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Takin' it to the streets
When my sister Sathya, a master's student in the Department of Epidemiology and Biostatistics, told me about a course on the study of street youth in Montreal, it piqued my curiosity. It's not the sort of class one hears about very often.
The idea behind the course is to provide a sense of how epidemiological methods are applied in a challenging and unconventional research setting.
"Many health care professionals will be taking the course," epidemiology and biostatistics professor Jean-François Boivin told me in an interview, "but my target is research students like your sister. I want them to see the broad range of research methods that are used in tackling a complex problem like the study of HIV in street youth."
Boivin has been interested in applying his research skills to the health concerns of street youth since 1994, when Dr. Elise Roy, a public health physician, approached him for help in designing a study focusing on the city's street youth.
"Upon the request of several community organizations, we decided to examine the prevalence of HIV among Montreal's street youth," explains Roy, an adjunct professor in Boivin's department and a doctor with the Montreal Regional Health Board.
Their first study, a cross-sectional analysis, indicated that the prevalence of HIV was indeed high among street youth. "A cross-sectional study," Boivin explains, "is a snapshot view and involves no follow-up."
"It is like a photograph rather than a movie," Roy elaborates.
"We wanted to look at trends over time," states Roy. So they set up a study that would follow up with the young research subjects every six months in order to examine patterns of drug use, sexual behaviour and other data related to HIV.
While several cross-sectional studies had been done throughout the continent, this would be the first cohort study on street youth in North America and perhaps in the world.
Boivin and Roy had to contend with many challenges that have perhaps discouraged others from undertaking such an endeavour. Tracking down street youth willing to participate in such a study was no easy task. The pair also had to provide incentives to keep these subjects involved in the study -- incentives both in the form of financial rewards and in the form of much-needed health services.
Working with street youth as research subjects required innovative approaches and a great deal of flexibility. "Sometimes a youth would show up intoxicated at an interview," says Roy, "but we just had to learn to adjust."
Street youth weren't just the subjects of the research either. An advisory committee consulted at many stages of the project's development included street youth. Participants in the study have been invited to attend conferences with Roy and are informed about the research findings on a regular basis.
The subjects also benefit from access to health services provided by Roy and Boivin's staff. For example, when the researchers discovered high rates of hepatitis B in their subjects, they implemented a vaccination program reaching over 1,000 street youth.
In addition, participants benefit from awareness campaigns that teach them to reduce high-risk behaviour. "We don't have power over the use of drugs," says Roy, "so we suggest less harmful ways of using drugs." As part of the harm reduction program, cocaine injectors are encouraged to snort or sniff instead, to reduce the risk of HIV transmission.
"We don't only look at diseases such as HIV," says Boivin. "We are also examining risk factors." For example, his graduate students at McGill are researching factors that influence the health of street youth, such as prostitution and patterns of drug use.
"In general, the street youth have been pretty cooperative and willing to participate in our study," says Boivin. Their main obstacle, as is the case for most researchers, is trying to find funds. "It is an expensive project and we need to continuously convince donors that it is worth it. Every year, we wonder if we will have the funds to continue."
The worldwide recognition their work has received has been helpful. Their publication on mortality among street youth in the esteemed medical journal, The Lancet, gave their study some prominence and facilitated the fundraising process.
"The striking mortality ratio we observed highlights mental health and substance abuse as major issues that must be addressed by health professionals involved in the care of street youth," they stated in The Lancet. Their committee made recommendations to the Quebec health ministry and managed to obtain $1 million per year for 3 years. The money was to be shared among several community organizations and helped set up a clinic for street youth in Montreal.
Boivin and Roy shared their findings and methods in a four-day course this May. With guest speakers from organizations working with street youth, including a representative from the Cirque du Soleil, the course promised to be rather unconventional.
Currently on sabbatical leave, Boivin is studying the literature on the mental health of street youth in the United States.
Asked about future plans, Roy replies, "If I allow myself to dream, I would conduct a study on mental health in Montreal's street youth." That is, if he can manage to find the funds for another expensive endeavour. Due to high rates of suicide and substance abuse, the study of mental health is vital in the study of street youth. It has not yet been done in Montreal.