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Title
Mental health and family relations among people who inject drugs and their family members
in Vietnam.
Permalink
https://escholarship.org/uc/item/5629g82d
Journal
The International journal on drug policy, 24(6)
ISSN
0955-3959
Authors
Li, Li
Tuan, Nguyen Anh
Liang, Li-Jung
et al.
Publication Date
2013-11-01
DOI
10.1016/j.drugpo.2013.06.007
Peer reviewed
eScholarship.org
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ContentslistsavailableatScienceDirect
International
Journal
of
Drug
Policy
j ou rn a l h om epa g e :w w w . e l s e v i e r . c o m / l o c a t e / d r u g p o
Research
paper
Mental
health
and
family
relations
among
people
who
inject
drugs
and
their
family
members
in
Vietnam
Li
Li
a,∗,
Nguyen
Anh
Tuan
b,
Li-Jung
Liang
c,
Chunqing
Lin
a,
Shu
C.
Farmer
a,
Martin
Flore
caSemelInstituteforNeuroscienceandHumanBehavior,CenterforCommunityHealth,UniversityofCalifornia,LosAngeles,CA,USA bNationalInstituteofHygieneandEpidemiology,Hanoi,VietNam
cDepartmentofMedicineStatisticsCore,UniversityofCaliforniaatLosAngeles,LosAngeles,CA,USA
a
r
t
i
c
l
e
i
n
f
o
Articlehistory:Received13March2013
Receivedinrevisedform18June2013 Accepted19June2013 Keywords: Druguser Familymembers Vietnam Depression Familyrelation
a
b
s
t
r
a
c
t
Background:Thisarticleexplorestheassociationofpeoplewhoinjectdrugsandtheirfamilymembersin termsofmentalhealthandfamilyrelations.Theobjectivewastounderstandthefamilycontextandits impactonpeoplewhoinjectdrugsinafamily-orientedcultureinVietnam.
Methods:Cross-sectionalassessmentdataweregatheredfrom83peoplewhoinjectdrugsand83oftheir familymembersrecruitedfromfourcommunesinPhúTho. province,Vietnam.Depressivesymptoms andfamilyrelationsweremeasuredforbothpeoplewhoinjectdrugsandfamilymembers.Internalized shameanddrug-usingbehaviorwerereportedbypeoplewhoinjectdrugs,andcaregiverburdenwas reportedbyfamilymembers.
Results:Wefoundthathigherlevelofdrugusingbehaviorofpeoplewhoinjectdrugswassignificantly associatedwithhigherdepressivesymptomsandlowerfamilyrelationsreportedbythemselvesaswell astheirfamilymembers.Familyrelationsreportedbypeoplewhoinjectdrugsandtheirfamilymembers werepositivelycorrelated.
Conclusion:Thefindingshighlighttheneedforinterventionsthataddresspsychologicaldistressandthe relatedchallengesfacedbyfamilymembersofpeoplewhoinjectdrugs.Thearticlehaspolicy implica-tionwhichconcludeswithanargumentfordevelopingstrategiesthatenhancetheroleoffamiliesin supportingbehavioralchangeamongpeoplewhoinjectdrugs.
© 2013 Elsevier B.V. All rights reserved.
Introduction
Vietnamhasalonghistoryofopiumuse(McCoy,1991).From 1994to2004,thenumberofpeoplewhoinjectdrugs(PWID)tripled inVietnam,yieldinganaverageannualincreaseof11.9%(Nguyen& Scannapieco,2008).In2011,Clatts,Goldsamt,Giangle,and Colón-López(2011)estimatedthatbetween100,000and180,000people whoinjectheroinliveinthecountry.Thispopulationengagesin high-riskbehaviorssuchasneedlesharingandriskysexual behav-ior,facilitatingthespreadofHIV(Hammettetal.,2012;Hoffman, Nguyen,Kershaw,&Niccolai,2011;Quanetal.,2010;Thanhetal., 2009).InVietnam,52%ofpeoplelivingwithHIVarePWID(Thanh etal.,2009).
Priorresearchsuggeststhatthefamilyplaysanimportantrole inPWID’sdruguse,adherencetotreatmentprograms,andother healthoutcomes.InarecentstudyinIndia,familypressurewas
∗Correspondingauthorat:SemelInstitute,UniversityofCalifornia,LosAngeles, 10920WilshireBoulevard,Suite350,LosAngeles,CA90024,USA.
Tel.:+13107942446;fax:+13107948297.
E-mailaddresses:lililili@ucla.edu,lili@mednet.ucla.edu(L.Li).
found tobe one of the most important correlatesof cessation (Mehtaetal.,2012).Inasurveyof543familymembersofdrugusers inJapan,itwasreportedthatthegeneralhealthofrelativesclosely correlatedwiththeirfamilymember’sabstinencestatus(Morita etal.,2011).InUkraine,Mimiagaandcolleagues(2010)identified thatemotionalsupportandremindersfromfamilyfacilitated medi-cationadherenceamongHIV-positivePWID.FamilyissuesofPWID werequotedasabarriertoimplementingalcoholandotherdrug usetreatmentprogramsintheUnitedStates(Appel,Ellison,Jansky, &Oldak,2004).
InVietnameseculture,thefamilyisconsideredanextensionof theselfandplaysanimportantroleinmostlifedecisions(Salter etal.,2010).DifferentfromPWIDinsomewesterncountries,most PWIDlivewiththeirfamilies.Thefamily presentstheprincipal sourceoffinancialsupportandcare,whichpreventsPWIDfrom sufferingserioussocialdeprivationandillhealth(Ogden&Nyblade, 2005;Rudolphetal.,2012;Salteretal.,2010).However,thenexus betweenthehealthstatusanddrug-usingbehaviorofPWIDand theirfamilymembershasbeenunderrepresentedintheliterature. ExistingresearchonPWIDandtheirfamiliesinVietnamhas pre-dominatelyrevolvedaroundstigmaanddiscrimination(Gaudine, Gien,Thuan,&Dung,2009;Nybladeetal.,2008;Ogden&Nyblade, 0955-3959/$–seefrontmatter© 2013 Elsevier B.V. All rights reserved.
546 L.Lietal./InternationalJournalofDrugPolicy24 (2013) 545–549
2005;Thietal.,2008)andtheroleofthefamilyinPWIDresponses toHIVstatusdisclosure(Rudolphetal.,2012;Salteretal.,2010). Todate,wearenotawareofanystudiesthathaveexaminedfamily members’well-beinganditsassociationwithhealth,social func-tioning,anddrug-usingbehavioramongPWID.Thisstudyaimsto elucidatetherelationshipsofPWIDandtheirfamilymembersin termsofmentalhealthandfamilyrelations.Wehypothesizedthat thementalhealthoffamilymembers,perceivedfamilyrelations, andcaregiverburdenwereassociatedwithPWIDmentalhealth, internalizedshame,anddrug-usingbehavior.Understanding fam-ilycontextandhowvariousfamilialrelationshipsaffectPWIDcan informfutureinterventiondesignanddevelopment.
Methods
Studydesignandparticipants
Thisstudyusedthebaselinedatafromaninterventionpilot, whichwasconductedbetweenAugust2010andJune2012inPhú Tho. province,Vietnam.PhúTho. isaprovinceinnorthernVietnam withhighratesof poverty,druguse, andHIV prevalence(Food andAgricultureOrganizationoftheUnitedNations,2012).TheHIV prevalenceamongPWIDinPhúThowasabout20%duringtheyears of2004–2006(UNAIDS/WHO,2008).
StudyparticipantsincludedlocalPWIDandtheirfamily mem-bersinthefourcommunesofPhúThoprovince.Thestudyused thelocalcommunehealthcenters(CHC)asthesamplingframe.In Vietnam,alargeproportionofPWIDsoughtroutinetesting and healthcarefromCHC, thustheCHCprovidersdeveloped direct workingrelationshipswithPWIDintheircommunes(WorldHealth Organization,2010).TheserviceprovidersintheCHCintroduced thestudytothePWIDintheircommunesthroughword-of-mouth anda printed flyer,andthePWIDwho wereinterestedin par-ticipatingwerereferredtotheprojectrecruitersforscreeningto determineeligibility.PWIDparticipantshadtomeetthefollowing criteria:(1)age18andabove,(2)ahistoryofinjectingdruguse, (3)residenceinthestudycommune,and(4)willingnesstoinvitea familymembertoparticipateinthestudy.Familymemberswere recruitedafterobtainingconsentofthePWID.Familymembershad tomeetthefollowingcriteria:(1)age18orover,(2)animmediate orextendedfamilymemberofarecruitedPWIDandlivingwiththe PWID,and(3)priorknowledgeofthedrugusestatusofthePWID participant.
Ethicalissues
WhenrecruitingPWIDandfamilymembers,researchstaff fol-lowedstandardizedscriptstointroducethepurposeofthestudy anditsprocedures,potentialrisks,andbenefits.Participantswere assuredthatthestudywasvoluntaryandtheirdecisiontoenroll would not affect their services or access to services. Written informedconsentswereobtainedfromPWIDand family mem-bersbeforedatacollection.Thestudyproceduresandmaterials wereapprovedbytheInstitutionalReviewBoardsofthe Univer-sityofCalifornia,LosAngeles,andtheVietnamNationalInstitute ofHygieneandEpidemiology.
Datacollection
Participantscompletedaface-to-facesurveythatwas admin-isteredby trainedinterviewers. Thesurvey wasconductedin a privatelocation suchas a local CHC office or theparticipant’s home.Eachassessmenttookabout45–60mintocomplete.All par-ticipantswerepaid 80,000dong (approximately U.S.$5.00) for completingthesurvey.
Measures
In additiontodemographic characteristics,several measure-mentscaleswereused.SomemeasureswereusedforbothPWID andfamilymembers,asdetailedbelow.
DepressivesymptomsweremeasuredforbothPWIDandfamily membersusingashortversionoftheZungSelf-RatingDepression Scale(Zung,1965).Thescalewascomposedof10itemsadapted fromtheoriginal20-item questionnairebasedoncultural rele-vancy.Theparticipantswereaskedthefrequencyof10situations, suchas“Ifeeldown-heartedandblue,”and“Igettiredforno rea-son.”Responsecategoriesrangedfrom1(alittleofthetime)to4 (mostofthetime).Theoverallscorefordepressivesymptomswas thesumofthe10items,withahigherscoreindicatingahigher levelofdepressivesymptoms(˛=0.84forPWIDand˛=0.75for familymembers).
FamilyrelationswerealsomeasuredforbothPWIDandfamily membersusingtheFamilyFunctioningScale(Bloom,1985;Bloom &Naar,1994).Forthisstudy,weadaptedtwosubscales(family cohesionand family conflict)from theoriginal 15 subscalesto reflectfamilyrelationship.Thetwosubscalescontained10 state-ments,withparticipantsevaluatinghowtrueeachstatementwas fortheirfamilyonafour-pointLikertscalefrom1(veryuntrue)to 4(verytrue).Samplestatementsincluded“Familymembersreally helpandsupportoneanother.”Thestatementsinthefamilyconflict subscalewerereversecodedsothatahigherscoreindicatedbetter familyrelations(˛=0.80forbothPWIDandfamilymembers).
Internalized shame perceived by PWIDwas assessed using a nine-itemsubscaleadaptedfromHerekandCapitanio(1993).The subscalehasbeenvalidatedinanAsianpopulationinprevious stud-ies(Li,Lee,Thammawijaya,Jiraphongsa,&Rotheram-Borus,2009). Theparticipantswereaskedtoevaluateiftheyagreewith state-mentssuchas“Iamadisgracetosociety,”and“Mylifeisfilledwith shame.”Responsecategoriesrangedfrom1(stronglydisagree)to 5(stronglyagree).Summativecompositescoreswerecreatedso thatahigherscoreimpliedahigherdegreeofinternalizedshame (˛=0.85).
DrugusebyPWIDwasdeterminedusingtheAddictionSeverity Index(ASI),awidelyusedclinicalresearchinstrumenttoquantify addictivebehavior(McLellanetal.,1992).ThePWIDparticipants reportedtheirfrequencyand severityofusingillicit substances intheprevious30days.Thesubstancesqueriedincludedheroin, otheropiates/analgesics,amphetamines,cocaine,orhallucinogens. Adrugcompositescorewasconstructedbasedontheresponsesto thesequestions,withahigherscoreindicatingmoreseveredrug usingproblem(McGahan,Griffith,Parente,&McLellan,1986).
Caregiverburdenperceivedbyfamily memberswasassessed usingthePerceivedCaregiver BurdenScale (Stommel, Given, & Given,1990),whichhasbeenusedinourpreviousstudies(Lee,Li, Jiraphongsa,&Rotheram-Borus,2010).This21-itemscaleassessed familymembers’perceptionofhavingadrug-usingrelativeandits impactonhealth,finances,andfeelingsofentrapment.Responses toindividualitemsrangedfrom0(never)tonearlyalways(4).A highersummedscorereflectedahigherlevelofburdenperceived byfamilymembers(˛=0.85).
Statisticalanalysis
DescriptivestatisticsandfrequenciesforPWIDandfamily mem-berdemographicsandothermeasuresofinterestaresummarized inTable1.Weexamineddifferencesincategoricalandcontinuous variablesbetweenthePWIDandfamilymembersusingChi-square (orFisher)testsandttests(orWilcoxonranktests),respectively. Next,Pearson’scorrelationsamongfivemeasuresofinterestwere calculated.Wealsousedlinearmultipleregressionmodels, con-trolling for age,years of education,and number of children to
Table1
Samplecharacteristics.
Parameter PWID Familymember p
N 83 83 Age(%) <35 53(63.9) 33(39.8) 36–45 24(28.9) 11(13.3) >46 6(7.23) 38(45.8) Mean±SD 33.7±6.83 43.6±16.0 <0.0001a Male(%) 83(100) 8(9.64) <0.0001b
Yearsofeducation(mean±SD) 10.6±2.38 10.02±4.12 0.1330a Depressivesymptoms(mean±SD) 17.5±5.32 18.41±4.93 0.1786a Familyrelations(mean±SD) 30.1±3.26 32.41±3.44 <0.0001a Internalizedshame(mean±SD) 32.1±5.44
Druguse(mean±SD) 0.14±0.07
Caregiverburden(mean±SD) 53.3±8.59
aWilcoxonsignranktest. bFisherexacttest.
assesseachofthefollowingrelationshipsindependently:whether internalizedshameordrugusereportedbyPWIDwereassociated withtheirownandtheirfamilymembers’depressivesymptomsor familyrelations,andwhethercaregiverburdenreportedby fam-ilymemberswasassociatedwiththeirownandPWIDdepressive symptomsorfamilyrelations.Estimatedregressioncoefficient( ˆˇ) and its95% confidenceinterval (CI)are presented.Lastly, since depressivesymptomsandfamilyrelationswerereportedbyboth PWIDandtheirfamilymembers,itwashighlyprobablethatthese twomeasureswerecorrelatedwithinthefamily.Thus,weuseda bivariatelinearmixedmodel(Weiss,2005)thatincludesrandom effectsandindependentmeasurementerrortoproperlyaccountfor thepairedmeasurestoexaminewhetherfamilyrelationsreported byPWIDandtheirfamilymemberswereassociatedwiththeirown reporteddepressivesymptoms.Themodels,withandwithoutthe covariatesmentionedabove,wereimplemented(unadjustedand adjusted,respectively).AllanalyseswereconductedusingSAS9.3 software(SASInstitute,Cary,NC).
Results
The meansand standard deviations of the levels of depres-sivesymptoms,familyrelations forPWIDand familymembers, internalizedshameanddrugusemeasuresfor PWID,and care-giverburdenforfamilymembersareshowninTable1.Allofthe PWIDparticipantsweremen,andmostoftheirfamilymembers recruitedinthisstudysamplewerewomen.ThePWIDwere,on average,about10yearsyoungerthanfamilymembers(p<0.0001). Themajority(64%)ofPWIDwereyoungerthan35,whileroughly 60%offamilymemberswereolderthan35.Nosignificant differ-enceinyearsofeducationbetweenthePWIDandfamilymembers wasfound.AlowerleveloffamilyrelationswasreportedbyPWID thanbyfamilymembers(30.1vs.32.4;p<0.0001).However, com-parablelevelsofdepressivesymptomsbetweenPWIDandfamily memberswereobserved.
Correlationcoefficientsforthefivemeasuresofinterestare pre-sentedinTable2.Bothdruguseandinternalizedshamereportedby PWIDweresignificantlyassociatedwithdepressivesymptomsand familyrelationsreportedbythemselvesandtheirfamilymembers. Thelinearregressionresultsforeachoftheserelationshipsof inter-estareshowninTable3.Controllingforage,numberofchildren, andyearsofeducation,weobservedthatcaregiverburdenreported byfamily memberswassignificantlyassociatedwiththeirown depressivesymptoms( ˆˇ=0.28,95%CI:0.16,0.40;p<0.0001)and familyrelations( ˆˇ=−0.11,95%CI:−0.22,−0.01;p=0.029).Also, PWIDdrugusewassignificantlyassociatedwiththeirownreported depressivesymptoms( ˆˇ=37.6,95%CI:23.7,51.5;p<0.0001)and familyrelations( ˆˇ=−20.1,95%CI:−29.2,−11.0;p<0.0001)as
well as theirfamily members’ depressive symptoms ( ˆˇ=14.6, 95%CI:1.38,27.8;p=0.031)andfamilyrelations( ˆˇ=−11.3,95% CI:−21.3,−1.21;p=0.029).Furthermore,theinternalizedshame reportedbyPWIDwassignificantlyassociatedwithhigher depres-sivesymptomsreportedbybothPWID( ˆˇ=0.46,95%CI:0.27,0.65; p<0.0001)andbytheirfamilymembers( ˆˇ=0.19,95%CI:0.004, 0.37;p=0.046).Similarly,internalizedshamereportedbyPWID wasnegativelyassociatedwithfamilyrelationsreportedbyboth PWID(p=0.017)andbytheirfamilymembers(p=0.027).Noneof thepotentialconfounderswerefoundtobesignificantintheabove regression models,exceptthat yearsofeducationwasfoundto besignificantlyassociatedwithdepressivesymptomsreportedby PWID( ˆˇ=−0.61,95%CI:−1.07,−0.15;p=0.010)inthepresence oftheirinternalizedshamemeasure.
Resultsfromthebivariatelinearmixedmodelwithout covari-ates indicated that the family relations reported by PWID and family membersweresignificantly positivecorrelated (=0.35; p=0.004).Giventhis,wefoundthattheleveloffamilyrelations reported by both PWID and their family members was nega-tivelyassociatedwiththeirownlevelsofdepressivesymptoms. The association reported by family members ( ˆˇ=−0.13, 95% CI:−0.27, 0.01)appeared tobe stronger thanthat reportedby PWID( ˆˇ=−0.08,95%CI:−0.20,0.05),butthedifferencedidnot reachsignificance.Theoverallassociationbetweenfamilyrelations anddepressivesymptomsestimatedfromtheunadjustedmodel was statistically significant( ˆˇ=−0.10, 95% CI: −0.20, −0.005; p=0.040).Therewasatrend towardsignificancefortheoverall associationestimatedfromtheadjustedmodel( ˆˇ=−0.09,95%CI:
−0.19,0.01;p=0.085),andnoneofthecovariatesweresignificantly associatedwithfamilyrelations.
Discussion
OurresultsdemonstratethedeepconnectednessofPWIDand theirfamily members.Drug usingis individual behavior,but it alsoimpactsothermembersofafamily.Oneofthebasicpremises withinthefamilystructureistheideaofcollectiveidentity(i.e., thedrug-usingbehaviorsofanindividualreflectbadlyonallfamily members)(Dean,1999).APWIDcannotdiscardhisorherpersonal responsibilitiestothefamily,norcanthefamilymember(s).These attributesarereflectedinourfindingsonthecorrelationsbetween PWIDandfamilymembersintermsoffamilyrelationsand depres-sivesymptoms.Our studyprovidesfurtherevidencethat PWID druguseandnegativeemotion(e.g.,internalizedshame)are associ-atedwiththedepressivesymptomologyoffamilymembersaswell astheirown,suggestingthatdruguseposestheriskofexposing theentirefamilytopsychologicaldistressandrelatedchallenges.
548 L.Lietal./InternationalJournalofDrugPolicy24 (2013) 545–549
Table2
Correlationcoefficientsamongselectedvariables.
PWID Familymember
Familyrelations (FR)
Druguse(DU) Internalizedshame(IS) Depressivesymptoms (DEP)
Familyrelations(FR) Caregiverburden(CB)
PWID
DEP −0.163 0.546** 0.422** 0.225 −0.162 0.090
FR −0.429** −0.269* −0.070 0.362* −0.136
DU 0.317* 0.226* −0.228* 0.160
IS 0.231* −0.272* 0.158
Familymember DEP −0.201 0.574
**
FR −0.292*
* p<0.05. ** p<0.0001.
Table3
Multipleregressionresultsforassociationsbetweendepressivesymptomsorfamilyrelationsandcaregiver’sburden,druguse,orinternalizedshame.
Predictor PWID Familymember
ˆ ˇ(95%CI) p ˇˆ(95%CI) p Depressivesymptoms Caregiver’sburden 0.05(−0.09,0.19) 0.4597 0.28(0.16,0.40) <0.0001 Druguse 37.6(23.7,51.5) <0.0001 14.6(1.38,27.8) 0.0308 Internalizedshame 0.46(0.27,0.65) <0.0001 0.19(0.004,0.37) 0.0455 Familyrelations Caregiver’sburden −0.06(−0.14,0.03) 0.1905 −0.11(−0.22,−0.01) 0.0290 Druguse −20.1(−29.2,−11.0) <0.0001 −11.3(−21.3,−1.21) 0.0285 Internalizedshame −0.16(−0.29,−0.03) 0.0165 −0.16(−0.29,−0.02) 0.0266
Note:Participantage,yearsofeducation,andnumberofchildrenwereincludedineachoftheregressionmodels.
Our study revealed that family member caregiving burden wasassociated withtheir own depressive symptoms and fam-ilyrelations.Thisfindingwasconsistentwithprior studiesthat demonstratedthattensionsinfamilyrelationshipsarisewhen fam-ilies provided care for a family member with a substance use problem,mentaldisorder,orboth(Cavaiola,2000;Fals-Stewart, O’Farrell,Birchler,Cordova,&Kelley,2005;Padiernaetal.,2012; Townsend, Biegel, Ishler, Wieder, & Rini, 2006). The tensions observeincludedworry,anger,guilt,shame,financialstrain, physi-caleffectsofstress,andadiminishedqualityoflifeandhopefulness. Ourstudyalsodemonstratedthatinternalizedshamereported byPWIDisasourceofdistressforthefamilybecausesocialstigma istypicallyattachedtonotonlyaPWIDbutalsotohisorherfamily household.Feelingsofshamemaystemfromcommunityattitudes, beliefsfromothers,discriminationorrejection,aswellasthe pos-sibilityoflosingorhaving“lostface”ordishonor.Therefore,PWID andfamilymembersmayexperiencefeelingsofrejectionfromthe communityandfromfamilymembers,whichexacerbates psycho-logicaldisturbances.
ThenotionoffamilyiscentraltomosttraditionalAsianfamilies. CopingwithillnessandmishapshasbeennotedinAsianfamilies asessentiallyaprivateandfamilyaffair,althoughdutyand respon-sibilitytothefamilyisparamount(Lee&Bell,2011;Lietal.,2008; Mok&Martinson,2000;Zhang&Chen,1996).TheVietnamese fam-ilyisnoexceptiontothisrule.Thefamilyisthebasicsocialunit ofVietnamesesociety.ConsideringmostPWIDinVietnamlivein theirfamilyhomes,familymembersplayanimportantroleinthe supportofPWID,andtheycanalsobemobilizedtoadvancethe country’sdrugcontrolandtreatmentpolicies.
Severallimitationstothisstudyshouldbenoted.First,thestudy wasconductedinoneprovinceofVietnam,sogeneralizationsto populationsinothergeographicareasshouldbemadewithcaution. Second,the sample size wasnot largeenough to clearly iden-tifysomerelationships. Third,theself-reportedmeasurescould beaffected bysocial desirabilityand/or recall bias.Fourth, the findingsmightnotbegeneralizabletoPWIDwhodidnotreceive routinehealth carefromtheCHC.Finally,causalinterpretations
ofthefindingscouldnotbeestablishedduetothecross-sectional natureofthestudy.Despitetheselimitations,thestudyhaspolicy implications.Existingliteraturetendstofocussolelyon individ-ualresponsibilitiesandtheimpactofPWIDandtheirpsychological vulnerabilitiesandotherfactors.Thisstudyandotherrecentwork, however,pointstotheneedtounderstandtowhatdegree fam-ilymembers’experiencesandperceptioninteractswiththoseof PWID.Effectiveinterventionsmayneedtoaddressbothindividual PWIDandfamiliesinresponsetothedeeplyingrainedsocialfactors inVietnameseculture.Inaddition,afamily-orientedintervention modelhasthepotentialtostrengthenafamily’sabilitytoadjust totheneedsofitsmembersandtoprovidethelong-termsupport neededtoinducebehaviorchange.
Acknowledgments
Thisstudy wasfunded by National InstituteonDrug Abuse (NIDA/NIH)grantnumberR34DA029493.Wewouldliketothank theprojectteammembersinHanoiandPhúTho.,Vietnam,fortheir contributionstothisstudy.
Conflictofinterest
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