The perspectives of injection drug users regarding safer injecting education delivered through a supervised injecting facility

Background Unsafe injection practices are prevalent among injection drug users (IDU) and have resulted in numerous forms of drug-related harm including HIV/HCV transmission and other bacterial and viral infections. North America's first supervised injection facility (SIF) was established in Vancouver in order to address injection-related harms among IDU. This study sought to examine injection drug users' experiences receiving safer injecting education in the context of a SIF. Methods Semi-structured qualitative interviews were conducted with 50 individuals recruited from a cohort of SIF users known as the Scientific Evaluation of Supervised Injection (SEOSI) cohort. Audio recorded interviews elicited IDU perspectives regarding the provision of safer injecting education within the context of a SIF. Interviews were transcribed verbatim and a thematic analysis was conducted. Results Participant narratives indicate that significant gaps in knowledge regarding safer injecting practices exist among local IDU, and that these knowledge deficits result in unsafe injecting practices and negative health outcomes. However, IDU perspectives reveal that the SIF allows clients to identify and address these gaps in knowledge through a number of mechanisms that are unique to this facility, including targeted educational messaging that occurs as a part of the drug use cycle and not outside of it, in situ demonstration of safer injecting techniques that takes place the moment a client is experiencing difficulties, and enhanced opportunities to seek help from 'expert' healthcare professionals. Importantly, study participants indicated that the overall environment of the SIF promotes the adoption of safer injecting practices over time, both within and outside of the facility. Conclusion We conclude that the SIF has been particularly effective in transmitting educational messages targeting unsafe and unhygienic injection practices to a population of active IDU. Consistent with previous work, results of this study indicate that SIFs represent a unique 'micro-environment' that can facilitate the reduction of numerous drug related harms.


Background
Injection drug use continues to present a major public health challenge in urban settings around the world [1,2]. Unsafe injection practices result in numerous forms of drug-related harm, including overdose [3], HIV/HCV transmission [4,5], and other forms of bacterial and viral infections [6].
Safer injecting education has been widely employed in order to address the harms associated with injection drug use [7,8]. For example, numerous harm reduction programs provide information on safer injecting and street outreach programs work to seek out injection drug users (IDU) in the public venues they frequent in order to provide safer injecting education and other forms of support [9]. However, supervised injection facilities (SIFs) constitute a unique form of intervention, in that they provide a sanctioned drug-using environment that is constantly supervised by healthcare professionals [10].
In September 2003, North America's first SIF, known as "Insite," opened its doors in Vancouver's Downtown Eastside. To date, over 7000 IDU have attended the facility, and approximately 600 injections are supervised at the facility each day [11]. Healthcare professionals are present at all times to supervise injections, intervene in the event of an overdose, and provide safer injecting education.
Previously, a quantitative study was conducted to examine the prevalence and correlates of receiving safer injecting education within the Vancouver SIF [12]. While the results of that study indicated that a significant proportion of SIF users received safer injecting education within the facility, little is known about how safer injecting education is delivered within SIFs, and whether this setting offers advantages over conventional clinic-based or street outreach safer injecting education programs. Further, we know of no studies that have assessed IDU perspectives regarding safer injecting education delivered in the context of SIFs, and there are few qualitative explorations of IDU experiences within SIFs. Therefore, while previous quantitative research has demonstrated the importance of safer injecting education for drug using populations [8,[12][13][14][15], we aim to extend this work by exploring injection drug users' experiences with receiving safer injecting education in the context of a local SIF.

Methods
We drew upon data from 50 in-depth qualitative interviews conducted from November 2005 to February 2006. Interviewees were recruited from the Scientific Evaluation of Supervised Injecting (SEOSI) cohort, which is composed of over 1000 randomly selected SIF users in Vancouver [16]. Interview participants were selected on a daily basis from persons attending the research office for quantitative cohort interviews. Recruiting efforts intentionally created a sample composed of individuals with differing levels of SIF utilization that was also representative of the local injecting population in terms of gender, age, and ethnicity (see Table 1). Interviews were undertaken by three trained interviewers (two male and one female) and facilitated through the use of a topic guide encouraging discussion of SIF use and experiences with receiving safer injecting education within the facility.
Interviews lasted between 30 and 60 minutes, were taperecorded, and were later transcribed verbatim. The content of transcribed interviews was reviewed, and all text segments (both positive and negative) related to safer injecting education received within the SIF were catalogued. The catalogued data was subsequently subjected to a thematic analysis which focused on the social processes and characteristics of the SIF which were reported to influence experiences with safer injecting education.
All participants provided informed consent to participate, and the study was undertaken with appropriate ethical approval granted by the Providence Healthcare/University of British Columbia Research Ethics Board. Participants were compensated for their time with a twenty dollar honorarium. There were no refusals of the offer to participate in the interview, and no drop-outs occurred during the interview process.

Results
The sample of qualitative interview participants was composed of 21 women, 28 men and one trans-gendered individual. The age of participants ranged from 25 years to 60 years, and the median age of participants was 38. Excerpts from the qualitative interviews are presented below in order to illustrate the central themes that emerged in the analysis. Considerable overlap was observed across thematic areas.
Participant narratives indicate that significant gaps in knowledge regarding safer injecting practices exist among local IDU; however, study participants also indicated that the SIF allows clients to identify and address these gaps in knowledge through a number of mechanisms that are unique to this facility.

Gaps in knowledge
Several participants articulated a general lack of knowledge regarding safer injecting practices prior to using the SIF. This lack of knowledge was not limited to new injectors: In a number of cases, participants were not aware that they were injecting unsafely until they began using the SIF and receiving safer injecting education from on-site healthcare professionals. Visits to the SIF allowed participants to identify and address specific gaps in knowledge, resulting in the adoption of safer injecting practices and improved health outcomes in several cases:

Addressing gaps in knowledge A. Educational messages delivered within a sanctioned drug-using environment
Despite the availability of safer injecting education via a number of other service providers in locations throughout the Downtown Eastside, several participants noted that the SIF was the first place that they had successfully been able to receive help: The SIF was described as providing a context in which onsite healthcare professionals are able to guide clients through each step of the safer injecting process at a comfortable pace, and often over the course of multiple interactions. Healthcare professionals are able to tailor educational messages to suit the specific needs of each client to address specific deficiencies in practice, and are able to intervene as a client is experiencing difficulties. Participants valued the non-judgmental attitudes of the SIF staff, and felt able to ask questions and raise concerns the moment they thought of them: In general, the safer injecting education received at the SIF enabled some participants to take greater control of their injecting practices, at least within the SIF.

An overall environment that promotes safer injecting practices
Even when participants had accessed safer injecting education prior to using the SIF, it was noted that the overall atmosphere of the SIF made them more conscious of these messages, and more diligent about putting them into practice:

Discussion
In sum, participant narratives indicate that significant gaps in knowledge regarding safer injecting practices exist among local IDU, and that these knowledge deficits result in unsafe injecting practices and negative health outcomes for numerous local IDU. However, IDU perspectives reveal that the SIF allows clients to identify and address these gaps in knowledge through a number of mechanisms that are unique to this facility, including targeted educational messaging that occurs as a part of the drug use cycle and not outside of it, in situ demonstration of safer injecting techniques that takes place the moment a client is experiencing difficulties, and enhanced opportunities to seek help from 'expert' healthcare professionals. Importantly, study participants indicated that the overall environment of the SIF -including the provision of comprehensive sterile injecting paraphernalia and the constant presence of healthcare professionals -promotes the adoption of safer injecting practices over time, both within and outside of the facility. Interestingly, we found little variation in experiences with receiving safer injecting education within the SIF according to gender, age or ethnicity, in spite of evidence which indicates that women may be more likely to require help injecting for a variety of contextual reasons [17][18][19], and may therefore be more receptive to assistance and education from on-site healthcare professionals.
IDU utilize the SIF for the primary purpose of consuming drugs; however, multiple visits to the facility give nurses the opportunity to provide hands-on, client-centered safer injecting education in a timely and unhurried manner. Within the SIF, in situ demonstration of targeted educational messages can occur the moment a client is experiencing difficulties, and at a pace that is acceptable to the client. In combination with the provision of sterile syringes and the necessary ancillary injecting equipment, this process encourages clients to reflect on and enact safer injecting practices without feeling rushed. This can be contrasted with the circumstances that often surround public injection, where exposure to police scrutiny and the possibility of arrest often results in skipped steps and unsafe injecting behavior [20][21][22][23][24], despite the availability of safer injecting education and sterile injecting paraphernalia in public venues via street outreach approaches.
Ongoing drug-related harms among IDU indicate that novel public health interventions are needed [19,25]. Educational approaches have typically been based on the assumption that IDU are autonomous actors operating within relatively stable social environments [26]. Even those street outreach approaches that seek out IDU in the public venues they frequent oftentimes fail to recognize the macro-and micro-environmental factors that limit an individual's ability to initiate behavioral change [27,28].
In order for educational approaches to be effective, attention must be paid to the physical and social environment that influences the production of safety and risk for individuals who use injection drugs [27,29]. Broader conceptualizations of risk, such as Rhodes' 'risk environment' framework [28], call for structural and environmental interventions that alter aspects of the context in which injection drug use occurs, thereby facilitating the adoption of safer injecting practices and the reduction of drugrelated harms [30]. The results of this study indicate that SIFs represent one such micro-environmental intervention with a unique social composition that serves to modify risk in ways that differ from conventional clinic-based and street outreach educational approaches. As such, SIFs have significant potential to facilitate the adoption of safer injecting practices where other educational approaches have failed or been less effective.
The results of this study indicate that, by addressing critical gaps in knowledge, SIFs can foster greater injecting independence among IDU and contribute importantly to the reduction of injection drug-related harms. Previous research has noted that a lack of knowledge regarding how to safely inject oneself is a primary explanation for requir-ing help with injecting [31], and that requiring help with injecting places individuals at heightened vulnerability for HIV and HCV infection [13]. These observations were reflected in IDU narratives that emphasized the importance of timely and appropriately delivered safer injecting education for individuals who engage in assisted injection as a result of lack of knowledge. The safer injecting education received at the SIF allowed some study participants to take greater control of their injecting habits. The fact that a previous quantitative study found that requiring help injecting was independently associated with receiving safer injecting education at the Vancouver SIF [12], combined with the results of this qualitative analysis, provides good indication that safer injecting education within the SIF may have significant implications for HIV and HCV prevention among frequent SIF users.
The present study has several limitations that warrant acknowledgement. Firstly, our findings are based upon interviews with local IDU participating in the current study. While an effort was made to ensure that the study sample reflects the demographics of the local SIF-using population, some perspectives may nonetheless be underrepresented. Secondly, although interviewees were told that the study was being conducted independently of the SIF, it is possible that social desirability bias affected the responses of some participants. Thirdly, the data collected and analyzed here presents only the viewpoints of IDU; the results of this analysis should be compared with the findings of ethnographic research utilizing participantobservation within the SIF. Interviews with healthcare professionals and other SIF staff should be conducted to elicit alternative perspectives. Fourthly, it must be recognized that the Vancouver SIF is not accessible to all local IDU; people who rely on others to administer all injections (such as IDU with physical disabilities), or who engage in assisted injection for a variety of socio-cultural reasons [32], are excluded from the facility as a result of regulations prohibiting assisted injection within the SIF. Thus, these individuals are not able to receive safer injecting education via the SIF, limiting the facility's effectiveness in addressing the needs of diverse local IDU. Furthermore, while those participants who had received safer injecting education within the facility reflected positively on their experiences, a minority of participants reported that they had not received safer injecting education within the facility, or that they disliked the overall environment within the facility (which would likely discouraged them from spending extra time necessary to seek out and engage in safer injecting education with on-site healthcare professionals). The results of this analysis suggest that the SIF can greatly benefit those individuals who visit the site regularly and have developed good relationships with on-site healthcare professionals; future research is needed to determine why some individuals use the facility more infrequently than others, and how this affects the uptake of safer injecting education.
In summary, the results of this study indicate that the SIF has been effective in transmitting educational messages targeting unsafe and unhygienic injection practices to a population of active IDU. The SIF facilitates the delivery and adoption of educational messages via a number of mechanisms that are unique to this facility and highly acceptable to local IDU. Consistent with previous work, results of this study indicate that SIFs represent a microenvironmental intervention with significant potential to reduce numerous drug-related harms. Importantly, this study contributes to the development of knowledge regarding alternative mechanisms of connecting IDU with safer injecting education.