The experiences of people who inject drugs of skin and soft tissue infections and harm reduction: A qualitative study

Abstract

Background: Bacterial skin and soft tissue infections (SSTI) among people who inject drugs (PWID) are considered a public health concern. There is a lack of qualitative research examining the lived experience of PWID who have had SSTI. This paper explores PWID views and experiences of their SSTI, their perceptions on the causes of their SSTI and their harm reduction (HR) behaviours. The implications for HR service delivery and practice will be discussed. Methods: Between October 2015-January 2016, 22 in-depth interviews were conducted with PWID who had experienced a SSTI within the past year. Interviewees were recruited from an injecting equipment provision service and a drug treatment service in Glasgow and Edinburgh respectively. The interview transcripts were transcribed verbatim and underwent thematic analysis. Results: We found that the experience of SSTI can cause strong negative feelings, including panic and stigma and that there was limited knowledge of SSTI prior to first hand experience. The awareness of the unacceptable social and physical consequences of SSTI fostered a sense of personal responsibility and agency which led to the introduction or improved HR uptake. However, when PWID were struggling to inject or when their physical and political environments were compromised there was an increased risk for SSTI and reduced effectiveness of HR. Conclusion: Compared to HCV and HIV, SSTI as an injecting related harm has received less policy attention. Policy makers need to address SSTI HR within enabling environments, such as 'safer environment interventions'. It is recommended that peer based support, improved NSP provision and medically supervised injecting facilities are needed to deliver SSTI HR.

Increased risk of HIV and other drug-related harms associated with injecting in public places: national bio-behavioural survey of people who inject drugs

“…Our findings are consistent with previous research demonstrating a link between people who inject in public and SSTI ( Salmon et al., 2009 ), as a result of their highly unsanitary injecting environment ( Dunleavy, Hope, Roy & Taylor, 2019 ; Small et al., 2007 ) and the reduced likelihood of following injecting related hygiene practices ( Marshall et al., 2010 ). In recent years, Scotland has experienced major outbreaks of spore-forming bacteria, including an outbreak of anthrax ( Palmateer, Ramsay, Browning, Goldberg & Hutchinson, 2012 ) and the largest documented outbreak of wound botulism in Europe ( Trayner et al., 2018 ), both associated with a contaminated drug supply.…”

Normalised pain and severe health care delay among people who inject drugs in London: Adapting cultural safety principles to promote care

“…An isolated surface reading of such accounts can further enact violence by solidifying self-depreciating or responsibilising narratives into actionable recommendations for behaviour and altitudinal change. Dunleavy et al (2019) draw on qualitative accounts, similar to those of the London participants, to recommend interventions promote “awareness of the unacceptable social or physical consequences of SSTI” as this can foster “a sense of personal responsibility and agency” toward SSTI care among PWID. If we consider claims of personal responsibility and culpability for ‘self-inflicted’ SSTI as one among multiple narratives, we can also see how awareness and internalisation of judgements around the “unacceptability” of SSTI can enact a symbolic violence, precluding care seeking rather than facilitating it.…”

“…Restrictive opening hours and competing priorities create additional barriers to timely attendance ( Small et al, 2008 ). Dunleavy et al (2019) emphasise the role of individual awareness and recommend that educational interventions ‘emphasise the unacceptable consequences of SSTI’ to promote timely care access as a means of stigma avoidance.…”

“…Stigma, as systemically embedded and un/consciously enacted during health care interactions ( McCall and Pauly, 2019 ), is key to understanding care delay – but also the way in which people account for it. Data drawn on in this paper include participant accounts similar to those reported by Dunleavy et al (2019) . Offered, however, is a different reading.…”

Frequency of injecting among people who inject drugs: A systematic review and meta-analysis

“…Similarly, PWID in treatment, in hospital or in recovery may not be injecting as frequently or at all. The appearance of abscess wounds motivates some people to reduce their injecting to allow the wound to heal (Dunleavy, Hope, Roy, & Taylor, 2019), potentially moderating the relationship between skin and soft tissue infection and frequency of injecting. Treatment engagement may also influence injecting frequency, which has been repeatedly shown for PWID engaged in OAT.…”