Safety in drug and alcohol research

The conduct of drug and alcohol research involves a wide range of research methods, many of which require face-to-face interviews with, and the collection of biological samples from, research participants. These participants are drawn from diverse backgrounds, representing a broad spectrum of people. Many are drug dependent, a disorder that disrupts normal motivational pathways [1–3], possibly resulting in behaviour that may have otherwise been considered unacceptable. Significant proportions are likely to have criminal histories [4–6], comorbid psychiatric conditions [7–10] and a range of physical health problems, including blood-borne viral infections [11–13]. That research samples may include participants with such characteristics gives rise to a number of issues of importance to the drug and alcohol field. A limited number of papers have addressed the process of, and difficulties encountered when, interviewing drug users [14,15]. Scant attention, however, has been given to the issue of interviewer safety in drug and alcohol research. Extant occupational health and safety and risk management protocols rarely adequately address safety issues specific to the drug and alcohol field. There is currently little information on the prevalence of adverse incidents in drug and alcohol research. The issue has, however, received limited attention in the mental health field; one study found that more than half the community mental health researchers surveyed had experienced some aggression, although physical violence was rare [16]. Although these data cannot be extrapolated to the drug and alcohol field, it does suggest that the issue warrants attention. This editorial therefore considers safety issues salient to drug and alcohol researchers, and the development of safety protocols that seek to address those issues. The population characteristics outlined above demonstrate that the potential for aggression and violence among a minority of research participants can constitute a risk to interviewers. Although these problems may not pose a risk in and of themselves, the effects of intoxication or withdrawal may exacerbate psychiatric symptoms and be associated with aggression or violence [17]. The risk of opportunistic property crime that may be accompanied by aggression or violence is increased when working with, and reimbursing, those with criminal histories. This does not imply that all drug users constitute a threat to interviewers’ safety; on the contrary, the sheer volume of drug and alcohol research suggests minimal risk, but incidents do occur and precautions are necessary. It is therefore imperative that interviewers possess good social skills and are equipped psychologically to manage these kinds of interactions [18]. Interview training is an integral component of interviewer preparation, and hence risk reduction, and the choice of interview location is a further issue to be considered. Training of interviewers is an essential component of ensuring methodological rigour, but can also significantly reduce potential risks. The degree of training required will depend on the project and the researchers involved, and need not be lengthy processes. However, systematic training delivered by a person familiar with the administration of the questionnaire to the target population will equip interviewers with the knowledge of potentially provocative questions or attitudes. Training relevant to the specific study and methodology should address a number of issues, including instrument administration, biological sampling (where applicable) and recruitment strategies. Issues specific to the population, such as ensuring that interviewers are familiar with the characteristics of the target population, also need to be addressed. Comprehensive training may also include general principles of, and procedures to ensure safety. Safety training should address generic issues, for example, basic self-defence; recognizing non-verbal signs of agitation or distress; the importance of non-confrontational body language; pacifying an agitated participant; terminating an interview prematurely; and the necessity for an interviewer's unimpeded access to a safe exit. While many clinically trained and experienced researchers already possess these skills, many researchers have only limited or no clinical experience, especially recently graduated research assistants, and are therefore less adept at identifying early signs of aggression and diffusing difficult situations. It is also important for interviewers to be trained in the assessment of intoxication. It is generally considered that participants should not be interviewed when intoxicated [14,15,19]; this can both mar the quality of the data and, in some cases, increase the risk of aggression. One further issue to be considered is that of gender. Research managers should consider whether it is appropriate and safe for female researchers to interview male participants. As with many safety issues, this will depend on the project and participants involved. The location of interviews with drug users varies widely depending on the nature of the research and the target population, but many are conducted outside research institutions. Two key points to be considered when choosing a location are: The integrity of the interview should never be compromised. A participant must feel safe, secure and assured of their anonymity and confidentiality to protect the quality of the data they provide and to ensure their comfort and thereby reduce the risk of aggression. Interviews typically require privacy; however, when conducted in public locations, efforts should be made to ensure that the location is one where attention is unlikely to be attracted, such as quiet locations in shopping centres. The safety of the interviewer must never be threatened. If it is necessary to strike a balance between these two requirements to arrive at a reasonable interview location, the safety of the interviewer must take precedence. The most desirable interview locations are those within agencies such as needle and syringe programmes or treatment services, but when alternative locations must be sought, the interviewer should suggest centrally located places with which they are familiar and comfortable. Ultimately, the appropriateness of an interview location will depend on the nature of the interview. Clinical interviews, or those where participants are known to the researchers, may warrant a different interview location to cross-sectional surveys where the participants are recruited through advertisements and are unknown to the researchers. All institutions undertaking interviews and fieldwork should consider protocols designed specifically to maximize interviewer security, covering a number of generic safety principles. Basic precautions include vaccination against transmissible infections, ensuring that interviewers’ personal contact details are accessible to the project supervisor in emergency situations, and that interviewers carry mobile telephones. Training in safety awareness, such as that outlined above, should be provided and the responsibilities of managers in terms of providing training support and supervision should be delineated. Effective safety protocols should stipulate guidelines on acceptable interview procedures. Issues to consider might include protocols for interviewing in the field alone or accompanied by others; requirements for visits to participants’ homes; and the choice of interview locations. Interviewers should feel confident about interviewing. If they do not, this can be addressed through more intensive training and supervision. Protocols should emphasize that interviewer safety is paramount and must never be compromised. It is important that interviewers feel supported by their supervisors and not pressured to obtain data above all else; this can be facilitated through appropriate support structures. Monitoring the whereabouts of those conducting interviews is also important. One option is an interview ‘monitor’, a colleague who is not interviewing and remains contactable for the duration of the interview [20]. Precautions to ensure safety during interviews conducted within the research institution may also need to be considered, such as the installation of duress alarms. Appropriate emergency procedures could be devised for ‘worst case scenarios’, prior to entering the field. As with other occupational health and safety procedures, incident reporting of adverse events should be mandatory. It may also be necessary to provide a supportive debriefing mechanism. Reviews of incident reports may help to identify risky situations that were not immediately obvious, for example interview locations previously considered acceptable may have proved problematic. Incident reporting also allows the evaluation of safety protocols, and may highlight areas where revision is required. Safety protocols serve to protect the institution as well as interviewers and participants. To this end protocols should include a specification of disciplinary action that will be taken in the case of breaches. It is paramount that protocols are ratified by institution management and appropriate structures or hierarchies are delineated to ensure support for their implementation and adherence. This editorial has outlined a number of safety issues salient for drug and alcohol research. Scant literature exists to allow researchers to benefit from the experience of others in attempting to minimise threats to interviewer safety. Further discussions of safety issues will facilitate future research and ensure that the topic is given the prominence it warrants. The authors wish to thank Mr Craig Fry, Turning Point Alcohol and Drug Centre Inc., for the impetus to write the editorial; Assoc. Prof Shane Darke for helpful comments on the manuscript; and the NDARC Safety Committee: Dr Kate Dolan, Ms Courtney Breen, Dr Sharlene Kaye, Ms Jo Kimber, Dr Joanne Ross and Dr Wendy Swift for enlightening discussions on safety and related issues.