Thomas Kerr

Professor

Relevant Degree Programs

 

Graduate Student Supervision

Doctoral Student Supervision (Jan 2008 - May 2019)
Improving hospital care for patients who use illicit drugs in Vancouver, Canada (2015)

Background: People who use illicit drugs (PWUD) experience a number of health-related harms that often lead to frequent hospitalizations. However, there exists little scientific evidence that has explored utilization and retention in hospital care, including leaving hospital against medical advice (AMA), among this population. The objective of this thesis is to provide evidence to improve hospital care for PWUD by first, identifying individual and contextual factors associated with leaving hospital AMA and other hospital-related experiences; and, second, to use these findings to develop and evaluate novel approaches to minimizing the risks and harms that PWUD experience in hospital settings. Methods: This dissertation draws on data collected from two open prospective cohort studies of HIV-positive and HIV-negative PWUD in Vancouver, Canada. These data were confidentially linked to a hospital discharge database as well as comprehensive records of HIV treatment and related clinical outcomes through a clinical monitoring laboratory. A variety of longitudinal and cross-sectional analytic techniques were used to examine the impact of intersecting individual and contextual factors on various hospital service outcomes. Results: This dissertation identified hospitals as a risk environment for PWUD, given the high prevalence of hospital discharge AMA and active illicit drug use in hospitals. The study findings highlighted various risk and protective factors for leaving hospital AMA, and discussed the negative consequences of being denied pain medication on illicit drug use in hospitals. The findings from this dissertation also point to novel strategies that may address these issues, including the implementation of an adult HIV/AIDS integrated health program operating in proximity to a hospital to minimize hospital discharge AMA among HIV-positive PWUD, as well as the potential for an in-hospital supervised injection facility (SIF) to reduce the harms associated with illicit drug use in hospital. Conclusion: Despite this setting of universal access to healthcare, there are individual- and contextual-level factors that play a pivotal role in shaping utilization and retention in hospital care among PWUD. The collective findings of this dissertation offer insights into how integrated harm reduction-based interventions may mitigate the risks associated with leaving hospital AMA and active illicit drug use in hospitals.

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The social and structural production of violence, safety and sexual risk reduction among street-based sex workers (2015)

Background: Globally, sex work is highly stigmatized, and the dominant policy approach has been criminalization and police enforcement. Despite a growing body of research on the social and structural determinants of violence, and sexual risk among sex workers, less is known about the specific features of these environments and the dynamic interplay that shape the negotiation of safety and sexual risk in sex transactions. Therefore, the objective of this dissertation is to examine how social and structural factors such as stigma, evolving sex work legislation and policing practices intersect to shape the working conditions of primarily street-based sex workers in Vancouver.Methods: This dissertation is based on in-depth qualitative interviews, focus groups and ethnographic fieldwork with street-based sex workers in Vancouver. Drawing on concepts of structural vulnerability and structural stigma, data analysis sought to characterize how evolving social and structural environments shape working conditions, health and safety among street-based sex workers. Results: The findings of this dissertation suggest that intersecting regimes of criminalization and stigmatization serve to perpetuate labour conditions that render sex workers at increased risk for violence and poor health, and further deny sex workers their citizenship rights to police protection and legal recourse. Despite police rhetoric of prioritizing the safety of sex workers, criminalization and policing strategies that target clients reproduce the harms created by the criminalization of sex workers, in particular, risks for violence and abuse. Despite the lack of formal legal and policy support for brothels in Canada, the environmental-structural supports afforded by unsanctioned, safer indoor sex work environments, in the context of supportive housing programs for women, promoted increased control over negotiating sex work transactions, including the capacity to refuse unwanted services, negotiate condom use, and avoid violent perpetrators.Conclusion: The collective work presented in this dissertation highlights the complex ways in which sex work related stigma, evolving sex work legislation, policing practices and sex work environments intersect to shape the working conditions of street-based sex workers, including citizenship and labour rights, violence, and ill health. The findings of this dissertation lend further support to calls for the full decriminalization of sex work.

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Policing and public health : experiences of people who inject drugs in Bangkok, Thailand (2013)

Background: In recent years, Thailand has intensified policing efforts as a strategy to address a continuing epidemic of illicit drug use. Thailand’s “war on drugs” campaign of 2003 received international criticism due to extensive human rights violations. However, few studies have since investigated the impacts of drug policing on people who inject drugs (IDU) in this setting. Drawing on the Risk Environment Framework, this dissertation sought to: explore IDUs’ lived experiences with police; identify the prevalence and correlates of experiencing beatings and drug testing by police; examine the relationship between exposures to policing and syringe sharing; and assess changes in the availability of illicit drugs among IDU in Bangkok, Thailand.Methods: Between June 2009 and June 2012, a community-recruited sample of IDU in Bangkok participated in a serial cross-­sectional mixed-­methods study and completed interviewer-­administered questionnaires and semi-structured in-­depth interviews. Audio-­recorded interviews were transcribed verbatim and a thematic analysis was conducted to document the character of IDUs’ encounters with police. A variety of multivariate regression techniques were used to estimate independent relationships between exposures to specific policing tactics and indicators of drug-­related harm, as well as to examine a temporal trend of street-­level availability of illicit drugs.Results: Respondents’ narratives indicated that drug policing involved numerous forms of human rights infringements and negatively influenced healthcare access among IDU in Bangkok. Reports of beatings and drug testing by police were common (38% and 67%, respectively) and were independently associated with various indicators of drug-­related harm, including syringe sharing and barriers to healthcare. Street-­level availability of illicit drugs increased significantly between 2009 and 2011.Conclusions: The findings indicate that the over-reliance on repressive drugpolicing is not suppressing the illegal drug market and is instead contributing to police-­perpetrated abuses, the perpetuation of risky injection behaviour, and an impediment to healthcare among IDU in Bangkok. These findings raise concern about the ongoing policing practices and point to the need for providing greater police oversight, as well as a shift toward more balanced approaches to drug control in this setting.

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Senses of place among young people entrenched in a "local" drug scene : an urban ethnography (2013)

In the public imagination, street youth are frequently defined through their relationships with place. Whether because they are viewed as innocent victims or violent criminals, young people who are homeless, destitute and visibly addicted to drugs are often understood to be out-of-place in the public spaces of city centers. This thesis is based on ethnographic fieldwork with a group of street-entrenched youth in Greater Vancouver conducted from January 2008 to January 2013. It included the creation of photography by youth exploring their sense of place in the city over time. Merging phenomenological perspectives on place-making with a focus on the processes of political economy and power that make some place worlds more enduring than others, I demonstrate that sense of place among youth who occupy the margins of urban space is far more complicated than conventional understandings imply. My findings reveal that, among youth, the “local” drug scene was produced in tension with a broader social spatial landscape of power, political economy and possibility, in which various remembered and imagined places were also implicated. In the context of this wider landscape-in-motion, involvement in Vancouver’s inner city drug scene could be articulated as both a sense of belonging and dislocation, “being in the center of something” and “getting lost in the city.” The drug scene could be a frontier of economic opportunity, in which anyone could attempt to stake a claim through activities like street-based drug dealing. And, it could be the site of a strictly enforced moral logic of violence and organized crime. The overarching objective of this thesis is to characterize these complex understandings, experiences and affects, and how they intersected with the regimes of living youth enacted on the streets. I conclude by highlighting that in order to meaningfully address youth’s initiation into and sustained involvement in “risky” forms of drug use and crime in settings like Vancouver, intervention at the level of policy is urgently needed in order to address social suffering across young people’s lives, and the wider geographies they implicate.

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The impact of environmental factors on risk, harm, and health care access among people who inject drugs (2013)

Background: Growing awareness of the role social, structural, and environmental factors in producing harm among people who inject drugs (IDU) has underscored the need for safer environment interventions. However, emerging evidence underscores how current interventions are insufficient to bring about more significant reductions in drug-related harm. To date, there have been few studies examining how contextual forces operating within the wider risk environment shape the socio-spatial relations of IDU in relation to safer environment interventions and health care settings. This dissertation seeks to address this gap by examining the socio-spatial dynamics within three settings in Vancouver, Canada: the street-based drug scene; an ‘unsanctioned’ supervised drug consumption room (DCR); and, hospitals.Methods: This dissertation used an ethno-epidemiological approach, and the individual studies were undertaken in connection with ongoing prospective cohort studies of current and former drug users. Ethnographic fieldwork, including participant-observation, in-depth interviews and qualitative mapping exercises, sought to characterize the socio-spatial relations of IDU in relation to the abovementioned settings.Results: Study findings underscored how contextual forces shaped the socio-spatial relations of IDU, and thus access to and engagement with safer environment interventions and hospital settings. First, findings highlighted the role of gendered power relations within the street-based drug scene in shaping the spatial practices of highly vulnerable IDU, and constraining their access to a supervised injection facility. Second, findings demonstrated how, by permitting assisted injections, the DCR created a ‘legitimate place’ for IDU who require help injecting, and enabled them to enact risk reduction. Finally, social (e.g., stigmatization) and structural (e.g., abstinence-based drug policies) factors within hospital settings were found to produce considerable suffering (e.g., inadequate pain management) and contribute to discharges from hospital against medical advice.Conclusions: The collective findings of this dissertation demonstrate how the socio-spatial relations of IDU, and the contextual forces that impact upon them, are key determinants of drug-related harm and access to interventions and hospital services. These findings point to the need to modify and scale up existing safer environment interventions, and expand these into hospital settings, to mitigate the impacts of contextual forces on IDU and better address their health needs.

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The epidemiology of methamphetamine use among street youth and injection drug users (2011)

Background: Given the limited understanding of the epidemiology of methamphetamine (MA) use among street-involved youth and injection drug users (IDU), this thesis sought to: systematically characterise the evidence base demonstrating associations between MA use and adverse health outcomes among young people; examine the incidence and predictors of MA injection initiation among a cohort of IDU in Vancouver; describe the prevalence and correlates of MA use among sexual minority drug users; determine whether frequent MA injection predicts emergency department (ED) utilisation; and finally, explore the pathways through which MA use drives injection-related risk behaviour including syringe sharing.Methods: Street-involved youth and IDU participating in three open prospective cohort studies were asked to complete semi-annual interviewer-administered questionnaires, provide blood samples for HIV testing, and consent to hospital database linkages. A variety of longitudinal techniques were used to investigate the association between self-reported MA-related outcomes (e.g., initiation, frequent use) and individual, social, and structural determinants of interest.Results: A systematic review identified consistent associations between MA use and a number of health outcomes, including depression, suicidal ideation, and psychosis. Scientific evidence to suggest an association between MA use and a number of previously suggested harms (e.g., infectious disease transmission, dental problems) is equivocal. Some subpopulations, including sexual minority drug users, are more likely to use MA, which appears to exacerbate exposure to HIV-related risks and other vulnerabilities. Longitudinal analysis revealed that young people, non-injection stimulant users, homeless individuals, and those involved in the city’s open drug scene are most likely to initiate MA injection. The injection of MA, particularly frequently, was associated with a number of health and behavioural outcomes, including an increased hazard of ED utilisation and syringe sharing. Barriers to accessing harm reduction and HIV prevention services likely account for many of these relationships. Conclusions: Methamphetamine use is increasingly common among street youth and IDU in Vancouver. Its use and resultant harms appear to be driven by intersecting individual, social, and structural factors. Comprehensive interventions that are based upon sound scientific evidence and that address existing health and social inequities among marginalised populations are required.

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The social, structural and environmental production of HIV transmission risk among women in survival sex work : evidence from the Maka project partnership (2008)

Background: Given the limited contextual understanding of the HIV risk environment of survival sex workers in resource rich settings, the objectives of this thesis were: To explore the role of social and structural violence and gendered power relations in mediating women’s negotiation of HIV prevention; To examine the relationship between drug sharing with clients and the negotiation of sexual and drug transmission risk; To model the impact of early sexual abuse on subsequent HIV infection; To investigate the relationshipbetween environmental and structural factors and the negotiation of condom use with clients.Methods: Qualitative and quantitative data were drawn from a community-basedresearch project partnership in Vancouver, Canada. Women engaged in street-based sex work were invited through targeted peer outreach and time-space sampling to participate in interview-administered questionnaires, HIV screening, and social mapping. Additionally, women were purposively sampled to participate in focus group discussions about the contextual factors shaping HIV prevention.Results: Analysis of the narratives of sex workers revealed the paramount role ofsocial and structural violence in mediating women’s agency and access to resources and ability to practice HIV prevention. Drug sharing with clients was shown to be an important risk marker for elevated violence and unprotected sex. Early sexual abuse before 12 years was independently associated with HIV infection, and any sexual abuse before 18 years was associated with suicidalideations and generational vulnerability to sex work. Finally, structural andenvironmental barriers, including violence, displacement, and servicing clients inpublic spaces, were shown to elevate women’s sexual HIV risk through being pressured into unprotected sex by a client. Conclusions: The findings support the urgent need for social and environmental-structural HIV prevention efforts, in particular legal reforms, concomitantly with gender-sensitive harm reduction, that facilitate sex worker’sability to negotiate condom use in safer sex work environments.

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