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Scholarly Works (6 results)

  • Thesis
  • Peer Reviewed
UC San Diego Electronic Theses and Dissertations (2020)

ABSTRACT OF THE DISSERTATION

The role of gender in experiences of substance use-related stigma and injection drug use initiation processes: An intersectional approach

by

Stephanie A. Meyers

Doctor of Philosophy in Interdisciplinary Research on Substance Use

University of California San Diego, 2020

San Diego State University, 2020

Professor Dan Werb, Chair

Background: Women who inject drugs (WWID) are disproportionately impacted by injection-related harms and substance use-related stigma. Guided by an integration of the Stigma and Substance Use Process Model and the Risk Environment Framework, this dissertation sought to further elucidate the impact of gender on substance use stigma and injection drug use trajectories.

Methods: This dissertation includes a systematic review of substance use-related stigma (Chapter 2) and mixed methods analyses from three prospective cohorts of people who inject drugs (PWID) linked within the PReventing Injecting by Modifying Existing Responses (PRIMER) study. Cohorts provide data from San Diego, USA (n = 352) (Chapter 3), Vancouver, Canada (n = 1,739) (Chapters 3 & 4), and Tijuana, Mexico (n =531) (Chapters 3 & 4). Chapter 2 systematically reviews the scientific literature on the intersection of gender- and substance use-related stigma. Chapter 3, using a mixed methods approach, examines how gender influences the risk environment for processes of injection initiation. Chapter 4 applies discrete time survival analyses to assess the association between gender and the provision of first-time injection initiation assistance.

Results: Of the 75 articles (Quantitative: n = 40; Qualitative: n = 35) included in Chapter 2, 23(57.5%) quantitative articles reported no association between gender and substance use-related stigma, whereas 34(97.1%) qualitative articles reported women experienced greater substance use stigma than men. Chapter 3 findings demonstrated a greater proportion of gender concordant (e.g., male-male vs. male-female) ‘assister’ and ‘assistee’ injection initiation pairs among PWID in Tijuana compared to Vancouver or San Diego. The gendered spatial risk environment of prisons/jails in Tijuana and social risk environments of intimate partnerships and caring in San Diego and Vancouver, respectively, likely explain differences in gender concordance of assister-assistee pairs by setting. Chapter 4 findings demonstrate that, compared to WWID, women were nearly 50% less likely to provide first-time injection initiation assistance in Tijuana, but not in Vancouver.

Conclusions: These findings illustrate the need for intersectional approaches to research on the influence of gender on stigma- and injection drug use-related processes. Furthermore, these results can inform the development of critically needed gender- and site-specific injection prevention and intervention efforts.

    Cover page: The role of gender in experiences of substance use-related stigma and injection drug use initiation processes: An intersectional approach
    • Article
    • Peer Reviewed
    UC San Diego Previously Published Works (2020)
    In 2017, there were large increases (260-500%) in overdose deaths among women in the United States across age groups (30-64 years and 55-64 years). In addition, U.S. women who inject drugs (WWID) are at increased risk for substance use-related disease transmission, bacterial infections, as well as sexual and physical violence compared to men who inject drugs. Relatedly, women face unique access barriers to substance use-related services, such as stigma and low coverage of gender-specific drug use-related services. Despite these heightened risks experienced by WWID, interventions specifically tailored to preventing women from transitioning into injection drug use have not been developed to date. As such, we advocate for the development of gender-responsive programs to prevent injection drug use initiation. This is critical to ensuring a comprehensive approach to preventing injection drug use initiation among those populations at highest risk of injection-related morbidity and mortality.
      Cover page: Preventing transitions into injection drug use: A call for gender-responsive upstream prevention
      • Article
      • Peer Reviewed
      UC San Diego Previously Published Works (2020)
      Women's initiation into injection drug use often establishes a pattern of risk following first injection. This study explored sources of gendered power dynamics in injection initiation experiences for people who inject drugs. A qualitative subsample from two prospective community-recruited cohorts of people who inject drugs in San Diego and Tijuana provided data on the contexts surrounding injection initiation processes. Intimate partnerships were identified in initiation; sub-themes were identified drawing on three concepts within the theory of gender and power. With reference to sexual division of labour, men were often responsible for access to resources in partnerships across both contexts, although there were limited accounts of women obtaining those resources. Extending the structure of power, women in San Diego reported that initiation events involving an intimate partner occurred from a position of vulnerability but expressed greater agency when providing initiation assistance. With regard to structure of cathexis, social norms proscribing injection initiation among women exist, particularly in Tijuana. Gendered power dynamics are a multifaceted component of injection initiation events, especially for women in intimate partnerships. These results stress the need for nuance in understanding the intersection of risk, gender and harm reduction within injection initiation events across socio-cultural contexts.
        • Article
        • Peer Reviewed
        UC San Diego Previously Published Works (2018)

        Aim

        Individuals experience differential risks in their initiation into drug injecting based on their gender. Data suggest women are more likely to be injected after their initiator and to share injection equipment. Little is known, however, regarding how gender influences the risk that people who inject drugs (PWID) may assist others into injection initiation. We therefore sought to investigate the role of "initiator" gender in the provision of injection initiation assistance across multiple settings.

        Methods

        We employed data from PReventing Injecting by Modifying Existing Responses (PRIMER), a multi-cohort study investigating factors influencing injection initiation assistance provision. Data were drawn from three cohort studies of PWID in San Diego, USA (STAHR II); Tijuana, Mexico (El Cuete IV); and Vancouver, Canada (VDUS). Site-specific logistic regression models were fit, with lifetime provision of injection initiation assistance as the outcome and gender as the independent variable.

        Results

        Overall, 3.2% (24/746) of the women and 4.6% (63/1367) of the men reported providing injection initiation assistance. In Tijuana, men were more than twice as likely to have provided injection initiation assistance after controlling for potential confounders (adjusted odds ratio = 2.17, 95% confidence interval: 1.22-3.84). Gender was not significantly associated with providing injection initiation assistance in other sites.

        Conclusion

        We identified that being male in Tijuana, specifically, was associated with providing injection initiation assistance, which could inform targeted outreach aimed at reducing the influence of PWID populations on non-injectors in this site. This will likely require that existing interventions address gender- and site-specific factors for effectiveness.
          • Article
          • Peer Reviewed
          UC San Diego Previously Published Works (2020)

          Background

          In the U.S. and Canada, people who inject drugs' (PWID) enrollment in medication-assisted treatment (MAT) has been associated with a reduced likelihood that they will assist others in injection initiation events. We aimed to qualitatively explore PWID's experiences with MAT and other drug treatment and related recovery services in Tijuana Mexico, a resource-limited setting disproportionately impacted by injection drug use.

          Methods

          PReventing Injecting by Modifying Existing Responses (PRIMER) seeks to assess socio-structural factors associated with PWID provision of injection initiation assistance. This analysis drew on qualitative data from Proyecto El Cuete (ECIV), a Tijuana-based PRIMER-linked cohort study. In-depth qualitative interviews were conducted with a subset of study participants to further explore experiences with MAT and other drug treatment services. Qualitative thematic analyses examined experiences with these services, including MAT enrollment, and related experiences with injection initiation assistance provision.

          Results

          At PRIMER baseline, 607(81.1%) out of 748 participants reported recent daily IDU, 41(5.5%) reported recent injection initiation assistance, 92(12.3%) reported any recent drug treatment or recovery service access, and 21(2.8%) reported recent MAT enrollment (i.e., methadone). Qualitative analysis (n = 21; female = 8) revealed that, overall, abstinence-based recovery services did not meet participants' recovery goals, with substance use-related social connections in these contexts potentially shaping injection initiation assistance. Themes also highlighted individual-level (i.e., ambivalence and MAT-related stigma) and structural-level (i.e., cost and availability) barriers to MAT enrollment.

          Conclusion

          Tijuana's abstinence-based drug treatment and recovery services were viewed as unable to meet participants' recovery-related goals, which could be limiting the potential benefits of these services. Drug treatment and recovery services, including MAT, need to be modified to improve accessibility and benefits, like preventing transitions into drug injecting, for PWID.
            • Article
            • Peer Reviewed
            UC San Diego Previously Published Works (2021)

            Objectives

            People who inject drugs (PWID) play an integral role in facilitating the entry of others into injection drug use (IDU). We sought to assess factors influencing PWID in providing IDU initiation assistance across three distinct North American settings and to generate pooled measures of risk.

            Design

            We employed data from three PWID cohort studies participating in PReventing Injecting by Modifying Existing Responses (PRIMER), for this cross-sectional analysis.

            Setting

            Tijuana, Mexico; San Diego, USA; Vancouver, Canada.

            Participants

            A total of 2944 participants were included in this study (Tijuana: n=766, San Diego: n=353, Vancouver: n=1825).

            Measurements

            The outcome was defined as recently (ie, past 6 months) assisting in an IDU initiation event. Independent variables of interest were identified from previous PRIMER analyses. Site-specific multiple modified Poisson regressions were fit. Pooled relative risks (pRR) were calculated and heterogeneity across sites was assessed via linear random effects models.

            Results

            Evidence across all three sites indicated that having a history of providing IDU initiation assistance (pRR: 4.83, 95% CI: 3.49 to 6.66) and recently being stopped by law enforcement (pRR: 1.49, 95% CI: 1.07 to 2.07) were associated with a higher risk of providing assistance with IDU initiation; while recent opioid agonist treatment (OAT) enrolment (pRR: 0.64, 95% CI: 0.43 to 0.96) and no recent IDU (pRR: 0.21, 95% CI: 0.07 to 0.64) were associated with a lower risk. We identified substantial differences across site in the association of age (I2: 52%), recent housing insecurity (I2: 39%) and recent non-injection heroin use (I2: 78%).

            Conclusion

            We identified common and site-specific factors related to PWID's risk of assisting in IDU initiation events. Individuals reporting a history of assisting IDU initiations, being recently stopped by law enforcement, and recently injecting methamphetamine/speedball were more likely to have recently assisted an IDU initiation. Whereas those who reported not recently engaging in IDU and those recently enrolled in OAT were less likely to have done so. Interventions and harm reduction strategies aimed at reducing the harms of IDU should incorporate context-specific approaches to reduce the initiation of IDU.
              Cover page: Involvement of people who inject drugs in injection initiation events: a cross-sectional analysis identifying similarities and differences across three North American settings
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