This thesis was undertaken to assess the characteristics of individuals who smoke crack cocaine and to examine the health-related risks and healthcare needs of this population. A literature review of 147 published articles was conducted to synthesize evidence regarding behaviours associated with crack use and to assess the risks of disease transmission through crack smoking behaviours. Qualitative interviews were subsequently conducted with thirty Ottawa residents who smoke crack to learn about their experiences with healthcare and harm reduction services. Results identified barriers related to accessing primary healthcare and drug treatment programming among people who smoke crack and gaps within existing harm reduction services. Individuals who smoke crack represent a marginalized population who are often missed through traditional health promotion and harm reduction programming. There is a need for increased coverage of current programming and a reduction of factors which currently hinder the delivery and effectiveness of crack-specific harm reduction programs.

In this study, I analyze the responses of police officers to questions regarding their involvement in the use of Community-Oriented Policing strategies. When the officer encounters a drug offender they must decide how to deal with the situation. There are a variety of trained responses and policies available. The data is grouped into nine variables; time in law enforcement, time in department, perceived support, perceived barriers, COP strategy, COP action, prevention, help, and citation. The data is then analyzed using structural equation modeling.

Street-involved women with co-occurring disorders experience distinct and overwhelming health and social issues, while facing considerable barriers to appropriate and helpful services. Street Connections, a Population and Public Health program, provides services to this and other street-involved aggregates using Harm Reduction and mobile outreach to prevent sexually transmitted infections and blood borne pathogens. Three conceptual frameworks, Gender-based Analysis, the Comprehensive, Continuous, Integrated System of Care, and Harm Reduction guided the practicum. The purpose of the practicum was to develop policy/practice recommendations for Street Connections regarding service enhancement for this aggregate. Literature-based best-practices were compared to three agency case studies of programs providing services to this aggregate including Street Connections, the Program of Assertive Community Treatment, and Dream Catchers. Data, consisting of agency documents and person-centered interviews with nine staff, were analyzed using open coding to identify themes. Recommendations incorporate gender-based analysis, recovery, access, engagement, screening, integrated services, and staff development/support. / October 2007

This thesis was undertaken to assess the characteristics of individuals who smoke crack cocaine and to examine the health-related risks and healthcare needs of this population. A literature review of 147 published articles was conducted to synthesize evidence regarding behaviours associated with crack use and to assess the risks of disease transmission through crack smoking behaviours. Qualitative interviews were subsequently conducted with thirty Ottawa residents who smoke crack to learn about their experiences with healthcare and harm reduction services. Results identified barriers related to accessing primary healthcare and drug treatment programming among people who smoke crack and gaps within existing harm reduction services. Individuals who smoke crack represent a marginalized population who are often missed through traditional health promotion and harm reduction programming. There is a need for increased coverage of current programming and a reduction of factors which currently hinder the delivery and effectiveness of crack-specific harm reduction programs.

Place is not a static backdrop for social relationships; rather, it is a dynamic product of the interactions among the people, practices, objects, and representations contained within it. Often, street-involved people who use drugs are excluded from interactions that would otherwise allow them to participate in community dynamics. In Vancouver, British Columbia, peer-based outreach groups redress these barriers by providing low-threshold positions to individuals living with active or past addiction. The overall question of this thesis is: what is the role of place in the health of an individual and of a community? Objectives include: (1) applying existing models of social exclusion to outline barriers preventing Peer Members from engaging in placemaking; (2) mapping the ideological positionality of the Peer Members and the rest of the community with regard to citizenship; and (3) exploring how Peer Members utilize their biosocial role as outreach workers to establish social capital and situate themselves as participants in a healthy community. By providing a platform where various social identities can interact with one another, ties of familiarity are established between these groups, thus enabling the transfer of resources, knowledge, and shared norms of respect. The first half of the discussion focuses on how social and geographic displacement legitimizes the process of social abandonment. Consequently, this relegated the Peer Members and their peers into the role of anti-citizen, rationalized their marginalization, and reinforced the wider community’s stigma toward people who use drugs. The latter half of the discussion illustrates how the Peer Members utilize their biosocial role of outreach and support workers to navigate boundaries and establish social connections to circulate knowledge and information within and among different social fields. This enabled the expression of mutual reciprocity, thereby negotiating the place of people who use drugs and harm reduction among the wider community. Place is therefore a concept that shapes, and is shaped by, the social networks that determine social legitimacy or illegitimacy. Although marginality and oppression cannot be transformed immediately, creating a social environment where Peer Members can be supported and support one another helps mitigate the marginalization that characterizes their lives.

Ett lågtröskelboende vänder sig till individer med missbruks- och boendeproblematik där intentionen är att erbjuda individen stöd i dennes alkoholproblematik samt en trygghet i boendet utan att ställa krav på nykterhet. Studiens syfte var att undersöka fenomenet: upplevelsen av att bo på ett lågtröskelboende utifrån ett brukarperspektiv, samt vad flytten till lågtröskelboendet har inneburit för de boendes livskvalitet. I analysen användes ett fenomenologiskt perspektiv med livsvärldsteorin som utgångspunkt. Resultatet visar studiens fenomen som existentiell samhörighet i alkoholmissbruk. Den delade alkohol- och boendeproblematiken gör att de boende upplever sig som jämlika med varandra, vilket också skapar en känsla av gemenskap och tillhörighet. Studien visar att alkoholkonsumtion, trots acceptans av alkoholbruk inom boendet, upplevs av de boende som om den minskar. Resultatet har betydelse för hur lågtröskelboenden kan utvecklas för att göra en än bättre anpassning till de boendes behov. / A low-threshold-home is a home for individuals that are struggling with alcohol addiction problems and finding it hard to find a place to stay. The intention of the home is to offer the residents support in their struggle with alcohol, and a safe place to stay, without putting pressure on the person to stay sober. The purpose of the study was to see how the individuals are coping with living at the low-threshold home and still struggling their addiction, and how the move there has changed their quality of life. A phenomenological perspective of theory of life has been used in the analysis and the results show an existential connection between the men in their alcohol-addiction. Because of their shared alcohol- and accommodation problems with addiction, the individuals feel a unity between them that creates understanding. The study shows by experiences by the residents that the acceptance of alcohol within this low-threshold-home in many cases leads to less consumption of alcohol. That is important and useful when trying to improve these low-threshold-homes even more in the future for the individuals living there.

RESUMEN La investigación analizó el control y la regulación del uso de drogas en el Brasil – donde se confrontan los modelos de abstinencia y de Reducción de Daños - y sus implicaciones para las políticas y prácticas locales. El marco teórico apoyase en el enfoque socio-cultural del fenómeno de las drogas a partir de Oriol Romaní, Howard Becker, Norbert Elias e Roger Chartier. La metodología articuló la investigación histórica, basada en análisis documental, y el estudio etnográfico en tres instituciones de asistencia as drogas en Salvador y espacios complementares (barrios populares, eventos científicos). Los resultados apuntan contradicciones en la actual política nacional de drogas. Los servicios especializados incorporan progresivamente el modelo de la Reducción de Daños. Sin embargo, el ideal de la abstinencia persiste fuertemente en el imaginario social brasileño y se refleja en las conductas de la policía, y ciertamente, en las dificultades de financiación de los servicios. / A investigação analisou o controle e a regulação do uso de drogas no Brasil – confrontando os modelos de abstinência e de Redução de Danos - e suas implicações para as políticas e práticas locais. O marco teórico apóia-se no enfoque sócio-cultural do fenômeno das drogas a partir de Oriol Romaní, Howard Becker, Norbert Elias e Roger Chartier. A metodologia articulou a investigação histórica, baseada na análise documental, e estudo etnográfico em três instituições de assistência às drogas em Salvador e espaços complementares (bairros populares, eventos científicos). Os resultados apontam contradições na atual política nacional de drogas. Os serviços especializados incorporam progressivamente o modelo de Redução de Danos. Entretanto, o ideal da abstinência persiste fortemente no imaginário social brasileiro e se reflete nas condutas da policia, e certamente, nas dificuldades de financiamento dos serviços.

Background: Women who inject drugs continue to represent a disproportionate percentage of new cases of HIV in Canada (PHAC, 2006). However, in Nova Scotia, HIV has still not been conceptualized as a major health issue, especially among women (Gahagan, Rehman & Baxter, 2006). At the same time, recent research findings suggest that female injection drug users in Nova Scotia are engaging in unsafe injection and sexual practices and often lack access to harm reduction-based programming and resources (Ploem, 2000; PHAC, 2006; Jackson et al., 2010; Parker et al., 2011; Hodder, 2011). In a provincial context of high prevalence of injection drug use and HIV risk behaviours, preventing increasing rates of HIV infection will depend on the development of proactive and gender-informed HIV prevention policies. Purpose: This study had two main aims. First, it aimed to chart the development of provincial HIV prevention and harm reduction policies and to identify how, and if, the policy development processes address the HIV prevention needs of women who inject drugs. Its second aim was to identify key barriers and facilitators to developing HIV prevention policy for women who inject drugs in Nova Scotia. Methods: This study involved a review of key HIV prevention and harm reduction policy documents as well as interviews with 27 key informants directly involved with HIV prevention and/or harm reduction policy decision-making. Findings/Discussion: The existing Nova Scotia-based policy development network, their policies, their processes and the context within which they have functioned over the past ten years do not appear to be supporting the development of HIV prevention and harm reduction policy which addresses the needs of women who inject drugs. Policy committee composition lacked inclusivity and organizations that work directly with women who inject drugs held less influence in policy processes. In addition, gender was not prioritized by decision-makers and therefore not comprehensively addressed in policy content. As a result, the needs of women who inject drugs have not been prioritized in policy processes and subsequently few targeted resources are going to the community-based organizations that provide services to these women.

Background: Much of the research on injection drug use practices has focused on adult populations and relatively little is known about safer and/or unsafe injection practices among youth who use injection drugs (YWID). Unsafe practices may be risk factors for blood borne illnesses, abscesses or other infections, and overdose. Multiple factors may create barriers to the access of clean supplies and the ability to practice safer injection. It is important to understand how YWID engage in safer and/or unsafe injection practices so that use of safer practices may be supported. Purpose: The purpose of this study was to explore the understandings and practices of safer and/or unsafe injection drug use among YIWD, as well as key social factors influencing these understandings and practices. Methods: Ten semi-structured qualitative interviews were conducted with YWID aged 18 to 29 in Halifax, Nova Scotia. Voluntary informed consent was obtained prior to conducting the interviews. All interviews were audio-taped and transcribed, then analyzed using a modified approach to grounded theory for key themes and subthemes. Results: The experiences of the YWID can be categorized into two overarching themes. The first theme relates to the power of the drugs and the control (or, at times, lack of control) YWID have over safer practices. This theme explores how access to clean supplies and understandings of safer use can influence the control YWID have over safer practices. The second theme describes experiences YWID have with “getting clean,” or gaining power over drugs, including experiences with methadone maintenance treatment. Discussion: YWID can and do practice safer use, however multiple factors, such as the perception of cleanliness in injection practices and the availability of clean needles in the community, impact how YWID understand and practice safer injection drug use. Barriers that impede YWID’s ability to practice safer use need to be addressed.

Street-involved women with co-occurring disorders experience distinct and overwhelming health and social issues, while facing considerable barriers to appropriate and helpful services. Street Connections, a Population and Public Health program, provides services to this and other street-involved aggregates using Harm Reduction and mobile outreach to prevent sexually transmitted infections and blood borne pathogens. Three conceptual frameworks, Gender-based Analysis, the Comprehensive, Continuous, Integrated System of Care, and Harm Reduction guided the practicum. The purpose of the practicum was to develop policy/practice recommendations for Street Connections regarding service enhancement for this aggregate. Literature-based best-practices were compared to three agency case studies of programs providing services to this aggregate including Street Connections, the Program of Assertive Community Treatment, and Dream Catchers. Data, consisting of agency documents and person-centered interviews with nine staff, were analyzed using open coding to identify themes. Recommendations incorporate gender-based analysis, recovery, access, engagement, screening, integrated services, and staff development/support.