Relevant Thesis-Based Degree Programs
Affiliations to Research Centres, Institutes & Clusters
Graduate Student Supervision
Doctoral Student Supervision
Dissertations completed in 2010 or later are listed below. Please note that there is a 6-12 month delay to add the latest dissertations.
Background: Canada and the United States are in the midst of an escalating overdose crisis. While poverty and socioeconomic disadvantage are increasingly recognized as important contributors to drug-related harm, their precise role in overdose remains understudied. This dissertation sought to: synthesize evidence regarding the pathways and mechanisms linking socioeconomic elements to overdose outcomes; examine the relationship between a comprehensive range of socioeconomic indicators and non-fatal overdose; identify and characterize gender-stratified profiles of socioeconomic exposures in men and women who use drugs; and, finally, determine whether these gender-stratified profiles predict non-fatal overdose. Methods: Data from Chapter 2 came from a realist review of research published between 2004 and 2019. Data for Chapters 3-5 cover the time period between 2014 and 2018 and are from two community-recruited prospective cohort studies of people who use drugs (PWUD) in Vancouver, Canada. A range of longitudinal analytic techniques were used, including: generalized linear mixed-effect models, repeated measures latent class analyses, and generalized estimating equations.Results: Findings from the realist review identified eight overlapping socioeconomic dimensions with documented linkages to overdose outcomes through material, normative, and bio-psychosocial pathways. In Chapter 3, across the total sample of PWUD from Vancouver, homelessness, lower material security, and participation in informal and illegal income generating activities were independently and positively associated with non-fatal overdose. In Chapter 4, gender-stratified analyses revealed that men and women experienced mutually reinforcing and overlapping socioeconomic exposures characterized by variations in income, material and housing security, participation in informal or illegal income generation, criminal justice involvement, and police contact. Gendered profiles of increasing socioeconomic disadvantage aligned with high-intensity drug use patterns (e.g., opioids and stimulants) and a range of health-related outcomes (e.g., HCV). In Chapter 5, exposure to multiple increasing dimensions of socioeconomic disadvantage was found to be independently associated with greater likelihood of experiencing non-fatal overdose in both men and women.Conclusions: Socioeconomic determinants are key drivers of overdose risk. To address the socioeconomic production of overdose risk, findings point to the urgent need to expand upstream and multilevel programs and policies, including inclusive, gender-informed health and social welfare programming, and broader drug policy reform.
To demonstrate the efficacy of an intervention, randomized controlled trials (RCTs) are considered the “gold standard” of study design. Yet RCTs are challenging to conduct, given the difficulty in recruiting and retaining representative study populations and ensuring external generalizability. These challenges may be amplified in substance use research with people who use drugs (PWUD), who often experience drug-related stigma, socioeconomic marginalization, and criminalization, that can deter them from trial engagement. Given these potential barriers, research has started exploring RCT participant perspectives, with a focus on individual and trial features, such as barriers or incentives to attending follow-ups. However, few studies have investigated features of the broader social and structural context in which clinical knowledge around substance use is produced. Considering this area for further research, I conducted a nested qualitative study with PWUD in a multi-site, pragmatic RCT for opioid use disorder. Using data from 115 interviews across five Canadian cities, I develop three analyses investigating micro-, meso-, and macro-level influences on PWUD trial experiences and processes of knowledge production in experimental substance use research. First, I characterize participants by their experience with treatment and drug cultures to demonstrate how participants’ accumulated experiences shape medication beliefs (e.g., safety, efficacy), as well as stigma and the sourcing of health information. Second, I link sociological concepts around alienation to drug use and research participation in order to investigate participants’ underlying reasons for trial enrollment, including instrumental (e.g., employment opportunities), altruistic (e.g., community benefit), and social (e.g., rebuilding social ties) motivations. Finally, I draw on theoretical linkages between place and health to compare participant experiences across Canada and demonstrate how spaces (e.g., proximity to drugscapes) and interactions within them (e.g., healthcare provider stigma) shape study experiences. I also consider how macro-level forces (e.g., medication coverage) structure treatment contexts, thus impacting the study (e.g., incentivizing enrollment). By applying a sociological lens to RCT processes, this dissertation reveals how contextual features, from drug-related stigma to drug policy, underlie supposedly objective processes of knowledge production. Building on these results, I provide key recommendations for adapting RCT processes to improve the research experiences of marginalized PWUD.
Background: Although optimal access and adherence to modern antiretroviral therapy (ART) reduces rates of HIV-related morbidity and mortality, HIV-positive people who use illicit drugs (PWUD) continue to experience suboptimal HIV treatment outcomes. This thesis sought to apply institutional perspectives to explore individual and organizational interactions in achieving person-centered care (PCC). This aim was met by first, systematically reviewing literature on medical and social service components linked to methadone maintenance therapy (MMT) in improving HIV care cascade outcomes, and second, in a series of empirical studies, assessing institutional-related structures associated with optimal adherence to ART among HIV-positive PWUD. These studies examined: 1) prescription of complex ART regimens, within a single domain of healthcare provision; 2) MMT-ART co-dispensation practices, within multiple domains of healthcare provision; and 3) the production of material insecurity through healthcare, social care and other institutional relationships. Methods: First, a specific search strategy was used to conduct the systematic review. Second, data from an ongoing prospective observational cohort study linked with comprehensive HIV clinical monitoring records in Vancouver, Canada was used to assess institutional-related structures. Multivariable models were built to estimate the relationships between institutional-related variables and adherence to ART, using longitudinal analytic techniques while controlling for relevant confounders. Results: The systematic review found a low number of studies that described MMT service delivery in detail and a lack of information on the effectiveness of social support within MMT programs on improving HIV care outcomes. Among HIV-positive PWUD in Vancouver, complex ART regimens, as demonstrated by greater number of pills, were significantly associated with suboptimal adherence; MMT-ART co-dispensation was positively associated with optimal adherence in a low-threshold setting; and although material insecurity was associated with institutional structures, it was not significantly associated with adherence. Conclusions: The alignment between institutional domains may potentially enhance HIV care outcomes among PWUD as they navigate institutional structures. Public health strategies that feature PCC approaches are needed to meet the complex needs of PWUD. Thus, future research should explore the application of implementation science as a potential avenue to align treatment and care services across institutions for HIV-positive PWUD.
Master's Student Supervision
Theses completed in 2010 or later are listed below. Please note that there is a 6-12 month delay to add the latest theses.
Prior research shows that people who use drugs and receive income assistance experience unique difficulties accessing and engaging with health and social services, contributing to unmet population health needs. While these findings are important, a deeper understanding of the factors shaping barriers is necessary so that effective strategies to facilitate access can be implemented. Drawing on 121 interviews conducted in a Canadian inner-city, this study analyzes the health and social service experiences of people who use drugs and receive income assistance during the ongoing opioid overdose crisis. Through an application of Coleman’s framework for linking macro social outcomes and micro-level behaviour, this research examines the institutional, operational and interactional dynamics impacting client experiences with service access. The findings show that institutional frameworks influence the decisions and actions of individuals when engaging with providers by structuring and constraining their available choices. Operational challenges and stigmatization during encounters with providers leads to disengagement, which limits the utilization and positive effects of services. Despite these obstacles, individuals exercise agency in navigating, adapting to and pushing back against these constraints in order to meet their service needs. Efforts to reform social policies and service delivery must be informed by a patient-focused perspective that considers the inter-related institutional, operational and interactional dimensions of this complex service landscape.
Illicit drug markets and drug use have long been associated with violence and disorder, especially in marginalized communities. Previous research on governance frameworks in drug markets has focused on violence and other modes of control enacted by drug distributors and dealers. This work has thus far neglected the experiences of marginalized people who buy illicit drugs for their own consumption as well as informal debt structures that exist outside the dealer/buyer relationship. Drawing on interviews with 75 people who use drugs within a disadvantaged neighborhood in Vancouver, Canada, we explore the role of social ties and negotiation in navigating credit and debt associated with drug procurement as well as managing conflict within a drug market contingent on credit. Our findings show that people who use drugs strategically engage in non-violent tactics to mitigate harm linked to drug procurement and, to a greater extent, debt and default. These strategies involve cultivating reputation capital to build trust and strengthen the relationship between buyer and dealer, which stabilizes the drug market and discourages violent retaliation. We also uncover reciprocal arrangements within social networks that strengthen social cohesion in the community. Our findings highlight the significance of the broader risk environment of poverty, structural vulnerability, drug policy, and unintended harms arising from government systems of financial support for marginalized populations. Further research is urgently needed to explore programmatic and policy interventions to complement existing community processes and structures that could further mitigate harms associated with purchase and use of illicit drugs.