Contextual factors of the risk environment surrounding injection drug use: A real-time approach

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Project Summary Amidst the current opioid crisis in the U.S., overdose (OD) rates among people who inject drugs (PWID) are high and many PWID continue to be at risk for viral (HIV, HCV) and bacterial infections (e.g., skin infections, endocarditis). Select high-risk drug and injection practices (“risk practices”), such as sharing injection equipment or using multiple drugs in combination (e.g., opioids and alcohol), have been shown to increase risk for these health outcomes. However, much of the past work on risk practices has been cross-sectional, retrospective, and/or focuses on individual-level behaviors, limiting the ecological validity of findings. One methodology that could mitigate limitations associated with past studies is ecological momentary assessment (EMA). EMA allows for data collection in real-time, in a person's natural environment, using mobile devices. One advantage when considering this methodology is that it can capture momentary information as the individual's context, location, or affect changes. This convergent parallel mixed methods study will apply both qualitative methods and EMA to the “risk environment” framework proposed by Rhodes (2002, 2009). The risk environment model suggests that complex environmental factors (subtypes: physical, policy, economic, social) interact with varying levels of micro- (individual and his/her immediate context) and macro-level (system) influence to produce drug-related harm. Few studies have examined multiple components of the risk environment model in combination or within the real-world context. This mixed-methods study has two primary goals: 1) conduct exploratory qualitative interviews with PWID to better inform the literature on micro- and macro-level (“contextual,” i.e., exogenous to the person) factors that may not have been previously identified, and 2) use EMA to examine relationships between risk practices and individual and contextual factors, thus providing real-time information on predictors of risk that have only been examined previously in cross-sectional studies or not at all, in the participant's natural environment. Street outreach will be used to recruit ethnically diverse PWID (N = 75) in Honolulu, HI to participate in a qualitative interview, baseline assessment, and 2-week EMA. The findings from this study will inform a larger project powered to examine complex relationships between contextual and individual-level factors with risk practices. The long-term objective of this line of work is to develop a comprehensive model of the risk environment that can be used to inform the delivery of harm reduction services and interventions for PWID, as well as impact policy decisions that affect people who use drugs.