qualitative research on substance abuse

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• > The Cambridge Handbook of Substance and Behavioral Addictions
• > Qualitative Approaches to the Study of Substance and Behavioral Addictions

Book contents

• The Cambridge Handbook of Substance and Behavioral Addictions
• Copyright page
• Contributors
• Acknowledgements
• Part I Concepts of Addiction
• Part II Clinical and Research Methods in the Addictions
• 5 Human Neurobiological Approaches to Hedonically Motivated Behaviors
• 6 Human Laboratory Paradigms in Addictions Research
• 7 Behavioral Economic Considerations of Novel Addictions and Nonaddictive Behavior: Research and Analytic Methods
• 8 Substance and Behavioral Addictions Assessment Instruments
• 9 Qualitative Approaches to the Study of Substance and Behavioral Addictions
• Part III Levels of Analysis and Etiology
• Part IV Prevention and Treatment
• Part V Ongoing and Future Research Directions

9 - Qualitative Approaches to the Study of Substance and Behavioral Addictions

from Part II - Clinical and Research Methods in the Addictions

Published online by Cambridge University Press:  13 July 2020

This chapter provides an overview of qualitative research methods in substance and behavioral addictions research and practice. It discusses the nature and importance of qualitative methodologies in iterating how individual perspectives, social meanings, and lived experiences impact the nature of substance and behavioral addictions. Methods addressed include ethnography, participant and nonparticipant observation, qualitative interviews, focus groups, and participatory action research (PAR), and empirical evidence in the context of addictions is provided. Additionally, a brief summary of each method and generally understood advantages and disadvantages of each are given. Data analysis techniques covered include grounded theory, narrative and discourse analysis, and thematic analysis. Lastly, major contributions to the field of addictions regarding research on hard-to-reach and marginalized populations, evaluating treatment and intervention services, measuring risk behaviors, investigating barriers to treatment programs, conceptualizing motivational and emotional components of addiction, and aiding in the formation of diagnostic criterion are reviewed.

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• Qualitative Approaches to the Study of Substance and Behavioral Addictions
• By Kelsey A. Simpson , Ricky N. Bluthenthal
• Edited by Steve Sussman , University of Southern California
• Book: The Cambridge Handbook of Substance and Behavioral Addictions
• Online publication: 13 July 2020
• Chapter DOI: https://doi.org/10.1017/9781108632591.013

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Qualitative Methods in Substance Abuse Research

• First Online: 20 June 2017

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• Paul Draus 4  

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This chapter begins with a brief philosophical discussion of three paradigmatic approaches underlying qualitative research: positivist, phenomenological, and pragmatist. Each is important, as they contribute to different methodological approaches and distinctive interpretations of research findings. The evolution of qualitative methods for studying substance use is also explored, from classical anthropology and sociology and continuing through the postmodernism of the late-twentieth century, finally touching on posthumanist approaches that have emerged in the early twenty-first century; providing a theoretical framework for a discussion of specific methodologies. An in-depth discussion of two foundational qualitative methodologies, participant observation, and ethnographic interviewing, as well as the practical and ethical issues attendant to all substance use research in the context of prohibition and social stigma is presented. Finally, the chapter briefly explore uses of complementary methods such focus groups, content analysis, cognitive and ethnographic mapping, space-time diaries and geographic information systems (GIS), autoethnography, Photovoice, and community-based approaches such as Participatory Action Research (PAR) in the context of substance abuse research.

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For a concise summary of the contributions of qualitative research to the study of substance abuse, including treatment and prevention, see Nichter et al. 2004 .

A thorough discussion of mixed-method approaches to the study of substance abuse is presented in Chap. 10 of this volume.

Recent work includes qualitative interviews with former street sex workers in Detroit, Michigan (Draus et al. 2015a , b ). In an analysis of women’s accounts of their transition from active substance use to a recovery-oriented existence, for instance, the importance of social networks and daily routines were identified as key components of the recovery process, as women reassembled their identities to align with the goals of recovery.

By definition, social network analysis is a transdisciplinary endeavor (Valente et al. 2004 ). See chapter by Reingle and Akers (this volume) for additional information on the importance of a transdisciplinary framework for substance abuse research.

See also Chap. 9 in this volume for information of the use of GIS in substance abuse research.

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Draus, P. (2017). Qualitative Methods in Substance Abuse Research. In: VanGeest, J., Johnson, T., Alemagno, S. (eds) Research Methods in the Study of Substance Abuse. Springer, Cham. https://doi.org/10.1007/978-3-319-55980-3_7

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Qualitative research: contributions to the study of drug use, drug abuse, and drug use(r)-related interventions

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• 1 Departments of Anthropology, Family and Community Medicine and Public Health, University of Arizona, Tucson, Arizona, USA. [email protected]
• PMID: 15587954
• DOI: 10.1081/ja-200033233

This article describes how qualitative social science research has and can contribute to the emerging field of drug and alcohol studies. An eight-stage model of formative-reformative research is presented as a heuristic to outline the different ways in which qualitative research may be used to better understand micro and macro dimensions of drug use and distribution; more effectively design, monitor and evaluate drug use(r)-related interventions; and address the politics of drug/drug program representation. Tobacco is used as an exemplar to introduce the reader to the range of research issues that a qualitative researcher may focus upon during the initial stage of formative research. Ethnographic research on alcohol use among Native Americans is highlighted to illustrate the importance of closely examining ethnicity as well as class when investigating patterns of drug use. To familiarize the reader with qualitative research, we describe the range of methods commonly employed and the ways in which qualitative research may complement as well as contribute to quantitative research. In describing the later stages of the formative-reformative process, we consider both the use of qualitative research in the evaluation and critical assessment of drug use(r)-intervention programs, and the role of qualitative research in critically assessing the politics of prevention programs. Finally, we discuss the challenges faced by qualitative researchers when engaging in transdisciplinary research.

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Substance Abuse Treatment, Prevention, and Policy volume  16 , Article number:  38 ( 2021 ) Cite this article

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Non-medical use of psychoactive substances is a common harmful behavior that leads to the development of Substance Use Disorders (SUDs). SUD is a significant health concern that causes adverse health consequences and elevates the economic burden on the health care system. SUD treatment plans that utilize a patient-centered approach have demonstrated improved treatment outcomes. It is essential for health care providers, including community pharmacists, to understand patients’ needs and prioritize them. Therefore, this study was conducted to explore the perspective of patients living with SUDs or who used substances non-medically regarding community pharmacist services and the delivery of services in a community pharmacy setting. The study took place in Saskatoon, a small urban center of Saskatchewan, Canada.

Qualitative methodology was used for this research inquiry. Four focus groups were conducted, with a total of 20 individuals who had experienced substance use and accessed community pharmacy services. The discussion of the four focus groups was transcribed verbatim and analyzed independently by two researchers. Agreement on the emergent themes was reached through discussion between the two researchers.

Data analysis resulted in four themes that described participants’ perspectives about community pharmacists. The four emergent themes are: 1) conflicted experiences with community pharmacists, 2) lack of knowledge concerning community pharmacists’ extended services, 3) negative experiences in Opioid Agonist Therapy (OAT) program, and 4) needs from community pharmacists.

There is significant potential for the patient-pharmacist relationship to address the varying needs of patients who use substances and improve their overall health care experience. Patients who use substances are receptive to pharmacists’ services beyond dispensary; however, respectful communication, provision of drug-related information, and counseling are among the primary demands. Future research should focus on studying the impact of meeting the needs of patients on their treatment outcomes.

Introduction

Substance Use Disorders (SUDs) are a prevalent disease that affects an individual’s social, physical, and psychological wellbeing. Other difficulties usually co-occur with SUDs, such as legal and financial problems, loss of productivity, family instability, and unemployment [ 1 ]. Lost workplace productivity is a common consequence of substance use and SUDs. In 2014, the estimated loss of productivity in Canada due to substance use was estimated at $15.7 billion, with tobacco, alcohol, and opioids responsible for most losses [ 2 ]. These social situations are both symptoms of SUDs and causes that exacerbate the disease. Other SUD-related problems vary among patients in terms of symptoms, intensity, and responsiveness to treatments [ 3 ]. For example, Relapses, a common aspect of SUDs recovery, can have varying triggers depending on the individual’s experience with substance use [ 4 , 5 ]. Therefore, it is integral that tailored treatments are provided for patients living with SUDs that address their etiological and symptomatic variations in a patient-centered approach. Addressing the needs of patients living with SUD, beyond the pharmacological aspects, has been proven to reduce substance use [ 6 , 7 ]. Health care providers, such as physicians and pharmacists, who interact with SUDs patients, need to acknowledge the positive impact of patient-centered care and prioritize patients’ needs in treatment decisions.

Community pharmacists are among the health care providers who most frequently encounter clients living with SUDs. In Canada, community pharmacists are the main providers of methadone, the primary treatment of Opioid Use Disorder (OUD). Community pharmacies provide Opioid Agonist Treatment (OAT) programs that primarily dispense oral methadone to facilitate patients’ accessibility to the therapy. Pharmacists working in a community pharmacy with OAT programs are uniquely positioned to encounter patients with SUDs and who use substances for non-medical reasons on a daily basis. In Canada, community pharmacists’ roles in OAT include dispensing and witnessing patients’ consumption of a prescribed dose of methadone.

Easy access and extended working hours make community pharmacists among the most accessible health care providers in Canada. Proximity and accessibility is an impactful combination to initiate and sustain effective strategies to address SUDs [ 8 ]. Pharmacists’ accessibility must also be utilized to deliver substance use preventative services like screening and referral. Community pharmacists have been successful in achieving the goals of many health initiatives, such as smoking cessation [ 9 ] and diabetes management [ 10 ]. Therefore, we would expect that involving community pharmacists in substance use preventative services would help manage and alleviate the negative consequences associated with substance use [ 11 , 12 , 13 ]. Utilizing community pharmacists in harm reduction and preventative services for patients with SUDs is not novel; however, not yet fully exploited [ 14 ].

Therefore, it is critical to closely investigate the relationships between community pharmacists and pharmacy clients who use substances, to recognize the facilitators and barriers towards providing preventative initiatives in community pharmacies. A study by Vorobjov et al., investigated pharmacists’ perspectives regarding substance use and providing services for people who use substances. The study found that pharmacists are willing to be educators for the public and provide preventative services for clients who use substances [ 15 ]. Some pharmacists also recognized opportunities in daily practice to intervene and help clients in the early stages of SUDs [ 16 ]. On the other hand, pharmacy customers with risky alcohol consumption had a positive attitude regarding utilizing alcohol screening services provided by their regular community pharmacists [ 17 ]. In contrary, people who inject drugs reported stigmatized encounters with community pharmacists when purchasing clean needles from community pharmacies [ 18 , 19 ]. Thus, the perspectives of patients who use substances regarding community pharmacists’ services must be further examined so that the provided services match patients’ needs [ 20 , 21 , 22 ], while applying patient-centered care for patients living with SUDs.

In a continuation to our past work in which we probed pharmacists needs [ 16 ], in this study the perspectives of patients who use substances non-medically, or living with SUDs, are explored regarding community pharmacist services and the delivery of care in a community pharmacy setting. The purpose of the study was to 1) explore patients’ perceptions regarding community pharmacists’ delivery of services, including harm reduction, counseling, and referral to community/social services; 2) identify available services and resources for patients who use substances in community pharmacies; 3) identify types of services and resources that are not provided by community pharmacists which patients want to receive, and 4) explore the barriers patients face while accessing care in a community pharmacy.

Setting, recruitment, and selection criteria

The study was conducted in the city of Saskatoon, Saskatchewan, Canada. Saskatoon is the largest city in the province of Saskatchewan (population of approximately 275,000) and is known for its high rate of HIV due to substance use [ 23 , 24 ]. Purposive and snowball recruitment for people who use substances was conducted with support from community-based and harm reduction organizations that have regular contact with people who use substances, namely AIDS Saskatoon, currently named Prairie Harm Reduction ( https://prairiehr.ca/ ) and Station 20. Purposive recruitment is popular in qualitative studies to yield informative cases for the phenomena under study. However, it also limits control over the sample criteria such as age and education [ 25 ]. A poster outlining the research was distributed throughout the organizations from June – July 2016. Participants had to be individuals over 18 and current substance users, or individuals who had engaged in non-medical substance use in the past 2 years (illicit drugs and/or prescription drugs), and accessed community pharmacy services. Ethical approval was obtained from the University of Saskatchewan Ethics Board (Beh#16–256).

Data collection

A qualitative methodology was considered the appropriate approach for this research project. Qualitative studies are used to explore and understand in-depth human-related phenomena [ 26 ]. Qualitative research is used to understand the participants’ lived experiences and develop patterns and relationships between different constructs. The focus group was the chosen method for data collection due to its effectiveness in exploratory studies, especially when interaction among individuals is needed to facilitate discussion and yield a broader range of ideas [ 27 , 28 , 29 ]. Focus groups have become one of the most frequently utilized data collection methods in primary research [ 30 , 31 ]. A discussion guide was developed and reviewed by two researchers of the research team to ensure validity and relevance to the research objectives. The discussion guide was developed to facilitate the conversation in the focus groups. The questions were carefully designed to lead the discussion towards the areas of interest (Table  1 ). There was a mixture of open and closed-ended questions that were tailored to be sensitive, clear, and unbiased.

Focus group procedure

For participants’ convenience, the focus groups took place at a private conference room in a community enterprise center (Station 20) in the west-side core neighborhoods of Saskatoon. All participants signed consent forms and completed a brief survey to verify their eligibility before the focus group. The participants had the chance to ask questions after the consent form was read and explained to them. Participants were informed about the research’s confidentiality, and that no data could be identified or linked to a specific participant. Also, participants were asked to maintain the privacy of other participants and not share members’ information with non-participants.

The focus group discussions were structured using the developed guide to maintain consistency across the multiple focus groups. At least one researcher acted as the moderator to prompt and engage participants in productive discussions during the focus groups while using the questions guide to maintain focus. At the end of each focus group, participants received honoraria ($25 Tim Hortons [a coffee shop chain] gift cards) for their participation in the research.

Data analysis

Four focus groups were conducted with a total of 20 participants (8 females and 12 males) for an average of 1 h per session. All the participants identified themselves as people who use/used substances nonmedically. No participants withdrew from the study. Participants were divided as follows: focus group 1 (7 participants); focus group 2 (4 participants); focus group 3 (5 participants); focus group 4 (4 participants). The age categories of participants were: one participant in the category of 18–24 years old; three participants in the category 25–34 years old; eight participants in the category of 35–44 years old; five participants in the category of 45–54 years old; and three participants in the category of 55–64 years old. Although it was not required, two participants identified themselves as HIV positive, and one participant identified with a first nation status. All participants but one were enrolled in the Opioid Agonist Therapy (OAT) program using oral methadone doses. OAT program in Canada is administered through community pharmacies to treat patients with Opioid Use Disorder (OUD) using several drugs, such as methadone and buprenorphine-naloxone. Community pharmacists must dispense and witness patients consume their daily doses of methadone. Having almost all participants enrolled in the OAT program unintentionally biased the sample recruited for the study.

The number of focus groups was predetermined to be four for this study, as a range of 3–5 participants per group is considered an acceptable range [ 32 ]. After four focus groups, saturation was reached, and no further groups were needed [ 32 , 33 , 34 ]. The focus groups were audio-recorded, then transcribed verbatim. Using NVivo software, inductive content analysis was performed independently by a research team member (SF) and a research assistant [ 35 ]. The latter was hired as an external researcher to reduce bias and ensure the validity of the analysis. The analysis started with repeated reading of the data transcripts to interpret the data as a whole. The initial coding system looked for all ideas and concepts that were described throughout the data. Similar and related codes were grouped into several sub-categories. The sub-categories were combined into higher-level categories (i.e., generic categories) [ 35 ]. Generic categories are the main themes represented in the results. Each researcher conducted these steps independently. After completing their independent analysis, the two researchers met to compare their coding systems and emergent themes. This iterative process was conducted until an agreement on the main categories was reached. Emerged themes were reported in all focus groups.

Four major themes emerged, and the analysis revealed several recommendations to improve community pharmacy services for patients living with SUDs. The four themes provided insights regarding participants’ experiences and perceptions of community pharmacists as health care providers. They also summarized the participants’ needs that went beyond the pharmacological aspects of treatment. The themes also explained the effect of physical space and the community pharmacy setting on the communication between pharmacists and those with SUDs. Finally, the developed themes described participants’ experiences with the services provided by community pharmacists, particularly harm reduction services, such as needle exchange and maintenance therapy of methadone.

Conflicted experience with community pharmacists

Through daily and weekly visits to community pharmacies, all participants had notable experiences with community pharmacists.. Participants’ visits to community pharmacies were mainly to obtain their methadone and HIV medications. They described community pharmacists as the most seen health care provider, indicating that pharmacists are nearby and have long working hours making them accessible. Paradoxically, pharmacists were described by participants as the health care providers they would be least likely to seek out when help was needed. They elaborated by saying pharmacists have a busy work environment and hardly reply to their questions or consultations.

“Participant A - ‘ I never really thought about going to him [referring to community pharmacist] for support for anything. I always just thought of him as someone serving me just to get the pills and … And, get out.’ Participant B – ‘Get your drugs, and that's it.’"

The main aspects that shaped participants experiences with community pharmacists are listed as sub-themes:

Lack of time was a core problem often reported by participants. They elaborated that community pharmacists are always busy and do not have time to communicate with their patients. Lack of time for appropriate communication, being too busy, and multitasking were common themes across all group meetings . Lack of time was the main reason that participants did not seek medical advice, or help from community pharmacists. Participants expressed that pharmacists did not have time in their daily routine to provide one-to-one counseling for them.

" Probably we don't go to them, like for counseling or whatever because it seems like they don't have enough time, [it] seems like they're so busy. Answering phones for the next prescription. They don't have time to even look at you. And, then when you do get a chance, they'll start and then … Oh, excuse me, I got to get going’."

Profitability

Participants explained that some community pharmacists could be helpful when they have time, but the business model of community pharmacy pushes pharmacists toward profitability. Profitability is mandated by the companies and forces pharmacists to “push drugs” and limit counseling time with their patients, as explained by participants.

"..They have very, very, very little time to spend with patients. As a matter of fact, zero time to spend with patients because their job is to push drugs."

Also, a number of participants articulated that pharmacists are multitaskers as they do not have time to properly counsel patients and provide medication-related information. They perceived that the extent to which pharmacists are required to multitask was harmful to patients’ care, resulting in suboptimal services. For example, several participants reported that the concentration of methadone varies from one time to another because pharmacists are multitasking and cannot stay focused on a specific task.

" Yeah, in [Pharmacy Name and Location], like that's a constant problem with me too. There's always a different pharmacist filling [the] bottles. There's never one person, and it's never the same. I'm always finding my methadone's too, too much.’" " You know, instead of having four different pharmacists doing one methadone … you know methadone for all these people, yeah. It's never constant, and it's always, yeah, I, I find sometimes that my, my methadone's too weak and I get that bone rot.’"

According to the participants, community pharmacists are “overworked, underpaid ” workers who are pushed by their companies to make a profit. Having this perspective of community pharmacy services affected patients’ engagement with pharmacists as they believe pharmacy services is a money-making business that endeavour to maintain power and control over the patients they serve.

"I truly think it's a power/control issue. Extremely, that's what it's become."

Consistency

Participants identified that lack of consistency in pharmacy services negatively affected their experiences in community pharmacies. Participants reported that dealing with a different pharmacist each time prohibits building trust and meaningful relationships with pharmacists. Having different pharmacists providing regular services like methadone, HIV, and Hepatitis C medication prevented the feeling of familiarity with the system and alienated patients.

"Yes, that's exactly what the problem [is] … There's always a different pharmacist doing something. Right, one pharmacist for methadone, period. That would be great. That way that pharmacist knows who's, what, where, how, when and why."

Lack of consistency in pharmacy procedures was also a concern for participants. For example, it was not clear for participants why some pharmacies would provide them with over-the-counter medications that contains opioid, such as a medication that contains acetaminophen with codeine (an opioid), while other pharmacies would deny it. Similarly, it was upsetting for participants that providing pamphlets containing information about their medications and illnesses was not a regular practice at all pharmacies. The following conversation took place in one of the focus groups:

"Participant A – ‘You know what is weird … because of my methadone, uh, some pharmacies will sell me ones [a medication that contains codeine, an opioid] , and some other pharmacies will not sell me ones.’ Participant B – ‘Yeah, I am wondering how come other pharmacies will sell me them? And, I have asked them too, like, why do you guys do this … like, are you purposely giving me a hard time? Because other pharmacies do it, no problem.’"

Participants suggested pharmacies hire more pharmacists to improve services. Participants believed that if pharmacies were properly staffed, pharmacists would have more time to answer questions, improve consistency, and augment the quality of the provided services.

"You know, it's, it's constantly like that. That's why if they got one pharmacist for the methadone, HIV, Hep C, whatever. Then, that pharmacist is just doing that job and able to answer questions for you. Then, that, I would feel much better about all pharmacists. But right now, when go I see my pharmacist, I got no time for them either. Cause, why? They don't, they look at you, they sneer their nose down at you, or whatever and then have a nice day."

Positive encounters

An interesting observation occurred when participants from different focus groups shared positive stories of the same pharmacists. A number of pharmacists, known by name, were able to provide a positive experience to multiple participants. Polite, genuine, friendly, and caring were the main characteristics of the pharmacists who created positive experiences for participants. Participants perceived that those pharmacists sincerely cared, tried to put their patients' health first, and never let them go without the necessary medications. The following conversation took place in one of the focus groups:

"Participant A –‘certain pharmacies are good, like, it depends on the pharmacist. Like, [Pharmacist Name] was an awesome pharmacist … ’ Interviewer – ‘What, what makes [Pharmacist Name], a good pharmacist?’ Participant A – ‘Well, his attitude.’ Participant B – ‘He cared about people.’ Participants A – ‘He actually cared.’ Participant C – ‘He, like, he mingled with the people, you know.’ Participant A – ‘He never ever let me go without my medication.’"

Lack of knowledge concerning community pharmacists’ extended services

Participants showed a lack of knowledge regarding the scope of services community pharmacists could provide. It was surprising for participants that community pharmacists are able to provide services beyond dispensing medications. The role community pharmacists provided for them has been limited to the dispensing of medications, namely methadone and HIV medications. However, even the dispensary services were reported as suboptimal because of pharmacists’ multitasking and poor communication.

"I always just thought of him as someone serving me just to get the pills and get out."

While another participant mentioned:

"The only reason, the only reason I use a pharmacist … they go get my, my product."

The limited understanding of community pharmacists’ roles, services, and responsibilities created a communication barrier for the patients when accessing pharmacy services. A lack of knowledge about the services pharmacists provide discouraged participants from seeking help and other services beyond dispensing medication. When a pharmacist offered additional services such as dose adjustment or medical advice regarding their drug regimen, participants felt annoyed as they believed pharmacists were overstepping their role and delaying the dispensary services. Participants stated that understanding the broad scope of a pharmacist’s role would facilitate information exchange between patients and pharmacists.

"I did not even know that they could do all that stuff because … they never … showed that they could do all that stuff."

Another participant reported:

"And, the pharmacist will sometimes say that, uh, I really do not think you need this medication, or it should be lowered, or something like that. And I do not think that it is their job to be doing that and when it comes to the doctor … I mean, when the doctor prescribes it, they should just be following what the doctor orders."

However, once participants became aware of the impact community pharmacists could provide, they showed interest in accessing additional services if offered by community pharmacists. Some participants indicated that their pharmacy uses posters to promote different services they provide. Stronger relationships appeared to be formed between patients and pharmacists when patients accessed additional services via community pharmacies.

‘Well, like at my pharmacy, they post up posters........, Like, even when I've been sick when it happened on a weekend when it hasn't been a doctor, they can look up stuff that … if they can give me something, they can give me something until I can get to a doctor. I think I've been through that system three times already and I think it's pretty good.’

Another participants added

‘Yeah, that's how [Pharmacy Name] in Winnipeg … when I was in Winnipeg, that's how they were. Like, they're very like one-on-one basis. Like, they care for you. like they knew when something was wrong with me and they come up to me. Because I have mental health issues. And, so they know, like, I'd be off balance and stuff like that.’"

Compared with other pharmacies in the vicinity, one specific Saskatoon pharmacy was identified across all focus groups as offering multiple services, resulting in a higher number of positive comments. Most participants recognized the “one-stop-shop” as convenient as most of them do not have transportation. It was the only community pharmacy in Saskatoon that has a unique patient-friendly arrangement, whereby participants were able to receive more services than what a usual pharmacy provides, including access to a nurse practitioner, a doctor 2 days a week, and a counselor. The pharmacists working in this pharmacy were also able to provide a positive experience for most of the participants.

"In my pharmacy my methadone doctor comes on Tuesday [s]. And, we got nurse practitioners, in the building. And, it's open all week too. Other things like talk to the counselors there, and … we have all of that [Pharmacy Name]."

Negative experiences in OAT program

Enrollment in an OAT program was the predominant reason why participants accessed community pharmacy services. Almost all participants were enrolled in an OAT program, and those experiences appeared to shape their perspective of community pharmacists. Participants were glad to have the advantage of accessing the program that helped them manage their SUDs. However, the way the OAT program was operated generated negative feelings and experiences among most participants. Several participants showed frustration with the idea of methadone as a lifelong commitment. They believed that it creates a power disparity where pharmacists “control how [their] health is right now.”

The negative experiences about methadone were centered around pharmacists’ attitudes, pharmacy settings, and unclear procedures.

Pharmacists’ attitude

Although participants reported a few positive encounters, most of the participants’ comments were characterized as unfavorable, describing both stigma and discrimination. Participants felt that pharmacists’ attitudes showed prejudice. Those negative feelings were combined with participants’ beliefs that pharmacists do not understand the hardship they are going through to stay on the OAT program. They explained the difficult lifestyle they have as drug users and the significant effects of unforeseen events like a death in the family or a house fire. Despite all their sufferings, patients felt that pharmacists did not offer proper assistance and are finding different reasons every time they visit to cut them off methadone. For example, losing methadone bottles, coming late to their methadone appointment, being rude to pharmacy staff have been reasons cited by a pharmacist to refuse to give them their methadone dose. Participants believed that community pharmacists lack sincere compassion and enact barriers for them because they are on methadone.

"Right. And, you got these people looking at you. Oh, you're on the methadone program. You're a user. You're garbage. That's how you feel because that's the response you get from all the people."

Another participant elaborated on how they felt abandoned

"No, health region helping us. I have some people hitchhiking on the highway, coming to get their methadone because the pharmacist won't give them a week or two days or three days."

A third participant explained how pharmacists can’t feel them

“Because they haven’t been in my shoes before, they don’t know what I’m going through. They’re not … they read books and think that they know everything.”

Participants also believed that they are being discriminated against and treated differently than other clients because they are engaged with the methadone. Participants reported that being on methadone or having HIV or Hepatitis C evokes negative attitudes and behaviors from community pharmacists. Participants expressed that pharmacists’ body language changes once they know that a patient is a methadone client. For example, they feel because they are methadone clients, they are ignored, stigmatized, and pushed aside in favor of serving other clients.

" We shouldn't feel discriminated against because we're sick … and, a lot of these pharmacists do that. They will look at you, … like if they know that you're Hep C or HIV. Right, they're automatically … just will not touch you. … their language, … eye appearance. … Their facial expression.”

Participants recognize how challenging the work environment is in community pharmacies. They explained that pharmacists provide services to a wide range of clients and that some methadone clients are rude and obstinate. They understand how stressful it is for pharmacists to validate the information provided by a SUDs patient as some patients may provide misleading information to break the rules. It was recognized that pharmacists’ behavior might be justified based on previous negative encounters with other methadone clients. However, participants felt that pharmacists should not judge all methadone clients negatively and should “ treat people how [they] want to be treated. ”

Pharmacy settings

Pharmacy settings for methadone patients were described as unwelcoming environments that made them feel uncomfortable, especially with pharmacies that designated a separate entrance and space for methadone patients. Using a different back door and dealing with pharmacists through a glass barrier was an upsetting experience for participants. Participants felt alienated because they had to access their services differently than other clients. In other pharmacies, the situation is less traumatic, but methadone clients were still treated differently and “pushed” aside to wait, unlike other clients.

" … even if they had some pictures up, behind [Pharmacy Name], in the back door … there's nothing to make that person feel comfortable. You are in the cold; you're in an enclosed space that's no bigger than this (Participant indicates the size of the space by tracing it out in the room). With a, with a big plexiglass window and that is all you got. There are no pictures. It is always gross on the floor, and you feel like you're in a prisoner's box"

Participants indicated that despite their negative experiences regarding a particular pharmacy setting or pharmacist’s attitude, they did not have the option of getting methadone from another pharmacy. They were forced by their SUDs and their doctors’ referrals to access certain pharmacies. Due to their SUD condition, they needed to utilize a nearby pharmacy, especially when they did not feel well.

Furthermore, the lack of privacy was reported as a communication barrier by different participants. Participants did not like to discuss and share sensitive information about their substance use with community pharmacists in such a public setting. Also, a few participants felt ashamed when a pharmacist discussed their medications and health concerns where others could hear. This behavior was perceived as a breach of confidentiality.

Procedures and policies of OAT

Unpredictability and lack of consistency in the procedures for methadone dispensing was a primary concern for several participants. Various reasons were shared as to why some pharmacists may refuse to dispense methadone, such as being late for appointments, being rude to the pharmacist, missing daily methadone doses for a couple of days, and losing carries bottles. While other pharmacists will provide methadone under the same circumstances as being late for appointment. The worst scenario was when, according to some participants, pharmacists refused to dispense medications without any explanation. Also, participants reported that pharmacists did not assist participants when they have unforeseen events like travel arrangements to attend an unexpected family funeral. It was not clear for participants what the policies were under such circumstances as pharmacists often lacked consistency in such situations. Participants theorized that pharmacists were prejudiced and enforced policy without caring about their patients.

Participants shared incidents of when they suffered from withdrawal symptoms after receiving their witnessed daily dose of methadone due to inaccurate dosing or because they vomited the dose. Participants explained how they felt abandoned as pharmacists did not help while witnessing their suffering. They explained the pharmacists did not replace their dose until they contacted a doctor. The situation sometimes resulted in the replacement of the methadone dose; however, other times, participants’ doses were not replaced. Participants felt controlled by pharmacists who may find different reasons not to give them their methadone carries – take-home methadone doses - or even their daily witnessed dose. It was upsetting for participants that pharmacists lacked compassion when enforcing policies and regulations.

Needs from community pharmacists

Participants’ responses aggregated around three main aspects concerning their needs, namely respect, education, and the needle exchange program.

Participants explained that they wanted to receive respectful communication from community pharmacists, similar to other clients. They expressed that they deserved to be treated with respect, politeness, and care and not judged because of their SUDs. Participants also described that they would appreciate it if pharmacists socialized and engaged in friendly exchanges with them. Genuine understanding and respectful communication were the paramount need reported by participants. However, participants also clarified that it might take some time to build trust and form a relationship with them; therefore, the best way to interact with SUDs patients is to be professional, polite, and “ do not force it .”

"If I [were] a pharmacist, I would look at each individual case separately and would not judge a person if they are having a bad day. I would ask them, are you ok? I would direct them, you know, if you need someone to talk to, here is a number, you can go here. There is a job there, you know. There is a lot of help out there; you just got to reach out."

Finally, participants wanted pharmacists to be sensitive to different cultures, languages, and practices, particularly the culture of the Indigenous peoples of Canada. An Indigenous participant described how great the experience would be for an Indigenous patient if a pharmacist showed a sign of cultural admiration.

"They (referring to First Nations peoples) are all flown here to get their drugs. And, they are just, it is intimidating. It is scary as hell, having a pharmacist there, the pharmaceutical company ready to hop on you. They got a whole team of doctors as soon as they get off the plane. Not one of them speaks their language."

Participants acknowledged the need to be educated by community pharmacists regarding their medications, such as toxicity, drug-drug interaction, and drug-food interaction. Health information provision and explanations were one of the main topics discussed across all four focus groups. Learning about SUDs and understanding the effect of the medications on functionality was reported as an essential need. A pamphlet (print-out) with information about SUDs or where to get help was recognized as a great approach to providing information.

"But they got to educate people more … and give them more information about the drugs people are taking. Instead of just prescribing and giving the person their prescription and, you know, go home and take your meds until they are done. And if they are prescribed Dilaudid or morphine, well, two weeks down the road they have no energy, they are sore, and they are sweating and everything. … they do not understand why because they did not get the information from the pharmacy when they started taking this."

Another participant elaborated

"what drugs interact with each other. I think it is a good idea that they should bring it to the drug addict's attention. Like say, for instance, this seizure medication combined with this medication, if you are abusing crystal-meth, it will do this to you, just a heads-up, … people just think that they are drug addicts and they do not care, who cares to let them know, but it's important because some of us are diabetic or suffering with mental illnesses like depression"

Similarly, participants wanted community pharmacists to learn about the difficulties and social hardships they are going through as substance users. Many participants expressed that they wanted pharmacists to understand how hard it was for them to secure basic needs like food, shelter, and transportation. Participants also believed that community pharmacists needed more education and training on SUDs. According to the participants, pharmacists had a knowledge gap concerning SUDs and HIV; thus, they needed to be further educated in order to better serve patients with SUDs.

"They do not know what we are talking about when I am discussing my lab results with them. CD4 count and … viral load. They did not know any of that. You know, just looked at me. They are real puzzled."

The needle exchange program

Several participants described the city’s needle exchange program as a non-effective program because of how it was operated. They elaborated that the operating hours, the quantity of provided syringes, in addition to the limitations of the exchange policy, made the program ineffective when needed. Community pharmacies were not currently providers of the needle exchange program in Saskatoon; however, participants believed they should be. Having community pharmacists involved in the distribution of clean needles would enhance the accessibility of the program, especially on weekends.

"The Health Bus* is done at 11. After 11 and on weekends, you are done. If you do not have a clean rig, well, all of a sudden, you are using one of your used ones. Heaven forbid you would use somebody else's, but I am sure you would not in this day and age. Or, you are sharpening one of yours. I am it is, it is really quite gross. I could go into it. or [Pharmacy Name] could have it … … . could have a mandate of giving out five."

* Health Bus is a mobile health initiative in Saskatoon. It is designed to bring health care services to people and is staffed with nurse practitioners and paramedics.

This study’s main goal was to understand the perspectives and experiences of patients living with SUDs about community pharmacists as health care providers. The study’s findings suggested that the participants’ experiences with community pharmacists are generally negative, with many interactions lacking proper counseling and support. Similar to other studies, lack of pharmacist time [ 36 ], stigma [ 37 ], lack of privacy [ 38 ], and need for additional education for pharmacists [ 16 ] were mentioned by participants among the barriers to accessing care in a community pharmacy setting. Some of these issues may overlap with the needs of other customers out of the SUD population. However, understanding SUD patients’ needs are required so that changes within the pharmacy profession is driven by evidence to eventually change the culture impacting SUD patients. We acknowledge that the business model is playing a key role in the patient-pharmacist interactions; however, this is out of the scope of the study and will to be investigated in a future study.

Supporting the notion that the public is often unaware of pharmacists’ full spectrum of services [ 39 , 40 ], participants shared their limited understanding of community pharmacists’ role beyond dispensing. Community pharmacists are not practicing the full potential of their role in caring for people with SUDs; therefore, it is not recognized by pharmacy consumers [ 41 ]. Community pharmacists are trained to provide extended services beyond the traditional model of pharmacy that focuses on filling and dispensing medications [ 42 ]. However, many barriers are hindering pharmacists from practicing their full capacity. Participants reported pharmacists’ lack of time as the main reason for not recognizing or accessing pharmacists’ extended services. Lack of time was also reported in other studies [ 36 ]. Pharmacist-patients relationship is “ritualised.” “Ritualized” relationship means that it involves well-known typical interactions. Based on previous encounters, pharmacists’ consumers, including people living with SUDs or consume substances, may not expect advice, help, or counseling from a pharmacist concerning their conditions, making it hard for pharmacists to initiate a conversation and change the ritual. Likewise, it may be challenging for patients to understand pharmacists’ extended role and seek their assistance [ 43 ]. To change the encounters between patients and pharmacists, the business model, guidelines and policies should encourage pharmacists to practice their responsibilities and set proper remuneration for such services [ 44 ]. Pharmacists’ roles and responsibilities should be clearly defined for pharmacists and promoted among patients. Also, to change or enhance this relationship, environmental contextual cues like promotional posters and pamphlets would encourage pharmacists and patients to utilize these services, as reported previously [ 45 ].

While patients’ satisfaction is an integral element for patients’ retention and adherence to the OAT program [ 46 ], the overall experience of participants with the OAT program in Saskatoon was mostly unfavorable. Poor communication, an unwelcoming environment, lack of counseling, and lack of proper information were the primary reasons cited by participants for their negative experiences. Also, participants reported that the lack of transparency in the OAT program policy and procedure added another layer of communication barrier. In fact, it was not clear to the participant if they are facing pharmacists’ judgment or difficulties due to policy and guidelines. In addition, the business model is another possible contributing factor that must be investigated in the future. Providing counseling and being respectful during patient-pharmacist encounters are referenced as the participants’ primary needs from community pharmacists. Educating patients regarding their health conditions and meeting their needs is already proven critical for positive treatment experiences and subsequent treatment outcomes [ 47 , 48 ]. Comprehensive substance abuse treatment, which addresses patients’ health and social needs concurrently with pharmacological treatment, leads to a significant reduction in post-treatment substance use and improved patient satisfaction [ 49 , 50 , 51 ]. Evidence indicates that applying SUDs preventative measurements rather than palliative care can reduce cost on the health care system [ 52 ]. Nevertheless, failing to meet patients’ needs in substance use treatment is a persistent problem [ 53 ]. For example, vocational training, child care, transportation, and housing are among the principal needs that have enhanced patients’ treatment outcomes [ 21 ], and many treatment programs still lack an adequate referral system.

Also, participants expressed that pharmacists’ attitudes and the stigma toward SUDs were a barrier to proper communication. The stigma toward SUDs, which has been found to exist among health care providers [ 37 ], remains a key barrier to accessing health care services and treatment [ 54 , 55 , 56 ]. Health care providers, including community pharmacists, should be aware of the stigma, its consequences on people’s physical and mental health, and should try to find new methods to limit its negative impact [ 57 ]. In contrast to the many negative encounters, some pharmacists were able to provide a positive experience for participants. Non-judgmental communication was the prevailing characteristic among community pharmacists who provided positive experiences for participants. This finding supports the integral role of social relations and support for the recovery and treatment retention of patients living with SUDs [ 58 , 59 ].

The following recommendations can be drawn from the current study: there is a need for 1) community pharmacists to become public health advocates and sources of medical advice, 2) training on communication skills for community pharmacists with additional education concerning SUDs and its social elements, and 3) addressing the identified gaps in the policy, dispensing procedures, and practices of the OAT program.

There are several limitations to this study. Firstly, the findings of this study can not be generalized to other settings. However, these findings can give an indication of the needs and barriers people living with SUDs can have in a small urban city like Saskatoon. Also, sampling was voluntary, which may have influenced the outcome of the study. Sampling was mainly through word-of-mouth (snowball sampling); therefore, the sample is not representative of the whole population of people living with SUDs in Saskatoon. Although the study targeted pharmacy clients who use substances, participants were mostly diagnosed with SUDs and enrolled in OAT. Having most of the clients in OAT may have also skewed the data by represented a narrow segment of people who use substances. However, some findings of the study were supported with similar studies in the literature that endorse the support needs and proper exchange of information between people with SUDs and health care providers [ 17 , 20 ]. In the future, we will investigate the specific needs of subpopulation within SUDs realm, such as injection drug users.

Community pharmacists have a golden opportunity to deliver preventative and harm reduction interventions. Unfortunately, the experience of patients living with SUDs with community pharmacists is often limited to dispensing medications. Patients’ receptivity for the broader range of services community pharmacists can provide are contingent on respectful communication and genuine, friendly and professional conversations. Health care providers, including community pharmacists, should be trained to address patients’ needs while properly delivering patient-centered care for optimum outcomes. Finally, the role of the business model in shaping pharmacist-SUD patient interactions should be investigated in the future to complement the data gathered in this study.

Availability of data and materials

The datasets [i.e., focus group transcripts] generated during and analyzed during the current study are not publicly available but are available from the corresponding author on reasonable request.

Abbreviations

Substance Use Disorders

Institute of Medicine

Human Immunodeficiency Virus

Acquired Immunodeficiency Syndrome

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Acknowledgments

AIDS Saskatoon and Station 20 staff for hosting the interviews in their buildings and supporting the research members while arranging the events. Special thanks to Jason Mercredi from AIDS Saskatoon and Lisa Erikson from Station 20 West for their help and support. Ms. Marla Rogers and Ms. Jessica McCutcheon form the Social Sciences Research Laboratories (SSRL) are acknowledged for validating the analysis and proof-editing the English of the manuscript, respectively. Interview Transcription credited to co-author, Mr. Daniel Bakke.

This project was made available by the generous funding from; Canadian Research Initiatives in Substance Misuse (CRISM) National Study Prairie Node subgrant, Canadian Institute of Health Research and Saskatchewan College of Pharmacy Professionals (SCPP). Also, funding and scholarship for Sarah Fatani were provided by the Ministry of Education of Saudi Arabia.

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SF collected and analyzed the data; co-conducted three focus groups and she drafted/revised the manuscript as needed. SF also helped in the design of the study and in securing funding for the project through CRISM. DB collected data and co-conducted the focus groups with SF and AE; DB also transcribed the focus groups and provided initial rough analysis of the findings. DB provided important suggestions to the draft manuscript. MD is a co-supervisor of SF, providing input in the various stages of the project particularly data analysis. MD also revised the various version of the manuscripts. AE is the PI of the project, conceptualized the project, secured funding for the project, designed the project and is the supervisor of SF & DB. AE conducted one focus group, provided input to the analysis and revised the various versions of the manuscript. The author(s) read and approved the final manuscript.

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Fatani, S., Bakke, D., D’Eon, M. et al. Qualitative assessment of patients’ perspectives and needs from community pharmacists in substance use disorder management. Subst Abuse Treat Prev Policy 16 , 38 (2021). https://doi.org/10.1186/s13011-021-00374-x

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Putting in Work: Qualitative Research on Substance Use and Other Risk Behaviors Among Gang Youth in Los Angeles

Bill sanders.

1 School of Criminal Justice and Criminalistics, California State University, Los Angeles, California, USA

Stephen E. Lankenau

2 School of Public Health, Drexel University, Philadelphia, Pennsylvania, USA

Jennifer Jackson-Bloom

3 Community, Health Outcomes and Intervention Research Program, The Saban Research Institute, Childrens Hospital, Los Angeles, California, USA

Gang youth are notoriously difficult to access for research purposes. Despite this difficulty, qualitative research about substance use among gang youth is important because research indicates that such youth use more substances than their nongang peers. This manuscript discusses how a small sample of gang youth (n = 60) in Los Angeles was accessed and interviewed during a National Institute of Drug Abuse-funded pilot study on substance use and other risk behaviors. Topics discussed include the rationale and operationalization of the research methodology, working with community-based organizations, and the recruitment of different gang youth with varying levels of substance use.

Introduction

Studies on youth gangs have a long tradition of using quantitative and qualitative methodology to examine behaviors such as crime and drug use associated with these groups ( Bursik and Grasmick, 1995 ; Hughes, 2005 ). As with crime and violence, quantitative research has found that gang youth are more likely to report drug and alcohol use compared to their nongang peers (see Sanders and Lankenau, 2006 for a review). Qualitative studies have identified the significance of substance use in the lives of gang youth and contextualized the interrelationship between substance use, violence, and unsafe sexual behaviors. In recent years, qualitative studies about gang youth have examined the significance of cannabis ( MacKenzie, Hunt, and Joe-Laidler, 2005 ), the relationship between substance use and violence ( Valdez, Kaplan, and Cepeda, 2006 ), the connection between using and selling drugs ( Valdez and Sifaneck, 2004 ), and substance use amongst female gang youth ( Cepeda and Valdez, 2003 ; Miller, 2001 ). Similar studies are needed of the relatively novel topics that have emerged in research about substance abuse 1 such as nonmedical prescription drug use (e.g. Lankenau et al., 2007 ) and polydrug or multiple drug use (e.g. Sanders, Lankenau, Jackson-Bloom, and Hathazi, 2008 ). This article identifies qualitative strategies that facilitate conducting research about drug use among youth in gangs.

“Putting in work” is an expression used by gang members in Los Angeles to describe committing criminal activity, such as selling drugs. Putting in work is also an accurate expression to describe the efforts of accessing and interviewing gang-identified youth in LosAngeles for research purposes.Thismanuscript discusses howa sample of gang youth ( n = 60) aged 16 to 25 years from various areas in the City of Los Angeles was recruited into a National Institute on Drug Abuse (NIDA)-funded qualitative pilot study about substance use and other risk behaviors. Topics discussed include the rationale and operationalization of the research methodology, working with community-based organizations, and the recruitment of different gang youth who use varying levels of alcohol and drugs.

Original Research: Aims, Plans, and Rationale

The aims of the research were exploratory in nature, intending to fill critical gaps in the existing research literature about gang youth. For instance, although gang youth are more likely to use drugs and alcohol, very little is known about the extent that such youth suffer from negative health outcomes in relation to substance use behaviors ( Sanders and Lankenau, 2006 ). Moreover, research about addiction, overdose, and cognitive impairment related to substance use among gang youth is relatively scant. Also of importance was the extent to which gang youth were exposed to HIV as a result of their drug and alcohol use. To date, the first and only study specifically regarding HIV among gang youth had recently emerged in Los Angeles. The study indicated that such youth had high rates of participation in risk behaviors and many instances when they may have been exposed to HIV ( Umanm, Urman, Malloy, Martinez, and DeMorst, 2006 ).

The original research plan was to gather data about risk behaviors (e.g., substance use, violence, sexual practices) through in-depth interviews and direct observations with 50 youth, aged 16 to 25 years, who self-identified as gang members, in areas of Western Los Angeles, including Culver City, Venice, Mar Vista, and Santa Monica. The goals were to enroll a fairly equal number of males and females and gang members from a variety of racial/ethnic backgrounds, including Caucasian youth. Moreover, the intention was to recruit gang youth from various locations within Western Los Angeles, which inevitably would result in drawing youth from several different gangs. Western Los Angeles was chosen because of the overall lack of data pertaining to gang youth within these areas despite their longevity and levels of serious violence there (see e.g., Umemoto, 2006 ). Moreover, gang activities appeared to be paradoxical within these areas, since particularly Venice and Santa Monica are regarded as affluent beach communities, and not necessarily gang territories. For instance, in April 2006, median housing prices in Santa Monica were approximately $980,000, and median housing prices in Venice were approximately $1,000,000, 2 which is in sharp contrast to what is generally known about the environments that give rise to gangs.

The research plan was to recruit gang youth into the study for interview purposes through the assistance of community members who work directly with such youth. Also, the plan was attempted to directly observe gang youth inject drugs in order to identify any potential windows of exposure to HCV/HIV through risky drug-injection practices. This methodology was based both on the research strengths of the investigators and the protocols followed in previous and/or current research exercises on high-risk youth, including gang youth ( Clatts,Welle, Goldsamt, and Lankenau, 2002 ; Lankenau et al., this volume; Sanders, 2005 ; Sanders and Lankenau, 2006 ). The in-depth interviews would gather rich data on the patterns of substance use, violence, and unsafe sexual behavior, particularly regarding initiations, frequencies, administrations (for substance use), and contexts (e.g., significance, environment). The interviews would also collect data on the interrelationship between these risk behaviors. The direct observations would attempt to validate information gathered during the interviews on gang youths’ drug-injection practices, and better understand the environment in which injection drug use occurred.

The research plan did not include “hanging out” with gang members. Some investigators have researched gang youth where they live, work, and play—the street, the home, and the neighborhood—and collected the data through close and consistent interactions in these locations over time ( Brotherton and Barrios, 2004 ; Fleisher, 1998 ; Moore, 1978 ; Padilla, 1992 ; Venkatesh, 2008 ; Vigil, 1988 ). These remarkable studies are relatively rare, even within the field of qualitative gang research. Moreover, such studies are time-consuming and usually focus on individuals from one specific gang. Following those examples was deemed infeasible given the limited time and other commitments of the research team (see Lankenau et al., this volume).

Chronology of Research Methodology

The research timeline was September 1, 2005 to June 30, 2007. The first four months of the project were dedicated to developing and programming research questions, obtaining Institutional Review Board (IRB) approval, and pilot-testing the interview questions and protocols. A Federal Certificate of Confidentiality was also obtained specifically for this research exercise to further protect the research participants. Data collection was intended to occur from June 2006 through March 2007, leaving the last 3 months for data analysis.

The data collection unfolded in two phases, though not as originally intended. During phase one, various community members who had worked in some capacity with gang youth were interviewed between January 2006 and June 2006. During phase two, 60 gang identified youth were interviewed between June 2006 and December 2007.

Phase One: Interviews with Community Members

Gang youth constitute a “hidden population” to the extent that their numbers and whereabouts may not necessarily be known ( Sanders and Lankenau, 2006 ; Valdez and Kaplan, 1999 ; cf. Clatts, Welle, and Atilllasoy, 1995 ). Previous qualitative research on gang youth in Los Angeles is scant, reflecting national trends. The most recent investigation of gang youth in Western Los Angeles is based on a decade-old data ( Umemoto, 2006 ). So how do researchers get a sense of the target population without their own prior investigations, and where does qualitative research start with youth who are notoriously difficult to recruit?

A way to overcome the difficulties of qualitatively researching gang youth is through interviewing community members who work with them. These interviews are an important first step toward both locating gang youth within a particular area and finding out more about their involvement in risk behaviors. Within an area known to have gangs, a variety of organizations and individuals are likely to work in some capacity with gang youth. Such individuals would have varying levels of knowledge about such youth and interact with them in a range of ways. An important part of interviewing community members is to identify those who are “wise” ( Goffman, 1963 ) about gang youth in the research area. This term refers to those who, due to their close working proximity, could provide intimate details about the lives of gang youth. Moreover, such “wise” individuals, due to this proximity, might be able to assist the researcher in accessing such youth for interview and observational purposes (cf. Sanders, 2005 ).

Who works directly with gang youth in Western Los Angeles? What level of details are these individuals able to provide about such youth? An important mindset when interviewing community members is to assume nothing, contact as many people as possible who may work with gang youth, and listen carefully to what knowledge these individuals have about such youth. From here researchers should gain a better understanding of gang youth in the area and identify other individuals who work closely with them.

A total of 25 adults from various organizations in Western Los Angeles were interviewed, either in person or by phone. Contact details for these individuals and organizations were gathered from publicly available listings of service providers in the target area, as well as referrals from service providers themselves. The adults interviewed included homicide detectives within a local police division; probation officers; personnel within mental health and sexual reproductive clinics; personnel at relief centers for homeless and substance-using youth; counselors at substance user treatment centers; high school administrators; administrators and outreach workers at delinquency diversion programs, counseling centers, and education and employment programs; personnel at youth activity centers; and adults working at programs tailored for “gang intervention.” At times, some overlap existed between these individuals and organizations. For instance, counseling centers and youth activity centers served as formal delinquency diversion programs, whereby juveniles arrested for nonviolent offences would be required, as part of their probation, to attend classes on anger management or life-skills building. Some adults worked with youth “on the street,” away from the community-based organizations that employed them, and such individuals were often acknowledged as doing something similar to conducting “outreach” work.

By the end of June 2006, all organizations and individuals in Western Los Angeles known to work with gang youth were either contacted or attempt was made to contact them. Of the 25 adults interviewed, only four were able to offer any detailed information about gang youth’s participation in substance use and other risk behaviors. These adults may be considered as “gang specialists” because they worked directly with youth in terms of attempting to steer them away from gang participation and/or reducing their involvement in risk behaviors. The gang specialists worked at a youth and community center, a counseling center, an outreach program for homeless and substance use, and a substance user treatment center. Their ties proved crucial in establishing links between the investigator and gang youth within the research area ( Sanders, 2005 ).

Many of the gang specialists were former gang members who made no attempts to hide this fact. Some of them still considered themselves as “gang members,” but had desisted from offending. One of the gang specialists was heavily tattooed, and, upon our initial meeting, showed the investigator old photos of himself and his former gang friends posing with an assortment of firearms, as well as pictures of “dead homies” in their coffins. Another talked about once drinking alcohol, “getting high,” and then, while heavily intoxicated, carrying out drive-by shootings with shotguns and rifles in rival gang territories. Others talked about being shot, shooting others, selling drugs and guns, being incarcerated, and their past lives in the gang. The combination of stories, appearances, and their current working conditions left little doubt over their past gang ties.

During the course of the research, several gang specialists working in various parts of Los Angeles were arrested for serious criminal acts. Two of these incidents were reported in local newspapers, and an additional one was revealed to the investigator by the specialist. In one case, a gang specialist was arrested with a large amount of crystal methamphetamine. Another was arrested on weapon charges, and his children, who worked along with him, for violence charges. Another gang specialist confided to the investigator about his arrest for multiple violence charges. In his words, he had “relapsed” back into gang life, if only temporarily.

Other gang specialists were seen with suspicion by the members of the community. Several individuals from various organizations across Los Angeles suspected one intervention program for its involvement in criminal activities. Below is a field note based on the conversation with a probation officer, who had been working near the suspected intervention program for over 12 years:

Also, she told me she believed that [gang intervention program] was a front for gang activity. She thought that the [community] center on [location] acts as a safe haven where gangsters sell drugs (crack), but that it’s viewed as a youth center aimed at gang intervention. She was a bit upset that the City had allocated themoney to the center, and then see it turn into such a haven. She also told me that the big guy who I met last month at the [organization’s] meeting was, in fact, a member of [adult criminal syndicate]. She said that he was able to skirt around the gang injunction—where two members of the same gang cannot meet up—by saying that he is doing counseling for gang youth. . .She doesn’t believe any of it.

On two occasions, organizations that worked directly with gang members declined requests to assist recruiting youth into the study. In one instance, the head of a youth service organization indicated that time constraints or concerns about the interviews conflicting with their working schedules were the reasons for their refusals. She offered encouraging remarks about the research and apologized for her helplessness. In another instance, the head of a gang intervention program refused to help unless paid thousands of dollars as a “collaborator” on the project, as indicated in the field note given below:

I talked with [specialist] today. He essentially said that his organization is not going to put me in touch with any gang youth unless they get paid. He kept on saying ‘collaboration’, meaning that I should’ve created some way to put [their organization] on payroll.

The four gang specialists who agreed to help in the recruitment of gang youth worked at four different locations within the selected research area. The specialists agreed to contact gang youth and to arrange interviews. Based on these commitments, the second phase of the research commenced.

Phase Two: Interviews With Gang Youth, Part One

Between June 2006 and October 2006, 15 interviews with gang youth from various parts of Western Los Angeles were completed. All interviews were digitally recorded and scripted using Questionnaire Design Studio—a computer program that manages interview responses. The interviews were straightforward, without any incident, and were conducted in secure and private locations, where the gang specialists worked. All interviews were anonymous, and neither the youths’ name nor the names of their gangs were recorded. Interviews normally lasted from 1 hr to 90 minutes, though some were slightly longer. All youth signed consent forms and were read their rights as research participants. All interviewed youth received $20, a packet of five condoms, a referral sheet listing various services within the research area, and the investigator’s contact information.

The interviews with 15 youth in Western Los Angeles was a very slow process, which lasted for over 4 months. During this period, three of the four gang specialists who agreed to help were able to assist in the youth recruitment. Part of the data collection lag stemmed due to relatively small number of youth who met the enrollment criteria. For instance, in several cases, the youth were gang-identified, but too young (under the age of 16); were former gang members; were not gang-identified, but had friends who were part of a gang; grew up in a family of gang members; or a combination of these. Finding youth who currently self-identified as gang members and could have their age and gang identification verified by adults who had worked with them proved difficult. Given the current pace of data collection, the goal of interviewing 50 gang youth within the remaining protected research time appeared improbable. Therefore, the decision was made to expand the research, and an attempt to interview gang youth in other areas of Los Angeles as well.

Change in Research Plan

The new research plan was to increase the sample size to 60 and to interview an equal number of gang youth from the four different areas: Western Los Angeles; Eastern Los Angeles (Boyle Heights, Lincoln Heights, East Los Angeles), Southern Los Angeles (Inglewood, Compton, South Los Angeles); and areas of the neighboring San Fernando Valley (e.g., Pacoima, Canoga Park).

Between July 2006 and October 2006, approval was sought from NIDA to expand the research, and the IRB was informed of the new protocols. During this time, various individuals and organizations, known to work directly with gang youth, were contacted in Eastern and Southern Los Angeles. Gangs are associated much more with these new research areas in comparison to the parts of Western Los Angeles (see Advancement Project, 2006). Concomitantly, many more individuals and organizations were found to be working directly with gang youth in these areas. Attempts were made to establish links with individuals and organizations in the San Fernando Valley, but a series of problems precluded research relationships, and the plan to collect data was eventually abandoned there.

Five organizations in Eastern and Southern Los Angeles and two additional in Western Los Angeles agreed to assist in the recruitment of gang youth into the study. As with the initial four, who agreed to assist in data collection, the individuals from these organizations could be considered “gang specialists” to the extent that their work was largely directed toward gang-involved youth. Three organizations contacted in the new research areas refused to assist in data collection, and offered reasons very similar to those in Western Los Angeles: They expressed either having little time to help, but offered encouragement and support, or required substantial payment for their cooperation. Below is a field note excerpt regarding the latter type of refusals:

[Name] of [organization] has decided not to help me. He said he wouldn’t do the interviews for anything less than $100.

The new revised research plan was to enroll an equal number of youth per area—20 in each of the three general research areas of Western, Eastern, and Southern Los Angeles—as well as an attempt to have a sample diversified by age, gender, and race/ethnicity. By November 2006, data collection with the youth was resumed.

Interviews with Gang Youth, Part Two

Data collection took longer than originally anticipated, and a 1-year, no-cost extension granted by NIDA allowed for the continuation of data collection and analysis until June 2008. In early December 2007, the 60th and the final interview was completed. Similar to the initial 15 interviews, the remainder of the interviews were straightforward and without incident. All interviewed youth received the same incentive and followed the same protocols.

In the end, 14 individuals from 11 organizations that had worked in some capacity with gang youth helped enroll 60 youth into the study: 20 gang youth from Western, 19 from Eastern, and 21 from Southern Los Angeles areas. While gang youth generally resided nearby the agency referring them, in some cases they lived relatively far away. For instance, one gang intervention program in the Eastern Los Angeles worked with gang youth from the Southern area. Likewise, the anti-violence program in Southern Los Angeles worked with some gang youth from the Eastern Los Angeles. Data collection in the Western area recruited some youth from the Eastern and Southern locations.

All of the youth recruited into the study had some sort of relationship with the service-providing organization, some of which stemmed from the youth’s desire for a change. Authorities required others to participate as a result of being caught for criminal offences. Table 1 shows by research area the type of organization that helped enroll gang youth, the number of youth recruited from there, and whether the youth volunteered or were court-ordered to attend the organization. Overall, six different types of agencies helped with the study, and nearly equal numbers of these youth either had volunteered to participate in these organizations ( n = 31) or were court ordered to do so ( n = 29).

Recruitment of gang youth by organization type, location, and volunteer status

Organizations from which youth volunteered to participate employed adults who interacted with the youth “on the street,” and attempted to steer them toward positive life-style choices. Others were youth and community centers, where youth came to the centers for recreational purposes (e.g., playing sports, writing music, rapping). The final one was an employment center, generally established for youth seeking to leave the gang.

In other instances, youth were court-ordered to attend programs offered by organizations. Essentially, the counseling center and the intervention organizations were all linked to youth probation. Youth who attended these programs were enrolled in delinquency diversion programs. Such youth had been arrested for nonviolent offences and were enrolled in these programs as a substitute to more punitive penalties (e.g., incarceration). The alternative school enrolled youth as a result of their previous involvement in the juvenile justice system. Also, the youth at the treatment center were court-ordered to attend through California’s Proposition 36, which mandates some form of drug user treatment 3 for those arrested for nonviolent drug-related charges.

Observations

Direct observations were not recorded among gang youth for a couple of reasons. For one, none of the recruited youth were injection drug users. Watching the processes of drug injection, with a focus on identifying any windows of exposure to HIV and HCV, was a driving reason behind attempting direct observations. Also, attempts to interact with gang youth in their own environments were unsuccessful. Youth and community organizations invited the investigator to several barbeques and sports events held at local parks with the idea of potentially contacting gang youth directly. At such events, some gang members were approached, but they would not talk about their participation in risk behaviors, let alone about their lives in the gang. Moreover, the gang specialists generally advised against the idea of attempting direct observations. The specialists said that the youth would unlikely to share such experiences with relative strangers. They also indicated, how such associations might arouse suspicion among other gang members in the area. Specifically, they believed the investigator would be misidentified as a police officer, and that, for these youth, being seen with any police connection could seriously jeopardize their well-being.

Other observations, however, did contribute to the research in important ways. One of these concerned the location of service providers within the areas where gang youth reside. Such observations were beneficial during the interviews, when asking the youth about their knowledge of such providers. For instance, during an interview, one youth, when asked about sexually transmitted infections, admitted that he had been suffering from one for the past 2 years. At that point the interview was stopped and the youth was informed that a reproductive health clinic was approximately 100 yards away, and that he would be eligible to receive free treatment because of his low socioeconomic status. An appointment was arranged, and the youth’s infection got cured. In other cases, youth were unaware of substance user treatment centers, counseling centers, or job-placement programs within their local area. If no time had been spent within the communities recording details about such service providers, the youth might have continued to remain unaware of such services. Such details were recorded in field notes, transferred into aWord document on a computer, and utilized in the development of the referral sheets given to each youth enrolled in the study.

Being Reciprocal

When interviewing adult community members, those who work with gang youth expressed how researchers often “take” but do not necessarily “give.” More importantly, after the research is completed, individuals who had helped the researcher access the gang youth rarely see the research results. “What good is research? You guys have everything you need to know,” was occasionally expressed. In order to counter this issue in the current research, reciprocity was attempted. Reciprocity here refers to efforts made to give back time and effort to the centers or individuals who had helped access gang youth. This occurred in several ways. One was to conduct workshops for youth regarding crime, violence, substance use, and unsafe sexual behaviors at intervention and delinquency diversion programs, and for adults at community centers. Another was writing letters of support for intervention programs renewing or starting their charters, or letters of character reference for the gang specialists regarding the importance of their work. Finally, the investigator “hung out” at youth centers, counseling centers, and gang intervention programs to offered general assistance (cf. Valdez and Kaplan, 1999 ). Attempts were also made to clarify the intentions of the research, and acknowledge that, while gang research has accomplished much, a great deal of information about such youth is simply lacking 4 . For instance, certain issues related to substance use among gang youth discussed earlier are unknown. Such explanations and interactions establish and foster relationships and trust between academics at universities and individuals at community and service provision centers.

Maintaining Safety

Interviews for this project were primarily conducted indoors, in private settings, usually in some unused room or space in the center, where the adult who referred the youth worked. Several of the interviews, though, were conducted in restaurants within the immediate vicinity of such centers due to lack of available space. On occasion, interviewing youth outside these centers became somewhat problematic.

One thing many of the youth talked about was the omnipresence fear of violent death and having to constantly “watch their backs” for attacks by rival gangs. Public settings were where these killings might occur. One youth, for instance, discussed his reluctance to take the bus because, as he rationalized, by sitting at a bus stop on a main road he could be targeted by rival gang members who might shoot him:

I can’t take the bus. I never take the bus because I don’t like sitting at a bus stop. That’s the one way you can get shot. If you’re sitting at a bus stop, someone is going to drive-by, they’re going to see you waiting at the bus stop and what happens? You’re a sitting duck. They’re going to run up on you. . ..You have no idea, they ain’t going to tell you nothing. They probably already know who you are because you put yourself out there, you’ve been to jail. So they just be like boom , smooth run up and that’s it. You’re dead [Interview #4]

Restaurants, too, are public settings where a gang youth might be seen by those who wish them harm. For instance, a gang youth might be observed being interviewed by a researcher at a restaurant by rival gang members. Then the rivals might decide to commit a drive-by shooting against that youth placing the researcher at unnecessary risk of injury or death. The safety of both the researcher and gang youth is better ensured if interviews are conducted in private settings in secure locations. The centers where the gang specialists work were ideal locations for this research.

An additional benefit of conducting interviews with gang youth in private and secure locations concerns avoiding curiosity generated by the interview process and the antagonism that might arise out of such curiosity. The interviews with gang youth were conducted with the aid of a laptop and were recorded digitally. Gang specialists often worked from the centers that were located within the areas known for gang activity, and the restaurants where some of the interviews occurred were near such centers. Interviewing a gang youth in a restaurant in the area having a long tradition of gang activity, with both a laptop computer and a digital recorder, in plain view during the interview itself might draw unnecessary attention. This is compounded when the investigator is a 6 feet tall, bald Caucasian male in his early thirties (as is the case with the investigator), and the interviewee an African American or Latino teenager, who often appeared to be a gang member (i.e., baggy clothes, tattoos, etc). In a couple of instances, arguments ensued. The field note given below captures one such instance:

I went and interviewed [#43] today at a [restaurant] near his home. He was keeping an eye on others coming in, and one of these people was a middle-aged woman who seemed a bit out of it, perhaps on drugs. She was commenting about the interview to the respondent. The respondent then said, ‘Do you know where you are? Do you know who I am? I can make a couple of calls.’ – something like that. She then made some more comments, left the restaurant, and then went wandering out across the street against traffic.

Nothing physical transpired during these events, but the potential was obvious. Again, such experiences suggested, in-depth interviews with gang youth should be conducted best in more private settings, so as to avoid the possibility of dangerous curiosity and altercations with random third parties.

Accessing Gang Youth With Various Levels of Substance Use

The methodology was able to unveil some relatively unexplored topics on substance use among gang youth. For instance, many were found to have used a variety of prescription drugs nonmedically, especially Vicodin and Codeine. Many also discussed mixing substances together, particularly cannabis and alcohol, but also these two and one other illicit drug (see Sanders, Lankenau, and Jackson-Bloom, 2007 ). Smoking cannabis joints containing crack cocaine, referred to as “P-dogs” among Latino gang youth, was also common. 5 Some polydrug combinations were more extreme. For instance, one youth discussed the combination of a variety of drugs into what he referred to as a “ghost buster.” This was “a [cannabis] joint, with [crystal], heroin, coke, some [crack], roll it up and dipped . . .in PCP.” Substance use was also linked to violence, particularly individual and collective fighting, as well as unsafe sexual practices, particularly “group sex.” Such sexual activities involved three (and often more) individuals simultaneously or sequentially. Substance use was also related to the youths’ arrest histories. Over one-third (35%) of the youth have been arrested for substance use possession, which at times was associated with more serious arrests. Below, one youth discusses how smoking cannabis was related to his arrest on weapon charges:

I was riding in a car. . .and [the police] stopped us and I was kind of tripping because I had weed on me and [my friends] were smoking. And then I was like ‘Damn, we’re going to get arrested and shit.’ And then [the police] come and they see the whole smoke come out [of the car] and shit. Then they get us out and they start checking us and they find the weed. They find three of the blunts in other people’s pockets and they start searching the car. They found a.357 Special, a.38, a.22, and a Tech 9, too. [Interview #6]

Within hours of each interview, details about the youth were recorded on a tracking sheet. The purpose of this tracking sheet was to keep brief notes about the youth, such as their age, ethnicity, gender, and general area of residence (e.g., West, East, or South), as well as the community-based organization who assisted in recruiting that particular youth. The sheet allowed any unique characteristics about the youth that emerged during the interview to be recorded. Additional purposes of the tracking sheet were to obtain an overview of their reports of substance use and participation in other risk behaviors. This data assisted in determining the association of certain behaviors with the type of community organization that helped recruit them into the study.

Each youth was scored on a scale between zero and four checks on the tracking sheet based on the investigator’s immediate impression of how the youth answered questions about risk behaviors. No check was equal to none or minimal participation, and four checks were equal to the extreme participation. Table 2 is a modified version of the tracking sheet that indicates the youths’ self-reported drug and alcohol use by area and type of organization that helped recruit them into the study. Regarding alcohol and drug use, no check refers to youth with any history of substance use, or those who had experimented with alcohol and cannabis once or twice in their lifetime. One check refers to occasional (e.g., once or twice a week) use of alcohol and/or cannabis and having tried “hard” drugs (e.g., crystal methamphetamine, ecstasy, crack, and powder cocaine) once or twice in their lifetime. Two checks refer to youth who frequently used cannabis (i.e., more than three times a week) over the past 30 days, and had tried a variety of other drugs, including prescription drugs, more than three times in their lifetime. Youth who reported regularly mixing of cannabis and alcohol use were also given two checks. Three checks refer to gang youth who used cannabis daily over the previous 30 days, and reported occasional but consistent use of other drugs over their lifetime. Such youth also reported occasional use of alcohol and/or cannabis alongside “hard drugs” simultaneously or sequentially (i.e., polydrug use). Four checks refer to youth who reported seeking treatment for substance use, previous and/or current daily alcohol and cannabis use, and the consistent use of a wide variety of other drugs over their lifetime, including polydrug use.

The investigator’s post-interview impression of respondents’ level of substance use by area

Note : R = respondent number; CBO = community-based organization; Outreach = outreach work; Youth/com. = youth and community center; Counseling = counseling center; Alternative = alternative school; Intervention = intervention program; Employment = employment center. Respondents are numbered to 63 as three respondents were excluded from the study.

x = one check, xx = two checks, xxx = three checks, xxxx = four checks.

Table 2 indicates the impression of the investigator about the respondents’ drug risk level by the geographical location and the type of community-based organization. Several general observations were made. Gang youth recruited from the alternative school program, employment center, and the substance user treatment center had relatively extensive histories of high-drug risk behavior compared to those recruited from the youth and community centers. Geographical location also has an association with the level of drug risk behavior. Outreach recruitment in Southern Los Angeles yielded considerably more gang youth with extensive drug histories than it did inWestern Los Angles. Furthermore, youth recruited in intervention programs in Eastern Los Angeles and Southern Los Angeles had similar levels of drug use-related risk behavior histories. In overview, both the type of community-based organization and its geographical location are associated with the level of drug use-related risk history of the gang youth that were recruited.

Qualitative Research on Gang Youth in Los Angeles

The difficulty of conducting qualitative research with gang youth in the City of Los Angeles is best reflected by its relative scarcity. Despite the longevity and significance of gangs in Los Angeles, this research is one of the handful of qualitative studies ever conducted in the region that directly speaks to gang members about their substance use (e.g., Harris, 1983 ; Fagan, 1989 ; Moore, 1978 ; Vigil, 1988 ).

The research team has now generated its presence in the area, and relationships have been established with various individuals and organizations throughout Los Angeles that work directly with gang youth. This pilot study, while important in its own right, was also intended to be one in series of public health-related research on gang youth. Future studies surely will benefit from the relationships established in the course of the current project.

An important aspect of the research was the attempts made to ensure that the youth enrolled into the study were bona fide gang members, as well as targeted within the appropriate age range (i.e., 16 to 25 years). All youth enrolled self-identified as gang members, and this identification was confirmed by the adults who helped to recruit them. Those adults also confirmed the youths’ age. The assistance of various community members allowed for the recruitment of gang youth from a variety of gangs throughout Los Angeles, gang youth of different ethnicities, and gang youth with differing experiences of life in the gang.

Study’s Limitations

The limitations of themethodology employed in this project are inherent in many qualitative studies. Findings from the sample cannot be generalized and do not claim to be representative. The 60 gang youth are a convenience sample, being both somewhat connected to a service-providing organization and also agreeing to be interviewed. As with other studies on sensitive research topics, particularly those in which the youth may feel ashamed of their previous behaviors, socially desired responses might have emerged, somewhat skewing the research findings (although see Webb, Katz, and Decker, 2006 ).

The study failed to obtain the desired variability in age, gender, and race/ethnicity of the sample. Out of the 60 youth, only 10% ( n = 6) were women, 18.3% ( n = 11) were aged between 20 years and 25 years, and largely identifying as African American or Latino with a few identifying as Latino/Caucasian or African American/Caucasian. Asian, Native American, Pacific Islander, and other gang youth were not recruited into the study because the investigator was not introduced to any, and the only Caucasian gang male located declined to be interviewed. In this and other aspects, both refusals and recruitment locales somewhat shaped the sampling biases, as some gang youth were more difficult to recruit than others. For instance, four of the six refusals from community organizations were from those that conducted “outreach” work with gang members. The outreach workers that refused to assist with the research had contacted “older” (i.e., 20 to 25 years old) gang youth, who generally had relatively higher histories of substance use and participation in risk behaviors. Also, one of the community organizations that declined to assist with the research worked specifically with young women involved in gangs. Had these organizations agreed to help the project, the sample would have contained youth with more serious histories of substance use, in older age range, and more gang-identified young women. 6

Without the help of gang specialists, this research would not have been possible. Most of the gang specialists who helped recruit the youth into the study were former gang members or current gang members who had desisted from offending. These individuals were not “snitches” working alongside law enforcement, but rather former “felons,” many of whom have been to prison. In fact, some of them related their experiences in prison as being central to the reasons they were now trying to steer youth away from gang participation. Some mentioned this being a way to redeem themselves for prior criminal and violent acts. Moreover, these adults now work in the areas where they grew up, often with the younger gang members from their previous gang, in communities where they still resided. In this respect, such adults have a vested interest in helping local gang youth because often both the adults and youth are living in the same neighborhood.

Interview responses are only from gang youth with some sort of connection to a service provider, and findings may be different among gang youth with no such connection. But where the gang youth with no service provider connection are to be found? The literature on gang youth indicates their increased likelihood to commit crime and participate in risk behaviors compared to their non-gang peers. This suggests, in turn, that there is a high likelihood that gang youth at some point in their lives will come in contact with some sort of service provision, whether through court or on voluntary basis. Consequently, it seems unlikely to recruit gang youth aged 16 to 25 years who have never received some sort of service provision into a study. The research methods employed here simply captured such youth at these particular stages in their gang careers.

Conclusions

The manuscript has outlined the operationalization of a qualitative study on substance use and other risk behaviors in a sample of 60 gang-identified youth from various parts of the City of Los Angeles. Data collection and its progress were shaped by constraints and prior research commitments and refusals and particular recruitment possibilities when sampling. Despite the long history and the sheer number of gang youth in Los Angeles, accessing active gang youth aged 16 to 25 years for interview purposes proved very difficult. Gang specialists, most of whom were former gang members, were the most efficient at recruiting active gang youth into this research. Without their help, data collection likely would not have occurred. Establishing trust and working relationships with such individuals and organizations is important and requires additional time and effort on the researcher’s part. Researchers willing to put in work may be able to negotiate inroads to qualitatively investigate this hidden population.

Despite all the difficulties, the project accomplished its aims. Moreover, valuable lessons were learned and relationships established that surely would benefit future research plans. One of the most salient lessons pertaining to the research methods, and concerned how the recruitment of gang youth with varying experiences of substance use and participation in other risk behaviors, was somewhat linked to the type of organization that helped recruit these youth. Future gang research might be benefit from these insights.

Acknowledgments

The authors thank the National Institute on Drug Abuse (NIDA) for funding this research (grant R03 DA020410). The views expressed herein are that of authors. Thanks to project consultants Malcolm Klein and Penny Trickett at the University of Southern California. We appreciate the assistance of the following community members, without their help this research would not have been possible: E. Banda, Outreach Coordinator, St. Joseph’s Center; R. Cortez at Clare Foundation; M. Diaz, Director, Outreach Services for the Southern California Counseling Center, and founder and director, CleanSlate, Inc.; O. De La Torre, founder/director, and Y. De Cordova and M. Jackson, Pico Youth & Family Center; Homeboy Industries; Skipp Townsend, 2nd Call; Virginia Avenue Teen Center, The City of SantaMonica; A. Diaz, director of operations, and J. Powell, outreach coordinator, Boys & Girls Club of Venice; F. Gutierrez, D. Gullart, and J. Godinez, Soledad Enrichment Action, Inc.; and K. Shah, founder/senior advisor and D. C. Staten, intervention specialist, Stop the Violence, Increase the Peace Foundation. Finally, our deepest appreciation is owed to the youth who shared their lives with us.

Biographies

Bill Sanders, PhD , is an Associate Professor in the School of Criminal Justice and Criminalistics at California State University, Los Angeles. He has approximately 20 publications on a diverse range of topics, including injection drug use, club drug use, polydrug use, drug sales, homeless youth, gang youth, youth culture, and urban ethnography.

Stephen E. Lankenau, PhD , is an Assistant Professor at the University of Southern California, Keck School of Medicine, Departments of Pediatrics and Preventative Medicine. Trained as a sociologist, he has studied street-involved and other high-risk populations for the past 10 years, including ethnographic projects researching homeless panhandlers, prisoners, sex workers, and injection drug users. Currently, he is a principal investigator of a four-year NIH study researching prescription drug misuse among high-risk youth in New York and Los Angeles.

Jennifer Jackson Bloom received her MPH with a specialization in epidemiology from the University of California, Los Angeles. She works in the Community Health Outcomes, and Intervention Research Program at Children’s Hospital Los Angeles. Her research interests include behavioral risk in substance-using populations, modeling longitudinal change in substance use, and the application of geography to drug use(r) research.

1 The journal’s style utilizes the category substance abuse as a diagnostic category. Substances are used or misused; living organisms are and can be abused. Editor’s note.

2 California’s home sale price median by city recorded in April 2007. Available at www.dgnews.com/ZIPCAR.shtm .

3 Treatment can be briefly and usefully defined as a planned and goal-directed change process of necessary quality, appropriateness, and conditions (endogenous and exogenous), which is bounded (culture, place, time, etc.) and can be categorized into profession-, tradition, and mutual-help-based (AA, NA, etc.) and self-help (“natural recovery”) models. There are no unique models or techniques used with substance users—of whatever types—which aren’t used with nonsubstance users. In the West, with the relatively new ideology of “harm reduction” and the even newer Quality of Life (QOL) treatment-driven model, there are now a new set of goals in addition to those derived from/associated with the older tradition of abstinence-driven models. Editor”s note.

4 See Katz and Jacob-Jackson (2004) and Short and Hughes (2006) for a discussion on the progress of gang research.

5 Crack cocaine has been referred to as “rock.” The word “rock” in Spanish is “piedra,” hence the term “P-dogs,” when referring to cannabis joints containing crack.

6 For instance, Uman et al. (2006) were able to interview gang males and females in Los Angeles in the 17–26 years age range about substance use and other risk behaviors through the assistance of outreach workers.

Declaration of interest: The authors report no conflict of interest. The authors alone are responsible for the content and writing of this paper.

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