Jill Fikowski, MPH Candidate School of Population & Public Health, University of British Columbia

1. Life History Calendar in a population of chronic opioid users: An evaluation of methodological utility and identifying patterns of drug use and addiction treatment Jill Fikowski, MPH Candidate School of Population & Public Health, University of British Columbia Canadian Public Health Association Conference Toronto, May 2014

2. Overview • Background • Brief description of study and design • Methods • LHC Description • Findings • 1. Factors impacting feasibility • 2. Challenges & Opportunities • Recommendations

3. Background • Vancouver’s Downtown Eastsidehas an estimated population of 16,275 and is the home for about 4,700 injection drug users1, 2 • High prevalence of chronic and infectious disease including HIV/AIDS, hepatitis, tuberculosis, and syphilis3,4 • 33% of the injection drug users in the Downtown Eastside are HIV positive4

4. Background • Public health concerns in this population: • Poverty & unhealthy physical environment • Social isolation • Drug dependency & mental illness • Non-legal activity • Low education levels • Limited access to addiction treatment

5. Study Design Descriptive cross-sectional pilot study with a mixed method design aimed at testing gender-specific patterns in drug use, victimization, access to care and physical and mental health among men and women with long-term opioid-dependence

6. Study Inclusion criteria • 19 years of age or older • Reside in metropolitan Vancouver area • Minimum of 5 years of opioid use prior to participation • Used opioids regularly within the past 6 months • One or more episode[s] of methadone maintenance treatment (MMT) or another form of opioid substitution treatment (e.g. Suboxone, Buprenorphine)

7. Methods • Recruitment & Enrolment • Participants & Setting • Collection Methods • Semi-structured questionnaires • Focus groups • Life History Calendar (LHC)

8. Life History Calendar (LHC) • Calendar style instrument used to collect time-linked retrospective data of events over a certain reference period5 Lifetime reference period • Identify life events that may have preceded or co-occurred during the same time periods as illicit drug use • Time units broken down by month and year ,

9. Variables

10. LHC-Layout • Insert screen shot

11. Procedures • Interviewer-coding manual used to guide data collection • Participants positioned at the table beside the interviewer with the study laptop open displaying the calendar

12. Sample • 174 individuals participated in the GeMa study (male=95; female=76; transgender=3) • 56 completed the LHC (male=33; female=22; transgender=1) • Descriptive analysis revealed: • Heroin primary illicit opioid injected for the first time (78.6%; mean age of first use=25 yrs.) • MMT most frequently reported as the first drug treatment accessed (41.8%; M= 2.5 attempts)

13. High use/ Low use High intensity /Low intensity Injection/ Smoke/Other Unstable/ Stable Physical (I=HIV, C=HCV) Good / Fair /Poor Yes/Somewhat Axis I / Axis II Regular / Sporadically

14. High use/ Low use High intensity /Low intensity Injection/ Smoke/Other Male / Female/TG Good/ Fair /Poor (DP, AP) / DP / AP F/J /V/ T/O RC/SC/NC/DK

15. High use/ Low use High intensity /Low intensity Injection/ Smoke/Other FT / PT / C Ym/ Yl Very Often / Often/ Sometimes/Rarely Severe / Moderate/Minimum Good / Fair / Poor

16. Factors affecting feasibility Interviewer Training • Familiarity with the demographic of population • Collection of data and layout of instrument 3. Subjectivity of ‘significant’ life events • Prompting vs. anchoring Interviewer Techniques • Events reported in semi-structured questionnaires used to anchor during interview

17. Factors affecting feasibility Characteristics of the Interviewer 1. Recognizing belief system surrounding drug use and marginalized populations 2. Ability to detect the emotional and physical state of the participant Characteristics of the Population • High prevalence of victimization • Cognitive/physical factors affecting memory recall

18. Would we recommend the use of the LHC again in this population?

19. Opportunities for Improvement • Shorten the reference period • Reduce the number of variables • Administer as a complimentary method to semi-structured questionnaires • Useful way of visually examining the relationship between patterns of drug use and major life events

20. Limitations • Retrospective memory recall • Psychometric evaluation • Intra & Inter-rater reliability • Objective measures to validate responses

21. Thank-you Questions?

22. References • Tyndall M, Craib K, Currie S, et al. Impact of HIV infection on mortality in a cohort of injection drug users. AIDS. 2007. • Vancouver/Richmond Health Board. Report on the health of the population of Vancouver/Richmond. Vancouver;1999:22. • SchecterM, O’Shaughnessy M. Distribution of injection drug users in the Lower Mainland. A brief report for the Vancouver/Richmond Health Board. Vancouver;1999:6. • StrathdeeS, Archibald C, Ofner, M, et al. Determinants of HIV seroconversion in injection drug users during a period of rising prevalence in Vancouver. Vancouver Injection Drug Use Survey. VIDUS Project, May 1997. Int J AIDS and Sex Transm Dis 1997;8:427-435. • Freedman D, Thornton A, Camburn D, Alwin D, Young-demarco L. The life history calendar: a technique for collecting retrospective data. Sociological methodology 1988;18:37-68.

23. References • AnglinM, HserY, Chou C.Reliability and Validity of Retrospective Behavioral Self-Report By Narcotics Addicts. Evaluation Review 1993; 17(91). • GlasnerT, van der Vaart W. Applications of calendar instruments in social surveys: a review. Quality & Quantity 2009;43(3):333-349. • Nelson IA. From Quantitative to Qualitative: Adapting the Life History Calendar Method. Field Methods 2010;22(4):413-428. • YoshihamaM, Gillespie B, Hammock AC, Belli RE, Tolman RM. Does the Life History Calendar method facilitate the recall of intimate partner violence? Comparison of two methods of data collection. Social Work Research 2005;29(3):151-163. • YoshihamaM, Bybee D. The Life History Calendar Method and Multilevel Modeling: Application to Research on Intimate Partner Violence. Violence against Women 2011;17(3):295-308. • Bailey J, Hill KG, Hawkins JD, Catalano RF, Abbott RD. Men's and women's patterns of substance use around pregnancy. Birth-Issues in Perinatal Care 2008;35(1):50-59.

24. Acknowledgements • Participants of the Gender Matters Study • Daphne Guh-Senior Statistician • Centre for Health Evaluation and Outcomes Sciences (CHEOS) • University of British Columbia -School of Population & Public Health • Canadian Institutes of Health Research (CIHR)