Unsterile Needle Acquisition Among PWIDs in Rural Puerto Rico: A Comparison Between Those in and out of Treatment
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[00:00:00.910]Hi my name is Clarice Ann Santos.
[00:00:03.670]I'm majoring in sociology and economics
[00:00:06.550]and for my McNair project,
[00:00:07.960]I looked into the unsterile needle acquisition
[00:00:10.290]among persons who inject drugs or PWIDs
[00:00:13.450]in rural Puerto Rico, comparing between those in
[00:00:16.110]and out of treatment.
[00:00:18.100]That epicenter of the opiod epidemic has been shifting
[00:00:20.870]from urban areas to rural areas.
[00:00:23.230]And with this issue comes a considerable rise
[00:00:25.430]in rural injection drug use or IDU.
[00:00:28.310]IDU is one of the most important factors in transmitting
[00:00:31.190]bloodborne illnesses, such as HIV and HCV.
[00:00:34.820]Which is why, in the US from 2010 to 2013,
[00:00:38.610]HCV infection rate was up by 150%
[00:00:42.270]with the rural areas having the highest increase with 364%.
[00:00:47.150]This fact especially holds true in Puerto Rico
[00:00:49.660]as from 2005 to 2011, IDU is the exposure category
[00:00:54.450]for half of the neonates cases.
[00:00:58.340]To understand more about this issue, I looked into
[00:01:00.430]the risk environment framework, or REF.
[00:01:03.317]REF claims that there are limits on individualizing
[00:01:06.440]risky behavior as a result of wants-decision making.
[00:01:10.080]Therefore, we need to focus on the relationship of drugs
[00:01:13.200]to want social, economic, political
[00:01:15.510]and physical environment instead.
[00:01:17.580]By looking to the risk factors found in one's environment,
[00:01:20.350]we can better understand how to reduce
[00:01:22.130]the transmission of bloodborne illnesses.
[00:01:24.650]However, most of the studies that use REF
[00:01:27.230]has mostly focused on urban areas rather than rural areas,
[00:01:31.350]which is why the purpose of this study
[00:01:33.010]is to examine plausible risk factors
[00:01:35.420]that increase the chances of injecting risk behavior
[00:01:37.880]among people who inject drugs or BWIDs in rural Puerto Rico.
[00:01:44.100]Based on the previous studies, I developed two hypothesis.
[00:01:47.560]One; participating in an opioid agonist treatment
[00:01:50.170]will reduce injecting risk behavior.
[00:01:52.460]And two; participants with higher education levels
[00:01:55.040]and older injection age will participate
[00:01:57.120]in less injecting risk behavior.
[00:02:00.810]Samples were recruited between June and November 2019,
[00:02:04.120]using respondent driven sampling or RDS.
[00:02:07.210]RDS is exactly as its name implies, as researchers gather
[00:02:10.670]an initial group of participants called seats.
[00:02:13.580]Upon completion of the survey, the seats are given $30
[00:02:16.377]and three coupons to distribute to people that they know.
[00:02:19.690]If the people that they know come in and complete
[00:02:21.960]the survey, the seats receive $10
[00:02:24.260]and the current participants receive $30 and three coupons
[00:02:27.350]of their own to distribute to people that they know.
[00:02:30.090]This cycle repeats itself until funding runs out
[00:02:32.730]or until the target sample size is met.
[00:02:35.430]All of the participants in this study were divided
[00:02:37.860]into two groups; those who are injecting opiates
[00:02:40.500]and those who have been injecting but are currently
[00:02:42.540]on an opioid agonist treatment.
[00:02:45.830]Eligible participants were at least 18 years old
[00:02:48.710]and had injected an illicit drug in the past 30 days.
[00:02:51.590]And this study was conducted in rural locations,
[00:02:54.050]about 30 miles south-west of San Juan, Puerto Rico.
[00:02:58.700]My independent variables are treatment status,
[00:03:01.040]education level and injection age
[00:03:03.270]and my control variables are gender,
[00:03:05.390]injection frequency and homelessness.
[00:03:08.020]My primary dependent variable are risky behaviors
[00:03:10.900]that the last time a participant injected with someone.
[00:03:13.960]Specifically, did they use a needle after someone else?
[00:03:17.110]Did they not use sterile needle?
[00:03:19.120]Did they share a cooker, cotton or water
[00:03:21.300]and did they back-load or front-load?
[00:03:23.490]Back-loading and front-loading are the practice
[00:03:25.410]where once syringe is used to prepare a drug solution
[00:03:28.520]and then the solution is shifted from one syringe
[00:03:30.930]into another, with a needle or plunger removed.
[00:03:35.590]To analyze the data, I used use logistic regressions
[00:03:38.220]in a program called Stata
[00:03:39.940]and there were a total of 170 participants.
[00:03:43.400]For the dependent variable; risky behavior,
[00:03:46.120]3% used a needle after someone else.
[00:03:48.730]12% did not use a sterile needle.
[00:03:51.010]56% share a cooker, cotton or water
[00:03:53.790]and 13% engaged in back-loading or front-loading.
[00:03:57.360]Due to the few responses made in the first category
[00:04:00.010]with only 3%, it was eliminated from analysis.
[00:04:05.160]For my independent measures,
[00:04:06.620]education was collapsed into three categories.
[00:04:09.390]36% said that they had less than a high school degree.
[00:04:12.840]47% had a high school degree or GED
[00:04:15.870]and 17% had more than a high school degree.
[00:04:18.950]The average participant first injected drug 23 years ago,
[00:04:22.640]with use ranging from 0 to 56 in the sample.
[00:04:25.940]And 47% of the participants claimed that they were currently
[00:04:29.210]in an opioid agonist treatment.
[00:04:33.000]For my other measures, 21% are currently homeless
[00:04:36.260]and 6% are female.
[00:04:37.980]Injection frequency was collapsed into three categories.
[00:04:41.430]30% injected less than once a day.
[00:04:43.880]39% injected one to three times a day
[00:04:46.580]and 31% injected four or more times a day.
[00:04:49.810]Due to the few responses made by females,
[00:04:52.380]gender was also eliminated from this study.
[00:04:56.700]For the risky behavior using unsterile needles,
[00:04:59.840]there were no significant association with injection age
[00:05:03.080]treatment status and any of the other measures.
[00:05:06.000]However, the odds of using unsterile needles did decrease
[00:05:09.020]by 72% when a participant had a high school diploma
[00:05:12.590]or GED compared to having less than a high school degree.
[00:05:17.100]For the risky behavior; sharing a cooker, cotton or water,
[00:05:20.110]there were no significant associations with any
[00:05:22.500]of the primary independent variables.
[00:05:24.770]However, the odds of sharing a cooker, cotton or water
[00:05:27.790]did increase by 156% when a participant injected
[00:05:31.900]four or more times a day, compared to less than once a day.
[00:05:36.890]For the risky behavior; back-loading or front-loading,
[00:05:39.280]there were no significant associations
[00:05:41.130]with any of the primary independent variables
[00:05:43.780]or any of the other outcomes.
[00:05:47.190]For the independent variable; OAT,
[00:05:49.070]my hypothesis was rejected
[00:05:50.730]as there were no associations with OAT
[00:05:53.230]and any of the outcomes,
[00:05:54.730]which is different from these studies
[00:05:56.860]that I reviewed which found association between OAT
[00:05:59.740]and a reduction in risky behavior.
[00:06:02.660]For the variable; injection age, my hypothesis
[00:06:05.180]was also rejected as there were no associations
[00:06:07.760]between injection age in any of the outcomes,
[00:06:10.530]which is also different from the other studies
[00:06:12.500]which ran an association between injection age
[00:06:15.327]and a reduction in risky behavior.
[00:06:19.150]And for the variable; education level,
[00:06:21.320]having a high school or GED was associated
[00:06:23.840]with using a sterile needle.
[00:06:25.450]However, having more than a high school was not.
[00:06:28.300]Therefore, we cannot conclude that there is an association
[00:06:31.070]between a higher education level
[00:06:33.120]and that particular risky behavior.
[00:06:35.620]Education was also not associated with the other outcomes,
[00:06:38.750]which is also different
[00:06:39.800]from the other studies that I reviewed.
[00:06:43.360]And amongst the control variables, only injection frequency
[00:06:46.330]had a significant association.
[00:06:48.500]Injecting four or more times a day increased the odds
[00:06:51.070]of sharing a cooker, cotton or water
[00:06:53.160]compared to injecting less than once a day.
[00:06:55.510]This may be the case as more frequent injecting
[00:06:57.790]requires more equipment used.
[00:07:01.730]My results may exist because Puerto Rico
[00:07:03.870]is a unique setting compared to the other studies
[00:07:06.120]that I previously reviewed.
[00:07:08.020]This study was conducted in rural areas and not urban areas
[00:07:11.770]And Puerto Rico is a US territory found outside
[00:07:14.410]of continental United States,
[00:07:16.410]so we may have to take into consideration
[00:07:18.480]the difference in politics.
[00:07:20.330]Puerto Rico was also recently hit with hurricane Maria,
[00:07:23.150]which disrupted their economy and social networks.
[00:07:27.730]This study shows that we need to be careful
[00:07:29.740]about generalizing other studies into other locations
[00:07:32.970]because of the difference in circumstances.
[00:07:36.070]For my future work, I plan on analyzing
[00:07:38.250]the injection age variable differently.
[00:07:40.650]For this study, I treated injection age
[00:07:42.880]as a continuous variable.
[00:07:44.390]However, it's possible that the learning process happens
[00:07:47.160]in the first three years of injecting and not continuously.
[00:07:51.020]I also plan on revisiting literature to find similar
[00:07:54.070]findings that may explain the results that I have.
[00:07:56.960]I would like to thank Doctor Patrick Habecker,
[00:07:59.060]my faculty mentor and the McNair Program
[00:08:01.580]for guiding me throughout this entire research.
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