QMJC September 2021: Hoots and harm reduction: a qualitative study identifying gaps in overdose prevention among women who smoke drugs

First published: 07 October 2021 | Last updated: 19 October 2021

The Qualitative Methods Journal Club discuss an article about a novel drug consumption room in Canada. The study found that this women-only smoking space provided a ‘temporary reprieve’ from violence against women and the overdose epidemic. For the Journal Club, which was not based in Canada, there was much to be learned from the paper about the public health disparity affecting First Nation women and the structural racism and colonialism affecting indigenous populations.

About this month’s Journal Club

The article (available here) was selected for the September 2021 meeting. It was discussed online (MS Teams) within the National Addiction Centre, Institute of Psychiatry, Psychology & Neuroscience at King’s College London, with all attendees from King’s College London. Stephen Parkin (National Addiction Centre, KCL) presented and led the discussion.

Summary of the article

This article adds to the wider harm reduction literature dedicated to the positive and negative effects of specific places used as drug-using environments. In this case the Bardwell and colleagues direct their attention to a women-only supervised consumption service (in Canada). This is made more noteworthy as the relevant setting not only provides gender-specific spaces for consumption but also permits smoking of substances within a formally supervised environment. Such features are atypical within overdose prevention interventions and the authors’ research sought to examine women’s perceptions and experiences of utilising such a novel form of harm reduction using qualitative research methods.

The research involved participant observation of the supervised consumption service and semi-structured interviews with 32 participants. These interviews identified a wide range of structural, gendered, and race-based issues (including gender-based, and structural, violence) that problematised harm reduction intervention and drug use by women. These issues led the authors to conclude that “women-only smoking spaces can provide temporary reprieve from some socio-structural harms and build collective capacity to practice harm reduction strategies, including overdose prevention.”

Discussion of the article

The SSA QMJC at King’s College London enjoyed this article immensely and discussed at length why this work should be regarded as a ‘good example’ of a qualitative research paper. These included ‘the writing style’, ‘the rapid ethnographic methods’ (that informed the study), and the assorted issues affecting or addressing First Nation people (throughout Canada and specifically British Columbia) that are acknowledged by the authors throughout the article. These qualities are summarised further below.

‘The authors’ writing style’

Overall, the group described the article as well written, well organised, and easily accessible (in that the content was coherent and clear throughout and did not confuse the audience with theoretical, sociological, or other academic jargon). The accessible and coherent style was applauded as it brought to the fore a variety of issues affecting Canadian people (public health, drug use, overdose, racism, colonialism and harm reduction practice and policy) in a manner that was didactic and comprehensible to a non-Canadian readership. Accordingly, it was considered a style deemed entirely fitting and relevant for publication in Harm Reduction Journal (raising international awareness of specific harm reduction intervention/s).

Other comments relating to the overall writing style were that the authors did not attempt to over-state (or over-interpret) their findings (as it was felt that some qualitative research articles have a tendency to over-inflate the interpretation of findings obtained from small groups of participants). Instead, the authors were applauded for seemingly presenting their work with a well-balanced, measured and considered approach, in which there were clear descriptive and sign-posted links between the Background to the study, and the authors’ overall qualitative study (Research Question, Methods, Analysis, Findings and Conclusion). Perhaps more specifically, the style of writing also appeared to reflect (and be consistent with) the qualitative method employed in this particular study: namely, rapid ethnographic methods.

‘Rapid ethnographic methods’

Although the authors did not dedicate much space to an explanation of their use of rapid ethnographic methods, the applied value of this approach is evident, albeit inferred, throughout this article. Rapid ethnography is a mode of inquiry that is grounded in anthropological/ethnographic studies in which such studies seek to provide ‘rapid’ responses to emergency public health situations (such as natural disasters, outbreaks of disease, displacement resulting from warfare etc) within a strict time-limited period (typically ranging from 3–6 months). In such circumstances, qualitative researchers will work with frontline services, agencies and organisations addressing the health and social conditions associated with the relevant emergency in order to provide an applied solution-focused response to the crisis. The rapid ethnographic methods briefly summarised in this article were consistent with this approach.

For instance, the study was grounded in a well-established North American opioid epidemic, and set against a regional (British Columbia, Canada) overdose emergency in which women account for one-fifth of overdose deaths, made further complicated by the disproportionate overdose mortality affecting First Nation women (described as almost nine times higher than the mortality rate for non-indigenous women). In addition to these public health emergencies, the authors also describe applying these ethnographic methods during a four-month period during 2019 (i.e. incredibly rapid when compared to ‘traditional’ ethnography that typically requires extended periods of time immersed in a field of study) in order to provide solution-focused responses to overdose intervention programmes aimed at women who use drugs.

Indeed, much of the writing style within the article similarly reflects this research design. For example, in the Background, the authors guide the reader through the macro-level situations underlying the overdose emergency, then move to more national, then regional understandings of the same issue whilst also spotlighting various forms of intervention relevant to the study and highlighting the various (gender and environmental) issues that intersect and problematise these emergencies and interventions. For these reasons, the authors have produced an article that does not require a ‘theory’ that drives their study (and thus may explain the absence of theory-focused jargon noted above). Instead, it is the methods that apparently drove this study (rapid ethnography) as the rationale of the work is grounded in providing rapid harm reduction responses to an emergency situation involving overdose mortality. This feature of the study is what makes this article such a great paper, but, unfortunately, much of the detail underlying this particular aspect is mainly inferred throughout (and thus may not be fully recognised by researchers less familiar with qualitative research methods and associated methodology). However, it is also possible that the authors were constrained by strict word limits attached to the journal’s submission requirements. Nevertheless, this article was considered by the group to be an outstanding example of a well-crafted qualitative research paper that perfectly reflects the authors’ method of inquiry.

‘Acknowledgement of First Nation people’

A further discussion point amongst the group focused less upon the explicit content, and more upon the implicit content of the article that related to First Nation people of Canada. For example, the authors drew attention (to a non-Canadian discussion group) to a shocking public health disparity affecting First Nation women and the structural racism and colonialism affecting indigenous populations. In addition, the authors’ acknowledgement at the close of their article that their study “took place on the unceded traditional territories of the Katzie, Semiahmoo, Kwantlen, and other Coast Salish Peoples” provoked a conversation of how the academic community might begin to address colonialism in their work.

Some members of the group stated that they had recently encountered such verbal/written acknowledgements from scholars in Canada (in online seminars, or whilst during peer review of manuscripts submitted to journals) and applauded these attempts by the academic community in that nation to acknowledge colonialism. One member of the group likened these acknowledgements to another form of ‘Taking the Knee’ in showing support for, and solidarity with, indigenous people. In recognition of this written acknowledgment, the author of this summary contacted Dr Bardwell prior to the journal club meeting to find out more about the purpose of including such statements. Dr Bardwell responded with the following answer (and has given permission for including this personal communication here):

“As for the land acknowledgements, it isn’t Canada-wide policy nor is it BC policy, but it is common practice in British Columbia to do a land acknowledgement at the start of a meeting (whether it’s a city council meeting, a union meeting, or a conference). Our team started doing this in articles more recently, but it is not a policy. In BC it is a bit different from other parts of Canada where we refer to “unceded” territories. Other parts of Canada there were legal agreements between government and First Nation bands regarding land ownership (though these were by no means “fair” agreements and are rife with issues, but they exist nonetheless). In BC, many of these lands were never legally signed away. It is important as settler communities to acknowledge our colonial past and doing a land acknowledgement is one step (among many) towards reconciliation. When I do any talks at conferences, I always do a land acknowledgement while also discussing the ways in which our colonial past has had lasting impacts on Indigenous communities, including an over-representation in homelessness, substance use issues, and overdose deaths.”

Other discussion points

This article also inspired discussion surrounding the excellent use of visual data (non-exploitative, non-stigmatising and the neutral/non-judgemental portrayal of a specific drug-using environment); the use of slang in academic article (as in ‘Hoots’ in the article title – this being local slang for inhalation [similar to a ‘drag’ on a cigarette in UK parlance]) and the circumstances in which researchers should / should not appropriate participants’ slang in academic texts/manuscripts, and the group also wondered how the researchers overcame any obstacles attached to a male researcher interviewing female participants about gender-based issues (structural violence, male violence etc).

Overall, the group thoroughly enjoyed reading and discussing this article and it was considered a fine example of a qualitative research paper written for both applied and academic purposes.

About the article

Bardwell, G., Austin, T., Maher, L., and Boyd, J. (2021). Hoots and harm reduction: a qualitative study identifying gaps in overdose prevention among women who smoke drugs. Harm Reduction Journal, 18, 29.

The article can be accessed here.

Author response to discussion (added as postscript)

(to follow)

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