Research setting
All interviews were conducted at a voluntary, non-government sponsored, inpatient, addiction treatment hospital in Beijing, China, which will henceforth, pseudonymously, be called “New Hospital”. We chose New Hospital as it was the only treatment facility in Beijing which granted us permission to interview patients in person. We solicited several government-sponsored treatment facilities in Beijing in the months preceding field work, but despite our efforts, we were not granted permission.
New Hospital officially opened on August 2013 as a for-profit, private, civilian-invested venture (“ming ban qi ye”) as distinct from more traditional government-run institutions. Although Beijing government officials are aware of the existence of New Hospital and have sanctioned its existence, as attested to by an official document we were shown, patients at New Hospital can receive their treatment without triggering registration with government officials as an illicit drug user, a status which becomes permanently attached to the individual identification card in the national civilian database.
New Hospital has 40 inpatient beds dedicated to the treatment of drug addiction, and averages 20–40 admissions per month. The average length of stay is 1 week. Eighty percent of patients seek treatment for heroin addiction. Ten percent seek treatment for methamphetamine addiction. Ten percent seek treatment for other drug addictions, including most commonly tramadol and meperidine. In terms of the patient population at New Hospital, the majority (75 %) of patients comes from outside the Beijing area, predominantly from urban areas in the provinces of Inner Mongolia and ShanXi. Over 90 % of admitted patients are men, and most are in their 40’s. The estimated percent of patient who returned at least once in the first year for a second round of treatment was approximately 40–50 %.
New Hospital has a website describing its services, but otherwise relies primarily on word-of-mouth referral from patients and providers. The advertised treatments offered at New Hospital include methadone detoxification, adjunctive psychiatric treatment including psychiatric medications, and behavioral interventions.
New Hospital does not take health insurance. Anyone who seeks admission and has the resources to pay out of pocket for the treatment can be admitted to New Hospital. Patients are expected to pay cash up front depending on the number of days they plan to stay. The average cost per day for treatment is 300 renminbi (RMB), or fifty dollars, not including meals, but can cost more or less depending on a pre-ordained algorithm that includes severity of drug use history, type of drug addiction, private vs shared room, etc. To put that in perspective, an average salary in Beijing, China is 5000 RMB per month [
10], or 833 US dollars. Given that the average length of stay is 1 week, treatment at New Hospital costs on average 2100 RMB, or nearly half of the average monthly salary.
Two psychiatrists staff the unit at any given time, along with a total of eight ancillary health care providers. Providers are paid according to a fee structure that is at least partly based on the number of patients seen, and the type of care delivered. In other words, New Hospital runs on a cash-basis fee-for-service business model similar to many US hospitals.
Data collection and analysis
Approval was obtained from the Stanford Institutional Review Board (IRB) to conduct anonymous interviews with patients with addiction in China. The consent form was translated into Mandarin Chinese and approved by the Stanford IRB in both English and Mandarin. The study protocol and consent form were subsequently approved by the administration of New Hospital prior to recruitment.
In July 2014, we conducted nine, in-depth interviews of heroin users with self-identified ‘heroin addiction’ seeking treatment for such at New Hospital. The sample was primarily determined by opportunity and access, which serendipitously included five unregistered heroin addicted persons (55.5 % of the study sample), an otherwise difficult population to capture. The criteria for participation in the study were: (1) Seeking treatment for heroin use/addiction, and (2) willingness to undergo an in-depth interview. All patients met DSM-V criteria for an opioid use disorder, although that was not an inclusion criterion per se.
Participants were recruited by New Hospital staff on the day of the interview, by asking who might be willing to sit for an interview. A portion of potential participants declined to participate, but specific number of refusals was not obtained. In a system known to be coercive, the knowledge of refusal of participation suggests true voluntariness, which is of ethical importance. Those who agreed to participate were led to a private room separate from regular hospital rooms and corridors, to maximize privacy. Prior to initiating the interview, the interviewer reviewed the verbal consent form with the potential participant. The consent form detailed the study purpose, procedures, and potential risks. Potential participants were again informed that participation was voluntary. None refused to participate at that juncture. Consent was obtained verbally. At no point was the participant asked his/her name. Nor was the participant’s name associated with the written notes at any time in the course of obtaining data, including on the verbal consent form, which did not include a signature line.
The research team consisted of the principal investigator who served as the interviewer. She was also the first reviewer for coding of the transcripts. The principal investigator is a psychiatrist and addiction medicine expert trained in qualitative interviewing skills, ethics, and safety. The interviews were conducted in Mandarin Chinese with the assistance of a skilled interpreter who had experience as a medical translator. The principal investigator asked questions in English and the interpreter translated the questions into Chinese. The interpreter then translated the participants’ responses into English. The principal investigator took hand-written notes in English during the interview, which later served as transcripts for coding. The research team also consisted of an independent reviewer who also coded the transcript and analyzed the data. The independent reviewer is a neurologist trained in qualitative interviewing skills, ethics, and safety.
This study used Grounded Theory methodology [
11,
12]. Grounded Theory seeks to characterize complex social phenomenon by inductive analysis of data which are gathered in an iterative process, which allows multiple potential hypotheses to emerge in the course of data collection, instead of generating hypotheses a priori. Subsequent interviews seek to challenge or confirm emerging themes. Interviews are concluded when the coders identify that emerging themes have been saturated.
This study represents a convenience sample of those individuals at New Hospital who were both willing and able to be interviewed during the time frame of the study period. Despite the small sample size (N = 9), both reviewers concurred that the sample reached saturation in terms of the types of themes that emerged from the interviews.
The in-depth interviews lasted up to 120 min. The interviewer began simply by asking participants to describe how the events of their lives led them to seek treatment at New Hospital. As per Grounded-Theory Methodology, the interviewer sought to minimize undue influence on the natural unfolding of the autobiographical narratives. The interviewer might interject at points to clarify or explore some point the participant raised in more depth; but with intention, the content generated was initially participant-driven. Two to three interviews were conducted during the morning and analysis was performed immediately in the afternoon (the same day as the interview) by the first and second reviewer. Coding was performed by each reviewer independently. Data were broken down into smaller components and labeled by topic such as “stigma” and “forced labor camps.” Qualitative coding software was not used.
After coding was completed, the two reviewers compared coding lists to understand and explain variation in the data [
13]. The codes were then combined and related to one another and classified into emerging themes/concepts such as “a desire for anonymous, confidential treatment.” Analysis highlighted relationships and demonstrated gaps in the existing data. For example, we wondered why individuals who were already in the government registry would value anonymous, confidential treatment, when their anonymity had already been compromised. Questions for future interviews were augmented to fill in those gaps and guide deeper exploration of the emerging theory. Theoretical saturation was reached when all of the major themes were well developed and supported by data.
When all the interviews were complete, the two independent reviewers came to consensus on the most important themes that emerged from the data. These themes constitute the results of this qualitative work (substantive theory), and are described below. Any text in quotes is a verbatim quote from a participant.