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This article elucidates the dynamics that occur in relationships where there have been both substance use and domestic abuse. It draws interpretively on in-depth qualitative interviews with male perpetrators and their current and former partners. The criminological implications of the competing models of change deployed in drug treatment and domestic violence intervention are discussed alongside the policy and practice challenges entailed in reconciling them within intervention contexts where specialist service provision has been scaled back and victims navigate pressures to stay with perpetrators while they undergo treatment alongside the threat of sanction should they seek protection from the police and courts. Explanatory Note Clause 3: It is proposed that compliance with such orders will be secured in part through electronic monitoring. The Bill is informed by a prolonged consultation in which over 3, responses were received by government and expert opinion—primarily from organizations representing victims and survivors of domestic abuse and stalking—was submitted to two Home Affairs Committees House of Commons, Cross-party support for the Bill was secured: as politicians registered the volume of domestic abuse cases raised with them by constituents; amidst news that the daughter of an MP had committed suicide following a relationship in which she suffered psychological—but not physical—torment that caused her to fear that she was mentally ill Elgot, ; and during a campaign by David Challen to enable his mother to appeal her conviction for murdering his coercively controlling father Moore, But this Bill was conceived within a more nuanced policy agenda than its predecessors. This article responds to this call to redress the dynamics of power that occur in relationships where substance use and domestic abuse co-occur. We contribute to such an understanding through the presentation of three couple dyads—each comprising a male perpetrator and his female partner—interviewed in-depth for the UK National Institute for Health Research funded Advancing theory and treatment approaches for males in substance use treatment who perpetrate intimate partner violence ADVANCE programme 1. Our conclusion returns to the challenges the Domestic Abuse Bill poses to policy, practice and criminological theorizing. Evidence for the relationship between domestic abuse and drug and alcohol intoxication is plentiful in crime surveys but tends to focus, peculiarly, on the behaviour of victims more often than offenders. The international evidence reveals that men, but not women, tend to perpetrate more severe assaults when they have been drinking Graham et al. Women are more vulnerable to assault when they too are intoxicated, but this is at least partly because those living with abusers are less diligent at pursuing safety strategies when they have been drinking Iverson et al. Substance use features in around half of all UK domestic homicides. Since , substance use has been detected among domestic homicide perpetrators more than four times as often as it has among those killed by them Home Office, In sum, the relationship between substance use and domestic abuse is not straightforward. Moreover, Different substances have different pharmacological properties. Cocaine consumption can induce similar reactions. Like cannabinoids and opiates—the effects of which are rarely studied in the context of aggression or violence—cocaine can also alleviate anxiety and exacerbate underlying problems with depression, paranoia and hallucinations Sacks et al. Consequently, regular use of such drugs, like the consumption of excessive alcohol, can impinge upon mental well-being and intimacy, generating indirect and belated relationships between victimization and substance use that extend far beyond periods of intoxication. Feminist scholarship on domestic abuse has tended not to engage with the pharmacological impacts of substance use and has focussed instead on how some abusive men retain power over women by attributing their violence to intoxication, by insisting that their drinking caused them to act out of character, or by denying any memory of assaults perpetrated when intoxicated Hearn, ; MacKay, Evaluations of interventions for perpetrators have thus needed to be alert to the ways in which substance use is invoked to minimize violence. His analyses reveal that some victims do self-medicate to manage the depression the daily anticipation of violence engenders and that some perpetrators control victims by increasing their dependence on substances before restricting their access to them. Finally, Stark highlights that some women who have been terrorized over many years take matters into their own hands after the law has failed to protect them, mounting grievous attacks on perpetrators when they are too intoxicated to retaliate. This is despite clinical evidence suggesting that drug use and violence co-occur most among men with diagnosed mental health issues, poor concentration and problems understanding and remembering their pasts Sacks et al. Answers to this question can be found in the few qualitative studies that explore how drugs and alcohol feature in the relationships of couples living with domestic abuse. These reveal that some perpetrators pose greater risks to their partners, not when they are high, but when they are irritable, withdrawing or are struggling to finance alcohol or drug purchases Gilchrist et al. Follow-up interviews with 20 couples where alcohol consumption was noted by the police revealed that, although drunkenness and its expense were the source of many arguments that led to violence, social drinking, especially at parties, was also what held some relationships together. Afterwards, some couples reconciled on the basis that it was the alcohol that caused the conflict. Men who had caused injuries when intoxicated often claimed they could only recall feeling hurt—sometimes in ways that reminded them of painful experiences in their pasts—by female partners who criticized them or acted aggressively towards them and not the assaults they themselves had perpetrated. Motz depicts the emotionally impoverished lives of abusive men with whom some drug-using women cohabit, many of whom feared abandonment because of experiences of abuse, neglect or institutional care. Some women described engaging in prostitution to raise money for drugs as evidence of their love and care for male partners. When the women subsequently refused to raise funds in this way or sought support from professionals to reduce their own drug use, some male perpetrators threatened further violence whereas others encouraged them to relapse back onto heroin or crack, thus entrapping stigmatized and socially isolated women in relationships with them. In what follows, we expand the argument for a more relationally sensitive analysis of the dynamics of power that pertain in the lives of couples where domestic abuse towards a partner occurs alongside substance use. We seek to illustrate these points by drawing on dyad interviews—with male perpetrators in treatment for substance use problems together with their current and former female partners—undertaken for the ADVANCE programme. The ADVANCE programme seeks to develop and test an integrated intimate partner violence and substance use group intervention that will reduce intimate partner abuse perpetrated by men receiving substance misuse treatment. This involved interviewing male domestic abuse perpetrators receiving treatment for substance use and their current or former partners about their relationships and support needs. Adult men were recruited from six community-based substance use treatment services in London and the West Midlands. Seventy men were screened for lifetime domestic abuse against a partner. Men who currently had court orders preventing contact with their ex partners were excluded. Forty-seven of the 70 men screened were eligible, and 37 of these 47 men were then interviewed. Male interviewees were asked to provide contact details of their current or former female partners, and in 14 cases these women were interviewed. All participants were advised that there were limits to the confidentiality that could be afforded where unaddressed risks of harm and safeguarding issues were disclosed. Women and men were always interviewed by different researchers to ensure no information was inadvertently shared between participants. Interviews were undertaken using reflective techniques derived from the Free Association Narrative Interview Method Hollway and Jefferson, , with participants being supported through active listening to tell the stories of their drug use, relationships, domestic abuse and intervention experiences. Digital recordings of the interviews were transcribed verbatim and transcriptions were checked twice for errors. Timelines were created to track the sequence of events through the life of each participant. In terms of their drug use, the 14 men who were interviewed with their partners appeared to be broadly comparable with the other 23 whose partners were not interviewed Table 1. Nine out of the 14 were also heavy drinkers. Five of the 14 men also described medical or psychological diagnosis consistent with emotional dysphoria. Eight males disclosed perpetrating violence that was extra-familial in addition to their abuse of partners. Contact with children had, at some point or other, been restricted for all the men in the study. Given the high degree of similarity among the men on key variables, we explored if more meaningful distinctions could be drawn by distinguishing the dyads in terms of whether victims had ever used drugs and, if they had, whether they were desisting from substance use or still using. Only four of the women described themselves as substance dependent at the time of the interviews. Five had never been substance dependent, and another five were desisting from substance use, either having become completely abstinent from using or having only had temporary relapses. A three-fold distinction could thus be drawn across the dyads that revealed some important variations in terms of how domestic abuse and substance use manifested themselves. Within the sample, there were five couples where the female partner had never been substance dependent, though all the women interviewed drank alcohol socially, and one smoked cannabis occasionally. Women in this group had almost no involvement in crime. Four of these women had never been separated from their children, but one woman had children who had been required to live with their grandfather as she would not leave her abusive partner. Within the sample, there were five couples where the female partner had abstained from using drugs or alcohol, having previously been substance dependent. None of these women had criminal convictions. The stories these desisting women told tended to be of intimacy lost. Sharing feelings and traumas that motivated drug use, and about what made it difficult to give up, had generated understanding and closeness when they had first met their partners. Conflicts had then developed when the men resumed drug use or drinking whereas the women were trying to reduce their own or abstain. Only two of the women in this group had children of their own. In both cases, these women had raised their own children, but with some intermittent professional oversight. Within the sample, there were four couples where both the male perpetrator and the female victim were both currently substance dependent. All the women in this group used crack cocaine and heroin to varying degrees. Though they sometimes mentioned love, they often explained their persistence with relationships that had become abusive in terms of daily needs for protection, somewhere to live and the sharing of drugs. The women in this group had much more frequent and entrenched patterns of criminal involvement than the other 10 in the sample. Their criminal involvement activities included shoplifting, petty frauds and prostitution to finance their drug use, typically with encouragement from male partners who relied, to some extent, upon the income the women generated. All four women in this group had been separated from their children when these children were young, though two women had re-established relationships with their children in adulthood. In what follows, we present one couple from each of these groups to further illustrate the different power dynamics that can pertain in relationships where domestic abuse and substance use co-occur. Italics are used to highlight points where the participants emphasized a relationship between substance use and domestic abuse. Rhian recalled that Wayne first assaulted her within a couple of months of moving in. After a drink with friends and not knowing that she was already pregnant, Rhian felt ill and went to bed. Wayne provided a detailed account of the emptiness he felt. After a nurse overheard Wayne discussing drugs on his phone during one of the few antenatal appointments he attended, Rhian took the opportunity to ask him what it was about because she was concerned that social services would see a child protection risk for her baby. Sometimes Wayne would speed off, with their baby in the back of the car, in a hurry to buy drugs. The violence only ceased, Rhian said, when Wayne called the police on himself after pinning her down and grabbing her by the neck. Mitchel early fifties and June mid-forties were in a relationship for over 15 years. As a child, June was repeatedly coerced into having sex by a man who threatened to report her to social services for caring for her siblings while her mother received hospital treatment. When she became pregnant, she weaned herself off it but relapsed when her mother accused her of inviting the sexual abuse she was subjected to as a child. Mitchel made no mention of these incidents but said June had become domineering about domestic matters when he returned from university. The police attended but arrested neither of them as they had both been drinking. After a period in hospital, June said June contacted a drugs and alcohol dependency team who put her on a methadone programme, but Mitchel started taking the methadone because he feared he would lose the house and his children if June recovered. Joe mid-thirties and Kate late twenties had been together for six years. Kate had been sexually assaulted both as a child and as a teenager and was estranged from her family. Joe, whose parents were both deceased, was sexually abused while in care and was estranged from his siblings. He said he worried that Kate would be raped or killed by men she had clipped and that he had lost teeth defending her from men she had tricked. While Joe was in prison for this assault, Kate twice attempted suicide. In this article, we have presented three relationship scenarios where domestic abuse pertained alongside drug or alcohol dependency. Wayne, Mitchel and Joe all described discrete, regrettable and unplanned assaults that derived from everyday conflicts over alcohol and drug use, financial pressures, sexual jealousies and domestic chores: conflicts that were sometimes accentuated by being intoxicated. Nevertheless, the stories these men told suggested that their need to control became increasingly acute when their relationships were in crisis, when they had secrets to keep, when they felt dependent on drugs or alcohol, were afraid of losing their minds, their partners and their children, when money was scarce, and when homelessness and criminalization were distinct possibilities. Despite their unhappiness, these men, like their partners, often lacked the emotional strength and economic resources required to separate Walby and Towers, By contrast, Rhian, June and Kate, described steadily accumulating patterns of abuse, forgiven initially as promises of fresh starts, either in new places or after drug treatment, were made. Hence, the reasons these women stayed were complexly configured around drug and alcohol use. Then, as someone with little experience of either drugs or relationships, Rhian was persuaded to give Wayne another chance while he sought drug treatment, assuming mistakenly that this would redress his violence. June, by contrast, had some empathy with Mitchel, having relapsed with heroin herself and recognizing that her own drinking contributed to their arguments. June had been persuaded that moving might facilitate a fresh start, without drug use. However, when June sought opioid substitution treatment for herself, Mitchel found a new way of controlling her, diminishing her capacity to leave by controlling her access to her prescription and then trying to administer an overdose. The challenges for Kate were different again. She had a long history of heavy alcohol consumption and illicit drug use, the latter of which Joe had joined in with, compounding their mutual dependence on shoplifting and pseudo-sex work to maintain their supplies. Joe construed his heroin use as an attempt to empathize with Kate, though it appeared that he persisted with drug treatment partly because it legitimized his management of her drug use. For the women in these relationships, criminal justice intervention was often greeted with trepidation, for it rarely provided the protection it promised. For June and Kate, the pains of child abuse, mental health problems and bereavement were partly responsible for the solace they had sought in alcohol and heroin consumption, as well as in their relationships with men. However, as their drug and alcohol usage became complicated by domestic abuse, a range of different strategies were pursued by each couple, typically to avoid attracting the attention of social services or the police. These dynamics were compounded as drinking and drug use generated financial pressures, which intensified conflicts that left the women, as well as some of the men, feeling that their partners regarded sustaining their substance use as more important than their relationship, avoiding criminalization and social services intervention, and the threats posed by those from whom money and drugs had been borrowed or defrauded. Evidently, some abusive men tell highly convoluted stories to exonerate themselves. But some women who are the primary victims in such relationships do not and cannot always tell the whole truth either, not only because they fear further violence and abuse but also because of the stigma of their own drinking and drug use, the fear of child protection proceedings being instigated and the risk of being incriminated by perpetrators they have hit in self-defence or retaliated against Wolf et al. Like many of the men in the ADVANCE programme study, the perpetrators we have depicted here dealt with feelings of trauma and grief from their pasts through drug use and by scaring their partners in ways that the women experienced as acutely controlling. While frequently terrifying, such behaviour was not only instrumental and controlling but also expressive of how painful some aspects of their pasts were and how unwilling they were to concede their dependency on both substances and partners who provided care, funds, a place to live and the support needed to maintain precarious relationships with children. Similar experiences of child abuse, mental health problems and drug dependency were sometimes part of the story of intimacy that held these couples together despite grievous domestic abuse. Then, when the risk of criminalization or estrangement presented, men who were coercively controlling sometimes used such prehistories against their partners by threatening to expose them for raising children in contexts that were unsafe. It has, to some extent, been be amplified by the advent of gender-neutral policy, which recognizes that men can be victims too, alongside incident-focussed approaches to policing that direct attention to what has just happened—such as a man being hit—rather than the history of the relationship—such as a woman being terrified or controlled by the same man over a prolonged period Walklate et al. The Domestic Abuse Bill attempts to counter this risk by prohibiting perpetrators from cross-examining victims in the family courts and providing greater recognition of the impact of the ways in which economic abuse makes it harder for many victims to leave. But compelling alcohol and drug-using perpetrators to receive treatment may introduce unforeseen possibilities for coercive use of the law. Others will stay under the misapprehension that the domestic abuse will cease once treatment for substance use begins. This is an unlikely outcome, though intervention is nonetheless worthwhile. There is tentative evidence to suggest that reducing drinking among perpetrators can diminish resort to violence Wilson et al. But, although treatment interventions can reduce the harms of substance use, where drug and alcohol use and domestic abuse co-occur, treatment needs to be part of a range of measures that include support in changes in thinking and modes of relating, securing the housing and economic resources couples need to be able to contemplate living apart, the support and empowerment of survivors, the safeguarding of children and professional help with mental health problems. These skilled forms of intervention are critical to deescalating the dynamics that sustain substance use in the lives of people enduring the worst forms of domestic abuse but are often in short supply. One danger with compelling drug or alcohol treatment is that it will place clinicians and health practitioners in the ethically compromising position of having to report those who relapse, together with those whose prescriptions have proved insufficient, or who have decided that they would be better trying to reduce their substance use gradually, to the courts where they may face further criminalization Seddon, ; Werb et al. Hence, acknowledgement of complexities in the power dynamics of domestic abuse that co-occurs with drug, alcohol and mental health problems raises acute challenges, not only for the delivery of policy that attempts to reconcile safety, justice and rehabilitation but also for academics who have framed the problem of domestic abuse primarily as one of either gender or psychology. Not only do criminologists need to reconceptualize domestic abuse more dynamically but they must also ask why some men choose to secure control in coercive ways when so many other aspects of their lives appear out of control. There is a need to recognize how the interdependencies—including the prospect of economic abuse—involved in intimate relationships are intensified by poverty, stigma, co-dependency, child abuse and neglect, poor mental health and the fear of police and social services intervention. In theory and in practice, we must ensure that shorthand explanations derivative of personality disorders do not obscure what can be learnt from the more complex descriptions both survivors and perpetrators can offer of their relationships. Policymakers need also to ensure that evaluations of treatment options for substance-using perpetrators extend beyond the longstanding fixation with acquisitive crime to include measures that take stock of their impact on children and partners, whether current and former, and to recognize that establishing effective practice will require the reestablishment of expertize and service provision that is increasingly scarce. Benitez , B. Google Scholar. Brandon , M. Broyles , L. Dobash , R. Google Preview. Douglas , H. Elgot , J. Felson , R. Gadd , D. Gilbert , L. Gilchrist , G. Gossop , M. Graham , K. Hearn , J. Heidensohn , F. Rafter and F. Heidensohn , eds. Open University Press. HM Government. Hollway , W. Holtzworth-Munroe , A. Home Office. House of Commons Home Affairs Committee. Scandinavian University Press. Iverson , K. Johnson , M. New University Press. Kelly , L. Leonard , K. MacArthur , G. MacKay , F. Moore , A. Motz , A. Reno , J. Robinson , A. Cardiff University. Sacks , S. Seddon , T. Stark , E. Oxford University Press. Strang , J. Tolmie , J. Vigurs , C. Walby , S. Walklate , S. Werb , D. Wilson , I. Wolf , M. Hobart , M. Zinberg , N. Yale University Press. Oxford University Press is a department of the University of Oxford. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide. Sign In or Create an Account. Sign in through your institution. Advanced Search. Search Menu. Article Navigation. Close mobile search navigation Article Navigation. Volume Article Contents Abstract. Correlations and typologies. Complex interdependencies. Group 1 exemplar. Victim was never substance dependent. Group 2 exemplar. Victim was desisting from substance use. Group 3 exemplar. Victim was substance dependent. Discussion and conclusion. Journal Article. David Gadd , David Gadd. Oxford Academic. Juliet Henderson. Polly Radcliffe. Danielle Stephens-Lewis. Centre for Violence Prevention, University of Worcester. Amy Johnson. Gail Gilchrist. Select Format Select format. Permissions Icon Permissions. Abstract This article elucidates the dynamics that occur in relationships where there have been both substance use and domestic abuse. Table 1 Open in new tab. Self-reported substance use within the sample. Number who said they had regularly used heroin. Number who said they had regularly used crack cocaine or powder cocaine. Number who said they had regularly used more than one illicit substance. Number who said their alcohol consumption had been high, heavy or problematic. Substance use among the 37 male perpetrators who undertook in-depth interviews 31 26 34 24 Substance use among the 14 male perpetrators whose partners were also interviewed 13 11 13 9 Substance use among the 14 female partners 7 5 6 6. Google Scholar PubMed. Google Scholar Crossref. Search ADS. Download all slides. Views 40, More metrics information. Total Views 40, Email alerts Article activity alert. Advance article alerts. New issue alert. Receive exclusive offers and updates from Oxford Academic. Citing articles via Web of Science Coercive Control. Barlow and S. More from Oxford Academic. Criminology and Criminal Justice. Social Sciences. Authoring Open access Purchasing Institutional account management Rights and permissions. Get help with access Accessibility Contact us Advertising Media enquiries.

Buying coke online in Velzen

Official websites use. Share sensitive information only on official, secure websites. JO conceptualized the research question and prepared the first draft of the manuscript. TN developed the analysis strategy. TN and AM performed statistical analyses. All authors reviewed and approved the final version of manuscript. Current models of HIV prevention intervention dissemination involve packaging interventions developed in one context and training providers to implement that specific intervention with fidelity. Providers rarely implement these programs with fidelity due to perceived incompatibility, resource constraints, and preference for locally-generated solutions. Moreover, such interventions may not reflect local drug markets and drug use practices that contribute to HIV risk. This paper examines whether provider-developed interventions based on common factors of effective, evidence-based behavioral interventions led to reduction in drug-related HIV risk behaviors at four study sites in Ukraine. We trained staff from eight nongovernmental organizations NGOs to develop HIV prevention interventions based on a common factors approach. We then selected four NGOs to participate in an outcome evaluation. At three sites, we observed reductions in the prevalence of both any risk in drug acquisition and any risk in drug injection. At the fourth site, prevalence of any risk in drug injection decreased substantially, but the prevalence of any risk in drug acquisition essentially stayed unchanged. The common factors approach has some evidence of efficacy in implementation, but further research is needed to assess its effectiveness in reducing HIV risk behaviors and transmission. Behavioral interventions to reduce HIV risk developed using the common factors approach could become an important part of the HIV response in low resource settings where capacity building remains a high priority. HIV infection among people who inject drugs PWID remains a significant public health problem, despite the existence of effective strategies to reduce HIV transmission among this population. However, efforts to scale up these interventions have faced significant challenges, particularly in low and middle income LMIC countries such as Ukraine. In the context of these challenges, HIV prevention interventions that promote behavior change can be an important tool that complements structural and policy interventions. As Rhodes , argues, the production of HIV risk is multifaceted and requires multi-level response. In addition, these interventions can often serve as important conduits for enrolling clients in other programs offered by nongovernmental organizations NGOs or health care providers, including drug treatment and HIV care. Also, because these programs often require implementing agencies to continually enroll new clients into on-going programs, they can also serve as an important strategy for reaching new populations that may not have received harm reduction services previously. As Rotheram-Borus et al. Common factors are broad constructs that support behavior change and can be incorporated into a variety of EBIs. According to this framework, successful interventions provide participants with a framework for understanding their HIV risk behavior and opportunities for change; build cognitive, affective, and behavioral skills; foster social support; include tailored, behavior-specific content; and address environmental barriers to behavior change. These interventions developed in one context are then packaged, and providers are trained to implement that specific intervention. Within implementation science, numerous studies have demonstrated that implementing interventions with high degrees of fidelity will lead to great program success Bopp et al. At the same time, research has also shown that implementing agencies rarely implement interventions with complete fidelity Dusenbury et al. They may expand interventions to new populations, eliminate activities or sessions, add elements that were not included in the original intervention, or combine them with other programs Galbraith et al. While implementation fidelity can be improved Horner et al. Several problems with this model exist, including the research-to-practice time lag Somerville et al. In addition, solutions developed to overcome shortcomings in the research-to- practice transfer process, including guidelines about how to select and purposefully adapt existing interventions, have their own potential limitations such as lack of rigorous evaluation themselves and uneven application in practice Craig Rushing, ; Gaglio et al. Moreover, an emphasis on core elements may diminish the importance of incorporating intervention components that address local drug mark characteristics, drug use practices, and risk environments that shape HIV risk for PWID in specific contexts Burris et al. Finally, the research-to-practice time lag and dependence of community organizations on the expertise of researchers may lead to delays in the development of effective interventions in the context of rapidly changing drug use contexts. This study took place in Ukraine between and As described in detail elsewhere Owczarzak et al. All study agencies worked in urban areas from a harm reduction perspective and provided a range of services that included HIV and hepatitis C testing, psychosocial support, case management, and community centers. Agencies varied in size, from a small NGO primarily staffed by volunteers to a large organization staffed by paid professionals. At the conclusion of Phase I, all participating agencies successfully developed a manualized intervention based on a common factors approach Owczarzak et al. The decision to evaluate the interventions of four agencies rather than all eight was built into the original study design. Resource constraints financial, human, logistical limited the number of sites we could work within the evaluation component of the study. Decision-making around which four agencies to continue working within Phase II was informed by 1 our understanding of the realities of staff turnover and agency and stability, based on our previous experience working with NGOs and in this region; 2 a goal of having agencies and interventions that represented diverse geographic regions, intervention content, and target populations among the final four agencies; and 3 selecting agencies whose interventions most consistently reflected the common factors training. For example, two agencies developed interventions primarily aimed at women. While both agencies developed strong interventions that reflected the common factors approach, we selected to work with the agency with the most stable funding and staffing. We did not select another agency for Phase II because it was located in AR Crimea, which was annexed by Russia and continuing to work there would have been logistically infeasible. Each NGO combined strategies of direct contact, participant referral, and street-based outreach to recruit individuals to participate in the intervention. Inclusion criteria included being at least 18 years of age and having injected drugs within the last 30 days. Eligible participants provided oral informed consent. Study participants included both existing and new clients recruited through outreach and participant referral. The four NGOs whose interventions included the largest number of common factors and most closely reflected the content of the training in their programs were selected to continue in the effectiveness evaluation component of the study see Table 1. Within their interventions, all agencies targeted behavioral determinants related to five theoretical concepts: 1 risk perception and appraisal, 2 self-perception, 3 emotion and arousal, 4 relationships and social influences, and 5 environmental and structural factors. Examples of targeted behaviors include developing and applying planning strategies to always have and use clean syringe, boiling drug solution bought in already pre-filled syringe, and negotiating clean syringe and condom use. Intervention activities included role playing, self-assessment, group discussions, video informational materials, and small lectures, as well as skills building for goal setting and planning drug use. Site 2 targeted PWID between 18 and 30 years old who injected stimulants and such behaviors as goal setting to reduce risky behaviors, developing strategies to access available services for PWID, cleaning syringes and needles, changing group norms regarding clean syringe and paraphernalia use, negotiating to buy drugs using own clean syringe, and using condoms with partners. Intervention sessions consisted of motivational interviewing, group discussions, small lectures, goal setting exercises, skills building for cleaning syringes and needles, and building negotiation skills through role playing. Experienced addiction treatment specialist facilitated the sessions. A separate session for women was facilitated by female social worker from the agency. Site 3 targeted their intervention toward heterosexually active women between 25 and 45 years old who inject drugs and have children. Within their intervention, the team targeted lack of knowledge about HIV, hepatitis, and sexually transmitted infections; low perceived risk of infection; low priority for preserving and maintaining health; lack of skills to access health services; maintaining safe injection and sex practices; and controlling emotion and arousal. Information sessions, skills building, group discussions, risk self-assessment, role playing, goal setting, planning and strategizing were utilized to achieve intervention goals. Intervention sessions were conducted by two female facilitators a psychologist and a social worker. Site 4 targeted PWID between 25 and 35 years old who use two or more type of substances for example, opiates and stimulants simultaneously or successively for more than 1 year. Low self-risk perception, prevalent myths about HIV risk, lack of knowledge and skills regarding safer injection and sexual practices, overdose prevention, and control of emotions, as well as lack of skills to change group norms were main targets of the intervention. Information sessions, video lectures, self-assessment, group discussions, skills building, identification of barriers, and role playing were the main strategies employed to achieve intervention goals. The sessions were conducted by an experienced seven years of fieldwork social worker. Participants at all sites completed a baseline assessment and a follow-up assessment 90 days after the last intervention session. In order to minimize social desirability bias that could result from having an interviewer ask the questions about the effects of an intervention they developed and implemented, the instrument was self-administered in Russian through a web-based online platform at the NGO venue in a private environment. NGO staff was available during the assessment to troubleshoot technical problems with the instrument. Additionally, agencies could use program support funds for intervention participation incentives e. Intervention participants in Sites 1 and 2 were provided food and a small financial incentive. Site 3 participants were provided hygienic kits as a small gift for attending the intervention. Site 4 participants did not receive a financial incentive by the agency to attend the intervention. The current paper focuses on the main outcomes of interest to the study: drug injection related HIV risk behaviors. We consider these behaviors in two broad groups: those related to drug acquisition and those related to injection itself. The time frame for these behaviors is the previous 30 days. Our current goal is to investigate differences between baseline and 3-month follow-up in the prevalence of these behaviors. It is important to note that we did not employ a randomized controlled trial RCT design. It was not an option to randomize sites given only four sites with unique interventions developed for different contexts. Randomization of clients within each site was not accepted by the frontline service providers with whom we work because they believed that all people who desired to participate in the intervention should receive it and that participants would not want to be randomized West et al. In addition, even if randomization had been more acceptable, contamination between intervention arms would have been hard to prevent given interaction among clients at each site. As the study uses a pre-post design without a comparison group, we will carefully discuss factors other than the intervention that may have contributed to an apparent outcome prevalence change, or the lack of one. Analyses were conducted separately for each site because the four sites are diverse, and the interventions are site specific. For each outcome at each site, the objective was to estimate i the pre-intervention outcome prevalence, ii the post-intervention outcome prevalence, and iii the pre-to-post outcome prevalence change the difference between ii and i. In this context of community-based interventions with hidden populations, some loss to follow-up was anticipated, especially at Site 1 where the client body tends to be transient due to migration and housing instability see below. As outcome variables are each coded based on several behavior specific items, an outcome variable may be missing because component behavior items are missing e. Our strategy was to impute the detailed items before combining them into the three outcome variables Rubin, We conducted multiple imputation in Mplus using a joint modeling approach treating categorical variables as manifestations of underlying continuous variables. In addition to letting the various specific risk behaviors inform one another, the imputation model incorporates auxiliary variables including baseline participant characteristics and types of drugs injected, among others. The number of imputations was picked based on White et al. This means the analysis for each site was based on the combination of the imputed datasets. Each imputed dataset provides a set of estimates for the parameters of interest — pre-intervention prevalence, post-intervention prevalence, and pre-to-post prevalence change, of each of the outcomes. We used bootstrapping to estimate variance. Specifically, from each imputed dataset, we resampled the individuals to draw bootstrap samples, which we used to estimate the covariance matrix of the parameter estimates. Thus, from each imputed dataset we have a set of point estimates and an estimated covariance matrix. Table 3 presents the characteristics of study participants at baseline. As expected, the sites are quite diverse. Participants in Site 2 were more likely than those at other sites to have some employment. Unstable housing was rare for participants in Sites 2 and 3, but not rare for the two other sites, and was common for those in Site 1. This may reflect differences in HIV prevalence, the degree to which participants were aware of their HIV status, and recruitment and screening strategies. The loss to follow-up proportion is highest in Site 1 Discussion with the partner organization at Site 1 indicated that high drop out at this site may be attributed to higher rates of unstable and transitory housing, exacerbated by the migration of internally displaced people fleeing conflict in eastern Ukraine. Based on our analysis strategies, this indicated the need to do a sensitivity analysis leaving out individuals without post-treatment data for Site 1. The other items had lower missing rates that are more similar across sites, ranging between 5. We conducted multiple imputation as described above. Table 4 provides a detailed report of missing rates in the specific risky behavior variables, and the corresponding missing rates in the composite outcome variables This table also shows the degree to which the variance of a prevalence or prevalence change estimate for composite outcome variables is inflated due to missing data; these variance inflation factors were estimated using the fmi function in the R package semTools Jorgensen et al. Missing data rates in pre- and post-intervention risk variables, and resulting variance inflation a in estimates of i pre-intervention prevalence, ii post-intervention prevalence, and iii pre-to-post-intervention prevalence change. This table reports variance inflation in estimating: i pre-intervention prevalence, ii post-intervention prevalence, and iii pre-to-post prevalence change see estimates in Table 5. We choose to directly report variance inflation because FMI, a variance partition measure, is often mixed with missing data rate. At all the four sites, the two items giving syringe to partner and giving syringe to middle person to get drug suffer from higher missing rates than other items due to a flawed skip pattern in the questionnaire. The composite outcome variables inherit missingness from the specific risky behaviors variables in the original data. Note that a missing value on a composite variable does not imply complete missing information on that value. For example, the composite variable risky behavior in drug acquisition variable is based on four specific risky behavior variables. If three of these component variables are 0 and one is missing, then we have partial information on the composite variable even though it is missing; such information is incorporated in the imputed data. Table 5 presents the estimated prevalence of each of the three outcome variables pre- and poster-intervention first and second numeric columns and the corresponding pre-to-post-intervention prevalence changes third numeric column , for each site. Despite variance inflation due to missing data see Table 4 , the standard errors are not substantial -- between 0. Pre- and post-intervention prevalence and pre-to-post-intervention change in risk behaviors. Percent symbols are left out of the standard error and confidence intervals to avoid cluttering. For example, at the top-left of the table, The confidence intervals in the pre-to-post change column, if not signed, should be interpreted to be of the same sign as the point estimate. The p-values here are for permutation tests of the null hypothesis that there was no difference in risk behavior prevalence between baseline and follow-up. There was variation in pre-intervention risk behavior prevalences across sites. Overall, these prevalences tend to be higher in Sites 2, 3 and 4 mostly in the seventies and eighties range, in percentage terms relative to Site 1 in the fifties and sixties range. There was also a substantial difference in prevalence between the two types of risk behavior at Site 3, where risk behavior in drug injection In Site 3, interestingly, the behavior with lower baseline prevalence any risk behavior in drug injection , The sensitivity analysis for Site 1 leaving out those lost to follow-up gave similar results. The degree of decrease is similar to that reported in evaluations of other behavior change risk reduction interventions in Ukraine Booth et al. Three of the four sites demonstrated risk reduction for both drug acquisition and drug injection, whereas one site demonstrated decrease in drug injection risk only. The intervention developed by Site 3 did not demonstrate the same decreases in drug acquisition risks as other sites. Site 3 general services targeted women specifically, including those who engage in sex work, and built their intervention using knowledge acquired from working with this population. The intervention addressed gender-specific aspects of HIV risk through sex and drug use, including negotiating condom use, communication, power imbalances, building safe injection skills such as negotiating to not use dirty syringes. Based on follow-up conversations with agency staff at Site 3, the organization of the drug market may have shaped the extent to which intervention participants could change their acquisition-related risk behaviors. Clients typically purchased their drugs through a courier, who would deliver the ordered amount in a disposable syringe i. There may be no other alternatives for procuring drugs in this region, and therefore reflects a dimension of HIV risk over which intervention participants felt they had little control. Further research on the underlying HIV risk mechanisms for women who use drugs and engage in sex exchange is warranted. In addition, this study did not address other outcomes such as entry into treatment and frequency of drug use that can lead to reduced HIV risk or use biomarkers such as HIV status to demonstrate efficacy. Interventions also did not have an explicit HIV testing and counseling component, although all study sites offered HIV testing and counseling as part of their standard package of services. In designing this study, we accounted for the realities that many NGOs face when conducting their work. Staff turnover, funding uncertainties, and shifting public health priorities can undermine organizational viability and sustainability. We purposefully included more organizations in Phase I intervention development than we could support in Phase II evaluation. Participating agencies understood at the outset of the study that not all organizations would continue into the evaluation component. Further research and innovation are necessary to address issues of sustainability, particularly for NGOs that depend on international donors for financial viability, and to simultaneously provide strong scientific evidence and correspond to the real-world circumstances in which programs are implemented. We attempted to minimize reporting bias e. Throughout the study and at its conclusion, we had extensive conversations with NGO staff about this possibility and did not note any changes services or drug acquisition and use practices that would account for the changes. The common factors approach would benefit from an RCT that rigorously establishes causal effects. Such a research project would require a sustained and deep collaboration between researchers and NGOs, a kind of collaboration that facilitates co-learning and enables NGO staff to become more familiar with research principles and concepts and allows researchers to better understand what is needed for real world frontline interventions. This collaboration would need to benefit both researchers and service providers. Harmonization between these two interests requires long-term and genuine understanding and partnership, as well as investment of financial and other resources. Finally, in addition to an RCT, a reasonable next step for understanding the common factors approach would be additional process evaluation studies that would advance implementation science. An evaluation using an implementation science framework such as RE-AIM or other process models and evaluation frameworks Nilsen, would provide important information needed to scale up the common factors approach such intervention costs, participant and implementing staff characteristics, and program maintenance at the individual and organizational levels. Improving the ways in which research evidence is used and decreasing the knowledge-to-practice gap is a critical step in the implementation of evidence-based programs by frontline service providers. It shares the basic principles of what makes an intervention effective with those who will implement an intervention and uses the experience-based knowledge and skills of the implementers to develop contextually relevant programs that respond to the needs and circumstances of the implementing community. Moreover, behavioral interventions to reduce HIV risk among PWID that are developed using the common factors approach could become an important part of the HIV response in low resource settings where capacity building remains a high priority. A common factors approach can bring together research-generated knowledge with local knowledge, creativity and solutions. Finally, the common factors approach is highly flexible and potentially transferrable to other approaches in addition to behavioral interventions. A common factors approach can be used in the development of these programs as well. We extend our gratitude to the staff in agencies participating in the project whose input in data collection was vital. Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. As a library, NLM provides access to scientific literature. Drug Alcohol Depend. Published in final edited form as: Drug Alcohol Depend. Find articles by J Owczarzak. Find articles by TQ Nguyen. Find articles by A Mazhnaya. Find articles by SD Phillips. O Filippova 5 Department of Sociology, V. Find articles by O Filippova. Find articles by P Alpatova. T Zub 7 Department of Sociology, V. Find articles by T Zub. Find articles by R Aleksanyan. Contributors JO conceptualized the research question and prepared the first draft of the manuscript. Issue date Jun 1. PMC Copyright notice. The publisher's version of this article is available at Drug Alcohol Depend. Open in a new tab. Similar articles. Add to Collections. Create a new collection. Add to an existing collection. Choose a collection Unable to load your collection due to an error Please try again. Add Cancel. Years in existence at project start. Number of sessions attended, median IQR. HIV and STI information personal risk assessment skill building for safer drug use and sex identify emotional triggers. Composite outcome variables of risky behaviors in c :. Composite outcome variables risky behavior in c :. Composite outcome variables of risky behavior in c :.

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