in their life in which their level of resi l ience increases or dec reases . The measure of resi l ience would vary and be determined according to the context. 12 Fine 's (1991) model articulated two related but separate p rocesses within resi l ience. The first includes an acute phase where the individual's energy is directed at minimizing stress. It is in the second , reorganization stage, that not only a return to the former homeostas is , but the possibil ity of learning from adversity and becoming stronger or more efficient as a result, is seen . Rutter (1993) in a model similar to Howowitz (1987) proposed a s imple continuum with vulnerability at one end and resi l ience at the other. Rutter suggested four potential protective p rocesses . The first was reduction of the impact of the risk by altering one 's exposure or involvement with the risk. The second protective process, similar to a harm reduction approach , was reduction of the negative chain of reaction following the introduction of the risk. The third w a s the promotion of sel f -esteem and self eff icacy through success fu l complet ion of tasks or the development of support systems and the fourth protective p rocess w a s the opening up of new opportunities or a new world view. Other models appeared out of the continuing need to understand the variation and complexi ty of resi l ience and all of these models defined resi l ience as a dynamic p rocess that w a s influenced by time, developmental stage and context (Brown & Kul ig, 1996; Mast in , 1994; R ichardson, Neiger, J e n s e n & Keumpfer , 1990; Tusa ie & Dyer, 2004). The Res i l ience P r o c e s s Model of R ichardson et a l . p roposes a biopsychospir i tual homeostas is that, when disrupted by a risk factor, results in one of four ou tcomes 1) resilient reintegration resulting in growth, sel f -understanding and increased resi l ience, 2) reintegration back to the former homeostas is , 3) reintegration with s o m e loss of former function or 4) dysfunctional reintegration. 13 Brown and Kul ig 's (1996) two level model of resi l ience, to be appl ied to either individuals or communit ies, has similarities to the two p rocesses of F ine 's (1991) model and the third and fourth protective p rocesses suggested by Rutter (1993). The first level of Brown and Kul ig 's model is reactive, in that the individual or communi ty is s e e n a s reacting to stress in order to be able to carry on. The best outcome that can be hoped for at this first level is a return to the former state before the stress occurred. The second level is proactive, in which the individual or community adapts or t ransforms so that the outcome is an increased capaci ty to anticipate st ress and to minimize or to avoid future st ressors. Brown and Kulig clearly state what Horowitz 's model (1987) impl ies, that the quest ion to be asked about resi l ience is not if an individual or community is resilient but what are the p rocesses that move the individual or communi ty towards or away from being more or less resilient. Physiological Model Of Resilience Explorat ion of the concept of resi l ience can be found in the literature of the physiological aspec ts of stress (Tusaie & Dyer, 2004). A physiological lens has much to contribute to an understanding of resi l ience within the area of addict ion and such treatment strategies as methadone maintenance programs. O n e branch of b iomedical research is currently focused on exploring the neurological and physiological factors that account for the intergenerational t ransmission of addictive behaviour (Schucki t , 1991). Brendtro and Longhurst (2005) d i scuss resi l ience in terms of speci f ic a reas of the brain that are involved in resilient behaviours. They state that recent research on the physiology of the brain indicates that everyone is resilient and those who are less resilient can be 'rewired' by positive learning exper iences. Johnson and Wiechel t 14 (2004) state that resilient outcomes are more common than originally real ized and that negative outcomes are the anomaly. However, there, is ev idence that once adaptat ion sys tems are compromised then negative outcomes become more prevalent (Johnson & Weichel t ) and this negative cyc le can be seen in individuals, such as those who use injection drugs, who are exposed to extreme and sustained adversity. Discrepant Views On the Conceptualization of Resilience Res i l ience has been defined in both positive and negative terms. Werne r (1989) identified resilient individuals as those who met child and adult developmental mi lestones. Others have defined resi l ience in chi ldren and ado lescents by the lack of internal and external psychopathological symptoms or psychiatr ic d isorders, using instruments such as the Chi ld Behaviour Checkl is t (Carbonel l et a l . , 2002). A d isagreement exists between those whose definition of resi l ience is conf ined to individuals who have never succumbed to risk factors or exhibited behaviours or symptoms such as mental i l lness, substance misuse, del inquency or post traumatic st ress syndrome (Rutter, 1993; Werner , 1989) and those who v iew resi l ience through a broader conceptual lens that encompasses recovery as a specia l c a s e of resi l ience (Brown & Kul ig , 1996; Horowitz, 1987; Miller, 2003 ; R o i s m a n , 2005). In this latter v iew, resi l ience includes successfu l adaptation following a period of maladaptat ion or developmental difficulty. V iewed through this broader conceptual lens, everyone is seen to have s o m e level of resi l ience and the quest ion to ask is not is this person resilient but what are the p rocesses that increase or dec rease resi l ience within this person (Brown & Kul ig, 1996; Horowitz, 1987). 15 A second controversy concerns the outcomes of the resilient p rocess . O n e opinion is that resi l ience is a one stage process that conc ludes with a return to the former, pre-risk state (F lach, 1988). However, many process models whi le incorporating the first stage have suggested a second stage of resi l ience that results in a new, improved post risk outcome in which the individual undergoes change character ized by being better equipped than formerly to anticipate and respond to risks and is, in fact, more resilient (Brown & Kul ig , 1996; Horowitz, 1987; R ichardson et a l . , 1990; Rutter, 1998). Tebes , Irish, V a s q u e z and Perk ins (2004) state that coping with adversity may result in cognit ive transformation leading to enhanced adaptat ion and that this enhanced adaptation is a marker of resi l ience. Further research is needed to address these areas of d isagreement in the conceptual izat ion of resi l ience and to clarify how protective p rocesses and risk factors interact to increase or dec rease resi l ience within individuals. Qualitat ive research is particularly suitable to explore and descr ibe this immature concept and move it towards read iness for use on the frontlines of nursing practice. Context Specificity It is general ly agreed in the literature that resi l ience is context dependent and this is thought to at least partially explain the variation in resi l ience seen between and within individuals. Variat ion within an individual in different developmenta l domains is exempli f ied by the child raised in poverty with an abusive family who successfu l ly ach ieves adult educat ion and career goals but is not able to ach ieve normal interpersonal relat ionships (Tusaie & Dyer, 2004). Johnson and Wiechel t (2004) suggest that a holistic framework to v iew resi l ience should include the contexts of age 16 and developmenta l stage, family history, socia l c lass , ethnicity, gender and change ove r t ime . Resiliency Research In Specific Populations Stud ies of resi l ience within the context of the injection drug using population were not found, however, studies in areas relevant to this context are d i scussed below. Werner (1989) found that children who grow up in poverty are more vulnerable to negative health and developmental outcomes. The negative influence of low soc ioeconomic status on resi l ience has s ince been recognized (Ferrar & Pa lmer , 2004). Starf ield, Ri ley, Wit and Rober tson (2002) looked specif ical ly at the connect ion between poverty and lowered adolescent health status. Hall (1999) and Zerwekh (2000) have d i scussed resi l ience in the context of marginalization and disenfranchisement. The illicit injection drug using population is more likely to live in poverty and suffer marginal izat ion, d isenfranchisement and stigmatisation (Stajduhar et a l . , 2000, 2004). The Vancouve r A r e a Network of Drug Users (Vandu, 2003) has stated that adequate housing is a necessary first step towards addiction recovery. Res i l ience has been studied in the context of home lessness (Rew, Chambers & Kulkarni , 2002 ; R e w , Tay lor -Seehafer , Thomas & Yockey , 2001) suggest ing that while home less people may p o s s e s s considerable resi l ience they face significant obstac les to success fu l ou tcomes that the housed do not face. Adult resi l ience has been studied in the context of speci f ic d i sease p rocesses such as ovar ian cancer (Wenzel et a l . , 2002) and breast cancer (Bowen, M o r a s c a & Me ischke , 2003). A medical model of addiction v iews addiction as the result of physiological problems and genet ic propensit ies similar to other d i sease p rocesses . 17 Whi le this v iew el iminates the view of addiction as a moral problem it does not account for the soc ia l aspec ts of the d i sease . A warm support ive family environment has been identified as a protective factor contributing to resi l ience (Garmazy, 1991). The resi l ience of famil ies has been studied in terms of health-promoting lifestyles (Monteith & Ford-Gi lboe, 2002) and the relationship between family connec tedness and sexual risk taking (Tuttle, Landau , Stanton, K ing & Frodi , 2004). Addict ion and mental health problems are often co-occurr ing condit ions (Publ ic Health Agency , 2005). The role of resi l ience in depress ion (Adams, Sande rs & Auth , 2004; Carbone l l et a l . , 2002; Miller & Chandler , 2002) and in suic ide (Rew, T h o m a s , Horner, Resn ick & Beuhr ing, 2001) has been studied. Katerndahl , Burge and Kel log (2005) studied predictors of resi l ience and adult mental d isorders in w o m e n survivors of chi ldhood sexua l abuse. Res i l ience and post traumatic stress disorder, in the context of war hostages (Saab, C h a a y a , Doumit & Farhood, 2003) and d isasters such as a nightclub fire (Badger, 2004) has a lso been the focus of research studies. Illicit injection drug use is assoc ia ted with high levels of physical and emotional t rauma both from the family of origin and from ongoing sources such a s sex trade work and marginal izat ion. Resilience Research From The Nursing Literature Nursing has long been interested in an understanding of factors that protect health by promoting emotional and physical wel l-being and quality of life. The Nursing literature add resses a wide range of topics on the psychosoc ia l aspec ts of resi l ience including family v io lence (Heinzer & Kr imm, 2002; Mart in, 2002), family relations and 18 sexual behaviour of young women (Tuttle et al . , 2004) substance abuse and sexua l risk taking in w o m e n (Lindenberg et a l . , 1998) post traumatic stress disorder (McCu l lough-Zander & La rson , 2004; S e n g , 2003) marginalization and d isenfranchisement (Hal l , 1999; Zerwekh , 2000) and health care inequalit ies (Lynam, 2005). Addit ional a reas , relevant to the illicit injection drug using populat ion, add ressed by nursing research are the role of self concept and the role of spirituality. S te in , R o e s e r and Markus (1998) in their study of the role of sel f -concept in ado lescent risk behaviours found that self concept may be a determining component not only a s an antecedent to but a lso in the continuing participation in risk behaviours. Sowel l (2000) looked at the connect ion between spiritual activities and wel lbeing among a group of HIV posit ive women . These studies suggest that a positive s e n s e of self and spiritual activities may be protective factors that contribute to resi l ience. Increased in-depth knowledge of the concept of resi l ience is significant to Nursing as well as other discipl ines as this concept holds the promise for the development of practice appl icat ions des igned to strengthen the resi l ience of vulnerable individuals and groups. Resilience And Substance Abuse R e s e a r c h on resi l ience in the context of substance abuse has mainly focused on identifying the characterist ics of resilient children of adults who misuse drugs (Pi lowsky, Zybert & V lahov , 2004) youth at high risk for substance abuse (Hostetler & Kirk, 1997) and the role of caring adults in the lives of children of a lcohol ics (Werner & J o h n s o n , 2004). Aust in (2004) states that the role of culture and the dynamics of the protective p rocesses of resi l ience are not fully understood and should be explored to al low for the development of effective prevention and treatment programs (Austin, 2004). Aust in 's 19 study of drug use and violent behaviours in native Hawai ians suggested that ethnic pride may be an important protective factor against v io lence in this group. Seve ra l studies, not des igned specif ical ly to look at resi l ience, nevertheless contributed knowledge of poss ib le protective factors that may promote resi l ience. Nyamath i , F laskerud and Leake 's (1977) study of HIV risk behaviours, mental health character ist ics and support sys tems of 240 homeless , drug recovering w o m e n suggested that those at risk for depress ion and illicit injection and non-injection drug use tend to chose support persons who are themselves at high risk for the s a m e problems. Nyamathi (2004) identified the characterist ics of homeless w o m e n who want to permanently quit a lcohol , coca ine or heroin use. The characterist ics of the one third of the 748 participants who wanted to quit drug use were: recognition that their subs tance use was an extremely ser ious problem, not associat ing with other drug users , a history of hospital ization for drug use and recent substance use treatment. T e b e s et a l . (2004) studied transformative change in a study of 35 young adults who had exper ienced the death of a parent in the previous two years. The study f indings suggest that individuals exposed to adversity may exper ience cognit ive transformation, which is seen as a form of enhanced adaptation and may be a marker of resi l ience. Cogni t ive transformation is character ized by a turning point in which the individual recognizes that coping with adversity has opened up new opportunit ies and as a result revaluates the exper ience from negative to posit ive or growth-promoting. T h e s e turning points may be an example of re-organizational points a s def ined by Horowitz (1987). 20 Aronwi tz and Morr ison-Beedy (2004) looked at resi l ience in the context of mother-daughter connec tedness , risk taking behaviours such as substance abuse and a hopeful v iew of the future in a population of impover ished Afr ican Amer ican girls. The study results contrasted with earlier studies in that no relationship w a s found between connec tedness and resi l ience. The girls with a more hopeful v iew of the future were found to be the most resilient. In summary, although resi l ience has not been a focus of study within the speci f ic context of injection drug use, it has been studied in many assoc ia ted areas . The negative effects of poverty, home lessness , co-occurr ing mental health d isorders, history of abuse and post traumatic stress disorder on resi l ience and the suggested positive effects of a positive self concept, spirituality, family connec tedness and hope for the future on resi l ience have implications for the injection drug using populat ion. There is a need to look at all these issues specif ical ly within the context of injection drug use and to identify these and other protective factors and p rocesses that work towards resi l ience in this vulnerable population. Resilience Intervention and Treatment Programs Intervention and treatment programs des igned to strengthen resi l ience are based on the assumpt ion that protective factors contribute in some way to resi l ience. Brown (2001) crit iqued the effect iveness of such programs as Drug A b u s e Res i s tance Educat ion (D .A .R .E . ) and Life Ski l ls Training (L.S.T) and recommended resi l ience-based programs as a more effective approach. A need for resi l iency based programs for high risk individuals and famil ies has been identified (Turtle et a l . , 2004) both for prevention of substance abuse (Glance—Cleavland, 2004; Harvey & Hill, 2004; Kap lan , 21 Turner, Norman & St i l lson, 1996; L indenberg et a l . , 2002; Rew , 2003 ; R ichardson et a l . , 1990; Sandau-Beck le r , Deval l & de la R o s a , 2002; Werner , 1998) and for those already involved in substance abuse (Miller, 2003 ; R o i s m a n , 2005). Johnson et a l . (1998) report on a program des igned to increase family resi l ience and thereby prevent or reduce alcohol and other drug use among high-risk youths. L indenberg et a l . (2002) favourably compared the effect iveness of a combined risk and resi l ience based intervention to a health information program in reducing sexual and subs tance abuse behaviour among young, low income Mex ican Amer ican women . A better understanding of resi l ience among illicit drug users could provide direction for new programs and pol icies. Summary The current interest in resi l ience came from the need to account for the 50 percent of individuals who suffer negative c i rcumstances yet who have unexpectedly good ou tcomes. Res i l ience, first v iewed as a state, is currently conceptual ized as a context dependent process. The bas ic constructs of resi l ience are protective factors and risk factors but the dynamics of the interaction between these is, as yet, poorly understood. Johnson and Wiechett (2004, p.665) refer to resi l ience as a "data scant f ield", and recommend research to increase knowledge of the multiple interactive p rocesses of protective and risk factors. Ungar (2003) identifies arbitrariness in select ion of outcome var iables as a problem with the research in resi l ience and , in addit ion, states there is a significant gap in knowledge of the influence of socia l and cultural context in which resi l ience occurs . Other key areas in the current thinking on resi l ience that 22 require further research are: the role of relationships, both familial and extrafamil ial, in the prevention of substance abuse , protective factors that contribute to resi l ience in speci f ic contexts and the relationship of cognitive transformation to indications of resi l ience (Johnson & Wiechett). In addit ion, there remains d isagreement concern ing the number of s tages within the process of resi l ience and if recovery can be v iewed as a specia l c a s e of resi l ience. Tebes et a l . (2004) recommend that future research explore resi l ience as it relates to recovery among specif ic populations including addict ions, mental d isorder and acute and chronic i l lness. Illicit injection drug use is a momentous public health problem. Due to the signi f icance of the problem and the variability of its presentation ac ross gender , age and geographica l contexts, studies to enhance understanding within a speci f ic context are required to guide the public health response. A m o n g the guiding principles that emerged from a study done in Victor ia, British Co lumb ia , on which this secondary study is based , were that differing phi losophical approaches be included in public health strategies for injection drug use and that people with addict ions must play an integral role in the development of serv ices that affect them (Stajduhar et a l . , 2000 , 2004). Al though the main phi losophical approaches focussed on in the original study were abst inence and harm reduction, this may be extended to include the considerat ion of resi l ience based programs to complement existing serv ices based on abst inence and harm reduction phi losophies. A l s o , studies that give a vo ice to resi l ience from the perspect ive of the illicit drug user have the potential of providing valuable information to the development of the concept of resi l ience and the des ign of resi l ience based strategies within this context. 23 C H A P T E R 3 Methods Introduction In this sect ion the research design of both the original study and the secondary study that is the subject of this proposal are descr ibed: its sampl ing method, data col lect ion procedures, means of ensur ing rigor and procedures for protection of human rights. The descript ion of data analysis will be confined to the proposed secondary study. Research Design for this Study A n exploratory descript ive approach to qualitative research w a s the des ign chosen for this secondary study. A qualitative research design is appropriate due to the immaturity of the concept of resi l ience (Johnson & Wiechett , 2004; T e b e s et a l . , 2004; Ungar, 2003) and the lack of in-depth knowledge of the specif ic research quest ion of this study (Morse & Fie ld, 1995, 2004). Qualitative secondary analys is is a credible method to focus on a concept or question that appeared to be evident but w a s not specif ical ly explored in the original study (Hinds, Voge l & Clarke-Stef fen, 1997; Thorne, 1994). Hinds et a l . (p. 420-421) provide an assessmen t tool to determine the fit of the secondary research quest ion to the data provided by the original study. Us ing this tool the following criteria were met 1) the concept of interest was reflected in sufficient depth in the data set, 2) it is likely the study sample could be expected to exper ience this concept , and 3) the data set of the original study w a s of sufficient quality, comple teness and fit with the secondary research quest ion. The fourth criteria w a s partially met in that the proposed research quest ion w a s somewhat similar to that of the primary study, 24 which is to further the understanding of injection drug use and HIV/AIDS. The select ion of an exploratory descript ive approach w a s based on the purpose of the study, which was to explore and descr ibe resi l ience as it is exp ressed from the perspect ive of the IDU. Descript ive research, a type of nonexper imental study, is des igned to descr ibe and document aspects of a situation from the emic perspect ive and to serve as a possible starting point for future hypothesis generat ion or theory development. Al though an in-depth understanding is sought, somet imes researchers can do little more than descr ibe existing relationships without fully comprehending the complex causa l pathways that exist (Polit & Hungler, 1995). Rather than causa l relat ionships or seeking to explain why the study participants are more or less resilient, the purpose of this study was to descr ibe resi l ience from their perspect ive. Th is study used secondary data obtained from a larger qualitative study, conducted in Victor ia, British Co lumbia in 2000. The purpose of the original study w a s to determine behaviours and contexts that place IDUs at risk for b lood-borne d i s e a s e s and to draw on this information to develop interventions to reduce the harm assoc ia ted with injection drug use (Stajduhar et a l . , 2000, 2004). The principal investigators of the original study were Kell i I. Stajduhar, R .N . , Ph .D . , Cl inical Nurse Specia l is t , Capi ta l Health Reg ion of Victor ia, B . C . and L inda Poffenroth, M.D., M S c , Communi ty Med ic ine , Deputy Media l Health Officer & Manager D i sease Surve i l lance, Capi ta l Health Reg ion , Victor ia, B . C . The co-investigator was Els ie W o n g , B . S . N . , M.B .A . , Field Survei l lance Officer, Health C a n a d a , B C Centre for D isease Control , S T D / A I D S Contro l . The project was funded by the Division of HIV Epidemiology, Bureau of H IV /A IDS, S T D & T B , Laboratory Centre for D i sease Control , Health C a n a d a , the B . C . 25 Ministry of Health and the Capital Health Reg ion , Victor ia, B C . Research Design of Original Study Rapid A s s e s s m e n t Response and Evaluat ion ( R A R E ) methodology was the research des ign chosen for the original study. The R A R E method is des igned to guide the development of prompt, community focused interventions in response to emerging d iseases and other public health problems (Stajduhar et a l . , 2000). The key components of R A R E methodology are a focused approach, short completion t ime, built-in evaluat ion, inclusion of community consultation and strong partnerships between front-line community workers and researchers. Data Collection Methods and Description of Sample There were three groups of participants: IDUs (20 female, 21 male) service providers and community leaders/pol icy makers (see Tab le 1). Th is study was limited to the use of the IDU and serv ice provider key informant interview and focus group data. Table 1. List of study participants Category Key Informant Interviews F o c u s Group Interviews Total Injection Drug Users 17 24 41 Serv ice Providers 20 25 45 Pol icy Makers /Communi ty Leaders 12 0 12 T O T A L 49 49 98 The three recruitment strategies used were nominated sampl ing, targeted sampl ing and advert is ing. The focus of the sampl ing strategies was to recruit key informants within each of the three groups with in-depth knowledge and exper ience of 26 injection drug use . Target sampl ing was used to find IDUs who were unknown to the research team. O n c e interviewed, the IDUs were asked to nominate their peers . Advert is ing consisted of posting notices in service delivery areas that IDUs frequent. Samp le s ize w a s not determined in advance but w a s based on saturation. Al l IDU participants received a $20 stipend to cover expenses incurred. Data col lection methods included: key informant interviews, focus groups, quest ionnaires to obtain demographic and drug and d i sease information from the IDU participants, IDU participant observat ion (70 hours), geo mapping to document serv ice and risk locat ions and 15 rapid assessmen t surveys to fill in gaps in the data. The field team members , who included street nurses and other frontline outreach workers, were crucial to the recruitment plan as they were able to invite people to participate w h o m they knew to be currently using injection drugs and to have in-depth knowledge and exper ience within the injection drug using community. Key Informant Interviews The interviews ranged from 30 to 120 minutes. Permiss ion w a s obtained to audiotape all but one of the interviews and these were transcribed in full. In addit ion, interviewers made extensive notes as soon after the interview as possib le. Interviewers were instructed to keep the interviews focused on the research objectives and were provided with quest ions to be used as a guide only (see Append ix A for Interview Gu ide - Injection drug Users & Append ix B for Interview Gu ide - Serv ice Providers) . Focus Group Interviews A total of seven focus groups were conducted with two participant groups a s fol lows: three IDU (24 participants) and four service provider (25 participants). The IDU 27 focus group participants did not take part in key informant interviews. Part ic ipants for each of the focus groups were selected to capture a speci f ic lens on injection drug use . For the injection drug use focus groups this was 1) youth, 2) female adult, and 3) male adult and for the service provider focus groups this was 1) mental health serv ice providers, 2) aboriginal serv ice providers, 3) people working in communi ty -based and non-profit organizat ions, and 4) pol ice constables. The focus groups were audiotaped and transcribed in full. A recorder w a s present during the group sess ions to record the main themes that emerged . The group facilitator promoted d iscuss ion concerning the research object ives and used quest ions similar to the key informant interview guide quest ions. Questionnaires Demograph ic and drug and d isease related information w a s col lected by a quest ionnaire adapted from the HIV seroprevalence study conducted in Victor ia in the Fall of 1999. The quest ionnaire was administered to the IDU participants at the start of key informant interviews and focus groups. Forty-one IDU quest ionnaires were completed. Demographics Twenty-one of the IDU participants were male and twenty were female; of these 11 were youth between the ages of 15 and 24 years of age . Ethnicity w a s identified by the participants as White (29), Aboriginal (6) and Middle Eastern (2). Four participants did not identify their ethnicity. More than half of the sample had not completed high schoo l ; s ix had completed high schoo l and seven had some post secondary educat ion. Fifteen participants reported relatively stable housing (apartment, house, boarding 28 house) in the past three months and 33 participants reported unstable housing (living on the street, squatt ing, hospital ization, incarceration) within the last three months. Just under half of all participants were or had been on socia l ass is tance and nine participants received government disability benefits. The majority (34) earned most of their income through drug deal ing, panhandl ing and working in the sex trade. Other sources of income were "squeegee ing" and criminal activities such as break and enter. Nineteen of the 40 participants that responded to the quest ion had previously worked in the sex trade (14 women , 5 men) and seven of these participants were currently working in the sex trade (6 female, 1 male). On average, the participants reported spending from $100 to $200 per day on their drug habit. Drug use patterns. A g e of first injection ranged from less than 15 years for eight participants and less than 20 years for 27 participants (13 female and 14 male). The drug of cho ice w a s heroin (4) coca ine (6) and both heroin and cocaine (25). There were no gender dif ferences in drug choice. Of the 40 participants who responded to the quest ion of shar ing injecting equipment, 29 had shared with another person (16 female , 13 male). Hepatitis C and HIV status. Thirty-six participants stated they had tested for H C V (19 female, 17 male) and of these 19 (11 female, 8 males) self-identified as H C V posit ive. Thirty-six (18 female , 18 male) participants a lso stated they had tested for HIV and of those tested 9 (7 females , 2 males) self-identified as HIV positive. Drug and alcohol treatment. Nineteen had a c c e s s e d a drug and alcohol treatment program in the 12 months 29 preceding the study. Approximately 12 had tried but been unsuccessfu l in access ing a drug and alcohol treatment program mainly due to long wait t imes. Data Management and Analysis for this Study In this sect ion, the analytic framework for this study, Horowitz 's construct of re-organizat ional points (1987) and analyt ic techniques related to grounded theory and other data management tools will be d i scussed . For the purpose of this study, relevant data segments were identified and retrieved from the IDU and service provider data of the original study. Horowitz 's construct of re-organizational points (1987) that correspond to a change in the degree of resi l ience was used as an analytic framework. This is a particularly suitable framework to guide but not limit the analys is of the data of this secondary study as it is a component of a process model that acknowledges the dynamic and complex nature of resi l ience. Horowitz based his model on the assumpt ion that everyone has s o m e "degree" of resi l ience that var ies over t ime (p. 151). Res i l ience is v iewed on a cont inuum in which the individual that is relatively invulnerable to adversity is sa id to have "strong resi l ience" whereas the individual that is relatively vulnerable to adversi ty is referred to as having "low resi l ience". Those who have exhibited negative behaviours and ou tcomes, such as the illicit IDU, may be said to have some level of resi l ience and that this level of resi l ience may vary over t ime . Examp les of poss ib le re-organizat ional points in the life of an illicit IDU may be exper iences related to surviving an overdose, having one 's chi ldren removed by social serv ices or connect ing with a new support person Other resi l ience models and studies d iscussed in the literature review contribute 30 to an understanding of resi l ience and were used in the analys is of the IDU and serv ice provider data. For example, protective factors identified by G a r m e z y (1991) and Werner and Smith (1982) and instances of cognit ive transformation as descr ibed by T e b e s et a l . (2004) were sought. In addit ion, the researcher used knowledge gained both as a frontline nurse working with illicit IDUs and as an interviewer and focus group facilitator for s o m e of the serv ice providers in the original study. Data analys is techniques used in grounded theory research, such as constant compar ison and open coding (Morse & Fie ld, 1995) were used . Immersion in the data was ach ieved by careful and multiple readings. Al l data segments were reviewed line-by-l ine, potential "rich points", data that appeared to be especia l ly relevant to resi l ience, were highlighted and first level codes that emerged were noted. Data was compared and contrasted both within and across individual interviews. In addit ion, particular attention was paid to repetitions, potential inconsistencies or contradict ions, and surprising or unusual language or information within an individual interview and ac ross interviews. "Memo ing" w a s used to increase the conceptual level of the analys is by capturing the ideas and insights of the researcher. Select ive coding w a s accompl i shed by identifying the relationships between the first level codes that al lowed them to be sorted or condensed into more abstract categor ies. In the final phase of analys is e a c h category w a s further ana lysed to al low identification of the major themes. Microsoft Word 2003 was used to cut and paste data into individual word documents for e a s e of sorting. Interviews and all documents containing data were stored in either a computer with password a c c e s s or in a locked file cabinet. The 31 researcher used a diary to document personal bias and the dec is ion-making trail and consul ted with her thesis committee and the principal investigators of the original study on the reliability and validity of the process and findings. In the final phase of the analys is , the researcher returned to the data to check that the major themes that had emerged were true to individual interviews. Ensuring Rigor in this Study There are a range of criteria to ensure rigor in qualitative research. The four criteria that were used in this study to guide the conduct of this research project were: credibility, transferability or applicability, dependabil i ty or cons is tency and confirmability or neutrality (Morse & Fie ld, 1995). Credibil i ty refers to the level of conf idence in the truth of the f indings and was addressed in this study by: supporting analys is and interpretation with direct quotes from the data; triangulation of data sources (IDUs and serv ice providers); and drawing on the researcher 's clinical exper ience in providing health care serv ices to the injection drug using populat ion. Transferabil i ty or applicability refers to whether the f indings can be appl ied to other contexts. The unique characterist ics of the smal l sample s ize were descr ibed to al low others to determine the applicability of the findings to individuals in similar c i rcumstances. The findings may have limited transferability to other injection drug using populat ions. However, the insights from this study provide important direct ions for future research on resi l ience as it relates to illicit injection drug use. Dependabi l i ty or cons is tency is used to evaluate whether the study findings could be dupl icated or similar in similar contexts. Al though an audit frail of quest ions, dec is ions, insights and 32 personal b iases and assumpt ions was kept, it is noted by Morse and Field (1995) that qualitative research focuses on the un iqueness of human exper ience and that variat ion, not repetition, is to be expected. Confirmabil i ty, or neutrality, is concerned with f reedom from, or at min imum awareness of, b iases and assumpt ions and maintaining research objectivity. A personal diary was kept to document and increase awareness of the researcher 's b iases and assumpt ions. In addit ion, all possible explanat ions of the data were explored and negative c a s e s were sought. Ethical Considerations The original study was approved by the Capital Health Reg ion (Victoria, British Columbia) R e s e a r c h Rev iew and Ethical Approval Commit tee and informed consent w a s obtained from all participants. The s igned consent st ipulated that the typed transcripts and notes obtained in the study would be retained for educat ional and future research purposes with the understanding that any additional research projects that use the transcript ions would be approved by the appropriate research and ethics commit tees. Approval of the University of British Co lumb ia Resea rch Rev iew and Ethical Approva l Commit tee w a s obtained for this study. Part ic ipants were given written information summar iz ing the purpose of the study and informing them that their participation w a s voluntary and that they could withdraw from the study at any time without suffering any negative consequences . The names and contact numbers of the principal investigators were a lso g iven to part icipants for any future quest ions or complaints. A numerical coding sys tem w a s used to protect the identity of participants. Al l interviews, except one where permission w a s den ied , were 33 audiotaped and transcribed in full with all identifiers removed. Aud io tapes were destroyed on complet ion of the original study and transcripts kept in a computer with password or in a locked storage cabinet. In this study, interviews and all documents containing data or other confidential information were stored in the s a m e secured manner. Chapter 4 Findings Introduction The purpose of this study was to gain a better understanding of resi l ience from the perspect ive of those who use illicit injection drugs. To contextual ize the f indings, this chapter begins with a descript ion of the condit ions in which the participants who used illicit injection drugs l ived. Un less otherwise indicated, "participants" refers to the illicit injection drug user group. Next, the exper iences of these participants that are assoc ia ted with a change in the level of their resi l ience are d i scussed . The serv ice provider data extends the understanding of these exper iences, many of which have been d i scussed in a different context in earl ier publications based on this data (Stajduhar et a l . , 2001 , 2004). In this study, Horowitz 's (1987) conceptual izat ion of resi l ience as a relative and dynamic process provided a lens with which to frame the analys is . The participants spoke of exper iences in their l ives that involved behavioural and attitudinal changes around their drug use. Part icipant 's descript ions of changes in their l ives that inf luenced drug use were used as a starting point for the analys is . Behavioura l and attitudinal changes related to quitting drug use, decreas ing drug use, safer drug use and support seek ing were v iewed as s igns of increasing resi l ience, while behavioural and attitudinal changes related to the initiation of drug use , increased drug use , unsafe drug u s e and relapse were interpreted as signs of decreas ing resi l ience. 35 Social Context of Drug Use and Resilience The socia l environment, including poverty, stigmatization and marginal izat ion, in which the participants lived has been descr ibed in previous publications (Stajduhar et a l . , 2001 , 2004). However, a brief overview is necessary to put the f indings of this study into context. The participants of this study lived in Victor ia, British Co lumb ia a smal l , urban, seas ide city with a mild cl imate and a population, including outlying a reas , of approximately 325,000. The illicit injection drug using population of Greater Victor ia, at the time of the study, w a s est imated to be1500 to 2000 (Capital Health Reg ion , 2000). In the original study the participants reported that their l ives centred on maintaining their drug habit. The average daily drug cost of their addict ion ranged from $100 to $200. Nine of the 41 participants received government disability benefits and less than half received socia l ass is tance benefits. Panhandl ing and criminal activity such as petty theft, sex trade work and drug deal ing were reported as major sources of income. The dai ly cyc le of accumulat ing enough money to pay for their drugs, connect ing with a drug dealer and purchasing and using drugs exhausted most of the f inancial , physical and emotional resources of the participants. Bas i c needs of shelter, nutrition, medical care and meaningful human contact with family and fr iends were, for the most part, unmet due to the unrelenting cycle of addict ion. A s almost all of their f inancial resources went towards purchasing illicit drugs, most of the participants lived in condit ions of poverty. In the three months prior to the study, 33 of the 41 participants reported living in unstable housing such as shel ters, squats and fr iend's apartments. Living on the street for intermittent per iods w a s a lso common . Serv ice providers spoke of the underlying issues of addict ion such as 36 poverty, under-housing, unemployment, malnutrition, lack of educat ion and job skil ls and psychiatr ic i l lness and other medical problems. Al though over half of the participants reported spending most of their t ime in the downtown area , illicit injection drug use was reported to occur in multiple locat ions throughout Greater Victor ia. A particular concern was drug use in public a reas such as parks, a l leys and public washrooms (Stajduhar et a l . , 2000). The interview, observat ion and geo mapping data of the primary study all suggested that there were too few serv ices for those who used illicit injection drugs and that those serv ices that did exist had ser ious a c c e s s barriers due to location, waiting lists and abst inence based programs (Stajduhar et a l . , 2000). Fo r example , 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 serv ices but were unable to due to long waiting lists. In addit ion, the participants reported that they were frequently treated in a judgemental manner, both general ly in the communi ty and specif ical ly when they sought health care and that this often had the effect of precipitating addit ional drug use and decreas ing healthcare seek ing behaviour. A s one long term drug user stated, "as soon as ... some people ... find out I use drugs, an IV u s e r . . . they treat me like I'm a different person, like I'm shit". The participants of this study lived in poverty, were al ienated and marginal ized from main st ream society and lacked a c c e s s to the basic health determinants, including health care, whi le they attempted to deal with a powerful addict ion. A n appreciat ion of these difficult c i rcumstances is essent ia l to understanding the exper iences they descr ibe. 37 Part ic ipants descr ibed two types of exper iences that were assoc ia ted with an increase in resi l ience and one type of exper ience that was assoc ia ted with a dec rease in resi l ience (see Tab le 2). Table 2. Part icipant exper iences assoc ia ted with a change in resi l ience Part icipant Exper iences Assoc ia ted With Increased Res i l ience Gett ing to the Point of C h a n g e • recogniz ing its not worth it • getting scared • recogniz ing an inner desi re to quit Envis ioning a better future Part icipant Exper iences Assoc ia ted With Dec reased Res i l ience Needing to dull the pain Al l of the participants descr ibed exper iencing at least one type of these exper iences and most participants descr ibed experiencing more than one type. Experiences Associated With Increased Resilience In this sect ion, a d iscuss ion of the f indings focuses on the w ays in which the participants constructed their exper iences that led to abst inence from drug use , dec reased drug use , safer drug use or support seek ing. Many of the participants a lso reported attitudinal changes in that they were "seriously trying to quit" "or felt "now it's t ime to get c lean" . From a harm reduction perspect ive, the participants reporting these exper iences had made positive change. Gett ing to a point of change was the first step for some participants, as one female participant expla ined, "I'm just to the point where I want to get more things going on in my life, more positive things". The exper iences assoc ia ted with posit ive change 38 and the ways in which they helped the participants begin to re-organize their l ives are descr ibed below. Getting To The Point of Change A s severa l participants reconstructed their exper iences, they descr ibed a variety of situations that got them to the point of evaluating their lifestyle and recogniz ing that they could no longer continue to use drugs in the way that they had been. Motivated by these self revelations individuals began to take steps to address their drug misuse . The participants descr ibed exper iences that "got them to the point" of making changes in their l ives including, "Recogniz ing It's Not Worth It", "Getting Sca red " , "Recogn iz ing an Inner Desi re To Quit" and "Reach ing Out For Support". Recognizing it's not worth it. S o m e of the participants recal led coming to the point where they had to admit to themse lves that their drug use was just not worth it. Part icipants descr ibed consc ious ly weighing the negative aspec ts of maintaining a drug habit and the benefits drug use brought to their l ives. There was considerable variation in what w a s cons idered too high a cost and the length of t ime the decis ion-making process took. However , drawing on past exper iences , these participants came to the conclus ion that some costs assoc ia ted with continued drug use were too high a price to pay. In particular, the participants drew attention to the personal costs of jail t ime, the hardships of street life, apprehens ion of one 's chi ldren and remorse for harm done to others. It w a s not unusual for a n individual participant to report that they had more than one of these exper iences. 39 O n e male participant, who had continued to use injection drugs while incarcerated, reported that four months before he w a s due to be re leased from the correct ional facility where he was complet ing his second , four-year term for drug trafficking he began to think about his future. He real ized that if he kept using and deal ing drugs he would probably have to face another prison term and , concluding 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 been out of prison for three years and w a s on a methadone program. He had one relapse one year after his re lease from prison but had not used any illicit drugs for the two years previous to the interview. The ongoing need for f inancial resources to pay for the next "fix" drove many of the participants into situations that exposed them to physical and emotional hardships. After 12 years of living for the 'high' that drugs could give her, one female participant considered the risks assoc ia ted with panhandl ing and sex trade work to support her habit and c a m e to real ize that "it wasn' t worth it". Al though after making the dec is ion to quit, she had severa l re lapses into cocaine use, at the time of the interview, this participant proudly reported that she had not used coca ine for three years . However , recogniz ing that the costs of continued drug use outweighed the benefits drugs provided did not a lways result in long-term abst inence. Another female participant, whose re-evaluation of the costs of her drug habit was precipitated by having her chi ldren apprehended by Soc ia l Serv ices , descr ibed deciding to quit drugs then suffering repeated re lapses. S h e did, however, explain that losing her chi ldren initiated a ser ies of attempts to quit drug use and her drug habit was never as out of control as 40 before this point in her life. At the time of the interview, this participant reported that it had taken her three years to get to the point where she mainly smoked and rarely injected coca ine . S h e had not regained custody of her chi ldren. Al l of the participants spoke of the personal "costs" assoc ia ted with drug use but only one, who stated he had been involved in sell ing drugs, expressed remorse for the harm done to others. This male participant, who had originally sought support at an inner city agency and then became a volunteer there, reported that see ing the plight of his former drug-seeking customers was a constant reminder of the harm he had done to others and helped him continue to abstain from illicit drug use . Speak ing of how those who use illicit injection drugs come to a point in their l ives where they start to re-evaluate their drug use, a serv ice provider descr ibed two factors that appear to be important 1) wi tnessing the negative consequences of drug use in others, and 2) becoming tired of deal ing with the personal consequences of drug use . The time lapse between initial drug use and becoming ready to re-evaluate the consequences varied for many of the participants. Most of the participants that had made posit ive changes had used drugs for over ten years before they reached this point, however, two of the female participants, aged 16 and 19 at the t ime of the study, used drugs for only two years before they reached the point where they were ready to seek treatment. Getting scared. Many of the participants descr ibed exper iences of achieving abst inence, dec reased drug use , safer drug use and support seek ing that appeared to be motivated by getting scared . There was considerable variation in the frightening exper iences that 41 the participants descr ibed and most of them reported having multiple fears that included being afraid of dangerous drugs and drug combinat ions, negative consequences of drug use to their health, including death, negative c o n s e q u e n c e s of drug use to their physical appearance, memory "blackouts" and re lapse. T h e s e fears appeared to be important catalysts in finding the strength to move toward more posit ive health behaviours. Somet imes exper iences of fear were unexpected. O n e female participant reported that she became fearful for her health when she looked in a mirror and s a w her facial acne and how much weight she had lost. Her fears were reinforced by see ing the s c a b s , a b s c e s s e s , acne and weight loss of her drug using fr iends. Motivated by these fears this female participant, with a history of three years of heavy injection coca ine use , greatly reduced the amount of coca ine she used and also changed from injecting to mainly smoking. From a harm reduction perspect ive reduced drug use and smoking the s a m e substance instead of injecting it is seen as a posit ive change . The fear of relapsing and the loss of gains already made in overcoming the addict ion appeared to a lso be assoc ia ted with posit ive change for s o m e part icipants. O n e female participant who had made strong gains in stabil izing her life reported that being frightened of relapsing strengthened her resolve to stay away from injection drug use: I know it wouldn't take much. If you do start using, then you'll start craving it and that scares me.. . the thought will c ross my mind ... And I just think "No. " It's not worth i t . . . I don't want to let myself down. 42 Somet imes the warnings of fr iends of the participant raised addit ional fears. O n e female participant who w a s already fearful about weight loss and losing her apartment reported that her fr iends kept telling her she was going to die if she kept on injecting drugs. Fear of dying, added to her other fears, motivated her to enter a detoxif ication facility. S o m e of the participants reported fearing for others as well as themse lves . For example , one male participant, who was on a methadone program but exper iencing re lapses, reported that he was extremely fearful for the health of his wife, who a lso used illicit drugs, and that this had motivated him to begin the process of quitting drug use. Support seek ing behaviour was also assoc ia ted with being fr ightened. O n e female participant, who w a s not injecting drugs at the time of the study interview, descr ibed being extremely frightened after fr iends told her she had been missing for a number of days and realizing she had no memory of where she had been or what she had been doing. This participant was motivated by this exper ience to move to a different city where she had friends who did not use drugs and seek community supports as well as medical help for home detoxif ication. Data from the serv ice provider interviews supported the participant reports that being scared often precipitated support seek ing. The serv ice providers said that their cl ients frequently reported that they had sought support serv ices because they became desperately frightened due to losing or spending all their money, pawning or sel l ing all their possess ions or because they had legal charges pending. O n e serv ice 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 l ives are very 43 peri lous, very unsafe, and somet imes if you can just offer a safe p lace away from the predators and the streets, they'll grab onto that." Recognizing an inner desire to quit. S o m e of the participants were convinced that a genuine "inner" desire to quit drug use must be present before they are able to benefit from external support or inf luences. O n e participant who had been through a drug treatment program three t imes with no apparent effect but who eventually had greatly reduced her drug use and stabi l ized her life, apparently without outside support, stated that nothing could have been done differently that would have helped her control her drug use sooner : B e c a u s e it's all on the inside ... A n d when I did finally quit I didn't need to go to t rea tment . . . when you want to quit you'll do it. A n d if you don't want to quit I don't care where they send you and for how long you're not going to quit. It all c o m e s from inside. Another participant who highlighted the importance of the decis ion to quit indicated that for her this involved deciding that she needed to stop and that she would be " O K " if she did stop. The fear of not being able to cope with life after quitting drug use has been d iscussed in an earlier publication based on this data (Stajduhar, et a l . , 2000). The participants reported that when they quit drugs they had to face the reasons they started using in the first place as well as the harm they had done to themse lves and to others during their drug use. Al though the data for this category w a s limited, s o m e of the participants strongly bel ieved that the personal dec is ion to quit drug use was a key point in being able to successfu l ly follow through on the dec is ion to quit. 44 Reaching out for support. The realization of some of the participants that they needed help to dea l with their addict ion w a s another mark of beginning to making positive changes that reflected increased resi l ience. This realization led individuals to seek support from many sources including community agenc ies , medical serv ices, street nurses, inpatient and outpatient detoxif ication serv ices, treatment, recovery and methadone programs, supported housing and counsel l ing and psychiatric serv ices. In contrast, the participants who were not at a point in their l ives where they were contemplating posit ive change tended not to seek support for even their bas ic medical needs: My whole time is locked up getting coin together. I've got a lot of health i ssues myself that need to be dealt with and I can't just get around to it right now and I can't s e e it getting any better until I can kick [drugs]. For those participants who sought support, being treated as a va luable human became a catalyst for change. Relat ionships of trust, in particular, were attributed great value by the participants. They descr ibed specia l individuals who they felt they could turn to because that person knew them wel l , was non-judgemental, and would go to great lengths to help them on an ongoing bas is . T h e s e kinds of relat ionships somet imes grew out of contacts with their medical practitioner, other t imes it w a s their methadone doctor or an outreach nurse or a staff member at a community agency . Many of the participants sought community supports that had a spiritual component but it is not c lear from the data that it was the spiritual component that attracted or helped them or the non-spiritual support ive serv ices that were offered. 45 There were no apparent a c c e s s barriers to those who did not have similar beliefs or did not want to be involved in religious or spiritual activit ies. A warm support ive family environment and an interested and involved parent are reported in the literature to be protective factors that bolster resi l ience (Garmezy , 1991; Werner & J o h n s o n , 2004). Fami ly support was mentioned much less frequently by the study participants than community support was , however, some participants reported that they did a c c e s s family support. A teenage participant descr ibed the posit ive effect the cont inued involvement of her family in her life had stating, "For me the difference between using and not using is having them [her family] in my life." Serv ice providers agreed that family support w a s very important and that family members often provided the resources, energy and motivation to deal with the addict ion and that, general ly, youth who could maintain contact with their family were better off than youth who did not have contact with their family. The importance of family w a s illustrated by one adult female participant who did not have family support when she first dec ided to abstain from drug use . This participant knew she needed some thing to care for and constructed a pseudo family situation for herself, "I got myself a kitten, and clung to her ... she was my reason for staying c lean, because if I started using again I would end up losing her." T h e ways of "getting to the point" of making change that have been d i scussed descr ibe how s o m e of the participants constructed their ability to marshal the strength and help they needed to begin the long road to abstaining or safer drug use . Other participants descr ibed wanting more, not only to control or e s c a p e their addict ion but a lso to real ize a better future. 46 Envisioning A Better Future Another way that some participants constructed their exper iences that appeared to be assoc ia ted with an increase in resi l ience was reflected in the category of "Envis ioning A Better Future". A s one male participant stated, "I fucked up for 30 years of my life ... let's try and make the next 30 better than the last 30." Two female participants were able to articulate a specif ic future goal , which w a s f inishing high schoo l . Both of these participants had started drug use in their mid teens and after being involved for only a few years had taken significant s teps to either stop or a lmost stop their drug use . O n e of these participants descr ibed her vis ion of being a n outreach worker after complet ing high school . Other participants, while apparently lacking speci f ic goals , expressed a general v is ion of a different, more positive life. A s one participant stated, "I want to get more things going on in my life, more posit ive things." Unl ike the conceptual izat ion of cognit ive transformation descr ibed by T e b e s et al . (2004), the participants in this study continued to see their past exper iences as negative. However , for s o m e of the participants wanting more from life appeared to be assoc ia ted with arriving at a new acceptance of self. O n e male participant, on methadone at the time of the interview, stated he wanted to change his life around and that, "There isn't a day that I've woken up and sa id , O h I'm happy that I'm an addict. The fact is that I am an addict. S o I have to deal with that". The serv ice provider data supported the view that having a v is ion of the future and goa ls to work towards w a s assoc ia ted with posit ive behavioural change in the injection drug using population. They encouraged their clients even while still act ively using drugs to find a vision of the future and goals to work towards. O n e serv ice 47 provider descr ibed the s u c c e s s e s ach ieved in enhancing work readiness and self-es teem by having individuals still actively involved in their addict ion volunteer to work in an inner city lunch program. S o m e of the participants descr ibed attitudinal and behavioural changes that involved new hope for a different and better future, a new vision of themse lves as non-drug users and for a few, specif ic goals for the future. T h e s e changes may be v iewed as similar to the transformative changes descr ibed by T e b e s et a l . (2004) and be seen as indicative of an increase in resi l ience. Experiences Associated With Decreased Resilience Although most participants descr ibed exper iences assoc ia ted with both increases and dec reases in resi l ience, a few participants descr ibed only exper iences assoc ia ted with dec reases in resi l ience. These participants were focused on the many types of pain in their past and current life and their attempts to dull or e s c a p e the pain of their ex is tence. Their feel ings of hope lessness were a chief characterist ic of their stories. T h e s e exper iences were captured under the category "Needing To Dull The Pa in " . Needing To Dull The Pain Exper iences of pain appeared to increase the vulnerabil ity of s o m e participants to initiation of drug use, continued drug use, unsafe drug use pract ices and re lapse. Al though there were many sources of physical pain assoc ia ted with injection drug use (systemic infections, local a b s c e s s e s , exposure to inclement weather, beat ings) the primary source of pain descr ibed by participants was emot ional , including feel ing hope less that their l ives would ever improve. 48 The emotional pain descr ibed by the participants arose from a variety of traumatic exper iences. O n e major source reported by participants w a s a history of chi ldhood sexua l abuse . S o m e of the participants told horrific stories of long-term abuse and being introduced into the sex trade and the drug world by their parents. Another source of pain that emerged from the data was untreated mental health problems. The serv ice providers reported that a large number of their cl ients were particularly vulnerable to addiction due to mental health i ssues , including depress ion and foetal a lcohol syndrome. Feel ings of alienation from both family and communi ty were a lso a frequently reported source of emotional pain. A lack of hope that their l ives could improve permeated the stories of these participants. The participants reported using illicit drugs in order to dull the emotional pain of past and ongoing physical , emotional and sexual abuse as well as the feeling of never belonging or being a part of any community. Unfortunately, using illicit drugs to e a s e the pain appeared to lead the participants into street life and sex trade work and an escalat ing need to sel f-medicate. In fact, as one serv ice provider descr ibed, it appeared to make their l ives worse: They just want to feel loved and they want to feel a part of and they want to feel like they're good enough for something. S o , I think to gain that feel ing they will put themselves at risk in other ways ... to feel good ... they will g ive something up and that could be their safety, that could be being so loaded that they just don't care. They' l l do another hit with somebody 's needle or they'll s leep with somebody or whatever. 49 Another source of pain was the emotional t rauma that occurred while incarcerated. Many of the participants had served sentences in correctional facil i t ies. A serv ice provider stated that many of the inmates do not have the coping mechan isms to deal with this t rauma and so they, "go into pr ison, never done heroin before, but when they c o m e out they're addicted". S o m e of the participants spoke of controlling their drug use at a minimal level for extended periods of time or quitting drug use completely until an unexpected adverse event, such as a depress ion or incarceration, occurred. Without adequate coping ski l ls, these events left them vulnerable to drug use. O n e female participant expla ined that she would be more likely to relapse if "life is going down, it's shitty [and] you have no where to live or nothing's happening". Another female participant said that she returned to drugs when her boyfriend went to jail. Even long-term abst inence could be undermined by an adverse event, as was the case with one male participant who w a s drug free for five years before relapsing after taking pain medicat ion for a back injury. The serv ice providers stated that becoming addicted was assoc ia ted with both the addict ive quality of the drug used and a lack of personal resources and supports to keep the drug use under control. Many service providers postulated that the pain of low se l f -es teem w a s the key i ssue that increased vulnerability to addict ion. O n e serv ice provider expla ined: If you don't feel very good about yourself, you just don't bother taking care of yourself. If you don't bel ieve you deserve to take care of yourself. There 's no purpose for tomorrow. It doesn' t matter. It can't get any worse. 50 Summary The primary aim of this secondary study was to descr ibe resi l ience from the perspect ive of those who use illicit injection drugs. Interviews with individuals who used illicit injection drugs served as a primary source, and where appl icable, interview data from serv ice providers was used to complement data obtained from the IDU interviews. Two types of participant exper iences were assoc ia ted with an increase in resi l ience, "Gett ing To The Point" and "Envisioning A Better Future". The participants reported exper iences of getting to the point of making positive change in the following ways , "Recogn iz ing It's Not Worth It", "Gett ing Sca red " , Recogn iz ing A n Inner Des i re To Quit" and "Reach ing Out For Support". "Needing To Dull the Pa in " of both the past and the present and an absence of hope for the future was assoc ia ted with a dec rease in resi l ience. The first two types of exper iences were assoc ia ted with support seek ing and quitting, decreas ing and safer drug use while the third type of exper ience was assoc ia ted with initial drug use , continued drug use, unsafe drug use and re lapse. By conceptual iz ing these efforts as part of the process of increasing or decreas ing resi l ience, analys is of the data resulted in increased knowledge of the participants' exper iences that could be linked to changes in resi l ience. 51 CHAPTER 5 Discuss ion To my knowledge this was the first study to explore resi l ience from the perspect ive of individuals who inject illicit drugs. Key f indings included ways that individuals constructed their exper iences that led them to marshal l ing the strength and help they needed to begin the long road to quitting, reducing and safer drug use . In contrast, at other t imes in their l ives, the need to address the pain they exper ienced appeared to increase vulnerability to continued or increased use of drugs, and deter individuals from consider ing any other option. By conceptual iz ing these efforts as part of the p rocess of increasing or decreas ing resi l ience, the f indings of this study extend the ways in which f rameworks of resi l ience have been appl ied to this populat ion. In this chapter, I d i scuss the f indings and limitations of the study and the implications for future research. Resilience In Populations In the Process of Recovery-There are d iscrepant v iews in the literature concerning ev idence of resi l ience in populat ions exper iencing problems such as addiction or mental i l lness (Brown & Kul ig, 1996; Miller, 2003 ; Ro i sman , 2005; Rutter, 1993; Werner , 1989). The f indings of this study lend support to the c la im that resi l ience can be demonstrated in populat ions who are in the process of recovery (Brown & Kul ig; Miller; Ro isman) . Al l of the participants in the study spoke of exper iences in their l ives that involved behavioural and attitudinal changes concerning their drug use that w a s conceptual ized as changes in resi l ience. Res i l ience w a s demonstrated in spite of their struggle with addict ion and the difficult 52 c i rcumstances, including poverty, marginal izat ion, under-housing, unemployment , i l lness, d i sease and barriers to health care that character ized their ex is tence. Resilience As A Dynamic Process Study f indings extend our understanding of resi l ience as a relative and dynamic process as conceptual ized by Horowitz (1987). The concept of multiple points of change in an individual's level of resi l ience is included in severa l of the p rocess models of resi l ience. Horowitz included the concept of "points of reorganizat ion", Rutter (1993) descr ibed "key turning points" and F lach (1988) referred to 'bifurcation points'. The f indings from this study suggest that there are multiple ways that behavioural and attitudinal changes may influence resil iency. Many of the participants spoke of how they got to the point of making positive changes in their l ives that helped them abstain or dec rease their drug use , begin to pay attention to their health, or engage in harm reduction strategies, where as at other t imes individuals talked of difficult t imes that marked changes that increased their vulnerability to continued drug use . T h e s e findings suggest that it may be important to identify individuals who are ready to make changes in their l ives and tailor serv ices to either support their efforts to make posit ive change or dec rease their vulnerability to making negative change by providing alternatives to address exper iences of pain. Resilience and A Transformed World View Part icipant reports of non-drug related future goals and plans was conceptual ized as an indicator of a transformed world v iew that w a s indicative of increased resi l ience. Whi le many of the participants expressed the desi re to quit drug use only a few reported future plans and goals that involved a life free of addict ion. 53 T h e s e f indings are similar to the construct developed by T e b e s et a l . (2004) in which transformation is v iewed as a turning point, marking an altered world v iew where in new opportunit ies are recognized. Unlike the construct of T e b e s et a l . , the participants did not reconstruct their past exper iences as positive and growth-promoting. However , participants appeared to gain a new acceptance of themselves and a new s e n s e of their self worth in spite of past mistakes. Severa l of the multi-stage p rocess models of resi l ience include a stage that has similarities to these exper iences of a t ransformed world view. The model of R ichardson et a l . (1990) includes a stage character ized by growth of sel f-understanding resulting in increased resi l ience. Rutter's (1993) model includes a third stage of resi l ience involving an increase in se l f -esteem and self-eff icacy while his fourth stage is character ized by the opening up of new opportunit ies or a new world v iew that is indicative of the highest level of resi l ience. Brown and Kul ig 's (1996) model includes a second , proactive stage involving positive adaptation and transformation as indicators of not only bouncing back to the former stage of resi l ience but becoming even more resilient than before. Protective Factors The findings of this study suggest that some of the protective factors identified as related to resi l ience in other populations may also be related to resi l ience in the illicit injection drug using population. D iscuss ion of protective factors will be divided into the categor ies of individual, family and community as proposed by G a r m e z y (1991). Individual Protective Factors Twenty-eight protective factors were identified in a review of the literature on resi l ience (Carbonel l et a l . , 2002; F ine, 1991; Ga rmazy , 1991; Jace lon , 1997; Mas ten , 54 1994; Pat terson, 2000; Tusa ie and Dyer, 2004; Werner , 1989; Werner & J o h n s o n , 2004; Werne r & Smi th , 1982). In this study 15 of the 28 protective factors emerged from the stories of participants as being related to exper iences that were assoc ia ted with posit ive change (see Appendix C) . The remaining factors may not have been represented by the participants in the study for a variety of reasons. This may be partially due to the s ize of the sample but perhaps more importantly the fact that this w a s a secondary analysis and specif ic quest ions about individual protective factors were not asked . It is a lso possible the remaining protective factors hold less re levance to explaining resi l iency among those who inject illicit drugs. The Individual protective factors of a sense of self worth, a s e n s e of purpose, hopefu lness and opt imism character ized the stories of those participants who were decreas ing their drug use or engaging in harm reduction pract ices. In the literature on resi l ience a posit ive sense of self (Carbonel l et a l . , 2002; Mas ten , 1994; Pat terson, 2000 ; Sowe l l et a l . , 2000 ; Stein et a l . , 1998; Werner , 1989; Werner & Smi th , 1982) hope and a s e n s e of purpose (Werner) and optimism (Carbonel l et a l . ; Mas ten ; Pat terson; Werner & Smith) are identified as significant to resi l ience in ado lescents with depress ion , women who have been d iagnosed with HIV, high risk chi ldren in young adul thood, adult children of a lcohol ics and famil ies. Two addit ional individual protective factors, identified in the literature by Tusa ie and Dyer (2004) that emerged from the data of this study were coping strategies and social skil ls. Barriers to health care serv ices created by the lack of these factors were often apparent and appeared to be related to another protective factor identified by Werner (1989) the ability to elicit a 55 positive response from others. Findings from this study support previous research that these protective factors are related to resi l ience. Family and Community Protective Factors Although in this study family protective factors were much less evident than community protective factors, f indings suggest that both are important as proposed by G a r m e z y (1991) and Werner (1989) and Werner and Smith (1982). R e a s o n s for the lack of data on family protective factors in this study may be related to the study des ign and the character ist ics of the substance abusing population itself which tend to be al ienated from family. Never theless, the importance of community or extrafamilial support suggested by G a r m e z y and Werner as well as Monteith and Ford-Gi lboe, (2002) and Tuttle et a l . (2004) was suggested in this study by the high va lue s o m e participants p laced on relationships of trust with serv ice providers and how these relat ionships were related to positive change. Marsh and Dale (2005) suggest that feeling cut off from the rewards afforded by schoo l , work, personal relationships and other more convent ional sources of support appear to increase vulnerability to substance misuse. The findings of this study illustrate the importance of a c c e s s to community resources as suggested by Werner (1989) and G a r m e z y (1991) as well as the negative consequences of barriers to community resources. Resilience and Context Specificity The f indings of this study provide an important beginning to extending understanding of the context specificity of protective factors as descr ibed by J o h n s o n and Wiechel t (2004) who stated that resi l ience should be v iewed using a holistic 56 f ramework that includes the contexts of age and developmental s tage, family history, socia l c lass , ethnicity, gender and change over time. For example , an aggress ive appearance and manner in the illicit drug using community may elicit the posit ive response of being left unmolested whereas in the non-drug community it may elicit a negative response creating barriers to serv ice. Alternately, some of the creativity and adaptabil i ty deve loped to survive life on the street may be transferred to non-drug sett ings. The f indings support the recommendat ion of Johnson and Wiechel t to explore protective factors in speci f ic contexts. Drug Misuse To Dull Emotional Pain The f indings suggest that many participants use illicit drugs to dull their emotional pain. Al though participants reported both physical and emotional pain, the emot ional pain caused by past and current sexua l , physical and emot ional a b u s e , mental health problems and alienation and marginalization appeared to play a larger role. T h e s e f indings lend support to previous studies on the relationship of subs tance misuse to family v io lence (Heinzer & Kr imm, 2002 ; Mart in, 2002) , sexua l a b u s e (Brems, J o h n s o n , Neal & F reeman , 2004) mental health problems (Adams et a l . , 2004; Carbonel l et a l . , 2002; Miller & Chandler , 2002; Publ ic Health Agency , 2005) and marginal izat ion and al ienation (van Voorh is , 1998; Zerwekh , 2000) . Further, the f indings support Hal l 's (1999) belief in the reality of pain for the marginal ized in the postmodern world in which marginal ized populations, such as those who use illicit drugs, are without power or voice. The f indings of this study extend understanding of the negative effects of the soc ioeconomic aspects of addiction that are not within the control of the individual. 57 Under-hous ing, unemployment, malnutrition and lack of educat ion and job skil ls are common issues of people who live in poverty and are marginal ized (Ferrar & Pa lmer , 2004; R e w et a l . , 2002; V a n d u , 2003). The findings indicate these issues not only co -exist with addict ion but support Room 's (2005) contention that al ienation, marginal izat ion and poverty increase vulnerability to substance misuse and need to be factored into health care strategies. Hope is recognized as a protective factor in the literature on resi l ience (Aronwitz & Morr ison-Beedy, 2004; Werner , 1989), but the findings of this study indicate that many of the participants felt trapped in their addiction with little opportunity of e s c a p e . The l ives of many of the participants in this study were character ized by i l lness, d i sease and encounter ing barriers to community resources that adversely affected their capaci ty for posit ive adaptation to life's chal lenges. In addition they lacked the vo ice to have their exper iences heard and the power to provide input into polit ical, soc ia l and health care policy dec is ions that concerned their welfare. Implications of the Study There are implications for research and for educat ion and practice interventions. Addit ional research is warranted to increase knowledge of the concept of resi l ience in the injection drug using population and to determine if protective factors, identified as significant to resi l ience in the general population, are related to resi l ience in the injection drug using population. The findings of this secondary analys is demonstrate the potential for a primary study focusing specif ical ly on resi l ience from the perspect ive of those individuals who inject illicit subs tances. A s a starting point, researchers could 58 examine exper iences related to getting to the point of posit ive change that appear to be important from the perspect ive of individuals who inject illicit drug including 1) observ ing the harmful effects of illicit drug use on self and on others, 2) fear of the negative consequences of drug use , 3) support seek ing, and 4) envis ioning a better future for oneself . Addit ionally, based on the f indings of this study there is likely to be benefit in studying in greater depth the negative effects on resi l ience including 1) drug misuse for the purpose of dulling emotional pain, 2) lack of individual and family protective factors, 3) barriers to community protective factors and the health determinants, and 4) soc ioeconomic status and assoc ia ted feel ings resulting from al ienation, marginal ization and hope lessness . B e c a u s e resi l ience is context dependent (Johnson and Wiechel t (2004); Tusa ie & Dyer, 2004) sampl ing f rames for future studies should be des igned to enable ana lyses of influencing factors on resi l ience such as sex, age, developmental s tage, family history, soc ioeconomic status, ethnicity, age of first drug use and time s ince first drug use . Study samp les should a lso include those who have absta ined from drugs for a lengthy period of t ime to determine what protective factors and p rocesses character ize this group. Further research is a lso indicated to increase knowledge of the ef fect iveness of educat ion and intervention strategies that include fostering of protective factors in those that are involved in substance abuse. Al l protective factors identified in the literature should be included in future research, however, the f indings of this study indicate the need for future research on coping mechan isms, socia l ski l ls, self es teem, the ability to elicit a positive response from others, sense of purpose, areas of accompl ishment , 59 decreas ing feel ings of al ienation from family and community and facilitating a posit ive world view. Further research is indicated to evaluate the effect iveness of educat ional interventions that include a resi l ience component. Programs that combine risk and resi l ience based interventions have been favourably compared to those that are limited to health information programs that focus exclusively on risk (Brown, 2001 ; L indenberg et a l . , 2002). In this study the participants spoke of their exper iences of building protective factors such as a sense of purpose and of self-worth, hopefu lness, socia l ski l ls, coping strategies and areas of talent and accompl ishment through job training, volunteer and recreational activities that provided exper iences for the drug user outside the drug using community. Limitations The major limitation of secondary studies is that the original study w a s not des igned to collect information on the secondary research quest ion (Hinds et a l . , 1997). However , the interview guide of the original study contained quest ions that focused on protective behaviours relevant to resi l ience and the study participants were, for the most part, g iven the opportunity to "tell their story". The principal researcher of this study took part in the original study as a member of the analys is team and as an interviewer for some of the key informant service provider interviews and a facilitator for two of the serv ice provider focus groups. This is both a potential strength because the researcher has specia l knowledge of the original study that may result in meaningful insights and a potential limitation as the researcher may be b iased by her previous exper ience. 60 Other possib le limitations are connected to the original study. The samp le s ize was relatively smal l and it is accepted that no age or culture speci f ic compar isons could be made. However , demographic and drug and d isease related information col lected via the quest ionnaire were used to descr ibe the sample and to contextual ize f indings. The subject matter of the interviews was directly related to behaviours that are illegal and possibly involved feel ings of shame and embarrassment . In addit ion, most of the interviewers were relatively inexper ienced. The influence of these factors on the data col lected was minimized in several ways . Efforts were made to enhance participant comfort with interviews by using interviewers who were a l ready known and trusted, ensur ing that information was kept confidential and removing all identifiers from the transcripts. Interviewers were provided with extensive training emphas iz ing the importance of a respectful, non-judgemental attitude. Conclusions Illicit injection drug use is a daunting health and socia l problem that cal ls for a multifaceted response. Res i l ience-based strategies are proposed as an important adjunct to the current abst inence, law enforcement and risk based pol icies and interventions that have been developed to address this issue. This study has been the first to explore resi l ience in the context of injection drug use and supports the contention that resi l ience is a dynamic process that can be demonstrated in those who are in the process of recovery from addict ion. Many of the protective factors identified in the literature as assoc ia ted with resi l ience in other populat ions can a lso be demonstrated in the context of injection drug use. T h e s e protective factors include hope, opt imism, a sense of purpose and self-worth, coping strategies, socia l ski l ls, the 61 ability to elicit a positive response from others, areas of accompl ishment and a c c e s s to family and community support. Dec reased resi l ience w a s assoc ia ted with using illicit drugs to dull the emotional pain caused by physical , sexual and emotional abuse , mental i l lness, marginal izat ion, al ienation, hope lessness and a lack of individual, family and community protective factors. A s the findings of this study indicate that the participants who used injection drugs lived in adverse soc ioeconomic condit ions and exper ienced marginalization and barriers to health serv ices, the coping strategies fostered by res i l ience-based interventions should include advocacy skil ls and other means of gaining a vo ice to have their exper iences heard and to inf luence the soc ia l , polit ical, economic and health care policy dec is ions that effect their l ives. Future research using primary data is implicated to increase knowledge of resi l ience in the context of injection drug use and to evaluate intervention strategies that foster protective factors for the purpose of strengthening resi l ience in this vulnerable populat ion. 62 REFERENCES A d a m s , K. B., Sanders , S . , & Auth, E. A . (2004). Lonel iness and depress ion in dependent living retirement communit ies: Risk and resi l ience factors. Aging and Mental Health, 8, 475-85. Retr ieved September 10, 2005 , from http:/ /search.epnet.com/login.aspx?direct=true&db=aph&an=15450731 Aronowitz, T., & Morr ison-Beedy, D. (2004). Res i l ience to risk-taking behaviours and mother-daughter connec tedness in impover ished Afr ican Amer i can girls. Research in Nursing and Health, 27, 29-39. Retr ieved Sep tember 10, 2005 , from ht tp: / /www3. intersc ience.wi ley.com/cgi-b in/ fu l l text /107063434/PDFSTART Aust in , A . (2004). A lcoho l , tobacco, other drug use , and violent behaviour among native Hawai ians: Ethnic pride and resi l ience. Substance Use and Misuse, 39, 721 -746. Retr ieved September 10, 2005, from http:/ /search.epnet.com/login.aspx?direct=true&db=aph&an=13176166 Badger , J . M . (2004). A nurse's perspect ive on a nightclub fire: Foster ing resi l ience during a disaster response. American Journal of Nursing, 104, 7 2 A A - B B , 7 2 E E -F F . Retr ieved June 10, 2005, from http:/ /gateway.ut.ovid.com/gw1/ovidweb.cgi B o w e n , D. J . , M o r a s c a , A . A . , & Me ischke , H. (2003). Measu res and correlates of resi l ience. Women & Health, 38, 65-76. Retr ieved June 9, 2005 , from http: / /www.haworthpress.com/store/ETextA/ iew E T e x t . a s p ? s i d = F R K T 5 X A L J Q A W 8 J 5 8 E A D 6 R R E 1 A X Q F A E 3 3 & a = 3 & s = J 0 1 3 & v = 3 8 & i = 2 & f n = J 0 1 3 v 3 8 n 0 2 % 5 F 0 5 Brems , C , J o h n s o n , M. , Nea l , D., & F reeman , M. (2004). Ch i ldhood abuse history and subs tance use among men and women receiving detoxification serv ices. American Journal of Drug and Alcohol Abuse, 30, 7 9 9 - 8 2 1 . Retr ieved J u n e 9, 2005 , from http:/ /search.epnet.com/login.aspx?direct=true&db=aph&an=14964915 Brendtro, L. K., & Longhurst, J . E. (2005). The resilient brain. Reclaiming Children & Youth, 14, 5 2 - 6 1 . Retr ieved September 2, 2005, from http:/ /search.epnet.com/login.aspx?direct=true&db=aph&an=17099201 Brown, J . H. (2001). Youth , drugs and resi l ience educat ion. Journal of Drug Education, 31, 83-122. Retr ieved June 9, 2005, from http:/ /www.metapress.eom/media/5n5dyj lwxr5v93h9j5m/contr ibut ions/3/6/4/c/ 365c6f4j7cx77jyh.pdf Brown, D. D., & Kul ig, J . C . (1996). The concept of resi l iency: Theoret ical l essons from communi ty research. Health and Community Studies, 4, 2 9 - 5 2 . Canad ian Foundat ion for Drug Pol icy. (2005). Retr ieved Sep tember 10, 2005 , f rom http ://www. cfd p. c a / 63 Capi ta l Health Reg ion . (2000). Victoria Capital Health Reg ion Strategic P lan for H IV /A IDS. Victor ia, B C : Capital Health Reg ion . Carbone l l , D. M. , Re inherz , H. Z . , G iacon ia , R. M. , Stashwick, C . K., Parad is , A . D., & Beards lee , W . R. (2002). Ado lescent protective factors promoting resi l ience in young adults at risk for depress ion. Child and Adolescent Social Work Journal, 19, 393-413. Retr ieved June 4, 2004, from http:/ /search.epnet.com/login.aspx?direct=true&db=aph&an=7677308 • Ferrar, R. L , & Palmer , R. (2004). Variat ions in health status within and between soc ioeconomic strata. Journal of Epidemiology and Community Health, 58, 3 8 1 -387. Retr ieved September 10, 2005, from http:// iech.bmiiournals.eom/cgi/content/ful l/58/5/381 F ine, S . B. (1991). Res i l ience and human adaptabil ity: W h o r ises above advers i ty? American Journal of Occupational Therapy, 45, 493-503. F lach , F. (1988). Resilience: Discovering new strength at times of stress. N e w York : Bal lant ine Books . Ga rmezy , N. (1991). Resi l iency and vulnerability to adverse developmenta l ou tcomes assoc ia ted with poverty. American Behavioral Scientist 34, 6-430. Retr ieved June 4, 2005 , from http: / /proquest.umi.com/pqdweb?index=0&did=732635891&SrchMode=1&sid=1 &Fmt = 1 0 & V l n s t = P R O D & V T y p e = P Q D & R Q T = 3 0 9 & V N a m e = P Q D & T S = 1 1 1 8 7 9 7 963&cl ient ld=6993 G lance -C leave land , B. (2004). Qualitative evaluation of a schoo l -based support group for ado lescents with an addicted parent. Nursing Research, 53, 379-386. Retr ieved April 23 , 2005, from http:/ /gateway.ut.ovid.com/gw1/ovidweb.cgi Hal l , J . (1999). Marginal izat ion revisited: Crit ical, postmodern and liberation perspect ives. Advances in Nursing Science, 22, 88-102. Retr ieved J u n e 9, 2005 , from http:/ /search.epnet.com/login.aspx?direct=true&db=aph&an=6821091 Harvey, A . R., & Hill, R. B. (2004). Africentric youth and family rites of passage program: Promoting resi l ience among at-risk Afr ican Amer ican youths. Social Work, 49, 65-74. Retr ieved June 9, 2005, from http://bll.epnet.com/citation.asp?tb=0& u g = s i d + 8 4 1 F C 9 5 B % 2 D C C B 9 % 2 D 4 4 9 D % 2 D 9 Health C a n a d a . (1994). C a n a d a ' s A lcoho l and Other Drugs Survey: A d iscuss ion of the f indings. Retr ieved September 10, 2005, from ht tp: / /www.hc-sc.gc.ca/ahc-asc/pubs/drugs-drogues/1994-cads/ index e.html 64 Health C a n a d a . (2001). Enhanced survei l lance of Canad ian street youth. Sexua l Health and STI Sect ion , Communi ty Acqui red Infections Div is ion, Centre for Infectious D i sease Prevent ion and Control , Health C a n a d a . Retr ieved Sep tember 10, 2005 , from http: / /www.phac-aspc.gc.ca/publ icat/epiu-aepi/epi update may 04/4 e.html Health C a n a d a . (2002). C a n a d a ' s Drug Strategy. Retr ieved September 10, 2005 , from http: / /www.hc-sc.gc.ca/ahc-asc/act iv i t /strateg/drugs-drogues/ index e.html Health C a n a d a . (2004). I-Track: Enhanced survei l lance of risk behaviours among injection drug users in C a n a d a . Pilot survey report. Survei l lance and Risk A s s e s s m e n t Div is ion, Centre for Infectious D isease Prevent ion and Cont ro l , Health C a n a d a . Retr ieved June 9, 2005, from http:/ /www.phac-aspc.gc.ca/ i- track/psr-rep04/1.html Heinzer , M. M. , & Kr imm, J . R. (2002). Barriers to screening for domest ic v io lence in an emergency department. Holistic Nursing Practice, 16, 24-33. Retr ieved J u n e 4 , 2005 , from http:/ /search.epnet.com/login.aspx?direct=true&db=aph&an=6753608 Hinds, P. S . , V o g e l , R. J . , & Clarke-Stef fen, L. (1997). The possibi l i t ies and pitfalls of doing a secondary analysis of a qualitative data set. Qualitative Health Research, 7, 408-422. Hodgins , D. (2005). C a n patients with alcohol use disorders return to socia l dr inking? Canadian Journal of Psychiatry, 50, 264-265. Horowitz, F. D. (1987). Exploring developmental theories: Toward a structural/behavioural model of development. Hi l lsdale, N e w Je rsey : Lawrence Er lbaum Assoc ia tes . Hostetler, M. , & Kirk, F. (1997). Project C . A . R . E . substance abuse prevention program for high-risk youth: A longitudinal evaluation of program effect iveness. Journal of Community Psychology, 25, 397-419. Retr ieved Sep tember 10, 2005 , from ht tp: / /www3. interscience.wi ley.com/cgi-b in/ fu l l text /46108/PDFSTART Inciardi, J . (2004). Pol icy issues in the sentencing of drug offenders. Criminology and Public Policy, 3, 397-400. Jace lon , C . S . (1997). The trait and process of resi l ience. Journal of Advanced Nursing, 23, 123-129. Retr ieved May 23, 2005, from http:/ /search.epnet.com/login.aspx?direct=true&db=aph&an=4536488 J o h n s o n , J . L., & Wiechel t , S . A . (2004). Introduction to the specia l i ssue on resi l ience. Substance Use & Misuse, 39, 657-670. Retr ieved Sep tember 10, 2005 , f rom http:/ /search.epnet.com/login.aspx?direct=true&db=aph&an=13176169 65 J o h n s o n , K., Bryant, D. D., Col l ins, D. A . , Noe , T. D., Strader, T. N., & Be rbaum, M . (1998). Prevent ing and reducing alcohol and other drug use among high-risk youths by increasing family resi l ience. Social Work, 43, 297-308. Retr ieved June 9, 2005 , from http://bll.epnet.com/citation.asp?tb=Q& u g = s i d + E D F 9 0 E E 9 % 2 D Kap lan , C . P . , Turner, S . , Norman, E. , & St i l lson, K. (1996). Promot ing resi l ience strategies: A modified consultat ion model . Social Work In Education, 18, 158-68. Retr ieved June 9, 2005 , from http://weblinks1 ,epnet.com/citation.asp?tb=1 & ua=bo+B%5F+shn+1 +db+aphjnh +bt+l Katerndahl , D., Burge, S . , & Kel logg, N. (2005). Predictors of development of adult psychopatho logy in female victims of chi ldhood sexua l abuse . Journal of Nervous and Mental Disease, 193, 258-64. Retr ieved June 9, 2005, from http://gatewav.ut.ovid.com/gw1/ovidweb.cgi L indenberg, C . S . , So lo rzano, R. M. , Bear , D., Str ickland, O. , Ga lv is , C , & Pi t tman, K. (2002). Reduc ing substance use and risky sexual behavior among young, low-income, Mex ican-Amer ican women : Compar ison of two interventions. Applied Nursing Research, 15, 137-148. Retr ieved Sep tember 10, 2005 , from ht tp : / /www.sc iencedi rect .com/sc ience?_ob=Mlmg&_imagekey=B6WB4-4 6 J X 6 M K - 4 L indenberg, C . S . , So lo rzano, R. M. , Krantz, M. S . , Ga lv is , C , Baroni , G . , & Str ick land, O. (1998). R isk and resi l ience building protective factors: A n intervention for preventing substance abuse and sexual risk-taking and for promoting strength and protection among young, low- income Hispanic women . American Journal of Maternal Child Nursing, 23, 99-104. Retr ieved June 4, 2005 , from http:/ /search.epnet.com/login.aspx?direct=true&db=aph&an=17216808 Lynam, M. J . (2005). Health as a social ly mediated process : Theoret ical and practice imperat ives emerging from research on health inequalit ies. Advances in Nursing Science, 28, 25-37. Retr ieved June 4, 2004, from http:/ /search.epnet.com/login.aspx?direct=true&db=aph&an=17216808 M a c C o u n , R. J . (1998). Toward a psychology of harm reduction. American Psychologist, 53, 1199-1209. Retr ieved October 5, 2005, at http:/ /search. epnet.com/login. aspx?direct=true&db=pdh&an=amp53111199 McCu l lough-Zander , K., & Larson, S . (2004). The fear is still in me: Car ing for survivors of torture. American Journal of Nursing, 104, 54-64. Retr ieved J u n e 4 , 2005 , from http://gatewav.ut.ovid.com/gw1/ovidweb.cqi Marsh , A . , & Dale , A . (2005). R isk factors for alcohol and other drug d isorders. Australian Psychologist, 40, 73-80. Retr ieved July 10, 2005 , from http:/ /search.epnet.com/login.aspx?direct=true&db=aph&an=17539812 Martin, S . (2002). Chi ldren exposed to domest ic v io lence: Psycho log ica l considerat ions for health care practitioners. Holistic Nursing Practice, 16, 7-15. Retr ieved J u n e 4 , 2005 , from http:/ /search.epnet.com/login.aspx?direct=true&db=aph&an=6753580 Mas ten , A . (1994). Res i l ience in individual development: Success fu l adaptat ion despi te risk and adversity. In M. C . W a n g & E. W . Gordon (Ed.), Educational resilience in inner city America: Challenge and prospects. New York: Er lbaum. Miller, A . , & Chandler , P . (2002). Acculturat ion, resi l ience, and depress ion in midlife w o m e n from the former Soviet Union. Nursing Research, 51, 26-32. Retr ieved June 9, 2005, from http://gateway.ut.ovid.com/gw1/ovidweb.cgi Miller, E. E. (2003). Reconceptual iz ing the role of resi l iency in coping and therapy. Journal of Loss and Trauma, 8, 239-246. Retr ieved Sep tember 25, 2005 , from http:/ /search.epnet.com/login.aspx?direct=true&db=aph&an=10779573 Monteith, B., & Ford-Gi lboe, M. F. (2002). The relationships among mother's resi l ience, family health work, and mother's health-promoting lifestyle pract ices in famil ies with preschool chi ldren. Journal of Family Nursing, 8, 383-407. Retr ieved J u n e 9, 2005, from http:// i fn.sagepub.eom/cgi/reprint/8/4/383 Morse , J . M. , & F ie ld , P . A . (1995). Qualitative research methods health professionals ( 2 n d ed). Thousand O a k s , C A : S a g e . Morse , J . M. , & F ie ld , P. A . (2004). Construct ing qualitatively derived theory: Concep t construct ion and concept typologies. Qualitative Health Research, 14, 1287-1395. Thousand O a k s , C A : S a g e . Nyamath i , A . (2004). Motivation to stop substance use and psychologica l and environmental characterist ics of homeless women . Addictive Behaviours, 29, 1839-1844. Retr ieved June 14, 2005, from ht tp : / /www.sc iencedi rec t .com/sc ience?_ob=Mlmg&_imagekey=B6VC9-4CDHF5Gcd i=5949&_user=1022551 &_or ig=browse&_coverDate=12%2F31 %2F2004&_sk=999709990&v iew=c&wchp=dGLbVzz-zSkWW&md5=5aa8d82 59447943a82a 1 b0085572dd7c&ie=/sdart ic le.pdf Nyamath i , A . , F laskerud, J . , & Leake , B. (1997). HIV-risk behaviours and mental health character ist ics among homeless or drug-recovering women and their c losest sources of socia l support. Nursing Research, 46,133-137. Retr ieved J u n e 4 , 2005 , from http://gateway.ut.ovid.com/gw1/ovidweb.cgi Pat terson, J . (2000). Understanding family resi l ience. Journal of Clinical Psychology, 58, 233-246. Retr ieved June 4, 2005 , from http:/ /search.epnet.com/login.aspx?direct=true&db=aph&an=10324278 Pi lowsky, D. J . , Zybert, P. A . , & V lahov, D. (2004). Resi l ient chi ldren of injection drug users. Journal of the American Academy of Child & Adolescent Psychiatry, 43, 1372-1379. Polit, D. F., & Hungler, B. (1995). Nursing research. New York: Lippincott. Publ ic Health A g e n c y of C a n a d a . (2004). HIV/AIDS among injecting drug users in C a n a d a . Retr ieved October 8, 2005 , from http: / /www.phac-aspc.gc.ca/publ icat /epiu - aepi /epi_update_may_04/11_e.html Publ ic Health A g e n c y of C a n a d a . (2005). Harm reduction and injection drug use : A n international comparat ive study of contextual factors influencing the deve lopment and implementation of relevant pol icies and programs. Retr ieved October 5, 2005 , from http: / /www.phac-aspc.gc.ca/hepc/hepat i t is c/pdf/harm reduct ion_ e/intro.html R e w , L. (2003). A theory of taking care of onesel f grounded in exper iences of home less youth. Nursing Research, 52, 234-241. Retr ieved June 4, 2005 , from http:/ /search.epnet.com/login.aspx?direct=true&db=aph&an=10324278 Rew, L , C h a m b e r s , K., & Kulkarni , S . (2002). P lanning a sexual health promotion intervention with homeless adolescents. Nursing Research, 51, 168-174. Retr ieved June 9, 2005, from http:/ /gateway.ut.ovid.com/gw1/ovidweb.cgi Rew , L , Tay lor -Seehafer , M. , Thomas N. Y . , & Yockey , R. D. (2001). Corre la tes of resi l ience in homeless adolescents . Journal of Nursing Scholarship, 33, 33-40. Retr ieved June 9, 2005, from http:/ /web1.infotrac.galegroup.com/itw/ infomark/33/804/68608741w1/purNrc1 H R C A Rew, L , T h o m a s , N., Horner, S . D., Resn ick , M. D., & Beuhr ing, T. (2001). Corre la tes of recent suic ide attempts in a triethnic group of ado lescents . Journal of Nursing Scholarship, 33, 361-367. Retr ieved June 8, 2005 , from http:/ /web1.infotrac.galegroup.com/itw/ infomark/33/804/68608741w1/purNrc1 H R C A R ichardson , G . , Neiger, B., J e n s e n , S . , & Keumpfer , K. (1990). The resi l iency model . Health Education, 21, 33-39. R o i s m a n , G . I. (2005). Conceptua l clarif ications in the study of resi l ience. American Psychologist, 60, 264-265. Retr ieved September 25 , 2005 at http://weblinks2.epnet.com/externalframe.asp?tb=1 & ua=bo+B%5F+shn+1 +db+ pdhjnh 68 R o o m , R. (2005). S t igma, socia l inequality and alcohol and drug use. Drug and Alcohol Review, 24, 143-155. Retr ieved June 9, 2005, from http:/ /search.epnet.com/login.aspx?direct=true&db=aph&an=17835341 Rutter, M. (1993). Res i l ience: S o m e conceptual considerat ions. Journal of Adolescent Health,14, 690-696. S a a b , B. R., C h a a y a , M. , Doumit, M. , & Farhood, L. (2003). Predictors of psychologica l distress in Lebanese hostages of war. Social Science and Medicine, 57, 1249-1257. Retr ieved September 25 , 2005, from ht tp: / /www.sciencedirect .com/science? ob=Mlmg& imagekev=B6VBF-4 7 T 8 9 3 R - 7 -Sandau-Beck le r , P. A . , Deval l , E. , & de la R o s a , I. A . (2002). Strengthening family resi l ience: Prevent ion and treatment for high-risk substance-af fected famil ies. Journal of Individual Psychology, 58, 305-333. Retr ieved September 10, 2005 , from http:/ /weblinks2.epnet.com/externalframe.asp?tb=1& ua=bo+B%5F+shn+1+db+ aphjnh Schucki t , M. (1991). A longitudinal study of children of a lcohol ics. In Galanter , Begleiter, (Ed.), Recent developments in alcoholism: Children of alcoholics (pp. 5-19). N e w York: P lenum P r e s s . S e n g , J . (2003). Acknowledg ing posttraumatic stress effects on health: A nursing intervention model . Clinical Nurse Specialist, 17, 34-41. Retr ieved J u n e 4 , 2005 , from http://gateway.ut.ovid.com/gw1/ovidweb.cgi Sowe l l , R., Moneyham, L , Hennessy , M. , Guil lory, J . , Demi , A . , & S e a l s , B. (2000). Spiri tual activities as a resistance resource for women with human immunodef ic iency virus. Nursing Research, 49, 73-82. Retr ieved June 9, 2004, 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. Victor ia: Capi ta l Health Reg ion . Stajduhar, K. I., Poffenroth, L , W o n g , E. , Arch iba ld , C . P. , Suther land, D., & Rekart , M. (2004). M issed opportunities: Injection drug use and HIV/AIDS in Victor ia, 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& imagekev=B6VJX-4 B V P 9 G F - 6 -Starf ield, B., Ri ley, A . W. , Witt, W . P., & Rober tson, J . (2002). Soc ia l c lass gradients in health during ado lescence . Journal of Epidemiology and Community Health, 56, 69 354-61 . Retr ieved September 10, 2005 , from ht tp : / / iech.bmi iourna ls .eom/content /vo l56/ issue5/#RESEARCH R E P O R T S Ste in , K., Roese r , R., & Markus , H. (1998). Se l f - schemas and poss ib le se lves a s predictors and outcomes of risky behaviours in ado lescents . Nursing Research, 47, 96-106. Retr ieved June 9, 2005 , 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 . , & Perk ins , D. V . (2004). Cogni t ive transformation as a marker of resi l ience. Substance Use & Misuse, 39, 769-788. Retr ieved June 9, 2005, from http:/ /search.epnet.com/login.aspx?direct=true&db=aph&an=13176164 Thorne, S . (1994). Secondary analys is in qualitative research: Issues and implicat ions. In J . M. Morse (Ed.), Critical research methods (pp. 263-279). London : S a g e . Tukka , T. (2004). The harm-reduction school of thought: Three fractions. Contemporary Drug Problems, 31, 381 -399. Tusa ie , K., & Dyer, J . (2004). Res i l ience: A historical review of the construct. Holistic Nursing Practice, 18, 3-10. Retr ieved June 4, 2005, from http:/ /search.epnet.com/login.aspx?direct=true&db=aph&an=11871554 Tuttle, J . , Landau , J . , Stanton, M. D., K ing, K. U., & Frodi , A . (2004). Intergenerational family relations and sexual risk behaviour in young women . American Journal of Maternal Child Nursing, 29, 56-6. Retr ieved June 4, 2005 , from http:/ /gateway.ut.ovid.com/gw1/ovidweb.cgi United Nat ions. (1997). International Narcot ic Control Board ( INCB) Annua l Report . Retr ieved September 10, 2005, from http://www.incb.org/incb/index.html Unger, M. (2003). Methodological and contextual chal lenges researching chi ldhood resi l ience: A n international collaboration to develop a mixed method des ign to investigate health-related phenomena in at-risk child populat ions. Summary Report on Y e a r O n e Activit ies and the first Halifax T e a m Meet ing. Retr ieved Sep t 25 , 2005 , from http:/ /66.102.7.104/search?g=cache:XuiKII nrQAJ:www.resi l ienceproject .org/cm p documents/documents/ res i l ience report.pdf+childhood+resil ience+Halifax&hl =en V a n d u . (2003). Vancouve r area network of drug users: Housing action commit tee. Retr ieved October 5, 2005, from http://www.vandu.org/vhacgroup.html van Voorh is , R. (1998). Culturally relevant practice: A framework for teaching the psychosoc ia l dynamics of oppress ion. Journal of Social Work Education, 34, 121-124. Retr ieved June 9, 2005, from 70 http:/ /search.epnet.com/login.aspx?direct=true&db=aph&an W e n z e l , L. B., Donnel ly, J . P., Fowler, J . M. , Habba l , R., Taylor, T. H., A z i z , N., & Ce l l a , D. (2002). Res i l ience, reflection, and residual stress in ovar ian cancer survivorship: A gynaecolog ic oncology group study. Psycho-Oncology, 11, 142-153. Retr ieved June 9, 2005, from ht tp: / /www3. intersc ience.wi ley.com/cgi-b in/ fu l l text /91015521/PDFSTART Werner , E. (1989). High-risk children in young adulthood: A longitudinal study from birth to 32 years . American Journal of Orthopsychiatry, 59, 72-81. Werner , E. , & Johnson , J . (2004). The role of caring adults in the l ives of chi ldren of a lcohol ics. Substance Use & Misuse, 39, 699-720. Retr ieved June 19, 2005 , from http: / /www.metapress.com/( iknp3p45if5ebgmvwpimar55)/app/home/contr ibut ion. asp?referrer=parent&backto=issue,3,10; iournal,17,50; l inkingpubl icat ionresults,1: 107866,1 Werner , E. , & Smi th , R. (1982). Vulnerable but invincible: A longitudinal study of resilient children and youth. New York: McGraw-Hi l l . Ze rwekh , J . V . (2000). Car ing on the ragged edge: Nursing persons who are d isenf ranchised. Advances in Nursing Science, 22, 47 -61 . Retr ieved J u n e 4 , 2005 , from http:/ /search.epnet.com/login.aspx?direct=true&db=aph&an=6682248 71 APPENDICES APPENDIX A Interview Gu ide - Injection Drug User Note: T h e s e quest ions are to be used as a guide only. Introductory Questions 1. C a n you tell me a little bit about yoursel f? Elaborat ing Quest ions • W h e r e are you f rom? • What is your background? I would like you to talk a little bit about drug activity. Context questions 1. Where are the "hot spots" for drug activity? Elaborat ing Quest ions • What is happening there? • W h y is this a rea a "hot spot"? • W h e n are people there (time of day, which days of the week)? • How do people find out this is a "hot spot"? • Does being in this area increase people 's chance of getting HIV? If so , how c o m e ? • What would make one place less risky than another p lace? • A re there p laces in this a rea where you think serv ices could/should be set up? 2. W h o do you think are the people most at r isk? • What makes them most at r isk? • Where are they from? (e.g. Do they live in Victor ia? Do they come from another municipali ty/city? Do they move between a reas?) • W h e n do you usual ly shoot up (time of day, etc.)? • Where do you usual ly shoot up? (e.g. own home, bar, park, etc.) • W h e n you shoot up, how do you do it (e.g. a lone, with a partner, etc.)? • C a n you demonstrate to me or descr ibe to me how you shoot up? • What do you think led you to begin injecting drugs? I a m now going to ask you some quest ions about the risks assoc ia ted with injection drug use. If you don't feel comfortable answer ing some of these quest ions, p lease don't 72 hesitate to let me know. Risk/Consequences Questions 1. What drugs do you commonly inject? • W h y these drugs? • Where do you get them from? • A re there other drugs that you use bes ides that ones that you inject? If so , what are they? • To what extent is alcohol an issue? 2. What kinds of things do you or others do that p lace you at risk (e.g. shar ing needles)? Elaborat ing Quest ions • What are some of the reasons that you or others p lace themse lves at r isk? • Where do you get your needles (rigs) f rom? • What do you do with your needles (rigs) when you are f inished with them? • How often do you re-use your needles (rigs)? • How do you c lean your needles (rigs)? • If you don't a lways c lean your needles (rigs), what is the reason for this? • What would you say to someone who is injecting drugs for the first t ime? 3. How does where you "hang out" influence whether you put yourself at r isk? • How do the people you hang out with inf luence your risk behav iours? • A re there s o m e groups that have higher levels of risk behaviour (e.g. youth, Abor ig inal people, etc.)? Is so , which groups and why? • A re there t imes when the risks are greater than others? If so , why? • What needs to happen to help reduce the r isks? 4. What do you know about how HIV is transmitted? 5. What kinds of things do you do to protect yourself from being infected? I just want to finish off the interview by asking you some quest ions about your exper ience with health care serv ices. Intervention Questions 1. What kinds of serv ices do you use? (e.g. S O S , Detox, etc.)? 73 Elaborat ing Quest ions • To what extent are they working? • A re there any gaps in the serv ices or interventions? If so , what are they? • What is your exper ience in getting into and using prevention, treatment and care serv ices? • How would you descr ibe your relationship with health care providers (e.g. doctors, nurses, emergency department, etc.)? 2. If you could change any health serv ices avai lable to injection drug users , what would this "wish list" look l ike? 3. What kinds of things get in the way of putting serv ices in p lace for injection drug users? Elaborat ing Quest ions • What adv ice could you give for overcoming these obs tac les? • Do you have anything to add that we haven't talked about or any quest ions for m e ? Closing Statement I would like to thank you again for taking the time to participate in this study. Y o u r input is va lued and integral for the wel l-being of our community and will help provide us with important information to develop a plan to help injection drug users. 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 A p p e n d i x B Interview Gu ide - Serv ice Provider Note: T h e s e quest ions are to be used as a gu ide only. Introductory Question 1. A s a way to begin, I wonder if you could tell me a little about the serv ices your organizat ion provides for injection drug users? Elaborating Questions • W h o are the clients you primarily serve (e.g. youth, adults, etc.)? • What do you know about these clients (e.g. whether they inject drugs)? • What do you know about the serv ices that these clients use (e.g. a c c e s s to methadone or other harm reduction serv ices, alcohol and drug serv ices, medical care, etc.)? Context Questions 1. Where are the "hot spots" for drug activity? (If the person is wil l ing, you may provide a map to them and ask them to map it out) Elaborating Questions • What is happening there? • W h y is this area a "hot spot"? • W h e n are people there? (time of day, which days of the week) • How do people find out that this is a "hot spot"? • How does being in these areas increase people 's chances of getting HIV infection? • What makes one place less risky than others? • How does this setting (hot spot) influence risk behaviour? • A re there p laces in this setting where serv ices could/should be set up? 2. W h o are the people most at r isk? Elaborating Questions • What makes them most at r isk? • W h e r e are they from (e.g. Do they live in Victor ia? Do they come from another municipali ty/city? Do they move between a reas?)? • W h e n are they commonly partaking in risk behaviours (time of day, etc.)? • W h e r e do people usual ly shoot up (e.g. own home, bar, park, etc.)? • W h e n people shoot up, how do they do it (e.g. a lone, with a partner, etc.)? 75 • W h y do you think people start injecting drugs? 3. What kinds of things might help people to inject more safe ly? I am now going to ask you some quest ions about the risks assoc ia ted with injection drug use. If you don't feel comfortable answer ing some of these quest ions p lease don't hesitate to let me know. Risk/Consequences Questions 1. What drugs are commonly being injected? Elaborating Questions • W h y are these drugs commonly injected? • W h e r e do people get them from? • A re there other drugs bes ides injection drugs that are being used by peop le? If so , what are they? • To what extent is alcohol an issue? 2. What kinds of things are people doing specif ical ly that p lace them at r isk? Elaborating Questions • What are some of the reasons why people put themselves at r isk? • W h e r e do people get their needles from? • What do you think people do with their needles once they are used? • How often do you think people re-use their need les? • How often do you think people c lean their need les? • If people don't use c lean needles, why is this s o ? 3. To what extent do socia l sett ings inf luence the risk behaviours of injection drug users? Elaborating Questions • How do socia l norms influence risk behaviours? • Do particular groups have higher levels of risk behaviour? If so , which groups and why? • A re there t imes when the risks are greater than others? If so , why? • What needs to happen to help reduce the r isks? 4. What level of knowledge do you think people have in general about HIV t ransmiss ion? 5. What do people do specif ical ly to protect themselves from being infected? 76 Elaborating Questions • How do people protect themselves from harm? • How do they take care of themse lves? I just want to finish off the interview by ask ing you some quest ions about your knowledge of the health serv ices avai lable for injection drug users . Intervention Questions 1. Bes ides serv ices that your organizat ion provides, what e lse is avai lable to serve injection drug users? Elaborating Questions • To what extent are they adequate and effective? • A re there any gaps in the serv ices or interventions? If so , what are they? • What do you think injection drug users ' exper iences are in access ing and utilizing prevention, treatment and care serv ices? • How would you descr ibe the relationship that most injection drug users have with health serv ice providers? 2. If you could change or expand any health serv ices avai lable to injection drug users , what would this look l ike? Elaborating Questions • If you could change them, what would you do? • If you could expand them, what would you do? 3. What new interventions are needed to help injection drug users? 4. What are the obstac les to implementing interventions? Elaborating Questions • What adv ice could you give for overcoming these obs tac les? 5. Do you have anything to add that we haven't talked about or any quest ions for me? A s a last quest ion, I wondered whether your organizat ion had any statistics that might help us with our s tudy? If so , are you willing to share those with u s ? (IF Y E S , P L E A S E G I V E T H E M D R . P O F F E N R O T H ' S C A R D T O C O N T A C T ) . 77 CLOSING STATEMENT I would like to thank you again for taking the time to participate in this study. Y o u r input is va lued and integral for the well-being of our community and will help provide us with important information to develop a plan to help injection drug users. 78 Appendix C Protect ive Factors Assoc ia ted With Res i l ience Protective Factors Identified In the Literature Analysis For this Study Indicates A Role In Resilience* Individual protective factors. 1 high activity level 2 the ability to elicit a positive response from others, * 3 autonomy 4 adaptabil ity 5 self-eff icacy 6 hopefu lness * 7 s e n s e of purpose * 8 areas of talent or accompl ishment ^ 9 ref lect iveness * 10 opt imism * 11 intell igence 12 creativity " 13 a belief sys tem that provides existential meaning 14 a cohesive-l i fe narrative 15 a s e n s e of self-worth * iw- an appreciat ion of one 's un iqueness and good fortune 17 coping strategies * 18 socia l skil ls * 19 female only - physical attractiveness Family protective factors. 20 a warm support iye^stable environment 21 presence of an attentive and caring parent 22 perceived family connec tedness Community protective factors. 23 extrafamilial support from peers, adults, role models 24 schoo l affiliation * 25 religious faith or church affiliation 26 a c c e s s to community resources * 27 adequate housing * 28 medium to high soc ioeconomic status * 79 A p p e n d i x D Terms Abst inence B a s e d Approach to Subs tance A b u s e T h e s e are alcohol and drug treatment strategies with an a c c e s s criterion of abst inence. Pertaining to law enforcement, this approach is des igned to dec rease the preva lence and inc idence of drug use by reducing or eliminating the drug supply and incarcerating both those who sel l and those who use illegal subs tances. G e o Mapping This is a data collection technique for the purpose of drawing pictorial representat ions of events and/or activities and their locations. This technique is often used in conjunction with participant observat ion. Harm Reduct ion This is both a phi losophical approach and a frontline strategy that focuses on reduction of harm that is assoc ia ted with a risk such as illicit drug use. Low Threshold This is a term that is used in the literature, usually in reference to harm reduction strategies, to denote e a s e of accessibi l i ty by clients to serv ices. This is in contrast to abst inence based pol icies and pract ices that require abst inence for eligibility to a c c e s s a serv ice. Protective Factors This is a key construct in resi l ience used to denote characterist ics of individuals, famil ies or communit ies that result in decreased vulnerability to a risk. Protect ive P r o c e s s e s Within resi l ience process models , this is a poorly understood context dependent interaction between protective factors and risk factors whose outcome is a dec reased vulnerability to risk. Protective p rocesses are thought to vary over time within one individual and a lso between individuals. Rap id A s s e s s m e n t Surveys This is a data gathering technique in the form of a quest ionnaire consist ing of a smal l number of quest ions (e.g. three to five) that are des igned to fill in gaps in research data. Re-organizat ional Points This is a term borrowed from Sys tems Theory that refers to turning points that may be encountered in an individual's life that act as an impetus to change. Risk Factors This is a biological, developmental or psychosoc ia l event that increases the l ikel ihood of a negative outcome in an individual or group. 

Cite

Citation Scheme:

        

Citations by CSL (citeproc-js)

Usage Statistics

Share

Embed

Customize your widget with the following options, then copy and paste the code below into the HTML of your page to embed this item in your website.
                        
                            <div id="ubcOpenCollectionsWidgetDisplay">
                            <script id="ubcOpenCollectionsWidget"
                            src="{[{embed.src}]}"
                            data-item="{[{embed.item}]}"
                            data-collection="{[{embed.collection}]}"
                            data-metadata="{[{embed.showMetadata}]}"
                            data-width="{[{embed.width}]}"
                            async >
                            </script>
                            </div>
                        
                    
IIIF logo Our image viewer uses the IIIF 2.0 standard. To load this item in other compatible viewers, use this url:
http://iiif.library.ubc.ca/presentation/dsp.831.1-0092575/manifest

Comment

Related Items