Among a cohort of street youth, levels of initiation of injection drug use were over twice as high in the DTS than levels reported by youth residing in the DTES. We also found that study participants residing in the DTES were significantly more likely to report having an illicit primary income source, report engaging in injection heroin use, and report preferring to buy drugs in the DTES compared with participants residing in the DTS. However, study participants living in the DTS were significantly more likely to engage in non-injection crystal methamphetamine use. Of concern, study participants reported initiating injection drug use in the DTS at a level twice as high compared with the DTES, and the initiation of crystal methamphetamine use was reported among study participants in the DTS at a level almost four times as high as the level of initiation reported in the DTES. Finally, in univariate analysis, individuals reporting initiating methamphetamine use in the DTS were more likely to report dealing drugs than those that reported initiating methamphetamine use in the DTES.
While preliminary, these results are surprising since we expected that residency within the DTES, which includes a large open-air illicit drug market, would be associated with substantially greater drug-related health risks. That we observed non-significant risks for a variety of types of drug use as well as for involvement in drug dealing and the sex trade between street youth residing in the DTS and the DTES may suggest that interventions to reduce youth entrenchment in an open-air illicit drug market should take into consideration the role of adjacent neighborhood street scenes in influencing drug use patterns (21
). Specifically, while we found that participants residing in the DTES were more likely than those in the DTS to report having a primary illicit income source, we found no significant differences in risk of drug dealing, as well as comparably high levels of this illicit activity, among individuals residing in both neighborhoods. These reported high levels are consistent with previous research in our study setting, which found that 79% of a sample of street-involved youth reported selling drugs, while 86% reported that they were involved in the drug trade in order to generate income for their personal drug use (40
). It is also of note that in univariate analysis, drug dealing was associated with reporting initiating crystal methamphetamine use in the DTS. While caution is warranted in the interpretation of univariate results, these data may suggest that the initiation of crystal methamphetamine by youth residing in the DTS signals an immersion into a street-based illicit drug scene, and may therefore represent a potential interventional point for the prevention of street entrenchment among youth. Taken alongside the findings of our multivariate analysis and previous qualitative work from our study setting, these results suggest that the DTS may be an introductory area for those youth drawn towards street-involvement and may uniquely facilitate transitions to the development of more intense risk behaviors as observed among youth in the DTES (21
). This phenomenon may also be a product of the socio-historical context of drug use, illicit drug culture, and policy responses in the city of Vancouver. Beginning in the 1950s, the DTES began to transform from Vancouver’s premier retail, administration, and entertainment district into an area now better known as a low-income setting marked by high levels of injection drug use (41
). This characterization has continued for decades, and has resulted in a commonly held perception of the DTES as a ‘closed’ space (23
). While the results of our study are limited, it is possible that this perception of the DTES may discourage novice street-involved youth from initially residing in that area (23
). For example, previous research in our study setting has hypothesized that non-injection crystal methamphetamine use may be predictive of the initiation of injection drug use among street youth (38
), and as noted above we found that study participants initiated crystal methamphetamine use at much higher levels in the DTS compared with the DTES. While the DTES is the site of a variety of programs servicing that neighborhood’s large polydrug-using community, the street youth population in the DTS may contain a high number of individuals who are newly-recruited to street involvement and highly vulnerable to street entrenchment and initiation of injection drug use (21
). This is particularly pertinent given that public health experts have suggested prioritizing the prevention of injection drug use among vulnerable populations (19
These preliminary results build on previous research on geographic factors associated with drug market entrenchment and suggest areas of future research. Observers have noted the ways in which geographic migration can modify health risks among vulnerable populations in a variety of settings (42
). While this research is often focused regionally, our findings suggest that considering micro-setting and intra-city migration may also be useful in identifying key opportunities for the reduction of risk for HIV and other blood-borne disease infection, the initiation of injection drug use, and street entrenchment. For example, the sexual transmission of HIV infection in southern Africa has been linked to the migration of laborers and the expansion of commercial sex trade work along the transit routes connecting South Africa to its neighboring countries (44
). As a result, policymakers have therefore targeted these particular transit routes for preventive campaigns to reduce sexual transmission of HIV (46
While little data exist regarding migration patterns among street-involved youth in Vancouver, a previous qualitative study reported that the majority of youth participants migrated from other Canadian cities in order to escape negative situations with law enforcement, while a minority indicated that they grew up ‘on the streets’ of Vancouver’s downtown (23
). In our study setting, like many other urban communities, street involvement appears to facilitate a range of high-risk behaviors among youth. Perhaps most relevant is our finding that participants report initiating crystal methamphetamine use at much higher levels in the DTS compared with the DTES. In this context, it is important to note that the DTS’ geographic proximity to the DTES and the mobility of street youth across these two areas appears to create a permeability that may facilitate further street entrenchment among youth in our study. While age-appropriate outreach and treatment services are available for youth in both the DTS and the DTES (47
), the utility of these services to newly-recruited street-involved youth may be limited, given that research suggests that such populations have minimal uptake of treatment services (48
). Further, both the DTS and the DTES suffer from a dearth of youth-targeted structural interventions such as assisted housing and harm reduction shelters (22
). For example, qualitative research from our study setting has demonstrated that street-involved youth residing in downtown Vancouver reported that inflexible shelter rules and the stigma and lack of safety associated with single-room occupancy hotels outweighed the benefits of sleeping indoors. In turn, this lack of appropriate housing greatly increases the risk of further entrenchment within a street-based illicit drug scene (22
). Given that public health experts have suggested prioritizing the prevention of injection drug use among vulnerable populations (19
), the implementation of interventions to address the built environment, particularly among newly-recruited street-involved youth in the DTS, is needed.
Our study has a number of important limitations. First, we are unable to infer causal associations between reported neighborhood of residence and the risk behaviors that we analyzed as a result of the cross sectional nature of our analyses. Specifically, we were unable to elucidate the mechanisms by which neighborhood of residence modifies risk, though it is noteworthy that previous qualitative investigations of such mechanisms are consistent with our current findings (23
). Further, we are unable to determine the causal direction between reported residence in each neighbourhood of interest and the drug use patterns reported by study participants. It is noteworthy, however, that previous research conducted in our study setting suggests that drug use behaviours may be the result of immersion within social networks and illicit drug scenes unique to each neighbourhood of interest (23
). Second, ARYS is not a random sample and its generalizability to other samples of street youth may therefore be limited. Third, because we relied primarily on self-report, risk behaviors among study participants may have been underreported as a result of social stigma (49
). Fourth, while we based our analyses on previous research conducted among street-involved youth in our study setting and were therefore able to confirm that our current findings were consistent with previous analyses, it is possible that we were still unable to adjust for all variables that may have contributed to the differences that we observed between participants residing in the neighborhoods of interest. In this regard, it is important to note that the low power in our sample excluded the possibility of controlling for factors in our subanalysis of crystal methamphetamine initiation, and these results in particular should therefore be interpreted with caution. Finally, while youth participating in the study reported on neighbourhood of residence, it is possible given the transient nature of this population that some youth may have migrated between areas. This may have resulted in an underestimate of the risk factors reported by each neighbourhood subsample.
Our findings suggest that while the DTES remains the epicenter of drug market activity among our sample, the adjacent DTS neighborhood may play a key role in the transition among street youth from lower-risk street involvement to high-risk street entrenchment, and may also be an important site of initiation into crystal methamphetamine. As well, on a number of indicators of drug-related behaviors, no differences existed between street youth residing in the DTES and those residing in the more affluent DTS. These results suggest that future research is needed to investigate whether neighborhoods peripheral to illicit drug markets are sites of increased risk for drug use initiation and entrenchment within adult drug injecting scenes.