"War stories": AIDS prevention and the street narratives of drug users

Older and Younger African Americans' Story Schemas and Experiences of Living with HIV/AIDS

This paper reports findings from a study that compared older (n = 21, ≥ age 50) and younger (n = 96, ≤ age 49) African Americans' stories (N = 117) of living with HIV/AIDS to determine how they make sense of the experience. The purpose was to: (1) identify and describe the cultural models African Americans use to inform their stories of living with HIV/AIDS, and (2) to compare older and younger adults' HIV stories. To characterize the cultural models engaged in the telling of these HIV stories, we conducted schema analysis. Analyses documented six diverse schemas, ranging from "Stages of Grief", "12 Steps", "Wake Up Call", "Continuity of Life", to "Angry and Fearful", "Shocked and Amazed". Comparison conducted by age group showed older adults more frequently expressed their story of living with HIV as "Stages of Grief" and "Continuity of Life", whereas younger adults expressed their stories as "12 Steps" and "Wake Up Call". Findings contribute by documenting African American stories of living with HIV/AIDS, important heterogeneity in cultural schemas for experiences of living with HIV and differences by age group. These findings may help by identifying the cultural resources as well as challenges experienced with aging while living with HIV/AIDS for African Americans.

"Why Am I the Way I Am?" Narrative Work in the Context of Stigmatized Identities

There are particular complexities faced by people attempting to tell their stories in the context of social stigma, such as the hostility which often surrounds injecting drug use. In this article, we identify some of the distinct advantages of taking a narrative approach to understanding these complexities by exploring a single case study, across two life-history interviews, with "Jimmy," a young man with a history of social disadvantage, incarceration, and heroin dependence. Drawing on Miranda Fricker's notion of "hermeneutical injustice," we consider the effects of stigmatization on the sociocultural practice of storytelling. We note the way Jimmy appears both constrained and released by his story-how he conforms to but also resists the master narrative of the "drug user." Narrative analysis, we conclude, honors the complex challenges of the accounting work evident in interviews such as Jimmy's, providing a valuable counterpoint to other forms of qualitative inquiry in the addictions field.

Using ethnography (or qualitative methods) to investigate drug errors: A critique of a published study

The effects of drug errors and any consequent adverse events frequently impact on patients, their relatives and professional carers. Furthermore, the financial cost to the National Health Service is considerable (DoH, 2000; DoH, 2001; DoH, 2004). In a study of two London teaching hospitals, Vincent et al. (2001) found that 10% of patients are exposed to an adverse event, which adds a mean 8.5 days to their hospital stay. Drug errors are recurrently reported to account for between 10 and 20% of all adverse events (DoH, 2004).

In response to Department of Health policy, NHS trusts are changing their approach to the management of error to encourage more reporting. The emphasis is on openness and support, and individual and organisational learning rather than blame. Research designed to increase a knowledge of the aetiology and context of drug errors should be carefully constructed and include qualitative methods which, if implemented according to established convention, can reflect the approaches described above.

This paper will critique a recently published study that focused on nursing practice and was, in our view, inappropriately described as ethnographic. The study undoubtedly adds to the body of existing knowledge about drug errors and, crucially, if the study contributes to improved patient safety, it must, fundamentally, be valued. Nevertheless, some qualitative research conventions were broken and, as such, it is suggested, some opportunities for a broader understanding and for learning may have been lost. The critique will lead to a range of recommendations about future qualitative studies in this research domain which, it is argued, could produce a fuller picture of the context, culture and, perhaps, even the cause of error.

In Their Own Voices: Breaking the Vicious Cycle of Addiction, Treatment and Criminal Justice Among People who Inject Drugs in Ukraine

AIMS

To understand how perceived law enforcement policies and practices contribute to the low rates of utilization of opioid agonist therapies (OAT) among people who inject drugs (PWIDs) in Ukraine.

METHODS

Qualitative data from 25 focus groups (FGs) with 199 opioid-dependent PWIDs in Ukraine examined domains related to lived or learned experiences with OAT, police, arrest, incarceration, and criminal activity were analyzed using grounded theory principles.

FINDINGS

Most participants were male (66%), in their late 30s, and previously incarcerated (85%) mainly for drug-related activities. When imprisoned, PWIDs perceived themselves as being "addiction-free". After prison-release, the confluence of police surveillance, societal stress contributed to participants' drug use relapse, perpetuating a cycle of searching for money and drugs, followed by re-arrest and re-incarceration. Fear of police and arrest both facilitated OAT entry and simultaneously contributed to avoiding OAT since system-level requirements identified OAT clients as targets for police harassment. OAT represents an evidence-based option to 'break the cycle', however, law enforcement practices still thwart OAT capacity to improve individual and public health.

CONCLUSION

In the absence of structural changes in law enforcement policies and practices in Ukraine, PWIDs will continue to avoid OAT and perpetuate the addiction cycle with high imprisonment rates.

Participant and staff experiences in a peer-delivered HIV intervention with injection drug users

We explore ethical issues faced by investigators as they conduct research as part of a peer-delivered HIV/AIDS risk reduction program for injection drug users (IDUs). Staff and participant experiences in peer-delivered interventions among IDUs have come under scrutiny by ethics researchers because of their potential to inadvertently and negatively impact participant rehabilitation due to continued engagement with drug-using networks during the course of outreach. This study explores whether enhanced communication of participant concerns and experiences with clinic and research staff helps to reduce inadvertent malfeasance in peer-delivered drug treatment interventions. Results contribute to the development of patient support infrastructure in peer-delivered risk reduction programs involving IDUs.

Routines and rituals: a grounded theory of the pain management of drug users in acute care settings

AIM

This study reviewed the perceptions and strategies of drug users and nurses with regard to pain management in acute care settings.

BACKGROUND

Drug users present unique challenges in acute care settings with pain management noted to be at best suboptimal, at worst non-existent. Little is known about why and specifically how therapeutic effectiveness is compromised.

DESIGN

Qualitative: constructivist grounded theory.

METHOD

A constructivist grounded theory approach incorporating a constant comparative method of data collection and analysis was applied. The data corpus comprised interviews with drug users (n = 11) and five focus groups (n = 22) of nurses and recovering drug users.

RESULTS

Moral relativism as the core category both represents the phenomenon and explains the basic social process. Nurses and drug users struggle with moral relativism when addressing the issue of pain management in the acute care setting. Drug users lay claim to expectations of compassionate care and moralise via narration. Paradoxically, nurses report that the caring ideal and mutuality of caring are diminished. Drug users' individual sensitivities, anxieties and felt stigma in conjunction with opioid-induced hyperalgesia complicate the processes. Nurses' and hospitals' organisational routines challenge drug user rituals and vice versa leading both protagonists to become disaffected. Consequently, key clinical issues such as preventing withdrawal and managing pain are left unaddressed and therapeutic effectiveness is compromised.

CONCLUSION

This study provides a robust account of nurses' and drug users' struggle with pain management in the acute care setting. Quick technological fixes such as urine screens, checklists or the transient effects of (cognitive-based) education (or training) are not the answer. This study highlights the need for nurses to engage meaningfully with this perceptibly 'difficult' group of patients.

RELEVANCE TO CLINICAL PRACTICE

The key aspects likely to contribute to problematic interactions with this patient cohort are outlined so that they can be prevented and, or addressed.

Altruism and peer-led HIV prevention targeting heroin and cocaine users

Peer-delivered HIV prevention and intervention programs play an important role in halting the spread of HIV. Rigorous scientific analysis of the aforementioned programs has focused on the immediate reduction of risk-related behaviors among the target populations. In our longitudinal study of the Risk Avoidance Partnership Peer Intervention for HIV, we assessed the long-term behavioral effects of a peer-led HIV intervention project with active drug users. Initial analysis of the qualitative data highlights the role of altruism as a motivator in sustaining peer educators beyond the immediate goals of the project. We contend that altruism found in volunteers is an important factor in maintaining long-term participation in HIV intervention programs and initiatives using peer educators.

Gender differences among older heroin users

OBJECTIVES

This purpose of this study was to explore the following question: Are there gender differences among older individuals with a history of heroin addiction with regard to social and family relationships and health problems?

METHODS

Eight gender-specific focus groups were conducted with 38 (19 women, 19 men) older (50+ years) individuals with long-term histories of heroin dependence. Four groups were conducted in a methadone maintenance (MM) clinic and four groups were derived from the Los Angeles community.

RESULTS

Modest gender differences were observed, but mainly in the focus-group dynamics. Women typically described the impact of their addiction on their families, while men typically described their surprise at still being alive. Hepatitis C was the primary health concern in all groups; mental health issues were also discussed.

DISCUSSION

Remarkable gender differences were not apparent in the qualitative experiences of these participants. Instead, we found overriding similarities related to the interactive effects of drug use and aging. Longitudinal studies of this population as they age and interact with the health-care system and other social systems will help to untangle the complicated relationship between aging, drug addiction, gender, and health.

A psychosocial comparison of New Orleans and Houston crack smokers in the wake of Hurricane Katrina

The purpose of this study was to compare psychological distress in a sample of African American crack cocaine users who relocated to Houston from New Orleans after Hurricane Katrina to African American drug users resident in Houston. Fifty-four African Americans from New Orleans were compared to a sample of 162 people in Houston. Data were collected between June 2002 and December 2005. There were no significant differences between the two groups on either depression or anxiety, but the New Orleans sample scored higher on the self-esteem scale and scored slightly lower on the risk-taking scale.

Barriers and opportunities for recruitment for nonintervention studies on HIV risk: perspectives of street drug users

This study used focus-group discussions in response to a video vignette to examine attitudes toward recruitment for nonintervention research involving HIV testing. Participants were 100 ethnically diverse, economically disadvantaged urban drug users, who were recruited from New York City and Hartford, Connecticut in the spring and summer of 2006. Content analyses revealed themes including (1) fears of stigma and legal trouble balanced by trustworthiness of the recruiter; (2) fears of learning one's HIV status balanced by prospects for health benefits, and (3) the right to receive fair monetary compensation balanced by risks of coercion during periods of cravings. Limitations and implications for recruitment practices have been discussed here.

Is Ricoeur's Notion of Narrative Identity Useful in Understanding Recovery in Drug Addicts?

From Ricoeur's narrative theory, we argue that drug addicts may particularly need the help of literature, in a broad sense- fiction, history, and also specialized literature on addiction-to make their lives intelligible, to construct their identities, and to be able to change. Their need for this popular and professional literature concerns the numerous theories in the field of addiction. This literature is encountered indirectly by patients via interaction with professionals. It reflects attempts on the part of practitioners to find turning points in their patients' life stories, as in the mimesis circle described by Ricoeur. Our hypothesis is therefore explored in the light of certain sociological and psychiatric models that plot patients' lives, especially in the recovery period. The risks of a noncritical appropriation of this literature are discussed. Indeed, patients may hesitate between several identification models, loss of identity, and identity withdrawal.

Homebirth as systems-challenging praxis: knowledge, power, and intimacy in the birthplace

In this article, I examine the processes and motivations involved when women in the United States choose to circumvent the dominant obstetric care paradigm by delivering at home with a group of care providers called direct-entry midwives. Using grounded theory, participant observation, and open-ended, semistructured interviewing, I collected and analyzed homebirth narratives from a theoretical sample of women (n = 50) in two research locales. Findings interpreted from the perspective of critical medical anthropology suggest that women who choose to birth at home negotiate fears associated with the "just in case something bad happens" argument that forms the foundation for hospital birth rationales through complex individual and social processes. These involve challenging established forms of authoritative knowledge, valuing alternative and more embodied or intuitive ways of knowing, and knowledge sharing through the informed consent process. Adherence to subjugated discourses combined with lived experiences of personal power and the cultivation of intimacy in the birthplace fuel homebirth not only as a minority social movement, but also as a form of systems-challenging praxis.

Street smarts and urban myths: women, sex work, and the role of storytelling in risk reduction and rationalization

Storytelling has a strong tradition in inner-city American communities. In this article, we examine patterns of storytelling among a sample of drug-using women from New York City who engage in street-based sex work. We consider two particular formats of storytelling for analysis: "street smarts" and "urban myths." Street smarts are stories of survival, and urban myths are compilations of street legends spread by word of mouth. The narratives are filled with tales of extreme risk across situations. The women used the stories to delineate the boundaries of risk as well as to rationalize risks they deemed to be inevitable but temporary in their lives. Few of the women capitalized on the greater instructive quality of the stories toward increased risk reduction, which may relate to the women's distance from an identity of "sex worker." If properly harnessed, the strength of storytelling suggests new avenues for risk-reduction interventions.

The concept of culture: a core issue in health disparities

Contemporary discourse contains numerous examples of use of the concept of culture by social and behavioral scientists. Simple reification, where the speaker makes culture into a thing capable of action exemplifies one usage in public discourse. Some quantitative social scientists attempt to characterize people's cultural identities by means of a single categorical variable, which often "lumps" people into categories such as "Hispanic" or "Black" that in fact have numerous culturally bounded subcategories. Approaches that emphasize cultural process are preferable to those who attempt to categorize; more complex measures of acculturation help investigators to make convincing analyses of circumstances in which health disparities occur. Examples in which investigators make appropriate use of cultural characterizations demonstrate their utility in investigating health disparities in Haitian American women, injecting and noninjecting drug users, Hispanic youth, and adult Hispanics at risk of HIV infection. Focus on culture in the study of health disparities can identify entanglements between structural factors such as poverty and lack of education and cultural factors such as beliefs about health. Qualitative methods coupled with quantitative methods have great potential to improve investigators' grasp of cultural nuance while capturing the distribution of qualitatively derived behaviors.

If I didn't have HIV, I'd be dead now: illness narratives of drug users living with HIV/AIDS

The purpose of this study is to illuminate the experiences of lower income, urban, HIV-positive drug users. The authors asked 60 participants about HIV risk behaviors, the impact of HIV on their lives, religious beliefs, life plans, relationships, and work-related issues both prior to and since diagnosis. They developed a theoretical framework based on illness narratives and ambiguous loss theories. Themes pertaining to both physical and emotional or spiritual dimensions were located within Benefit, Loss, or Status Quo orientations. The findings contribute to researchers' understanding of the HIV/AIDS illness experiences among the very marginalized and have important implications for physical and mental health care professionals working with HIV-positive drug users.

Drug injectors and dealers in Odessa, Ukraine

This article reports on the results observed in a series of focus groups and in-depth interviews with injection drug users (IDUs) and drug dealers in Odessa, Ukraine. Ukraine has the highest rate of HIV infection in Eastern as well as Western Europe, and Odessa ranks among the cities in that country with the highest seroprevalence. The epidemic is largely concentrated among IDUs, although heterosexual transmission is increasing. The purpose of this study was to further understand the context in which HIV-related risk behaviors occur in order to recommend intervention strategies that might reduce the rate of new infections. The drug users who participated in the research were impoverished and severely addicted. Findings revealed that there were two sources for drugs in Odessa: either from gypsies in preloaded syringes, or from drug dealers also in a liquid form. The most common drug injected was liquid poppy straw, a weak opiate known as "hemia." Results showed widespread victimization of drug users by police officials, leading to increased risk-taking to avoid arrest or harassment. Needle/syringe sharing was common and users rarely had time to disinfect their works. The most common product used to clean was urine, believed to be an antiseptic. When asked to recommend prevention strategies to reduce the rising rate of HIV, the most common response by the users and dealers was to legalize drugs. The drug and HIV epidemics in Odessa, as well as all of Ukraine, call for urgent public health measures to impact and improve the health of its citizens.

Beyond the "fetishism of words": considerations on the use of the interview to gather chronic illness narratives

The author explores the technique of interviewing chronic illness patients to obtain narratives of their illness experiences. It is argued that the perspective that interview responses are accurate reflections of experience (the "fetishism of words") hampers the understanding of patient voice and agency. Discussions of chronic illness and narrative are followed by an examination of the interview based on the work of Charles L. Briggs. The author then uses the concepts of self-presentation and social support to examine what interviewers and interviewees contribute to the coconstructed discourse that is produced by the interview and addresses the question of how these concepts contribute to the beneficial outcomes of constructing narratives. The author offers specific suggestions for future research.