Studien undersöker förekomsten av brukarinflytande vid implementeringen av det första sprututbytet i Stockholms län. I studien ges en bakgrund till Sveriges narkotikapolitik och hur dess utvecklingen har sett ut från 70- talet fram till idag. I bakgrunden till studien presenteras ett governace-perspektiv på brukarinflytande och de deliberativa processer där brukarinflytande är en naturlig del av policyprocessen. Syftet med studien är undersöka förekomsten av brukarinflytande i implementeringsdelen av den besluts- policyprocess som ledde fram till sprututbytets öppnande i april 2013. Studiens teoretisk ramverk består av teorier som ifrågasätter givenheten i governance-synsättet på brukarinflytande genom hänvisning till svårigheter med aktörskap och risken med konstruerat brukarinflytande. Forskningsstrategin som studien utgår ifrån är intervjuer med utvalda respondenter som har varit delaktiga vid implementeringen av sprututbytet samt brukarorganisationer som representerar och företräder sprututbytets målgrupp. Resultatet av studien visar på en svag förekomst av brukarinflytande vid implementeringen av sprututbytet. Det brukarinflytande som kan anses har förekommit har varit på en individuell nivå och icke-formaliserat. I analysen presenteras tre möjlig förklaringar till den svaga förekomsten av brukarinflytande vid implementeringen av sprututbytet samt en analys om svårigheter med aktörskap vid implementeringen kopplat till studiens teoretiska ramverk. / This study examines the occurrence of user influence during the implementation of the first Needle and Syringe exchange Programme (NSP) in Stockholm County. The survey in his study consists of interviews conducted with persons that have been involved during the process and debate around the NSP in Stockholm County. The interviews have been conducted with two different groups of actors: User organizations and public actors. The first group called user organizations consists of actors from three different user organizations representing and organizing the target group for the NSP. The second group called public actors consists of public actors which have been involved under and/or before the implementation of the NSP in Stockholm County. The study contains a description of the background of NSPs in Sweden. The study describes the development of the Swedish drug policy from 1970 until today. Further it covers the development of the NSPs in other parts of Sweden as well as the development of harm reduction as a general strategy for drug addiction management. Several definitions to the terms user and user influence are presented. Four are conventional definitions of the term user, together with a fifth one which is then used within in the context of the study. The study presents definitions of the term user influence by a model dividing user influence in three categories: individual level, operational level and system level. Another division of the term user influence presented is formalized and non-formalized user influence. These different classifications are used in the analysis of the results. The study also presents a background to the governance view on user influence as a natural and unproblematic part in the policy process. The theoretical framework in the study consists of two parts: The first part questions governance and the given of user influence within a policy process. The study highlights the problems with a governance view on actorhood and user influence. The second part of the theory chapter presents a model for the policy process. The policy process is described in five stages: Initiation, processing, decision making, implementation and evaluation. The results of the survey show little occurrence of user influence during the implementation of the NSP. By using the classification with the three different levels of user influence the result is that the occurrence of user influence found in the investigation has the characteristics of individual level user influence. The study also shows that the user influence found can be classified as non-formalised influence. The analysis first discusses the factors of why there has been little occurrence of user influence during the implementation of the NSP and proposes three different plausible explanations: Politically sensitive question, structural difficulties and users view was already known. The analysis also discuss the problem with a governance view on actorhood and user influence in relation to the study. The study concludes that there has been little occurrence of user influence during the implementation of the NSP in Stockholm County and that the occurrence of user influence found can be classified as individual level user influence, with one plausible exception.

This thesis presents a theoretically informed social history of the New Zealand Needle Exchange Programme (NEP) which has operated since 1988. Close attention is paid to how this 'harm reduction' programme demonstrates a pattern of 'peer-professional' hybridity - a form of quasiprofessionalism developed by injecting drug user (IDU) peers who began operating private needle exchanges funded by both illicit clients and state agencies. In this hybrid mechanism, the personal distrust required to pursue 'criminal' motivations has been connected, through the vulnerable yet influential intermediaries of peers and syringes, to the trust required to 'empower' the health of marginalised IDU communities. This research has drawn on immersed participant experience and on accounts from archival documents, supported by interviews. A reworking of actor-network methodologies has provided a core analytical approach to tracing the critical moments and boundary-shifts in the development and realignments of the NEP's hybrid heterogeneous assemblages. The assembling and reassembling has entangled policy goals, technologies, historical reviews, stigma, laws, logics, logistic systems, narratives, organisations, sterile and bloody syringes, monitoring systems, and professional occupations. IDU, health policy officials, peerprofessionals, managers, politicians, HIV/AIDS community organisers, and medical professionals have prevented HIV transmission by altering key strategic connections and alignments within this active network, while pursuing their public-private interests. The peer-professionals have publicly represented IDU, have advocated professionally for inclusive rather than exclusive public health provisions, while guaranteeing that the monitoring of syringes by state agencies would not harm IDU. The difficulties in shaping and stabilising the NEP have illustrated the 'messy reality' of its institutional and policy environment, yet have also led to highly successful and sustainable health promotion work.

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.

On May 31, 2008, one of Canada’s oldest needle exchange programs was forced to close its doors. Street Outreach Services (SOS), run by AIDS Vancouver Island, was evicted from its fixed site location in downtown Victoria, BC, due to years of inadequate funding and resources, and pressure from community members who blamed SOS for “public disorder” on the city streets. Without a new location from which to house the program, SOS has since operated as a mobile service. This case study documents the context surrounding the closure of SOS and the perspectives of outreach staff regarding the transition from fixed site to mobile services-only. Specifically, this study addresses the question: How have service delivery changes and restrictions impacted SOS outreach work? In addition to participant-observation, media and report analysis, primary data are derived from six semi-structured interviews with SOS outreach workers and a thematic analysis highlights common experiences of loss, isolation and changes in relationships with clients. A discussion of strategies for collective responses to ethical distress includes social justice perspectives. / Graduate

While female sex workers (FSWs) are often the focus of human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) and other sexually transmitted infections (STIs) research in Kenya, little else is known about their lives, including their intimate relationships. This thesis explores the relationships between FSWs and their intimate partners in Kibera, an urban informal settlement in Nairobi, Kenya. As part of the Kenya Free of AIDS (KeFA) project, previous field research found that FSWs with an intimate partner saw over 50% fewer clients per week and were statistically more likely to use a condom with clients. These findings suggested that FSWs' intimate relationships might act as a form of harm and/or use reduction. Sex work harm reduction aims to diminish the occupational harms associated with sex work, such as discrimination, violence and disease, through strategies such as empowerment and education. Use reduction aims to reduce FSWs' frequency of exposure to these occupational risks through a reduction in clients. Specifically, it is proposed that FSW intimate relationships promote harm and/or use reduction in three ways: 1) by reducing the number of clients on a weekly basis, 2) by reducing harm from the virus through adherence to antiretroviral drugs (ARV), and 3) by offering a supportive environment financially, emotionally, and in terms of health and/or childcare. To test these theories this thesis analyzed interviews with 27 HIV positive FSWs from Kibera. Results showed that HIV was normalized in intimate relationships, whereas sex work was stigmatized. As a result, FSWs in this study were more likely to tell their partners that they were HIV positive than disclose their involvement in sex work. Therefore, rather than genuine use reduction, client reduction was unintentional and, in reality associated with sex work stigmatization that prevents women from disclosing their occupation. Some intimate partnerships were found to be a source of emotional and health-related support for Kibera FSWs. Intimate partners provided support for participants' HIV status and adherence to ARV. They also provided emotional support in the form of advice and comfort. Overall, this study suggested it would be difficult to include intimate partners in interventions with HIV positive Kibera FSWs because of the considerable, continued stigma surrounding sex work but that intimate partners can have a positive and/or protective role to play in HIV positive Kibera FSWs’ lives. / Graduate / 0573 / 0327 / 0626 / kimberly.m.sharpe@gmail.com

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.

A presente pesquisa problematiza a polarização presente no debate acerca da política sobre drogas no Brasil, a fim de contribuir com a construção de uma Clínica do Possível no cuidado de pessoas que usam drogas propondo a aproximação entre os princípios e diretrizes da Redução de Danos e da Política Nacional de Humanização. A fim de superar os embates que contrapõem, de um lado o paradigma proibicionista - centrado na abstinência - e, de outro, o antiproibicionismo – pautado pela singularidade - a aposta é em uma clínica-política que coloca o sujeito como protagonista no processo de produção de sua saúde. A tentativa é a de dar visibilidade às novas práticas de cuidado, focadas na produção de saúde como potência de vida, a partir de referências conceituais da filosofia nietzscheana. Na perspectiva teórica adotada pelo presente estudo, utilizamos como fundamento metodológico a pesquisa-intervenção, propondo cartografar os caminhos tecidos pelos usuários de drogas em seu território, a fim de detectar e analisar quais os “nós” (rituais, estratégias, serviços, afetos...) da rede produzem saúde e apontam uma Clínica do Possível pautada no cuidado, vínculo e afeto. A pesquisa foi realizada em um território da rede de saúde do município de Caxias do Sul, na serra gaúcha, sendo construída por várias mãos, pois contou com o apoio de técnicos da equipe da Unidade Básica de Saúde da Região e alunos da Faculdade da Serra Gaúcha. A intervenção desenvolveu-se ao longo de três etapas, organizadas em torno de diferentes instrumentos de intervenção (pin-hole, oficinas de fotografias, hip-hop) contando, ao todo, com 18 participantes, sendo que 09 usuários permaneceram em todas as etapas. As atividades foram realizadas ao longo de oito meses, 26 encontros ocorridos entre o ano de 2011 e início de 2012. No percurso da pesquisa o Hip Hop emergiu como dispositivo expressivo do cotidiano dos usuários que demarcava seus espaços de produção de saúde, potencializando a vida através da arte. Entre os resultados, foi possível identificar a criação de um espaço coletivo que emergiu dessa experimentação proposta pela pesquisa-intervenção, aproximando os usuários tidos como “não aderentes” aos tratamentos ofertados na rede, de um modo diverso àquele com que eles usualmente referiam (e resistiam) (a) os atendimentos que recebem dos serviços de saúde. Ao final da pesquisa, a produção coletiva e espontânea de um rap ritmando as vivências e posições dos usuários que podem pautar a construção de uma política sobre drogas na perspectiva da Redução de Danos apontou a possibilidade de criação de novos territórios existenciais, para além do ressentimento, que sejam produtores de saúde compreendida como expansão de vida. / This project is based on discusses about drug´s politics polarization in Brazil in order to contribute for the construction of a Possible Clinical care for people who use drugs proposing closer relations between the principles and guidelines of the Harm Reduction and the National Humanization´s Politics. In order to overcome the conflicts that opposed, on one hand the prohibitionist paradigm - centered on abstinence - and on the other side, the anti prohibitionist - guided by the singularity - the focus is in a clinical politic that to put the subject as the protagonist in the production process of your health. The attempt is to bring out new care practices, focused on the production of health as a power of life, from conceptual references of nietzschean philosophy. According with the theoretical approach adopted by this study, we used as a methodological research-based intervention, proposing to record the informations about the paths woven by drug users in their territory in order to detect and analyze which "knots" (rituals, strategies, services, affections. ..) from the network produce health and show a Possible Clinical based on the care, link and affection. The search was conducted in a territory of the health network at Caxias do Sul, Rio Grande do Sul, a city in the mountains, being built by many hands, it had the support of the technical staff of the Basic Health Unit in the Region and the students from Serra Gaúcha College. The intervention was developed over three stages, organized around different kinds (pin-hole, photo workshops, hip-hop) overall, with 18 participants, within 09 users remain at all stages. The activities were held over eight months, 26 meetings that occurred between 2011 and early 2012. During the Hip Hop research emerged as an expressive device of daily users that demarcated spaces of health production, enhancing life through art. Among the results, it was possible to identify the creation of a collective atmosphere that emerged from this trial proposed by the research intervention, bringing users considered "non adherent" to treatment offered on the network, in a different way to that with which they usually referred (and resisted) the care that they receive from health services. Concluding, it´s possible to refer that at the end of the study, the collective´s production and spontaneous rap were responsible to put rhythm at the experiences and views of users that can guide the construction about drug´s politic in the perspective of harm reduction, pointed out the possibility of creating new existential territories, beyond the resentment, which are producers of health understood as an expansion of life.

Este trabalho traz algumas considerações e problematizações das políticas sobre drogas, transcorrendo pela história da Redução de Danos em seu percurso clínicopolítico desde o campo da AIDS e sua transição como diretriz de trabalho para o cuidado a pessoas que usam álcool e outras drogas no campo da saúde mental. Para isso, utilizamo-nos do Método da Roda, que serviu também para pensar o papel do apoiador institucional e a cogestão de coletivos, para nos aproximamos de um município em que foi possível acompanhar os modos de andar a redução de danos também no campo micropolítico e, assim, pensar nessa transição e nas perspectivas de trabalho para a atenção básica. Com isso, apresentamos a Redução de Danos como tecnologia leve de cuidado, que circula pelo território e acompanha os diferentes modos de andar a vida, que está atravessada pelos impasses da Reforma Psiquiátrica e pela precarização do trabalho, que acompanha o trabalho da redução de danos desde o seu início e que se atualiza neste campo de pesquisa. / This essay brings some consideration and render problematily of the politics about drugs, elapsing between harm reduction in its political clinical course since Aids field and its transition as guideline of working to care to people that use alcohol and other drugs in the mental health field. For this, we use the wheel method, that fit also to think about the institucional supportes role and the co-management of collective to approach to a county that was possible to follow the way of the harm damage goes and also in the micropolitical field and, so, think about this transition and in the work perspectives to the basic attention. Therewith, we show the harm reduction as light care technology, that moves within the territory and follows the different ways of livong life, that is crossed by impasses of the psychiatric reform and by Precariously of the work, that follows the harm reduction work since its updates in this research field.

Esta dissertação inscreve-se nos campos dos Estudos de Gênero e Culturais, em uma aproximação com a perspectiva pós-estruturalista de análise; investiga as posições de sujeito usuário/a de substâncias psicoativas e os atravessamentos de gênero (re)produzidos no âmbito da Política de Redução de Danos. A Política de RD está preocupada em reconhecer as escolhas dos/as usuários/as de substâncias psicoativas (SPA) que demandam algum tipo de cuidado e, desse modo, alcançar a esfera do direito à saúde, à cidadania e aos direitos humanos. O material empírico é composto pelos documentos normativos da política e seus desdobramentos. Para o exame do corpus de investigação, foi utilizada a análise cultural, em combinação com a pesquisa documental, operando com os conceitos de posição de sujeito, norma, poder e gênero. Os documentos da política e seus desdobramentos foram tomados como artefatos culturais e pedagógicos que (re)produzem e veiculam discursos biomédicos, psicológicos, morais e jurídicos implicados com a produção de sujeitos e de práticas de cuidado no campo da saúde mental voltada para o uso de SPA. A análise permitiu descrever, discutir e problematizar os sentidos de termos como usuário, dependente, droga, substância, autonomia, dentre outros utilizados de forma naturalizada na política; com esse movimento analítico, foi possível explorar sua multiplicidade, conflitualidade e historicidade. As análises empreendidas contribuem para que sejam desnaturalizadas determinadas noções tão presentes nas formulações de propostas para o cuidado desses usuários/as. A (in)definição de termos discutidos permitiu visualizar a aparente sobreposição de sentidos de alguns termos como usuário/dependente para explorar distinções entre eles; também algumas relações lineares, como uso/consumo = dependência, que podem levar o indivíduo a evitar a aproximação com serviços de saúde como o CAPS mesmo quando deles precisa, com receio de ser nomeado como um/uma dependente, uma vez que essa nomeação produz diferentes efeitos em sua vida. Do ponto de vista do gênero, parece haver algumas pistas na (in)definição desses termos, mostrando que, em alguma medida, não se contemplam distinções produzidas pelo gênero, talvez porque haja ainda uma dificuldade em associar a mulher ao uso/abuso de SPA, embora os estudos mostrem o uso crescente destas entre as mulheres. Assim, um olhar sensível às abordagens de gênero na política permitiu ir "encontrando" pistas em relação à naturalização da relação entre uso de SPA e masculinidade e de uma feminilidade que não se droga. Nesse sentido, a pesquisa intentou desnaturalizar e mostrar alguns silenciamentos nas representações de feminino/masculino ainda ativas na cultura que contribuem para dificultar o dimensionamento de uma demanda de cuidado. / This dissertation is inserted in the field of Gender and Cultural Studies, approaching the poststructuralist perspective of analysis. It investigates the places of the subject/user of psychoactive substances and gender crossings (re)produced under the National Policy of Harm Reduction, a public policy concerned in recognizing the choices of the users of psychoactive substances (PAS) who require some sort of care, so reaching the boundaries of health protection and social citizenship and social rights. The empirical material consists of normative documents of the policy and its consequences. Cultural analysis, in combination with documentary research, was used for data analysis, considering the concepts of subject position, rule, power and gender. The policy documents and its consequences were taken as cultural and educational artifacts that (re)produce and convey biomedical, psychological, moral and juridical discourses involved in the production of subjects and care practices in the field of mental health addressed to the use of PAS. The analysis allowed to describe, debate and discuss the meanings of terms such as user, addicted, drug, substance, autonomy, among others used in a naturalized way in the policy, whose multiplicity, conflictuality and historicity was explored from this analytical movement. The undertaken analyses contribute to denaturalize certain notions usually used in the texts of the care proposals for those users. The (in)definition of discussed terms allowed to perceive the apparent meaning overlaps of some terms such as user/addicted to explore distinctions between them; it was also possible observe some linear relations, such as use/consumption = addiction, which can lead the individual to avoid looking for healthcare services, such as the Centers of Psychosocial Care (CAPS), even when he/she needs those services, fearing being named as addicted, since this nomination causes different effects in his/her life. From the gender point of view, there seem to be some clues in the (in)definition of these terms, showing that, to some extent, distinctions produced by the genre are not considered, perhaps because there are still some difficulties in associating the woman to the use/abuse of PAS, although some studies show increasing use among women. Thus, a sensitive reading to gender approaches in the policy allowed to go "finding" clues regarding the naturalization of the relationship between the use of PAS and masculinity, and regarding a femininity that is not addicted. In this sense, this research intended denaturalize this relationship and show some silences regarding the female/male representations still active in the culture that contribute to hinder the design of a care demand.

Social factors and social contexts have long been implicated in shaping/influencing behaviours, actions, and outcomes, including social and health inequities. The social determinants of health concept has shown that health and health inequities are shaped by a variety of socio-cultural factors including education, socio-economic status, gender, ethnicity, and the social and physical environments in which people live. Critical drug scholars have specifically sought to understand how contexts and environments shape drug use and related harms. The “risk environment” framework, for example, suggests that drug use, risky drug use practices (e.g., needle sharing), and drug use-related harms are shaped by social, physical, economic and policy environments. Yet while contexts are frequently implicated in framing and shaping behaviours, the specific mechanisms at play are rarely unpacked. I address this gap by further “opening up” contexts of drug consumption and social marginalization in order to extend our knowledge of drug use among marginalized people who use drugs (PWUD) My dissertation includes 3 analyses of my data in the form of published (2) and submitted (1) manuscripts. Two-stage interviews (a short quantitative survey and longer qualitative interview) were conducted with fifty PWUD in the Downtown Eastside (DTES) neighbourhood in Vancouver, Canada. Data were analyzed with conceptual and theoretical tools borrowed from Situational Analysis, as well as actor-network and assemblage theories. In my first paper, I explore reasons for using drugs, and suggest that, despite known negative consequences of drug use, substance use among marginalized PWUD can be meaningful and beneficial. Participant narratives revealed four main themes regarding positive aspects of drugs and drug use in their lives: (1) pain relief and management; (2) alleviating mental health issues; (3) fostering social experiences; (4) pleasurable embodied experiences. These findings draw attention to the fallacies of drug prohibition and much current drug policy which has fabricated boundaries between the acceptable and unacceptable, resulting in the criminalization and stigmatization of certain substances and the people that use them. In my second paper, I draw upon actor-network theory and event analysis to explore how contexts shape drug consumption practices. My findings illustrate how specific methods of drug consumption (e.g., smoking or injecting) are shaped by an assemblage of objects, actors, affects, spaces and processes. Rather than emphasising the role of broad socio-structural factors (e.g., poverty, drug policy) participant narratives reveal how a variety of actors, both human and non-human, assembled in unique ways produce drug consumption events that have the capacity to influence or transform drug consumption practices. In my third paper, I explore how spaces/places frequently used by PWUD in the DTES that are commonly associated with risk and harm (e.g., alleyways, parks) can be re-imagined and re-constructed as spaces/places of safety and wellbeing. Conceptualizing spaces/places as assemblages, I trace the associations among/between a host of seemingly disparate actants – such as material objects, actors, processes, affect, temporal elements, policies and practices – to better understand how experiences of harm, or conversely wellbeing, unfold, and shed light on how risky spaces/places can be re-constructed as places that enable safety and wellbeing. Taken together these 3 papers/analyses provide unique insight into not only drug use among marginalized PWUD, but our understanding of the ways in which contexts and environments shape behaviour and social phenomena. These findings have direct implication for harm reduction theory and drug policy. With greater insight into the contexts of drug use, drug policy and harm reduction strategies may be better tailored to prevent drug use-related harms. / Graduate / 2019-12-07