Learning from people who inject drugs

Adjunct Professor Greg Rickard has qualifications in nursing and management and has undertaken health leadership roles in the public and private sectors, in consulting, recruiting, and academia throughout Australia and South-East Asia. Greg has a doctorate in public health, from the Menzies School of Health Research, Charles Darwin University (2010). Greg is passionate about addressing health inequalities and social justice, in particular recognising the needs of First Nations’ peoples and other minority groups.


Dr Bethne Hart (PhD)
is a mental health nurse and sociologist, currently leading a mental health team within primary healthcare services. Her academic career has included the School of Nursing (University of Notre Dame, Australia) and in nursing and health sociology at the University of Newcastle, New South Wales. Bethne's research projects include cultural safety, gender safety, moral competence, trauma informed care, and the Mental Health First Aid (MHFA program). Rickard, G, Hart, B, (2022) Survival, safety and belonging: An ethnographic study of experiences and perceptions of people who inject drugs accessing a supervised injecting centre. Australian Journal of Social Issues, 57 (4) researchfeatures.com I t's convenient to dismiss people who inject drugs (pwid) as criminals or, at best, the victims of their own bad decisions. But this approach not only eschews our responsibility to help marginalised and vulnerable people, it also keeps us impervious to broader social issues. Top-down, authoritarian policies steered by legal priorities don't address these issues, and those based on medical knowledge, even with the best intentions, risk being condescending and unhelpful. The alternative is to listen to the people the policies are supposed to support. That is precisely what two senior public health researchers did. What they discovered was a series of recurring themes that challenge our biases and give clearer direction for co-designed harmreduction approaches.

Learning from people who inject drugs
It was important that themes should emerge from the interviewees' own voices.
People who inject drugs (pwid) are often stigmatised and marginalised by uninformed policies.
Australian healthcare researchers Dr Greg Rickard and Dr Bethne Hart used a critical ethnography approach to understand pwid and their experiences.
By enabling themes to emerge from their interviews, they cast new light on pwid as agents of positive change.
Dr Greg Rickard is an adjunct professor of health and director of the College of Health and Medicine at the Rozelle Campus of the University of Tasmania in Sydney, Australia, and Dr Bethne Hart is a mental health nurse and sociologist based at Newcastle, Australia. As public health researchers who are passionate about addressing the needs of marginalised people and groups, they were drawn to the plight of pwid -arguably the most marginalised drug population. Sydney is home to one of the hundreds of supervised injection centres worldwide where pwid are offered a safe space to inject, using sterilised needles and syringes under the supervision of trained healthcare professionals. Such centres are controversial spaces, but Rickard and Hart discovered that they provide rare opportunities for pwid to engage openly and tell their stories, which is critical if Australia is serious about its mandate for personcentred healthcare.

Power structures that harm
For Rickard and Hart, listening to the voices of the marginalised is the first step in Rickard and Hart's critical ethnographic approach enabled interviewees' voices to be heard.

researchfeatures.com
An overwhelming theme was the need to be seen as human.
People who inject drugs found Sydney's Medical Supervised Injection Centre offered safety and helpful daily routines that brought structure to their otherwise chaotic lives.

How do you see your research influencing policy changes?
Our research will help inform policymakers about the lives of the people that their policies profoundly shape, influence, and have impact on. It can challenge assumptions and professional dominance. It demonstrates the principles of co-design, encouraging new and revised practices of knowledge-making and decision-making. People and populations in research and policy change are viewed as collaborators, not research and policy subjects.

How would you like to see colleagues in your field develop your research?
To use the methodology and findings to educate othersstudents, policymakers, health professionals, communities, politicians -so that misconceptions and discriminations can be lessened and challenged. We ask our colleagues and collaborators to question the 'power' differential/imbalance when undertaking their research and working with minority groups and populations. We'd like them to use our work to conduct further research, evaluating co-design implementations.

What is the most important lesson we could learn from your use of critical ethnography as a methodological and epistemological framework?
It allows us to see, make explicit, and challenge social and health inequalities; giving power to people and groups who are frequently marginalised, stigmatised, unseen, and ignored. These inequalities and power relations are central to the struggles that many people have in illness and trauma.
addressing the prejudiced power structures that stigmatise and marginalise minorities. This critical ethnographic approach was a crucial part of their research design. With the help of the staff at the respective centres, the researchers encouraged 23 pwid at Sydney's Medical Supervised Injection Centre (MSIC) and five at Clinic 180, a nurse-led clinical services facility, to answer semi-structured interviews on their experiences. Anonymity is protected at these facilities, so the participants could speak freely and frankly.
It was important for the researchers that, instead of analysing the interviews from preexisting perspectives, themes should emerge from the interviewees' own voices. And that's exactly what happened. An overwhelming theme was the need to be seen as human; not labelled as a stereotypical 'junkie' or 'drug addict'. The participants were aware of what people thought about them and yearned for privacy, dignity, and respect, and recognition that they were actively (in their own way) coming to terms with their condition.
This central theme of 'I'm human' had three sub-themes. The first was survival. Most participants had intimately witnessed the factors that prompted the establishment of MSIC -high levels of overdosing and death, the violence and trauma of street living, and the risks of using shared, contaminated needles and syringes in unlit areas.
The second sub-theme was around the benefits offered by MSIC -the safety, and the importance of the daily routines and rituals it offered to assist with their security and day-to-day existence. The visits brought much-needed structure and moderation to their otherwise chaotic and dangerous lives. The care, compassion, and respect of the staff at MSIC helped them survive life outside it. In fact, many participants were volunteers at MSIC and extended that care to others in their world.
The third sub-theme was a sense of belonging to a community, which is so vital for people pushed to the margins of society. Entering MSIC made them feel part of a supportive 'family', but notably not one that encouraged drug taking. This countered a central criticism of MSIC.

Contesting prevailing discourses
Indeed, Rickard and Hart discovered that the narratives of those they interviewed are in stark contrast to, and even contest, many of the prevailing medical, moral, and criminal models and discourses about pwid. Most pwid have complex histories of mental illness and childhood trauma; they need help, not to be further marginalised and stigmatised. Importantly, they want to be heard and not receive moral and medical judgements from a distance. They want an active role in codesigning their care.
Rickard and Hart's research shows that pwid who find safety, structure, and survival through supervised injection centres such as MSIC demonstrate agency and choice. They see such centres as starting points for getting their lives back on track and helping others. This understanding challenges the stereotypical and stigmatising views about pwid. Significantly, the use of critical ethnography as a methodological and epistemological framework has brought the voices, experiences, and perceptions of pwid into the public spaces of health policy development, healthcare, and media constructs. Combined with the philosophy of co-design in service development and evaluation, what the researchers have learned should encourage the politicians and administrators who control the multiple levers of change to reach out to those they aim to help for guidance in the most effective way. researchfeatures.com