Joanne Neale

Barriers to accessing generic health and social care services: a qualitative study of injecting drug users

While research has clearly documented the difficulties injectors encounter in accessing specialist addiction services, there is less evidence of the problems they face when securing general health care and non-substance-misuse-specific support. This paper seeks to fill some of these knowledge gaps. Between January and May 2006, 75 current injectors were recruited and interviewed through three needle exchange programmes located in diverse geographical areas of West Yorkshire. Interview data were transcribed verbatim and analysed using Framework. Findings showed that injectors were often positive about the help they received from generic health and social care services. Nonetheless, they identified a range of barriers relating to inability to access desired assistance, the burden of appointments, travel to services, stigma and negative staff attitudes, personal ill-health, lack of material resources, and anxieties about accessing support. Although some types of barriers were more evident at some services than at others and/or affected particular subgroups of injector more than others, the impact of any barrier was contingent on a range of factors. These included the attitudes of individual professionals, the circumstances and needs of individual injectors, the local availability of suitable alternative services, and the frequency with which a service needed to be accessed. In order to better understand and potentially reduce service barriers, findings are linked to broader conceptual and theoretical debates relating to social exclusion and Foucaults analyses of power and knowledge.While research has clearly documented the difficulties injectors encounter in accessing specialist addiction services, there is less evidence of the problems they face when securing general health care and non-substance-misuse-specific support. This paper seeks to fill some of these knowledge gaps. Between January and May 2006, 75 current injectors were recruited and interviewed through three needle exchange programmes located in diverse geographical areas of West Yorkshire. Interview data were transcribed verbatim and analysed using Framework. Findings showed that injectors were often positive about the help they received from generic health and social care services. Nonetheless, they identified a range of barriers relating to inability to access desired assistance, the burden of appointments, travel to services, stigma and negative staff attitudes, personal ill-health, lack of material resources, and anxieties about accessing support. Although some types of barriers were more evident at some services than at others and/or affected particular subgroups of injector more than others, the impact of any barrier was contingent on a range of factors. These included the attitudes of individual professionals, the circumstances and needs of individual injectors, the local availability of suitable alternative services, and the frequency with which a service needed to be accessed. In order to better understand and potentially reduce service barriers, findings are linked to broader conceptual and theoretical debates relating to social exclusion and Foucaults analyses of power and knowledge.

Homelessness and theory reconsidered

Abstract Theory will not directly explain the development of policy and provision for homeless people, but it is an important consideration and one deserving of careful attention. In the UK, however, homelessness has often been explained simplistically and somewhat atheoretically as either a housing or a welfare problem, caused either by structural or by individual factors. Likewise, homeless people have been frequently classified as either deserving or undeserving. Such dualistic explanations are less than adequate and any policy and provision influenced by them will, consequently, also likely be less than optimal. Accordingly, this paper explores the potential of alternative theoretical perspectives (feminism, post‐structuralism, postmodernism, structuration and critical theory) for increasing our understanding of homelessness and so potentially improving policy and provision for homeless people in the future.

Putting it in context: the use of vignettes in qualitative interviewing

The article draws on two separate studies employing developmental vignettes (hypothetical scenarios which unfold through a series of stages) to interview research participants. One study used the ‘Davie’ vignette, which was a conventional fixed narrative, while in the second, the ‘Jack and Jenny’ vignettes were made interactive by hyperlinking a series of PowerPoint scenarios and making the choice of the succeeding slide dependent on the interviewee’s reaction to its predecessor. Our analytic standpoint, in respect of both vignettes, is that of Schutzian phenomenology. We point to differences in both topical and motivational relevances in the processes of interpretation undergone by participants in considering the vignette scenario and in the situation of action. However, we show that research participants’ responses to vignettes can yield data of interest in their own right as participants perform ‘Thou-orientations’ and ‘They-orientations’ in their consideration of the stimuli. We close with a comparative evaluation of the fixed ‘Davie’ and the interactive ‘Jack and Jenny’ vignettes.

Drug users in society.

This book provides a candid insight into the lives of individuals who are addicted to heroin and other opiates. The processes of obtaining and using drugs are explored within the wider context of personal biographies and daily routines. Key topics considered include childhood experiences, crime and violence, housing situations, family relationships, prison life, health matters, and drug treatments.

Abstinence and drug abuse treatment: Results from the Drug Outcome Research in Scotland study

Aims: To identify the proportion of drug users contacting drug treatment services in Scotland who were able to become abstinent 33 months after having started a new episode of treatment and to identify which services were most closely associated with such abstinence. Design: Follow-up survey of 695 of the Drug Outcome Research in Scotland respondents 33 months following recruitment into the study. Setting: Scotland. Participants: Injecting drug users who were initially contacted at drug treatment services and then followed up for 33 months post-recruitment. Measurements: Self-reported drug use and service usage. Findings: Although becoming drug free was the expressed goal of the majority of drug users recruited into the Drug Outcome Research in Scotland study, at 33 months following recruitment only 5.9% of females and 9.0% of males had been totally drug free (excluding possible alcohol and tobacco use) for a 90-day period in advance of being interviewed. There was considerable variation within this study in the proportion of drug users becoming drug free dependent upon the services they had been in contact with. The level of achieved abstinence in this Scottish study was substantially lower than that identified in the National Treatment Outcomes Research Study in England. Conclusions: There is a need to establish why so few drug users in contact with the methadone programme in Scotland appear able to become drug free 33 months after having contacted this service. On the basis of the results presented in this paper there is a need to ensure that drug users seeking help in becoming drug free are able to access residential rehabilitation services although at the present time such services are relatively rare within Scotland.

“You’re all going to hate the word ‘recovery’ by the end of this”: Service users’ views of measuring addiction recovery

Abstract Aims: To explore how service users’ views of measuring addiction recovery differ from those of service providers. Methods: Five focus groups conducted in two English cities with (i) people currently using Class A drugs (n = 6); (ii) people currently using alcohol (n = 12); (iii) individuals in residential detoxification (n = 12); (iv) individuals in residential rehabilitation (n = 7); and (v) people who defined themselves as ex drug or alcohol users (n = 7). Each focus group reviewed 76 measures of recovery previously identified by senior service providers. Findings: Service users identified multiple problems with the 76 measures. Difficulties could be categorized as expecting the impossible of service users; the dangers of progress; the hidden benefits of negative outcomes; outcomes that negate the agency in recovery; contradictory measures; failure to recognise individual differences; entrenched vulnerabilities; the misattribution of feelings and behaviours; and inappropriate language. Conclusions: Service users experience recovery as a process and personal journey that is often more about ‘coping’ than ‘cure’. Involving service users in designing measures of recovery can lessen the likelihood that researchers develop assessment tools that use inappropriate, contradictory or objectionable outcomes, and ambiguous and unclear language. People who have experienced drug or alcohol problems can highlight important weaknesses in dominant recovery discourses.

Employability and problem drug users

The New Labour government in Britain has introduced a major programme of welfare to work, known as the New Deal, which aims to help unemployed and economically inactive people into paid work. Although welfare to work programmes may be appropriate for those who are more or less job ready, it is less clear that they are suitable for hard-to-help groups with multiple disadvantages. This article draws on new survey evidence from Scotland to question the suitability of welfare to work for problem drug users. It demonstrates that many people using drug treatment services suffer from a range of serious personal, health, lifestyle, and other problems that would need to be addressed before they are in a position either to complete welfare to work programmes successfully or to take up and retain paid employment.

Iterative categorization (IC): a systematic technique for analysing qualitative data

Abstract The processes of analysing qualitative data, particularly the stage between coding and publication, are often vague and/or poorly explained within addiction science and research more broadly. A simple but rigorous and transparent technique for analysing qualitative textual data, developed within the field of addiction, is described. The technique, iterative categorization (IC), is suitable for use with inductive and deductive codes and can support a range of common analytical approaches, e.g. thematic analysis, Framework, constant comparison, analytical induction, content analysis, conversational analysis, discourse analysis, interpretative phenomenological analysis and narrative analysis. Once the data have been coded, the only software required is a standard word processing package. Worked examples are provided.

How should we measure addiction recovery? Analysis of service provider perspectives using online Delphi groups

Aims: To explore ways of measuring addiction recovery and the extent of agreement/disagreement between diverse service providers on potential recovery indicators. Methods: Separate online Delphi groups with (i) addiction psychiatrists (n = 10); (ii) senior residential rehabilitation staff (n = 9); and (iii) senior inpatient detoxification unit staff (n = 6). Each group was conducted by email and followed the same structured format involving three iterative rounds of data collection. Content analyses were undertaken and the results from each group were compared and contrasted. Findings: Indicators of recovery spanned 15 broad domains: substance use, treatment/support, psychological health, physical health, use of time, education/training/employment, income, housing, relationships, social functioning, offending/anti-social behaviour, well-being, identity/self-awareness, goals/aspirations, and spirituality. Identification of domains was very consistent across the three groups, but there was some disparity between, and considerable disparity within, groups on the relative importance of specific indicators. Conclusions: Whilst there is general consensus that recovery involves making changes in a number of broad life areas and not just substance use, there is substantial disagreement on particular measures of progress. Further studies involving other stakeholder groups, particularly people who have personally experienced drug or alcohol dependence, are needed to assess how transferable the 15 identified domains of recovery are.

Drug users' views of substitute prescribing conditions

Abstract Concern about the leakage of methadone and other substitute drugs into the illicit market has recently prompted a tightening of the procedures surrounding prescribing and dispensing practices. Nowadays, drug users are frequently obliged to comply with a number of conditions in order to receive their medication. The aim of the present paper is to examine these conditions from the perspective of drug users. The research was funded by the Scottish Office and involved semi-structured, qualitative interviews with 124 illicit drug users. All interviews were audio-recorded with full transcription and analysis of the transcribed material was carried out using the software package, Winmax. The findings reveal that the various conditions attached to substitute prescribing are neither uniformly enforced by prescribers and dispensers nor uniformly experienced by users. Sometimes restrictions are experienced as a pointless exercise and an infringement of civil liberties; sometimes they are accepted as a necessary evil; and sometimes they are welcomed as a useful aid in controlling and overcoming addiction. It is concluded that drug users do not generally consider substitute drugs to be just like any other medication. Furthermore, their opinions and experiences may have much to teach policy makers and providers about how to use conditions to their optimal advantage.