Linn Gjersing

Cross-cultural adaptation of research instruments: language, setting, time and statistical considerations

BackgroundResearch questionnaires are not always translated appropriately before they are used in new temporal, cultural or linguistic settings. The results based on such instruments may therefore not accurately reflect what they are supposed to measure. This paper aims to illustrate the process and required steps involved in the cross-cultural adaptation of a research instrument using the adaptation process of an attitudinal instrument as an example.MethodsA questionnaire was needed for the implementation of a study in Norway 2007. There was no appropriate instruments available in Norwegian, thus an Australian-English instrument was cross-culturally adapted.ResultsThe adaptation process included investigation of conceptual and item equivalence. Two forward and two back-translations were synthesized and compared by an expert committee. Thereafter the instrument was pretested and adjusted accordingly. The final questionnaire was administered to opioid maintenance treatment staff (n=140) and harm reduction staff (n=180). The overall response rate was 84%. The original instrument failed confirmatory analysis. Instead a new two-factor scale was identified and found valid in the new setting.ConclusionsThe failure of the original scale highlights the importance of adapting instruments to current research settings. It also emphasizes the importance of ensuring that concepts within an instrument are equal between the original and target language, time and context. If the described stages in the cross-cultural adaptation process had been omitted, the findings would have been misleading, even if presented with apparent precision. Thus, it is important to consider possible barriers when making a direct comparison between different nations, cultures and times.

Diversity in causes and characteristics of drug-induced deaths in an urban setting

Aims: To assess demographic characteristics, treatment utilization and circumstances of death among those who died from drug-induced deaths in an urban setting and to identify possible subpopulations that should be targeted specifically to further develop preventive public health policies. Methods: Subjects (N = 231) who died, from drug-induced deaths, in the Norwegian capital Oslo (2006–2008) were identified through the National Cause of Death Registry. Data on toxicology, prison release and contact with health and social services in Oslo were collected. Results: Majority of cases were men (78%) and the mean age was 37 years. Nearly all cases (90%) were polydrug intoxications. Heroin was implicated in 67%. Residential address was the most common place of death (67%). Most cases (82%) had been in contact with health and social services in the year before death. Women were 4 years older, more often Oslo residents (82% vs. 64%) and fewer died from heroin intoxication. Non-Oslo residents were younger and more likely to have been found outdoors with heroin as the main intoxicant. Other identified subpopulations were those who died after prison release and those discharged from drug treatment. Conclusions: The findings suggest that the majority of cases could have been available for preventive measures through their contacts with health and social services. Yet, the heterogeneity among cases indicates that such measures need to be multifaceted. Finally, it is important for policymakers and health and social workers in various countries to consider subpopulations such as women and non-city residents when developing public health interventions to prevent overdose deaths.

Attitudes and beliefs towards methadone maintenance treatment among Australian prison health staff

INTRODUCTION AND AIMS Justice Health NSW has one of the most extensive prison-based methadone programmes in the world. We examine prison health staff attitudes towards methadone treatment and compare these with community methadone staff. DESIGN AND METHODS A cross-sectional survey of 202 staff employed by Justice Health New South Wales was undertaken in 2003. Results. The mean scores on the various sub-scales were: abstinence-orientation (AO) 2.9 (95% CI 2.8 - 3.0); disapproval of drug use (DDU) 3.3 (95% CI 3.2 - 3.4); knowledge (Know) 2.7 (95% CI 2.4 - 2.9); and toxicity 4.6 (95% CI 4.2 - 5.0). Both the AO and DDU score were correlated negatively with the Know score (r = -0.37 and r = -0.13, respectively). Prison health staff had higher AO (2.9 vs. 2.6, p < 0.001) and DDU (3.3 vs. 2.6, p < 0.001) scores, and lower Know (2.7 vs. 7.0, p < 0.001) scores than methadone staff working in the Australian community. They were more knowledgeable than US community methadone staff about the toxicity of methadone (4.6 vs. 0.0, p < 0.001). DISCUSSION AND CONCLUSIONS This is the first survey to examine prison health staff attitudes to methadone treatment. Correctional health staff tend to be more abstinence-orientated, more likely to disapprove of drug use, and less knowledgeable about the risks and benefits of methadone than Australian community methadone staff. The findings have important implications for training health staff working in the prison environment with regard to client retention on methadone treatment.

Illicit use of opioid substitution drugs: prevalence, user characteristics, and the association with non-fatal overdoses.

BACKGROUND AND AIMS Diversion of opioid substitution drugs (OSD) is of public concern. This study examined the prevalence, frequency, and predictors of illicit OSD use in a group of injecting drug users (IDUs) and assessed if such use was associated with non-fatal overdoses. METHODS Semi-annual cross-sectional interviews conducted in Oslo, Norway (2006-2013), from 1355 street-recruited IDUs. Hurdle, logistic, and multinomial regression models were employed. RESULTS Overall, 27% reported illicit OSD use in the past four weeks; 16.8% methadone, 12.5% buprenorphine, and 2.9% both drugs. Almost 1/10 reported at least one non-fatal overdose in the past four weeks, and roughly 1/3 reported such experience in the past year. Use of additional drugs tended to be equally, or more prevalent among illicit OSD users than other IDUs. In terms of illicit OSD use being a risk factor for non-lethal overdoses, our results showed significant associations only for infrequent buprenorphine use (using once or less than once per week). Other factors associated with non-fatal overdoses included age, education, homelessness, as well as the benzodiazepines, stimulants, and heroin use. CONCLUSIONS Users of diverted OSD may represent a high-risk population, as they used more additional drugs and used them more frequently than other IDUs. However, illicit OSD use may be less harmful than previously assumed. After accounting for an extensive set of covariates, only infrequent illicit buprenorphine use, but not methadone use, was associated with non-fatal overdoses.

Gender differences in mortality and risk factors in a 13-year cohort study of street-recruited injecting drug users

BackgroundInjecting drug users (IDUs) are at risk of premature mortality. This study examined gender differences in mortality, risk factors, and causes of death among IDUs.MethodsIn a 13-year cohort study including 172 street-recruited IDUs from Oslo, Norway in 1997, interview data was merged with the National Cause of Death Registry. Crude mortality rate (CMR) and indirect standardized mortality ratio (SMR) were estimated with 95% confidence intervals (CI). A log-logistic multivariate survival analysis model was estimated for the full sample. For a smaller data set (1.1.1998-31.12.2004) the influence of substitution treatment and prison were assessed using cox regression survival analysis.ResultsEight females and 37 males died. Acute intoxications were the most common cause of death. Women were more at risk in the short-term, but more protected in the long-term. CMR was 16.0 [95% CI 8.0, 31.9] for women and 26.0 [95% CI 18.0, 35.8]) for men. SMR was 39.4 [95% CI 0.2, 220.8]) for women and 21.3 [95% CI 5.7, 54.1] for men. More women injected heroin (98% vs. 88% [x2 = 3.5, p = 0.063]), used prescription drugs (73% vs. 52% [x2 = 5.6, p = 0.018]) and combined these to inject (45% vs. 26% [x2 = 5.9, p = 0.015]). Mixing prescription drugs in heroin injections, and sex work (only women) were associated with decreased survival time. There were no gender differences in access to substitution treatment, while significantly more men had been in prison (74% vs. 51% [x2 = 7.5, p = 0.006]). The instance of substitution treatment and prison significantly decreased the mortality risk. Prison release increased the risk, but not statistically significantly.ConclusionsThere were gender differences in mortality and risk factors; sex work and prison were gender specific risk factors. These factors should be investigated further to better design future preventive measures.

Is opioid substitution treatment beneficial if injecting behaviour continues

BACKGROUND Opioid substitution treatment (OST) is recognised as an effective treatment for opioid dependence. Still, a subgroup of OST users continues to inject drugs. This study examines health risks and criminal activity in a population of needle exchange programme (NEP) participants by comparing those identified as current OST users to (i) those identified as former OST users and (ii) those with no OST experience. METHODS This was a semi-annual cross-sectional study conducted from 2002 to 2011. NEP participants were interviewed in Oslo, Norway (n=1760); 341 were identified as current OST users, 356 as former OST users and 1063 had no OST experience. The associations between OST status and health risk and criminal activity were assessed through univariate and multiple logistic regression analyses. RESULTS Among NEP participants, those currently in OST had fewer non-fatal overdoses (OR=0.5 [95% CI 0.3, 0.9]) compared to former OST users and those never in OST. Additionally, they were less likely to have injected frequently (OR=0.4 [95% CI 0.3, 06]), to have used heroin daily or almost daily (OR=0.3 [95% CI 0.2, 0.4]), and to have committed theft (OR=0.6 [95% CI 0.4, 1.0]) and engaged in drug dealing (OR=0.7 [95% CI 0.5, 0.9]) in the past month. Overall, there was a high level of polysubstance use and no group differences on this measure. CONCLUSIONS NEP participants who are currently in OST have substantially reduced health risks and criminal activity than other NEP participants. The high level of polysubstance use nevertheless poses a public health challenge.

Open drug scenes: responses of five European cities

BackgroundOpen drug scenes are gatherings of drug users who publicly consume and deal drugs. The authors conducted a study of five European cities that have met such scenes constructively. The aim was to investigate shared and non-shared interventions and strategies in order to increase the understanding of this type of problem.MethodsFirst a description was made for the cities of Amsterdam, Frankfurt, Vienna, Zürich and Lisbon. These descriptions were sent to contact persons in each city prior to visit by the researchers. The methods and strategies in each city were discussed and core choices and efforts extracted. A report was sent to the contact group for corrections and clarifications. The paper analyses shared and non-shared traits and strategies.ResultsAll of the cities had initially a period with conflict between liberal and restrictive policies. A political consensus seems to be a prerequisite for effective action. A core shared characteristic was that drug dependence was met as a health problem and drug use behaviour as a public nuisance problem. Low threshold health services including opioid maintenance treatment were combined with outreach social work and effective policing.ConclusionPrevention, harm reduction and treatment should be combined with law enforcement based on cooperation between police, health care and social services. The aim should be “coexistence” between society and users of illegal substances and the strategy based on several years planning and conjoint efforts. The solutions are found in appropriate combinations of harm reduction and restrictive measures.

Are overdoses treated by ambulance services an opportunity for additional interventions? A prospective cohort study

AIMS To assess whether people who inject drugs (PWID) and who are treated for overdose by ambulance services have a greater mortality risk compared with other PWID, and to compare mortality risk within potentially critical time-periods (1 week, 1 month, 3 months, 6 months, 1 year, 5 years) after an overdose attendance with the mortality risk within potentially non-critical time-periods (time before and/or after critical periods). DESIGN A prospective cohort study. SETTING Oslo, Norway. PARTICIPANTS A total of 172 PWID street-recruited in 1997 and followed-up until the end of 2004. MEASUREMENTS Interview data linked to data from ambulance records, Norwegian Correctional Services, Opioid Substitution Treatment records and National Cause of Death Registry. Separate Cox regression models (one for each critical time-period) were estimated. FINDINGS Ambulance services treated 54% of the participants for an overdose during follow-up. The mortality rate was 2.8 per 100 person-years for those with an overdose and 3.3 for those without; the adjusted hazard ratio (HR) was 1.3 (95% CI = 0.6, 2.6, P = 0.482). Mortality risk was greater in all but the shortest critical time-period following ambulance attendance than in the non-critical periods. The mortality risk remained significantly elevated during critical periods, even when adjusted for total time spent in prison and substitution treatment. The HR ranged from 9.4 (95% CI = 3.5, 25.4) in the month after an overdose to 13.9 (95% CI = 6.4, 30.2) in the 5-year period. CONCLUSIONS Mortality risk among people who inject drugs is significantly greater in time-periods after an overdose attendance than outside these time-periods.

Misuse of prescription drugs and overdose deaths

Abstract Aims. This study examined overdose deaths involving benzodiazepines and prescription opioids, and studied associated factors. Methods. In a retrospective registry study of drug-overdose deaths (n = 167) with post-mortem toxicological findings of benzodiazepines and/or opioids/carisoprodol (strong analgesics) in Oslo, Norway, from 2006 to 2008, prescribing and dispensing patterns were investigated, and factors associated with benzodiazepines and/or strong analgesics in post-mortem toxicology where these medications were not prescribed were identified. Results. Among deceased with toxicological findings of only benzodiazepines, 28.1% (20.7–36.9) had been dispensed benzodiazepines four weeks prior to death; only strong analgesics, 33.3% (13.0–61.3) had been dispensed strong analgesics; both benzodiazepines and strong analgesics, 58.3% (36.9–77.2) had been dispensed benzodiazepines and/or strong analgesics. Also, 33.0% of the deceased had five or more different prescribing physicians of either benzodiazepines or strong analgesics in the year prior to death. Doses of both dispensed benzodiazepines and strong analgesics were higher than recommended. Younger age and residing outside Oslo were associated with having benzodiazepines and/or strong analgesics in the toxicological findings when these medications had not been dispensed (p = 0.006 and p = 0.039, respectively). Conclusion. The majority of benzodiazepines and strong analgesics detected in overdose deaths were non-prescribed and/or associated with less than optimal prescribing practices by some treating physicians.

Emergency service use is common in the year before death among drug users who die from an overdose

Abstract Aims: This study compares the characteristics of those who were or were not attended by the emergency services in the year before death. It describes the reasons for emergency service attendance and the prevalence of such attendance. It reports the number of days between the last emergency service attendance and death and examines contact with other health and social services and the association of this with emergency service attendance. Finally, it examines the association between the frequency of emergency service attendance and the frequency of contact with other services.Methods: A retrospective registry study where all overdose fatalities (n = 231) in Oslo, Norway (2006–2008), was identified through the National Cause of Death Registry and linked with data from other health and social services. Results: Overall, 61% were emergency service attendees and 18% were frequent attendees. Somatic complaints were the most common reason for attendance. Attendees were more known to a number of other services compared to the non-attendees. Furthermore, there was an association between the frequency of emergency service attendance and the frequency of contact with other services.Conclusions: Screening for drug use among emergency service attendees may be a way to identify those at risk of overdose death and enable the introduction of additional interventions.