Society For The Study Of Addiction

QMJC November 2022: Diaries and the life-cycle of a syringe

This is the fourth Qualitative Methods Journal Club from Drexel University (Philadelphia, United States). This time, the group discussed using diaries to record activities and emotional responses from people who inject drugs. The study on which the discussion was based was from 2004 meaning that it was conducted before social media was widely accessible, posing a range of thought-provoking questions. 

Article Summary

The article discusses the use of diaries to understand HIV risk behaviors among people who inject drugs. The research is part of the Syringe Access, Use and Discard (SAUD) Study among people who inject drugs (n=989) that took place in three US cities, including Hartford, CT, New Haven, CT, and Springfield, MA. The SAUD study utilized a variety of qualitative methods – ranging from participant observation/ ethnography to focus groups, in-depth interviews, and daily diaries – to assess factors that shape the ability of people who inject drugs to obtain and use sterile syringes, and to discard them safely.

Original article: Writing about risk: Use of daily diaries in understanding drug-user risk behaviors by T Stopka and colleagues. Published in  AIDS and Behavior (2004).

The diary component of the study involved a subsample of 23 participants, of whom 18 people wrote and 5 people dictated daily diary entries over a period of 5-7 days.  Each entry included the date, time, and details of past 24-hour injection events; participants were also encouraged to provide additional information.  One of the project ethnographers met with each participant to discuss the previous day’s entry and made notes. Diaries were transcribed and analyzed by ethnographers. The article reported that diaries: helped identify patterns of drug use and other life events; captured sporadic and high-risk events; helped understand a life cycle of a syringe; documented emotions and feelings related to drug use; and had an unexpected intervention effect as some participants indicated in their diaries they wanted to quit drugs or engage in drug treatment.

Group

Seven members of the Department of Community Health and Prevention at Drexel University’s Dornsife School of Public Health, including faculty and doctoral students with backgrounds and interest in substance use research and/or qualitative methods, took part in a one-hour discussion via Zoom on August 31, 2022.

Discussion Summary

The group said that diary keeping was an exciting method of data collection, yet rarely utilized in drug research. A faculty member with substantial qualitative research experience explained that diaries were part of the anthropological tradition of the early 2000s (when the article was written) to generate the granular level of data to understand lived experiences of people at risk.

Though nobody in the group had used diaries in their research, members found a number of parallels between diary keeping and other qualitative methods they had previously utilized. For example, a faculty member mentioned that in the early 2000s, his own qualitative research involved understanding drug injection practices. He noted that asking about the most recent injection event during a qualitative interview felt equivalent to a dictated diary entry since the last injection usually occurred on the same day or a day before. Another member recalled that in the past, her qualitative interviews with women who used drugs started with an ice-breaking question asking how was the woman’s day yesterday. Unexpectedly, responses to that question yielded a valuable account of the participant’s past 24 hours, including drug procurement, income generation, or strategies for finding food or shower.  The group concluded that responses to qualitative interview questions about recent events may resemble dictated diary entries. Still, asking participants to record or write about recent events in their own words brings additional benefits as participants add valuable nuances, document important life events, or mention novel drug use practices.

Diaries were also compared with data generated by ecologic momentary assessments (EMA).  One member noted that her advisor’s EMA project asked participants with risky behaviors to answer some specific questions during random days of week.  Similar to diaries, EMA generated a granular level of data. Yet, EMA data were quantitative and limited to the questions asked, while diaries – even where participants receive some guidance – generated rich datasets, which included feelings, emotions, and details of personal relationships. The member felt that lessons learned from the era of anthropologically-oriented drug use research helped to prepare EMA as a quantitative version of diaries.

The group also acknowledged that diaries represent a powerful exploratory technique to identify new drug use trends, hidden practices, or hidden populations, as was highlighted in the article.  One member said that despite the fact that diaries are usually kept for a short period of time, they still provide a good snapshot of things taking place in the person’s life. Overall, the group agreed that diaries can become a jumping off point for more in-depth qualitative or quantitative exploration and be useful in projects focused on hidden/unknown/unrecognized areas of risk.

Members also praised the article for its engagement with ethical issues.  One member said it was useful to learn how recording daily events caused a negative emotional reaction in some participants and catalyzed a behavioral change in other people. Another member added that some emotional distress recorded by the diary study could have also happened during a “traditional” qualitative interview. The group also agreed that it is worth remembering that for people who use drugs, especially those who are street-based, trauma is common. The researcher’s responsibility is to provide participants with the right information, for example, by giving participants a general warning beforehand that some questions may evoke negative memories and emotional reactions. This is different however from studies directly focusing on trauma or suicide that require the researchers to prepare a detailed safety plan.

The group also discussed some ethical dilemmas faced by the researchers.  On one hand, the researchers wanted to protect the participants from health risks stemming from unsafe injecting practices. Yet, supplying participants with clean syringes could have led to the researchers being arrested in one of three study locations (due to the local ban on syringe sales).  Moreover, providing syringes in any study location would have compromised the overall study aim to accurately describe practices predisposing people who inject drugs to HIV. The group praised the researchers for finding a compromise, a “middle-road” solution, as they eventually decided to provide bleach kits without syringes to participants in all three locations. The group concluded that in some cases, the implementation piece of research needs to be adjusted and that the diary study exemplified how the integrity of research questions can be matched with ethical concerns.

The group also noted some challenges of the diary methodology.  For example, one member said that diaries may impose a burden on participants to keep accounts of their lives that may result in high attrition rate. However, another member argued that people who use drugs may actually appreciate having an opportunity to share the details of their lives as it may feel like someone cares about them.  One member also noted that it’s worth remembering that diaries were just one of several components of the larger study, which also utilized ethnography, focus groups, and interviews.

Physical writing was mentioned as a considerable challenge posed by diaries.  One member said that the article was written in the era preceding social media and texting, using three-letter acronyms and emoji, and people’s journaling abilities could have declined since. Moreover, writing may be impeded by inadequate literacy skills. Yet, another member mentioned that literacy has always been a barrier for some people, and the article reported that dictation was offered as an alternative to writing. One member shared that even a contemporary project she’s engaged in, which uses writing as a trauma intervention among people who use drugs, asks participants to write with a pencil and paper, though also offers audio-recording as an alternative.  Another member wondered if recording has the same effect as writing, especially given that in a social work setting, writing is considered to offer a cathartic release.

The group also discussed whether diaries pose a threat to data confidentiality by recording personal data on paper and what may happen if the police come in contact with journal entries.  In contrast, one member argued that she would consider paper and pencil to be relatively secure compared to digital recordings and their uploads to the cloud.

Interestingly, the fact that the article was written 18 years ago, encouraged the group to think creatively about the ways diaries could be adapted to the present time. For example, one member said that diaries made her think about the BeReal photo-sharing app popular among young children. BeReal sends notifications to a cell phone at random parts of a day asking users to record and share a picture of what they are doing in real time.  And this is how perhaps diaries could be used in the present – in addition to personal stories, participants could be asked to record and share pictures of what they’re looking at in the real time.

Overall, the group concluded that diaries offer a powerful method to learn about real-world experiences and they have a lot of untapped potential in contemporary drug use research.

by Dr Janna Ataiants 


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