Socially sensitive lactation: Exploring the social context of breastfeeding

Many women report difficulties with breastfeeding and do not maintain the practice for as long as intended. Although psychologists and other researchers have explored some of the difficulties they experience, fuller exploration of the relational contexts in which breastfeeding takes place is warranted to enable more in-depth analysis of the challenges these pose for breastfeeding women. The present paper is based on qualitative data collected from 22 first-time breastfeeding mothers through two phases of interviews and audio-diaries which explored how the participants experienced their relationships with significant others and the wider social context of breastfeeding in the first five weeks postpartum. Using a thematic analysis informed by symbolic interactionism, we develop the overarching theme of ‘Practising socially sensitive lactation’ which captures how participants felt the need to manage tensions between breastfeeding and their perceptions of the needs, expectations and comfort of others. We argue that breastfeeding remains a problematic social act, despite its agreed importance for child health. Whilst acknowledging the limitations of our sample and analytic approach, we suggest ways in which perinatal and public health interventions can take more effective account of the social challenges of breastfeeding in order to facilitate the health and psychological well-being of mothers and their infants

Estimated Drug Overdose Deaths Averted by North America's First Medically-Supervised Safer Injection Facility

Illicit drug overdose remains a leading cause of premature mortality in urban settings worldwide. We sought to estimate the number of deaths potentially averted by the implementation of a medically supervised safer injection facility (SIF) in Vancouver, Canada.The number of potentially averted deaths was calculated using an estimate of the local ratio of non-fatal to fatal overdoses. Inputs were derived from counts of overdose deaths by the British Columbia Vital Statistics Agency and non-fatal overdose rates from published estimates. Potentially-fatal overdoses were defined as events within the SIF that required the provision of naloxone, a 911 call or an ambulance. Point estimates and 95% Confidence Intervals (95% CI) were calculated using a Monte Carlo simulation. Between March 1, 2004 and July 1, 2008 there were 1004 overdose events in the SIF of which 453 events matched our definition of potentially fatal. In 2004, 2005 and 2006 there were 32, 37 and 38 drug-induced deaths in the SIF's neighbourhood. Owing to the wide range of non-fatal overdose rates reported in the literature (between 5% and 30% per year) we performed sensitivity analyses using non-fatal overdose rates of 50, 200 and 300 per 1,000 person years. Using these model inputs, the number of averted deaths were, respectively: 50.9 (95% CI: 23.6–78.1); 12.6 (95% CI: 9.6–15.7); 8.4 (95% CI: 6.5–10.4) during the study period, equal to 1.9 to 11.7 averted deaths per annum.Based on a conservative estimate of the local ratio of non-fatal to fatal overdoses, the potentially fatal overdoses in the SIF during the study period could have resulted in between 8 and 51 deaths had they occurred outside the facility, or from 6% to 37% of the total overdose mortality burden in the neighborhood during the study period. These data should inform the ongoing debates over the future of the pilot project

Factors associated with optimal pharmacy refill adherence for antiretroviral medications and plasma HIV RNA non-detectability among HIV-positive crack cocaine users: a prospective cohort study

BACKGROUND: Crack cocaine use is known to contribute to poor adherence to antiretroviral medications; however, little is known about facilitators of or barriers to effective HIV treatment use among HIV-infected crack cocaine users. We sought to identify correlates of optimal pharmacy refill adherence for antiretroviral medications and plasma HIV RNA viral load (pVL) suppression among this population. METHODS: Data from a prospective cohort of HIV-positive people who use illicit drugs in Vancouver, Canada, were linked to comprehensive HIV clinical monitoring and pharmacy dispensation records. We used multivariable generalized linear mixed-effects modelling to longitudinally identify factors associated with ≥95 % adherence to pharmacy refills for antiretroviral medications and pVL <50 copies/mL among crack cocaine users exposed to highly-active antiretroviral therapy (HAART). RESULTS: Among 438 HAART-exposed crack cocaine users between 2005 and 2013, 240 (54.8 %) had ≥95 % pharmacy refill adherence in the previous 6 months at baseline. In multivariable analyses, homelessness (adjusted odds ratio [AOR]: 0.58), ≥daily crack cocaine smoking (AOR: 0.64), and ≥ daily heroin use (AOR: 0.43) were independently associated with optimal pharmacy refill adherence (all p < 0.05). The results for pVL non-detectability were consistent with those of medication adherence, except that longer history of HAART (AOR: 1.06), receiving a single tablet-per-day regimen (AOR: 3.02) and participation in opioid substitution therapies was independently associated with pVL non-detectability (AOR: 1.55) (all p < 0.05). CONCLUSIONS: Homelessness, and daily crack cocaine and/or heroin use were independently and negatively associated with optimal HAART-related outcomes. With the exception of opioid substitution therapies, no addiction treatment modalities assessed appeared to facilitate medication adherence or viral suppression. Evidence-based treatment options for crack cocaine use that also confer benefits to HAART need to be developed

Do law enforcement interactions reduce the initiation of injection drug use? An investigation in three North American settings.

BACKGROUND:The prevention of drug injecting is often cited as a justification for the deployment of law enforcement and for the continuation of drug criminalization policies. We sought to characterize the impact of law enforcement interactions on the risk that people who inject drugs (PWID) report assisting others with injection initiation in three North American countries. METHODS:Cross-sectional data from PWID participating in cohort studies in three cities (San Diego, USA; Tijuana, Mexico; Vancouver, Canada) were pooled (August 2014-December 2016). The dependent variable was defined as recently (i.e., past six months) providing injection initiation assistance; the primary independent variable was the frequency of recent law enforcement interactions, defined categorically (0 vs. 1 vs. 2-5 vs. ≥6). We employed multivariable logistic regression analyses to assess this relationship while controlling for potential confounders. RESULTS:Among 2122 participants, 87 (4.1%) reported recently providing injection initiation assistance, and 802 (37.8%) reported recent law enforcement interactions. Reporting either one or more than five recent interactions with law enforcement was not significantly associated with injection initiation assistance. Reporting 2-5 law enforcement interactions was associated with initiation assistance (Adjusted Odds Ratio=1.74, 95% Confidence Interval: 1.01-3.02). CONCLUSIONS:Reporting interactions with law enforcement was not associated with a reduced likelihood that PWID reported initiating others into injection drug use. Instead, we identified a positive association between reporting law enforcement interactions and injection initiation assistance among PWID in multiple settings. These findings raise concerns regarding the effectiveness of drug law enforcement to deter injection drug use initiation