Drug and Alcohol Dependence 144 (2014) 274–278
Contents lists available at ScienceDirect
Drug and Alcohol Dependence journal homepage: www.elsevier.com/locate/drugalcdep
Short communication
Perceived discrimination and injecting risk among people who inject drugs attending Needle and Syringe Programmes in Sydney, Australia Hannah Wilson, Loren Brener ∗ , Limin Mao, Carla Treloar Centre for Social Research in Health, Level 3 Goodsell Building, UNSW, Sydney 2052, NSW, Australia
a r t i c l e
i n f o
Article history: Received 2 June 2014 Received in revised form 27 August 2014 Accepted 29 August 2014 Available online 6 September 2014 Keywords: Perceived discrimination Injecting drug use Needle exchange Healthcare workers Risk practices
a b s t r a c t Background: Previous research indicates that stigma and discrimination have negative consequences for both healthcare delivery and for health outcomes of people who inject drugs (PWID). Also important but not as well researched is the association between perceived discrimination and increased engagement in risky behaviours. This research aimed to explore whether perceived discrimination from workers in Needle and Syringe programmes (NSPs) is associated with increased engagement in injecting risk practices such as the sharing of injecting equipment. Method: Convenience sampling was used across eight NSP sites within Western Sydney, Australia. All clients who attended one of the NSPs were eligible to participate. Results: A total of 236 clients completed the survey. Perceived discrimination from NSP staff was found to be significantly associated with some injecting risk practices. Respondents who reported greater perceived discrimination from NSP staff were significantly more likely to report being injected by someone else after they had injected themselves (OR 1.2, 95%CI 1.1–1.3) and reusing a needle or syringe (OR 1.1, 95%CI 1.0–1.3) in the last month. Although clients reported perceiving more discrimination from general health workers than from NSP workers (12.8 vs. 10.2, t = 7.739, df = 226, p < 0.001), perceived discrimination from general health workers was not associated with increased injecting risk practices. Conclusions: The findings of this study suggest that NSP workers need to be aware that although they work in a model that is usually non-judgemental, their clients may still have a heightened sensitivity to discrimination which can then have consequences for on-going engagement in risk practices. © 2014 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Injecting drug use is a behaviour that attracts strong moral and social condemnation. People who inject drugs (PWID) are often the subject of stereotypical media portrayals where they are depicted as living ‘chaotic’ and ‘risky’ lifestyles (Ahern et al., 2007; Room, 2005). Additionally, PWID are often blamed for their drug use and for any associated illnesses, such as hepatitis C or HIV/AIDS (Crocker et al., 1998; Weiner et al., 1988). Stigmatising attitudes towards PWID may translate into discrimination, which is the differential treatment of individuals based on their association with a stigmatised group (Giddens et al., 2009). One area in which stigma and discrimination appears to commonly occur is in healthcare (Day et al., 2003; Hopwood and Treloar, 2003).
∗ Corresponding author. Tel.: +61 2 9385 6530; fax: +61 2 9385 6455. E-mail address: [email protected] (L. Brener). http://dx.doi.org/10.1016/j.drugalcdep.2014.08.018 0376-8716/© 2014 Elsevier Ireland Ltd. All rights reserved.
Stigma and discrimination in healthcare can impact on healthrelated outcomes via increased stress and anxiety, less frequent visits to health providers, restricted disclosure of health conditions and lower adherence to health regiments (Brener et al., 2010; Jamison, 2006; Miller et al., 2001; Pascoe and Smart Richman, 2009). As important but less researched is the notion that stigma and discrimination can lead to increased negative health behaviours and risk taking such as smoking (Guthrie et al., 2002) and risky sexual behaviours (Preston et al., 2004). One of the principle harm reduction strategies aimed at reducing the health complications associated with injecting drug use in Australia is Needle and Syringe Programmes (NSP). The primary objective of NSPs is to provide access to sterile injecting equipment and safe disposal facilities (Health Outcomes International Pty Ltd et al., 2005). While it can be assumed that health workers who choose to work at NSPs will not hold overtly negative attitudes towards PWID, the influence of stigma and discrimination within the NSP setting should not be ignored given the noted
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impact of covert bias on workers’ attitudes and behaviours towards PWID (von Hippel et al., 2008). Additionally, people who have experienced discrimination in the past may be very sensitive to the attitudes of others, and may interpret attitudes and behaviours negatively even when this is not so (Pachankis, 2007). Previous research from the UK suggests that NSP workers’ attitudes and behaviours towards PWID can play a key role in encouraging and improving clients’ engagement with NSP services (Neale et al., 2007; Matheson et al., 2008). The NSP setting is important to explore as this is a key site for the prevention of blood–borne viruses. Given that feeling stigmatised may reduce the effectiveness and potential impact of harm reduction interventions (Simmonds and Coomber, 2009; Skinner and Mfecane, 2004), addressing stigma and discrimination in NSPs will contribute to improving efforts to prevent hepatitis C and HIV. This research aims to address the implications of perceived stigma and discrimination on injecting risk practices by establishing whether an association exists between clients’ perceived discrimination by NSP workers and sharing of needles and syringes used for injecting drugs.
attendance patterns in the last year (“how often did you get sterile needles and syringes from any NSP service in the last 12 months”), and were asked about their injecting networks, e.g. “how many of your friends inject drugs” and “how much free time is spent with PWID”. Two questions assessing injecting risk practices in the last month were used as the outcome variables. One question established whether someone else had injected them after injecting themselves or others (“how many times last month did someone else inject you after injecting themselves or others”), and the second asked whether they had reused a needle and syringe after someone else had used it (“how many times last month did you reuse a needle and syringe after someone else had used it, including your sex partner”; Iversen and Maher, 2013; Stafford and Burns, 2013). Responses to these questions were dichotomised into ‘yes’ or ‘no’. Finally, participants were asked a number of demographic questions including gender, age, education, Aboriginal identity, income and sexuality.
2. Method
In order to assess the bivariate associations between perceived stigma and discrimination by NSP staff and the outcome of sharing injecting equipment, Spearman rho correlations were conducted. All variables significantly associated at the bivariate level with the two outcome variables were entered into a multivariate logistic regression to assess whether perceived stigma and discrimination from NSP staff remained an independent predictor of injecting risk practices. A paired sample t-test was used to compare whether participants experienced greater perceived stigma and discrimination from general healthcare staff compared to NSP staff.
2.1. Sample and procedure Convenience sampling was used across eight NSP sites within Western Sydney, Australia. The recruitment sites, which were purposefully selected to represent the range of publicly-funded NSP services in this area, included four primary NSPs (stand-alone services with specialist staff), two vending machines (coin operated machine dispensing sterile injecting equipment in Fitpacks), and two secondary NSPs (where equipment distribution occurs as part of other health services; NSW Ministry of Health, 2013). All clients who attended one of the NSP sites between October and December 2012 were eligible to participate. NSP staff informed clients of the survey and they were then directed to the researchers who were on site. Participants were provided with an information sheet outlining the study. The survey was self-complete either on a touchscreen computer or on paper. Participants were given a $20 voucher on completion. The study had ethics approval from the Human Research Ethics Committee at UNSW, Australia and relevant health authorities. 2.2. Measures To examine perceived stigma and discrimination, participants were asked five identical questions, for both NSP staff and general health workers (“NSP staff/healthcare workers do not treat me with any respect”, “NSP staff/healthcare workers make me feel guilty and ashamed about my drug use”, “NSP staff/healthcare workers do not judge me”, “NSP staff/healthcare workers listen to what I say”, “NSP staff/healthcare workers discriminate against me because I have a history of injecting drug use”). This scale had been previously used to measure stigma and discrimination among clients attending a hepatitis C community Clinic (Horwitz et al., 2012). Each item was answered on a five point scale from ‘strongly disagree’ to ‘strongly agree’. Responses were collapsed to create two scales, the NSP staff stigma and discrimination scale (˛ = 0.70) and the health worker stigma and discrimination scale (˛ = 0.79). Both scales ranged from 5 to 25 where a higher score represented greater perceived stigma and discrimination. Respondents were asked a number of questions about their injecting drug use in the last month including frequency of injecting and whether they had injected in a public place (e.g. street, park or bench, public toilet and car). They were also asked about their NSP
2.3. Data analysis
3. Results A total of 236 PWID were recruited. Just under two-thirds of the sample was male, with one participant identifying as transgender (see Table 1). The mean age of participants was 39 years (SD = 9.5), and the majority were heterosexual. Approximately three-quarters were on government benefits and a similar proportion had formal education of year 10 or less. Around one in five identified as Aboriginal and/or Torres Strait Islander. When compared to a 2013 national sample of NSP attendees (Iversen et al., 2014) this sample of NSP clients was similar in age, gender and sexuality, however, there was a slightly higher representation of Aboriginal and Torres Strait Islanders. The mean score of the NSP staff and general health worker stigma and discrimination scales was 10.2 (SD = 3.7) and 12.8 (SD = 4.2), respectively. A significant difference in scores was found indicating that participants perceived significantly more stigma and discrimination from general health workers compared to NSP staff (t = −7.739, df = 226, p < 0.001). As illustrated in Table 2, reusing a needle and syringe after someone else in the last month was positively correlated with perceived stigma and discrimination from NSP staff. Reusing a needle and syringe after someone else in the last month was also associated with frequency of injecting, injecting in a public place, number of friends who inject and time spent with other PWID. Being injected after someone else had injected themselves in the last month was significantly correlated with perceived stigma and discrimination from NSP staff, with injecting in a public place and with amount of free time spent with PWID. Perceived stigma and discrimination from general health workers was not correlated with either outcome variable, nor was any of the demographic variables. Two multivariate logistic regressions were computed to assess whether perceived stigma and discrimination by NSP staff
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Table 1 Demographics, NSP attendance and risk profile.
injected after someone else (OR 1.2, 95%CI 1.1–1.3), as did injecting in a public place (OR 3.1, 95%CI 1.5–6.6). n (%)
Gender Female Male Transgender
4. Discussion 81 (34.3) 153 (64.8) 1 (0.4)
Age (M, SD)
38.7 (9.5)
Aboriginal or Torres Strait Islander Yes No
52 (22.0) 182 (77.1)
Education ≤year 10 >year 10
181 (76.7) 55 (23.3)
Income Full/part time Government assistance Other
43 (18.2) 171 (72.5) 21 (8.9)
Sexuality Heterosexual Gay, lesbian, bisexual or other Other/unsure
206 (87.3) 21 (8.9) 7 (2.9)
Obtained sterile needles from in the past montha Primary NSP Secondary NSP Vending machine Pharmacy/chemist
129 (54.7) 167 (70.8) 122 (51.7) 75 (31.8)
Reuse a needle and syringe after someone else had used it in the last month 48 (20.3) Yes 188 (79.7) No Someone else inject you after injecting themselves or others in the last month 46 (19.5) Yes 189 (80.1) No a
Not mutually exclusive.
remained an independent predictor of reusing a needle and syringe after someone else and being injected after someone else in the last month. Reusing a needle and syringe after someone else last month was significantly more likely to occur among participants who perceived greater stigma and discrimination from NSP staff (OR 1.1, 95%CI 1.0–1.3), and was also four times more likely among respondents who reported injecting in public (OR 3.9, 95%CI 1.8–8.7). In the second regression, perceived stigma and discrimination from NSP staff remained a significant predictor of being
These findings suggest that perceived stigma and discrimination from NSP workers could have an impact on injecting risk practices. Participants who reported greater levels of perceived stigma and discrimination from NSP staff were significantly more likely to report reusing a needle and syringe after someone else and that someone injected them after they had injected themselves or others in the last month. Both outcome variables are of particular relevance as they are indicative of receptive equipment sharing—the most risky behaviour in terms of blood borne virus transmission as the equipment could be contaminated by its first use. Findings from this study shed light on the continued sharing of unsterile injecting equipment even in areas where access to sterile equipment is good. Recent Australian research found no independent relationships between inadequate syringe coverage and receptive equipment sharing (Bryant et al., 2012) indicating that other factors contribute to injecting risk practices. The data further suggest that continued sharing of injecting equipment, especially in the case of being injected by some else, may be indicative of a range of other personal or social factors that may be involved in sharing practices, rather than a lack of access to equipment. While it is known that sharing of injecting equipment is more common among intimate partners (Bryant et al., 2010; Jackson et al., 2010), young or new users (Maher et al., 2006; van Beek et al., 1998) and in rural areas where access is poor (Aitken et al., 1999; Day et al., 2006), this is the first study to find an association between perceived stigma and discriminatory practices by NSP staff and injecting risk practices. Stigma and discrimination have been found to be related to substantial mental health issues such as severe depression and anxiety among marginalised groups (Mak et al., 2007; Pascoe and Smart Richman, 2009) including PWID (Ahern et al., 2007). Moreover, several studies have reported associations between depressive symptoms and injecting risk practices among both treatment and community-based samples of PWID (Mandell et al., 1999; Pilowsky et al., 2001; Stein et al., 2003). Therefore it is possible that factors which exacerbate depression, such as perceiving or experiencing stigma or discrimination from NSP staff, could contribute to clients’ involvement in injecting risk practices (Strathdee et al., 1997). This suggests that stigma and discrimination and its impact on clients’ mental health need to be acknowledged and addressed within NSP
Table 2 Spearman’s rho correlation table for outcome and predictor variables. Someone else inject you after injecting themselves or others in the last month Someone else inject you after injecting themselves or others in the last month Reuse a needle and syringe after someone else had used it in the last month NSP Staff discrimination scale General health workers discrimination scale Age Gender Education Frequency of using any NSP service in the last year Frequency of injecting in the last month Injected in a public place Friend who inject drugs Free time spent with PWID * ** ***
p < 0.05. p < 0.01. p < 0.001.
Reuse a needle and syringe after someone else had used it in the last month
1
–
0.442***
1
0.235*** 0.075 0.021 0.077 −0.019 0.095 0.116 0.184** 0.123 0.146*
0.138* 0.017 0.013 0.009 −0.030 0.058 0.153* 0.299*** 0.185** 0.215***
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settings. Hence, these results challenge the emphasis of NSP operations on a narrow focus of equipment distribution only (Kwon et al., 2009, 2012). It may be that those who perceive stigma and discrimination from NSP staff are less likely to access NSPs to obtain sterile equipment. However, no significant relationship was found between frequency of NSP use and perceived stigma and discrimination. Based on this, it cannot be concluded that perceived stigma and discrimination does not influence NSP access, but rather suggests that further research is required to understand the complexities of the relationship and interaction between psychological distress, perceived stigma and discrimination, access to equipment and injecting risk practices. The findings of this study also suggest that NSP staff are perceived of as less discriminatory than general health workers. Additionally, the results illustrate the association between sharing practices and injecting in public spaces a finding that has been reported in previous research (DeBeck et al., 2009; Marshall et al., 2010; Navarro and Leonard, 2004). Despite the study limitations such as the use of convenience sampling along with measures of self-reported perceived stigma and discrimination, the findings have both practical and theoretical importance. At a theoretical level this research points to the need to understand the implications of stigma and discrimination as conceptually complex and that the potential health or behavioural outcomes of discrimination may often be linked to the source of the perceived discrimination (von Hippel and Brener, 2012). This is evident in that perceived stigma and discrimination from NSP workers was found to be associated with increased risk behaviours around injecting practices, whereas perceived stigma and discrimination from general health workers was not. Additionally the findings have some significant practical implications. Any health workers working with PWID need to be aware that although they work in a model which is usually non-judgemental, their clients may have a heightened sensitivity to stigma and discrimination (Pachankis, 2007) that could influence interpretations of workers’ discussions of safe injecting and might ultimately lead to on-going engagement in injecting risk practices. Role of funding source The local health authority provided funding for this study. Contributors Author Wilson was involved in the writing up of the study, the data collection and the data analysis, under the guidance of author Brener who assisted in the conceptual framing of the paper and in the data analysis. Author Brener also reviewed numerous drafts of the paper. Authors Moa and Treloar were involved in the design of the survey instrument and in the data analysis, as well as commenting on and contributing to numerous drafts. All authors contributed to and have approved the final manuscript. Conflict of interest All other authors declare that they have no conflicts of interest. Acknowledgements We acknowledge our partners in the health authority area who funded the larger project and who facilitated access to client group. The Centre for Social Research in Health is supported by a grant from Department of Health, Australian Government.
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Contents lists available at ScienceDirect
Drug and Alcohol Dependence journal homepage: www.elsevier.com/locate/drugalcdep
Short communication
Perceived discrimination and injecting risk among people who inject drugs attending Needle and Syringe Programmes in Sydney, Australia Hannah Wilson, Loren Brener ∗ , Limin Mao, Carla Treloar Centre for Social Research in Health, Level 3 Goodsell Building, UNSW, Sydney 2052, NSW, Australia
a r t i c l e
i n f o
Article history: Received 2 June 2014 Received in revised form 27 August 2014 Accepted 29 August 2014 Available online 6 September 2014 Keywords: Perceived discrimination Injecting drug use Needle exchange Healthcare workers Risk practices
a b s t r a c t Background: Previous research indicates that stigma and discrimination have negative consequences for both healthcare delivery and for health outcomes of people who inject drugs (PWID). Also important but not as well researched is the association between perceived discrimination and increased engagement in risky behaviours. This research aimed to explore whether perceived discrimination from workers in Needle and Syringe programmes (NSPs) is associated with increased engagement in injecting risk practices such as the sharing of injecting equipment. Method: Convenience sampling was used across eight NSP sites within Western Sydney, Australia. All clients who attended one of the NSPs were eligible to participate. Results: A total of 236 clients completed the survey. Perceived discrimination from NSP staff was found to be significantly associated with some injecting risk practices. Respondents who reported greater perceived discrimination from NSP staff were significantly more likely to report being injected by someone else after they had injected themselves (OR 1.2, 95%CI 1.1–1.3) and reusing a needle or syringe (OR 1.1, 95%CI 1.0–1.3) in the last month. Although clients reported perceiving more discrimination from general health workers than from NSP workers (12.8 vs. 10.2, t = 7.739, df = 226, p < 0.001), perceived discrimination from general health workers was not associated with increased injecting risk practices. Conclusions: The findings of this study suggest that NSP workers need to be aware that although they work in a model that is usually non-judgemental, their clients may still have a heightened sensitivity to discrimination which can then have consequences for on-going engagement in risk practices. © 2014 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Injecting drug use is a behaviour that attracts strong moral and social condemnation. People who inject drugs (PWID) are often the subject of stereotypical media portrayals where they are depicted as living ‘chaotic’ and ‘risky’ lifestyles (Ahern et al., 2007; Room, 2005). Additionally, PWID are often blamed for their drug use and for any associated illnesses, such as hepatitis C or HIV/AIDS (Crocker et al., 1998; Weiner et al., 1988). Stigmatising attitudes towards PWID may translate into discrimination, which is the differential treatment of individuals based on their association with a stigmatised group (Giddens et al., 2009). One area in which stigma and discrimination appears to commonly occur is in healthcare (Day et al., 2003; Hopwood and Treloar, 2003).
∗ Corresponding author. Tel.: +61 2 9385 6530; fax: +61 2 9385 6455. E-mail address: [email protected] (L. Brener). http://dx.doi.org/10.1016/j.drugalcdep.2014.08.018 0376-8716/© 2014 Elsevier Ireland Ltd. All rights reserved.
Stigma and discrimination in healthcare can impact on healthrelated outcomes via increased stress and anxiety, less frequent visits to health providers, restricted disclosure of health conditions and lower adherence to health regiments (Brener et al., 2010; Jamison, 2006; Miller et al., 2001; Pascoe and Smart Richman, 2009). As important but less researched is the notion that stigma and discrimination can lead to increased negative health behaviours and risk taking such as smoking (Guthrie et al., 2002) and risky sexual behaviours (Preston et al., 2004). One of the principle harm reduction strategies aimed at reducing the health complications associated with injecting drug use in Australia is Needle and Syringe Programmes (NSP). The primary objective of NSPs is to provide access to sterile injecting equipment and safe disposal facilities (Health Outcomes International Pty Ltd et al., 2005). While it can be assumed that health workers who choose to work at NSPs will not hold overtly negative attitudes towards PWID, the influence of stigma and discrimination within the NSP setting should not be ignored given the noted
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impact of covert bias on workers’ attitudes and behaviours towards PWID (von Hippel et al., 2008). Additionally, people who have experienced discrimination in the past may be very sensitive to the attitudes of others, and may interpret attitudes and behaviours negatively even when this is not so (Pachankis, 2007). Previous research from the UK suggests that NSP workers’ attitudes and behaviours towards PWID can play a key role in encouraging and improving clients’ engagement with NSP services (Neale et al., 2007; Matheson et al., 2008). The NSP setting is important to explore as this is a key site for the prevention of blood–borne viruses. Given that feeling stigmatised may reduce the effectiveness and potential impact of harm reduction interventions (Simmonds and Coomber, 2009; Skinner and Mfecane, 2004), addressing stigma and discrimination in NSPs will contribute to improving efforts to prevent hepatitis C and HIV. This research aims to address the implications of perceived stigma and discrimination on injecting risk practices by establishing whether an association exists between clients’ perceived discrimination by NSP workers and sharing of needles and syringes used for injecting drugs.
attendance patterns in the last year (“how often did you get sterile needles and syringes from any NSP service in the last 12 months”), and were asked about their injecting networks, e.g. “how many of your friends inject drugs” and “how much free time is spent with PWID”. Two questions assessing injecting risk practices in the last month were used as the outcome variables. One question established whether someone else had injected them after injecting themselves or others (“how many times last month did someone else inject you after injecting themselves or others”), and the second asked whether they had reused a needle and syringe after someone else had used it (“how many times last month did you reuse a needle and syringe after someone else had used it, including your sex partner”; Iversen and Maher, 2013; Stafford and Burns, 2013). Responses to these questions were dichotomised into ‘yes’ or ‘no’. Finally, participants were asked a number of demographic questions including gender, age, education, Aboriginal identity, income and sexuality.
2. Method
In order to assess the bivariate associations between perceived stigma and discrimination by NSP staff and the outcome of sharing injecting equipment, Spearman rho correlations were conducted. All variables significantly associated at the bivariate level with the two outcome variables were entered into a multivariate logistic regression to assess whether perceived stigma and discrimination from NSP staff remained an independent predictor of injecting risk practices. A paired sample t-test was used to compare whether participants experienced greater perceived stigma and discrimination from general healthcare staff compared to NSP staff.
2.1. Sample and procedure Convenience sampling was used across eight NSP sites within Western Sydney, Australia. The recruitment sites, which were purposefully selected to represent the range of publicly-funded NSP services in this area, included four primary NSPs (stand-alone services with specialist staff), two vending machines (coin operated machine dispensing sterile injecting equipment in Fitpacks), and two secondary NSPs (where equipment distribution occurs as part of other health services; NSW Ministry of Health, 2013). All clients who attended one of the NSP sites between October and December 2012 were eligible to participate. NSP staff informed clients of the survey and they were then directed to the researchers who were on site. Participants were provided with an information sheet outlining the study. The survey was self-complete either on a touchscreen computer or on paper. Participants were given a $20 voucher on completion. The study had ethics approval from the Human Research Ethics Committee at UNSW, Australia and relevant health authorities. 2.2. Measures To examine perceived stigma and discrimination, participants were asked five identical questions, for both NSP staff and general health workers (“NSP staff/healthcare workers do not treat me with any respect”, “NSP staff/healthcare workers make me feel guilty and ashamed about my drug use”, “NSP staff/healthcare workers do not judge me”, “NSP staff/healthcare workers listen to what I say”, “NSP staff/healthcare workers discriminate against me because I have a history of injecting drug use”). This scale had been previously used to measure stigma and discrimination among clients attending a hepatitis C community Clinic (Horwitz et al., 2012). Each item was answered on a five point scale from ‘strongly disagree’ to ‘strongly agree’. Responses were collapsed to create two scales, the NSP staff stigma and discrimination scale (˛ = 0.70) and the health worker stigma and discrimination scale (˛ = 0.79). Both scales ranged from 5 to 25 where a higher score represented greater perceived stigma and discrimination. Respondents were asked a number of questions about their injecting drug use in the last month including frequency of injecting and whether they had injected in a public place (e.g. street, park or bench, public toilet and car). They were also asked about their NSP
2.3. Data analysis
3. Results A total of 236 PWID were recruited. Just under two-thirds of the sample was male, with one participant identifying as transgender (see Table 1). The mean age of participants was 39 years (SD = 9.5), and the majority were heterosexual. Approximately three-quarters were on government benefits and a similar proportion had formal education of year 10 or less. Around one in five identified as Aboriginal and/or Torres Strait Islander. When compared to a 2013 national sample of NSP attendees (Iversen et al., 2014) this sample of NSP clients was similar in age, gender and sexuality, however, there was a slightly higher representation of Aboriginal and Torres Strait Islanders. The mean score of the NSP staff and general health worker stigma and discrimination scales was 10.2 (SD = 3.7) and 12.8 (SD = 4.2), respectively. A significant difference in scores was found indicating that participants perceived significantly more stigma and discrimination from general health workers compared to NSP staff (t = −7.739, df = 226, p < 0.001). As illustrated in Table 2, reusing a needle and syringe after someone else in the last month was positively correlated with perceived stigma and discrimination from NSP staff. Reusing a needle and syringe after someone else in the last month was also associated with frequency of injecting, injecting in a public place, number of friends who inject and time spent with other PWID. Being injected after someone else had injected themselves in the last month was significantly correlated with perceived stigma and discrimination from NSP staff, with injecting in a public place and with amount of free time spent with PWID. Perceived stigma and discrimination from general health workers was not correlated with either outcome variable, nor was any of the demographic variables. Two multivariate logistic regressions were computed to assess whether perceived stigma and discrimination by NSP staff
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Table 1 Demographics, NSP attendance and risk profile.
injected after someone else (OR 1.2, 95%CI 1.1–1.3), as did injecting in a public place (OR 3.1, 95%CI 1.5–6.6). n (%)
Gender Female Male Transgender
4. Discussion 81 (34.3) 153 (64.8) 1 (0.4)
Age (M, SD)
38.7 (9.5)
Aboriginal or Torres Strait Islander Yes No
52 (22.0) 182 (77.1)
Education ≤year 10 >year 10
181 (76.7) 55 (23.3)
Income Full/part time Government assistance Other
43 (18.2) 171 (72.5) 21 (8.9)
Sexuality Heterosexual Gay, lesbian, bisexual or other Other/unsure
206 (87.3) 21 (8.9) 7 (2.9)
Obtained sterile needles from in the past montha Primary NSP Secondary NSP Vending machine Pharmacy/chemist
129 (54.7) 167 (70.8) 122 (51.7) 75 (31.8)
Reuse a needle and syringe after someone else had used it in the last month 48 (20.3) Yes 188 (79.7) No Someone else inject you after injecting themselves or others in the last month 46 (19.5) Yes 189 (80.1) No a
Not mutually exclusive.
remained an independent predictor of reusing a needle and syringe after someone else and being injected after someone else in the last month. Reusing a needle and syringe after someone else last month was significantly more likely to occur among participants who perceived greater stigma and discrimination from NSP staff (OR 1.1, 95%CI 1.0–1.3), and was also four times more likely among respondents who reported injecting in public (OR 3.9, 95%CI 1.8–8.7). In the second regression, perceived stigma and discrimination from NSP staff remained a significant predictor of being
These findings suggest that perceived stigma and discrimination from NSP workers could have an impact on injecting risk practices. Participants who reported greater levels of perceived stigma and discrimination from NSP staff were significantly more likely to report reusing a needle and syringe after someone else and that someone injected them after they had injected themselves or others in the last month. Both outcome variables are of particular relevance as they are indicative of receptive equipment sharing—the most risky behaviour in terms of blood borne virus transmission as the equipment could be contaminated by its first use. Findings from this study shed light on the continued sharing of unsterile injecting equipment even in areas where access to sterile equipment is good. Recent Australian research found no independent relationships between inadequate syringe coverage and receptive equipment sharing (Bryant et al., 2012) indicating that other factors contribute to injecting risk practices. The data further suggest that continued sharing of injecting equipment, especially in the case of being injected by some else, may be indicative of a range of other personal or social factors that may be involved in sharing practices, rather than a lack of access to equipment. While it is known that sharing of injecting equipment is more common among intimate partners (Bryant et al., 2010; Jackson et al., 2010), young or new users (Maher et al., 2006; van Beek et al., 1998) and in rural areas where access is poor (Aitken et al., 1999; Day et al., 2006), this is the first study to find an association between perceived stigma and discriminatory practices by NSP staff and injecting risk practices. Stigma and discrimination have been found to be related to substantial mental health issues such as severe depression and anxiety among marginalised groups (Mak et al., 2007; Pascoe and Smart Richman, 2009) including PWID (Ahern et al., 2007). Moreover, several studies have reported associations between depressive symptoms and injecting risk practices among both treatment and community-based samples of PWID (Mandell et al., 1999; Pilowsky et al., 2001; Stein et al., 2003). Therefore it is possible that factors which exacerbate depression, such as perceiving or experiencing stigma or discrimination from NSP staff, could contribute to clients’ involvement in injecting risk practices (Strathdee et al., 1997). This suggests that stigma and discrimination and its impact on clients’ mental health need to be acknowledged and addressed within NSP
Table 2 Spearman’s rho correlation table for outcome and predictor variables. Someone else inject you after injecting themselves or others in the last month Someone else inject you after injecting themselves or others in the last month Reuse a needle and syringe after someone else had used it in the last month NSP Staff discrimination scale General health workers discrimination scale Age Gender Education Frequency of using any NSP service in the last year Frequency of injecting in the last month Injected in a public place Friend who inject drugs Free time spent with PWID * ** ***
p < 0.05. p < 0.01. p < 0.001.
Reuse a needle and syringe after someone else had used it in the last month
1
–
0.442***
1
0.235*** 0.075 0.021 0.077 −0.019 0.095 0.116 0.184** 0.123 0.146*
0.138* 0.017 0.013 0.009 −0.030 0.058 0.153* 0.299*** 0.185** 0.215***
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settings. Hence, these results challenge the emphasis of NSP operations on a narrow focus of equipment distribution only (Kwon et al., 2009, 2012). It may be that those who perceive stigma and discrimination from NSP staff are less likely to access NSPs to obtain sterile equipment. However, no significant relationship was found between frequency of NSP use and perceived stigma and discrimination. Based on this, it cannot be concluded that perceived stigma and discrimination does not influence NSP access, but rather suggests that further research is required to understand the complexities of the relationship and interaction between psychological distress, perceived stigma and discrimination, access to equipment and injecting risk practices. The findings of this study also suggest that NSP staff are perceived of as less discriminatory than general health workers. Additionally, the results illustrate the association between sharing practices and injecting in public spaces a finding that has been reported in previous research (DeBeck et al., 2009; Marshall et al., 2010; Navarro and Leonard, 2004). Despite the study limitations such as the use of convenience sampling along with measures of self-reported perceived stigma and discrimination, the findings have both practical and theoretical importance. At a theoretical level this research points to the need to understand the implications of stigma and discrimination as conceptually complex and that the potential health or behavioural outcomes of discrimination may often be linked to the source of the perceived discrimination (von Hippel and Brener, 2012). This is evident in that perceived stigma and discrimination from NSP workers was found to be associated with increased risk behaviours around injecting practices, whereas perceived stigma and discrimination from general health workers was not. Additionally the findings have some significant practical implications. Any health workers working with PWID need to be aware that although they work in a model which is usually non-judgemental, their clients may have a heightened sensitivity to stigma and discrimination (Pachankis, 2007) that could influence interpretations of workers’ discussions of safe injecting and might ultimately lead to on-going engagement in injecting risk practices. Role of funding source The local health authority provided funding for this study. Contributors Author Wilson was involved in the writing up of the study, the data collection and the data analysis, under the guidance of author Brener who assisted in the conceptual framing of the paper and in the data analysis. Author Brener also reviewed numerous drafts of the paper. Authors Moa and Treloar were involved in the design of the survey instrument and in the data analysis, as well as commenting on and contributing to numerous drafts. All authors contributed to and have approved the final manuscript. Conflict of interest All other authors declare that they have no conflicts of interest. Acknowledgements We acknowledge our partners in the health authority area who funded the larger project and who facilitated access to client group. The Centre for Social Research in Health is supported by a grant from Department of Health, Australian Government.
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