In multicultural countries such as New Zealand, it is particularly important that gambling research take into account possible cultural differences. Many New Zealanders come from cultures that do not have a history of gambling, including the Mäori , Pacific Islanders, and recent migrants. Little research has examined the reasons why people start and continue to gamble, especially among different ethnic groups. This research project thus aimed to develop a framework to explain how environmental, cultural, and social factors interact with personal attributes to determine gambling behaviors. In a qualitative study, 131 people broadly representative of Mäori, Pacific, Asian, and Päkehä/New Zealand European groups residing in New Zealand were interviewed individually or in focus groups. They included social and problem gamblers, families of problem gamblers, and professionals. Different personal, socioeconomic, environmental, and cultural factors were identified, summarized in a developmental framework, and compared to factors found for ethnic groups in other countries. Public health policy issues were raised, including greater control of gambling promotion. Historically, societies in many parts of the world did not gamble. Most parts of Australia and the South Pacific are among the regions where gambling was absent until the time of European colonization Binde . Since tAccording to the latest census, the total population of New Zealand reached 4.4 million in 2011. A full 69 % of the population consists of persons of European descent, with the indigenous Mäori being the largest minority (14.6 %), followed by Asians (9.2 %) and Pacific peoples (6.9 %) . An information sheet and consent form informed participants about the purposes of the survey, their rights as participants, the handling and anonymity of data, and the contact details of various ethnic problem gambling agencies in the event they felt distressed by the questionnaire. These forms clearly specified that all responses were to be anonymous and that no identifying details would be sought.Four groups of people were recruited: people with gambling problems, people who gambled without problems, family members affected by problem gambling, and professionals working with gamblers. The individuals selected were broadly representative of the four main ethnic groups in New Zealand: Mäori, Pacific Islanders , Chinese , and Päkehä/New Zealand Europeans. “Päkehä” refers to people who are of European settler background.Participants with problem gambling were recruited from specialized counseling services. People eligible to use free, government-funded services for problem-gambling treatment must meet the diagnostic criteria of problem/pathological gambling as measured by the South Oaks Gambling Screen  and what meaning the individual gave to gambling. Part two asked about how the individual started gambling. The third part contained questions about the individual’s gambling experiences.This guideline was used to interview all four groups of participants, with slight modification to suit their particular background. For example, during interviews of practitioners, participating counselors were invited to provide their general observations instead of referring to individual clients. The focus-group discussion explored the link between sociocultural background and level of participation in gambling based on different structural factors  between ethnic groups . Data were analyzed using a general inductive approach to identify key themes relevant to the research objectives Thomas . ConceptFinally, we addressed the trustworthiness of the final analysis through triangulating data interpretation. The key findings were presented to members of the Mäori and Pacific National Reference Group and two problem-gambling counselors, who were asked to comment on their validity and the adequacy of analysis, and who confirmed that the findings reflected their experiences and perspectives well. In general, participants from different backgrounds—such as family members and people who gambled—had similar views on why people become gamblers, but the ethnicity-related differences were more complicated and will be elaborated in the Economic reasons, such as winning or close-to-winning experiences.Personal reasons, such as cognition, motivation for gambling, mental health, or mood.Recruitment (or retention) reasons, such as how gambling is normalized, encouraged, and promoted through advertising, consumerism, or government policy.Environmental reasons, such as the availability and accessibility of gambling activities, features of gaming machines, the gambling entertainment environment, and the Internet environment.Social reasons, such as the modeling of gambling behaviors and social participation with friends and family members who gamble.On the whole, the interviews provided an opportunity to raise personal experiences, feelings, and thoughts about gambling experiences. In contrast, the focus groups provided in-depth material on wider environmental and sociocultural factors explaining why people gamble. Specifically, five major content themes were extracted from the participant discussions of the reasons why people gamble, as follows:“I like to win. But it does not happen very often” . Financial reasons included the need for money to pay a debt or the potential of winning a big prize with a small amount of money; for example, the Lotto is a quick way to win money. One participant said that he gambled “to get money mainly to pay my bills, mortgage, family needs” . Problem-gambling counselors thought that Mäori people take up gambling mainly for socioeconomic reasons in that they are trying to “catch up” to the rest of society.Most participants said they gambled because they expected to win money. Ongoing gambling was encouraged by positive memories, such as recollections of winning a prize, or by “close-to-winning” experiences. One participant said: “When my family has no money, sometimes I just try my luck” . For some Pacific Islanders, migration to New Zealand resulted in increased exposure to wealth and the placing of a monetary value on material things.Niue social gamblers believed that people start gambling to win money for the family. They viewed it as an easy activity that could lead to financial gain or that served as a time-out from family. “We Tongan people as well as other PI [Pacific Islanders] came to New Zealand as a site or place of milk and honey. But now there is no milk and honey anymore. So we are looking for a new site or place within New Zealand for milk and honey and no wonder we have chosen gambling areas” .Samoan interviewees felt that people start gambling to win money to help their family, pay bills, or give fa’alavelave , and so in general to ease financial problems. Likewise, according to the Tongan interviewees, people start to gamble because they need quick money for their bills, mortgage, or family. As one participant commented, it was “to win some money, like I said earlier, to fulfill my dreams, like uplifting my family quality of life from poverty to riches” . Another Pacific focus-group member observed that people gamble because of a “lack of priority” when comparing themselves with other people’s material wealth, and gradually they develop “a sense of grandiosity” (as quoted by one practitioner) of wanting a big house, car, and other material possessions. Furthermore, among Pacific people money is always needed for church or family; for instance, “for Samoans there are too many demands like fa’alavelave, church, work, or children” ; also, there is “pressure from the congregation to participate in fundraising—housie [bingo]; it starts out as fundraising and now becomes problematic” . In general, the group felt that the church’s acceptance of gambling behaviors was linked to the participation by individuals in gambling activities.In contrast, according to Samoan focus-group participants, the main reason to begin gambling was poverty or low socioeconomic status. As one participant explained in detail:“I wanted to win all the time” ; “I thought I could outsmart them” ; “Winning was exciting at first, later I was trying to recoup losses, so I bet more” .In comparison, European participants said they started gambling to win money or because they were in need of it. Sample comments included “big return by a small investment”  as reasons why Chinese began to gamble. In the beginning, gambling is “recognized as a kind of entertainment and most of the people can gain some winnings” . Additionally, some Chinese people took up gambling because of low incomes compared with their earning capacity before migrating to New Zealand, seeing it as an opportunity to win money and regain status. Also, if unemployed, they had a lot of free time.The participants in the Chinese focus groups identified the chance to gain a “their gambling behavior was a form of relief from depression” . Gambling was often perceived as an opportunity to improve quality of life, especially when boredom is constant.A major personal reason to gamble was for excitement, relaxation, or “getting a rush.” According to participants, gambling was used as an escape mechanism from the depressing realities of their lives, stress resulting from moving to the city, and sometimes grief. One participant observed that “To have a break from family issues . . . cooking, washing, etc., pokie machines take my mind away from family boredom issues” . One issue that appeared to be specific to Mäori people was the changing lifestyle of urban Mäori. Those who reside in urban areas, such as metropolitan Auckland, live fast-paced lives with long working hours. Also, more often than not, both parents in the family are working. Such a life is stressful, and managing stress is a priority. Many Mäori thus used gambling as a form of rest and relaxation.Some Mäori participants said that gambling made it possible to be alone, and it could be a way to escape relationship problems. Samoan participants added that gambling was also a form of time-out, a release of stress from belonging to a large family. Similarly, Tongan participants said they also gambled to relieve boredom, as a break from housework, and as a form of socializing: fa’alavelave could become a financial burden, especially if someone was unemployed or “not everyone [is] pulling their weight” . Another source of stress was boredom in the sense that some traditional activities were no longer available in New Zealand. The Pacific peoples’ focus group felt that people who were unemployed had more free time than those who worked, and so they would get bored and become tempted to gamble, especially on payday or benefit day.For some Pacific Island peoples, a lot of stress came from being unemployed or having no money. In particular, “I gambled to find direction” . Some members said that New Zealand was boring and did not provide suitable entertainment for Asian people. Gambling was also a problem for international Chinese students studying in New Zealand who were without a proper role model. One group member elaborated: “The parents of these children have always over-spoiled them or put too much pressure on these young generations who do not have good self-control” .Like the ethnic groups above, Asian participants saw gambling as a release from the stresses of work, allowing them to escape tough situations or relieve depressive feelings. As reasons to start gambling, participants cited immigration and post-immigration adjustment issues, such as communication problems, relationship problems, boredom, frustration, unemployment (or under-employment in some cases), and the absence of places to socialize and express themselves. As one participant vividly described: “excuse to go to the [gambling] venue” .Between 50 % and 80 % of participants across the four ethnic groups could recall advertisings for Lotto, casino gambling, pokie (electronic gaming) machines, horse or dog racing, Keno, and Internet gambling. According to problem-gambling counselors from all four ethnic groups, advertising is a major influence on gambling, especially advertising for prizes and the high visibility of gambling opportunities in low socioeconomic areas. The practitioners in the group felt that the advertising was all positive in nature, for example, announcements of large jackpots or the opportunity to escape poverty. Advertisements portrayed city casinos as popular, safe, exciting, and glamorous places. One Mäori participant observed that in addition to advertising, alcohol played a role in the initiation of gambling. A Päkehä member in a focus group also pointed to alcohol as a trigger for gambling, giving the individual an The Pacific Island practitioners additionally identified repetitive exposure to advertising as an important factor in initiating the gambling habit, such as sandwich boards located at congregation points. They viewed gambling venues, such as city casinos, as exciting and glamorous places to take family visiting from overseas. Another practitioner added that young people were often the targets of advertising, which was normalizing them to gambling at a very young age.Asian participants also referred to new campaigns targeting specific ethnic groups, such as a city casino offering promotional deals to attract Asian people to gamble there. In a focus group, several participants also identified promotional materials used by casinos as an element that tempted self-barred patrons to continue going back.“gambling supports society, while society supports gambling” . Participants said that gambling activities were available in family restaurants that had side entrances so that young people could engage in them despite age restrictions. Pokies were particularly addictive, and even housie (bingo) led to problems. As one focus group member elaborated: “Where money is a real issue for everyone, we’re being sold lotto  and the dream of winning—it’s on TV all the time, network marketing” . The variety of gambling facilities or the abundance of types of gambling was linked to the beginning of gambling, especially some activities that cannot be age-controlled, such as those involving toll-free numbers, text messaging, or Internet gambling. Other participants said that most gambling games were so easy to learn that they seemed to be tailored to different people’s skill levels and needs.In addition to advertising, gambling’s availability and prizes were given as other reasons to take up the habit. Gambling was a part of society; one participant observed that whänau (extended family) gatherings  would often be held in the home of a whänau member or at the marae (Mäori meeting place). But currently such occasions were more likely to take place at venues for private functions, such as restaurants, pubs, or clubs. These new celebratory facilities usually had easy access to gambling.Other reasons included being brought up in an environment of gambling or being around people who gambled. Furthermore, in the past, “At a low tide in their lives, [casinos make them] feel like special, elegant people with their pleasant and polite greetings, VIP rooms, and consumer cards” . An added reason for favoring casinos was that Asian people prefer table games to other forms of gambling.For some immigrants, gambling was illegal in their home countries, and so its legality in New Zealand encouraged them to try it. Furthermore, casinos became popular destinations because people would see similar faces there, and so they felt safe and welcome. One participant said that the casino attracted a lot of Asian people because casino workers were well-trained and made patrons to feel welcome. Another participant elaborated: “hearing about other people often winning from pokies” . Family or friends can influence gambling behavior in two main ways: by initiating the gambling and by normalizing it. The participants in the Päkehä focus group felt that having a family background in gambling increased a person’s exposure to it and normalized such behaviors. Some Mäori focus group members outlined a “generational trend” of learned gambling behaviors and explained how they had been taught to use pokie machines by older members of their whänau: “My dad and uncles played the horses; if I picked a winner I would get a lolly”; “It was normal for my whänau to bet on horses, housie, and cards” . Among Asian people, the gambling behavior of family members and friends influenced participation: “Ninety percent of my friends are gamblers” . “My friends convinced me to gamble. I had to show them I had money to save face” . “Those gambler friends called me to gamble; if I did not wish to go, they would say something that really harmed and challenged me, so that I had to bet for the sake of my face” .The influence of the people around them—particularly friends and family—can also encourage gambling among individuals, such as “Just to relieve myself from boredom. To have a break from family issues like cooking, washing etc. [The] pokie machine takes my mind away from family, boredom” . In some cases Asian migrant women were employed in lower-skilled jobs and had not integrated into the larger society, and so they would look for others like themselves and find them at the casino. With regards to gambling among older Pacific peoples, participants emphasized that it was important to understand that grown-up children taking their parents out to dinner, to restaurants (where gambling machines are often present), or to the casino was “a gift of love, a special treat” . For older Mäori, it was about recreation while meeting with other people. It was more of a hobby when there was nothing else to do and they were bored.Gambling and the associated social environment could also be quite attractive for women. Gambling gave them something to do while also being a social occasion, a night out with “the girls” from the household. The Pacific/Samoan people enjoyed the social aspect of gambling: “isolated relationship with the pokie machines”  and did not like to be interrupted during this time.In some cases, gambling replaced people-to-people relationships. One Mäori participant described vividly how he liked engaging in an Although different findings emerged from this study, the following discussion focuses on two specific areas. The first is the impact of the environment on gambling behaviors. Also, because a major aim of this project was to compare gambling experiences and patterns across four New Zealand ethnic groups, the second area of discussion covers culture and gambling.The last two decades in New Zealand have witnessed an increase in both the availability of gambling opportunities for individuals  and New Zealanders’ participation in gambling. As Abbott  suggesteTo date, most research explaining why people gamble and why some continue to do so at intense levels has focused on idiosyncratic, psychopathological motivations as well as the biological makeup of gamblers ;Families initiate and normalize gambling;Gambling is introduced by workmates and friends.In summation, this project outlines how the “environment” introduces people to gambling:This understanding of gambling and its relationship to the environment resonates with the public-health approach to gambling. This approach views gambling in the environment itself, taking into account the level of gambling activities available in the area and the associated advertising . On the whole, gambling is becoming a part of Mäori community and social activities, such as the gambling activities located in marae (Mäori meeting places).This is the first qualitative gambling study in New Zealand to examine gambling behaviors across four ethnic groups in a single study  differed from that in a public facility like a casino. In this study, the Asian or Chinese participants did not mention private gambling at all. But Asians in Canada and New Zealand face similar post-migration adjustment difficulties such as language barriers or a boring life in their new host country, and so “gambling in the casino, therefore, seems a possible way for the gamblers to put aside the problems facing them”  on their reasons for taking up gambling.Two recommendations emerge from this study. First, because a large number of participants commented that they were drawn (some said they were targeted) by advertising or promotional materials to gamble and subsequently developed problem gambling, it must be considered whether certain at-risk groups  are being targeted at a disproportionate level. Another important consideration is whether the product is presented fairly and accurately, given the addictive elements and potential harm caused by gambling. And second, some participants in this study said they started gambling because gambling venues were easily accessible and plenty of gambling options were available to cater to different interests and abilities. This particular finding raises the issue of the need to regulate the distribution of gambling activities .


Health Systems Performance and Health Systems Building Blocks frameworks. This map can be an aid to decision makers to identify the relevant criteria for priority setting in their specific context.In rationing decisions in health, many criteria like costs, effectiveness, equity and feasibility concerns play a role. These criteria stem from different disciplines that all aim to inform health care rationing decisions, but a single underlying concept that incorporates all criteria does not yet exist. Therefore, we aim to develop a conceptual mapping of criteria, based on the World Health Organization’s We made an inventory of all possible criteria for priority setting on the basis of literature review. We categorized the criteria according to both health system frameworks that spell out a country’s health system goals and input. We reason that the criteria that decision makers use in priority setting exercises are a direct manifestation of this.Our map includes thirty-one criteria that are distributed among five categories that reflect the goals of a health system  and leadership/governance one category that reflects feasibiliy based on the health system building blocks .This conceptual mapping of criteria, based on well-established health system frameworks, will further develop the field of priority setting by assisting decision makers in the identification of multiple criteria for selection of health interventions. Concerns on the costs, effectiveness and cost-effectiveness of health interventions have dominated the debate on health rationing in a wide range of countries since long -3. More et al., categorizes criteria according to the principles of allocative justice for rationing health care, i.e. need, maximizing and egalitarian principles, but is therefore limited in scope [At the same time, surprisingly little work has been done to develop a meaningful conceptual mapping of criteria that can help to identify the relevant set of criteria. A recent report that advices the UK’s National Institute for Health and Clinical Excellence (NICE) for the use of MCDA reviewed the literature and one of the findings was that most applications have a fixed set of criteria and lack explanation of the rationale behind the selected criteria and the categories used. In addition, it was concluded that the applications give neither flexibility nor assistance to decision makers to select an unique set of criteria in their decision context . More spin scope . Our papCategorization of criteria is important for two main reasons. Firstly, for decision makers, the grouping of a large and diffuse set of criteria into categories may ease their interpretation and facilitate decision-making. Second, such a categorization may be an aid to well-define criteria, and to avoid overlap and double-counting of criteria. Criteria, especially those related to health distribution (i.e. equity) concerns are often difficult to define and a proper mapping sets boundaries to facilitate this.Health Systems Performance framework[Health Systems Building Blocks framework[Health System Performance framework is a generally accepted concept to reflect the goals of a health system. Here, in our interpretation, the framework reflects criteria that indicate the goals of interventions in health, i.e. to improve the level and distribution of health, to improve responsiveness, to offer financial protection and to make efficient use of resources. This can be loosely defined as ‘what should a health system do’. The Health System Building Blocks framework is a generally accepted concept to reflect the required components (or inputs) for an effective health system. Here, in our interpretation, the framework reflects criteria that relate to the feasibility of interventions, or loosely defined as ‘what can a health system do’. These criteria relate to the building blocks: ‘service delivery’, ‘health workforce’, ‘information’, ‘medical products, vaccines & technologies’, ‘financing’, and ‘leadership/governance’. Together, the two frameworks offer a comprehensive framework for classifying priority setting criteria. We employ both WHO frameworks because they are worldwide used by decision makers at country level and are credible conceptualizations of health systems [This paper introduces a conceptual mapping of criteria based on an integration of two well-established health systems frameworks, i.e. the World Health Organization’s (WHO) framework and Healframework,16 , disease status (‘severity of disease’) or the ‘availability of treatment’ [On the right panel of the map we distinguish five categories of criteria related to intervention’s goals. The first category is ‘health level’, and includes criteria ‘effectiveness on individual level’, ‘effectiveness on population level’ ‘patient reported health status’ and ‘safety’. Whereas reviews include ‘quality of evidence on effectiveness’, we excluded this from our map, as we consider quality of evidence to be relevant to all criteria, e.g. how costly or complex an intervention is. Rather, we propose to capture quality of evidence in uncertainty analysis. The second category is ‘health distribution’, and included criteria that relate to the core concept of ‘equal life time health’, which means that all people - independent of their background, their disease status or the availability of treatment - should have a fair chance to live a full healthy life . This coeatment’ . ‘Responeatment’ ,19. TherThe third category is ‘responsiveness’, and includes ‘patient perceived quality of care’. Interventions should be responsive to people’s expectations in regard to non-health matters and reflect the importance of people’s dignity and autonomy, and the confidentiality of information. Although this seems a general, and therefore system-wide concern, some interventions do better than other interventions in satisfying perceived quality of care. We include ‘burden of disease’ to represent the wish of society to target high burden diseases. The fourth category is ‘social and financial risk protection’ and includes ‘catastrophic health expenditure’, ‘economic productivity and care for others’ and ‘rare diseases’. Regarding the latter, interventions targeting rare diseases may deserve priority because they may be very costly  development costs are only shared by a small number of patients) and could push people into poverty. The fifth category is ‘improved efficiency’ and reflects the economies of scale that can be obtained when reaching large number of people. Therefore we have included the criterion ‘size of target group’. We decided to exclude ‘cost-effectiveness’ as a criterion on itself, as theoretically costs (as a feasibility constraint) and effectiveness  are both implicitly included in the mapping as individual criteria. However, regarding the importance of the criterion of cost-effectiveness in decision-making, decision-makers may nevertheless consider it as a separate criterion.On the left panel of the map we distinguish one category of criteria related to the feasibility of implementation of interventions. This category is divided in six subcategories, based on the building blocks, i.e. ‘service delivery’, ‘health workforce’, ‘information’, ‘medical products, vaccine and technologies’, ‘financing’, and ‘leadership/governance’. In contrast to the criteria related to intervention goals (discussed above), little work has been done on these criteria (except on the criteria ‘cost’) and the criteria we put forward are first propositions. The first four subcategories relate to the current capacity of the health system and criteria reflect the requirements the for implementation of an intervention. The fifth subcategory on financing encompasses ‘unit costs’, ‘budget impact’ and ‘financing party’. The ‘unit costs’ are the total costs per patient from a health systems perspective whereas 'budget impact' incorporates the scale of an intervention. The ‘financing party’ criterion captures who is paying for a health intervention and reflects notions on its financial sustainability. The sixth subcategory represents the feasibility in terms of leadership/governance and includes ‘congruency previous priority setting’, ‘cultural acceptability’, ‘political acceptability’, ‘stakeholder acceptability’, and ‘legal barriers’.Our map should not be regarded as a top-down expert advice on a fixed set of criteria that should always be considered in all prioritization decisions, but rather as an aid to decision-makers in their selection of relevant criteria. We see two broad applications of priority setting, and therefore of our mapping of criteria. First, it can inform decision makers who work in a specific context, e.g. on the reimbursement decision of a single intervention. These decisions are taken in the presence of a known budget and are likely limited by factors such as the currently available physical infrastructure, human resources or political consideration, at least in the short- to medium-term. This is labeled ‘context-specific priority setting’. The second application is to guide decisions on a wide range of interventions, to provide general information on their relative rank order to arrive a more informed debate on resource allocation priorities. Because priority setting in this application is not meant to provide a solution to a specific resource allocation question, it need not be highly contextualized in terms of e.g. physical infrastructure and/or human resources constraints. This is labeled ‘generalized priority setting’ . The setAs our mapping is based on the WHO health systems frameworks, it has a certain credibility among decision makers. However, the choice of a different underlying framework might lead to another mapping of criteria.In our framework, we included criteria related to the health system inputs and health system goals, but no criteria related to intermediate outcome measures as access and utilization. These measures are instrumental to reach health system goals, and are as such no goals in themselves. However, decision-makers can use them to monitor and evaluate progress towards the realization of the health system goals.Another important step in MCDA is to define indicators to operationalize the criteria. For example, the severity of disease that an intervention targets can be measured in terms of health state valuations  and healWe consider the presented mapping of priority setting criteria as preliminary only and not as a final map. We welcome discussions to further develop it, to improve the use of MCDA for setting priorities in health.This conceptual mapping of criteria, based on well-established health system frameworks, will further develop the field of priority setting by assisting decision makers in the identification of multiple criteria for selection of health interventions.EVIDEM: Evidence and Value: Impact on DEcisionMaking; MCDA: Multi Criteria Decision Analysis; NICE: National Institute for Health and Clinical Excellence; WHO: World Health Organization.The authors declare that they have no competing interests.NT contributed to the design of the study, led the data collection and selection of criteria for inclusion in the map and drafted and finished the article. RB contributed to the design of the study and the selection of criteria for inclusion in the map and assisted in writing the article.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6963/12/454/prepubOverview of criteria considered for inclusion in criteria map.Click here for file


It is my husband―my world―my life-dream―the air I breathe,” said Rosa Bonheur, explaining her life choices. “Art is absorbent―a tyrant. It demands heart, brain, soul, body, the entireness of its votary.” A native of Bordeaux, France, Bonheur was betrothed to art early in life, born into a family of artists. They moved to Paris when she was still a young child. Precocious and headstrong, she had to be coaxed to learn how to read by her mother, who had her select and draw an animal for each letter of the alphabet. Bonheur later attributed her love of drawing animals to this early practice.During her early days in Paris when the family lived in an apartment, she kept a small menagerie of ducks, rabbits, squirrels, and a sheep that had to be carried up and down the stairs regularly. Expelled from traditional schools for rebelliousness by age 12 and refusing to apprentice with a seamstress, another conventional option, she was turned over to her father Raimond Bonheur, a painter, sculptor, and educator, for instruction. She showed herself a diligent and conscientious art student and soon began copying masterpieces at the Louvre. She assisted him with painting commissions and excelled as sculptor. She started visiting Paris abattoirs and the École nationale vétérinaire d’Alfort to learn animal anatomy by dissecting carcasses. “Oh! You’ve got to be devoted to art to live in pools of blood, surrounded by butchers.”She also attended horse fairs and farmers’ markets to observe animals’ emotions and behavior. During these outings, “I was forced to recognize that the clothing of my sex was a constant bother. That is why I decided to solicit the authorization to wear men’s clothing from the prefect of police. But the suit I wear is my work attire and nothing else.” Despite her protestations, Bonheur’s independent thinking, original approach to societal restrictions, and bohemian lifestyle created an aura of notoriety about her that at times eclipsed her artistic accomplishments.She met and became friends with Étienne Geoffroy Saint-Hilaire and his son, Isidore, renowned anatomists and zoologists. Her sympathetic portrayal of animals was influenced by their studies in natural history, particularly the father’s unity of composition principle. He believed that all organisms shared the same underlying design and that diversity in external form was simple variation. If birds and reptiles are built on a single plan, “an accident that befell one of the reptiles … could develop in every part of the body the conditions of the ornithological type.”Bonheur’s style was part of the realist movement of the mid-1800s, led by Gustave Courbet and Jean-François Millet. In this style, which relied on direct observation and meticulous draftsmanship, naturalism was aligned with social causes and the labor movement. Despite prevailing trends, which favored rural life, the plight of peasants, and the ills of growing industrialization, she chose animals as her subjects. Even in rural scenes, her focus was on them. Her affinity to animals and her devotion to showing them in their natural environment established her as the foremost animalière of her century, one of the best of all time.Although she was aware of the impressionists, Bonheur did not adopt their style. For inspiration she turned instead to the Parthenon friezes and the romantic paintings of horses by Théodore Géricault and Eugène Delacroix. She was also influenced by her friend, the acclaimed English animal painter Edward Landseer.Her work attracted early attention. She began exhibiting in the Salon at age 19 and continued to exhibit there successfully over many years. She stopped showing sculpture when she became aware of her brother Isidore’s talent in that art. She “did not want to hinder [his] artistic career.” Her painting Cows and Bulls of the Cantal received a gold medal at the Salon. After this success she received a commission from the government to create a painting of animals at work in the fields. The work, Plowing in Nivernais, was very well received.When her father died, she succeeded him as director of the art school for girls where he had worked. At that time she also established a studio with friend and fellow artist Nathalie Micas and began to work on massive paintings of horses. One of these, The Horse Fair, became a sensation and attracted the attention of Britain’s Queen Victoria. Bonheur’s fame was far-reaching. She received the Cross of San Carlos of Mexico; membership in the Académie des Beaux-Arts of Antwerp, Belgium; the Commander’s Cross of the Royal Order of Isabella from Spain’s Alphonso XII; and the French Legion of Honor. She handled fame gracefully and wore the medals.As her commercial success increased, she was able to move to a chateau outside Paris near the forest of Fontainebleau. On these spacious grounds, she created a small zoo, with ponies, deer, monkeys, cattle, and other animals that populated her future work. “One of her pets was a young lion whom she allowed to run about and often romped with.”Bonheur’s fascination with the New World and the American West began with Buffalo Bill’s Wild West extravaganza, a combination of circus and historical reenactment, during its European tour through France. She traveled to the United States and painted American themes and a famous portrait of Buffalo Bill Cody, who became her friend. Her interest in the United States led to her long connection with Anna Klumpke, an American artist, who after Bonheur’s death, found hundreds of paintings and drawings unseen by anyone in her friend’s studio and pulled together the artist’s (auto)biography.Plowing in Nivernais, on this month’s cover, is a copy by Bonheur of the original government commission, made a year later and likely inspired by The Devil’s Pool, a novel by George Sand (1804–1876). This story, about the displacement of peasants by industrialization, contained the lines, “But what caught my attention was a truly beautiful sight, a noble subject for a painter. At the far end of the flat plow land, a handsome young man was driving a magnificent team [of] oxen.” Bonheur lived in Nivernais, in central France, for weeks, observing the animals and the land, the people at work, the agricultural tools. Her depiction was so accurate that the region was immediately identified when the painting was unveiled.“Oxen that rattle the yoke and chain or halt in the leafy shade, what is that you express in your eyes?” wondered Walt Whitman in his poem Song of Myself, “It seems to me more than all the print I have read in my life.” In Bonheur’s own “poem,” the massive beasts crisscross the good earth, plowing uphill. Slow and solid, they dominate a landscape vast as the sky, tails whisking, mucus glistening. The peasants are in the sidelines. Small and unimposing, they follow or step next to them, light-footed, like dancers. The man toward the front holds a thin stick above his head, exerting dominance, choreographing the animals’ movements. He is their colleague, a member of the herd, who grooms and feeds them and lives with them. The animal in the lead squints ahead, one that follows looks directly at us. Industrialization has not yet arrived in this agrarian corner.Nineteenth-century concerns about the spread of urbanization have only grown in our times. The percentage of residents in urban areas is projected to increase from 50% in 2008 to 70% in 2025. But along with displacement of agriculture, other fears cloud the horizon. Crowded urban areas have become uniquely vulnerable to public health crises, not least of them pandemic (H1N1) 2009. Recent outbreaks in Mexico City and New York demonstrate that surveillance efforts and management of public health communication and response demand exceptional alertness and coordination.And the animals? “[T]hey are so placid and self contan’d, / I stand and look at them long and long,” wrote Whitman when he offered to “turn and live with” them. For the poet, they held as much fascination as for Bonheur, who first brought them into her apartment and later established them in her own zoo at Fontainebleau, shunning portraiture and trendy interiors to paint them exclusively. He was attracted to their non-humanness, “They do not sweat and whine about their condition, / They do not lie awake in the dark and weep for their sins.” Furthermore, “Not one is dissatisfied, not one is demented with the mania of owning things, / Not one kneels to another, nor to his kind that lived thousands of years ago, / Not one is respectable or unhappy over the earth.”Bonheur understood animals. Her unconventional spirit was drawn to their wildness. “I too am not a bit tamed, I too am untranslatable, / I sound my barbaric yawp over the roofs of the world.” But, like the poet, she did not know all we share with them. Her furry friends in the apartment or the chateau―rodents, rabbits, goats, deer, cattle, lions―and some that she did not collect, appear in the pages of this issue. For they share with us not just living space but countless infections.Bartonella rochalimae in raccoons, coyotes, and red foxes; Ehrlichia chaffeensis in Sika Deer; Mycobacterium bovis and M. tuberculosis from goats. We have learned to live and work with animals. Now if we could also choreograph the microbes we all share ….How could the artist have known the litany of zoonoses that continue to complicate our relationship with animals: highly pathogenic influenza A virus (H5N1) in backyard chickens; human trichinellosis associated with ingestion of soft-shelled turtles; new adenovirus in bats; polycystic echinococcosis in jaguar hunters;


We report on an in-depth qualitative study of 28 active and former substance addicted women of low or marginal income on the core components of a harm reduction-based addiction recovery program. These women volunteered to be interviewed about their perceptions of their therapeutic needs in their transition from substance addiction to recovery.Data were gathered about women’s experiences and essential needs in addiction recovery, what helped and what hindered their past efforts in recovery, and their views of what would constitute an effective woman-centred recovery program. The research was based upon the experience and knowledge of the women in interaction with their communities and with recovery programs. The study was informed by harm reduction practice principles that emphasize the importance of individual experience in knowledge construction, reduction of harm, low threshold access, and the development of a hierarchy of needs in regard to addiction recovery.Three core needs were identified by study participants: normalization and structure, biopsychosocial-spiritual safety, and social connection. What hindered recovery efforts as identified by participants was an inner urban location, prescriptive recovery, invidious treatment, lack of safety, distress-derived distraction, problem-focused treatment, coercive elements of mutual support groups, and social marginalization. What helped included connection in counselling and therapy, multidisciplinary service provision, spirituality focus, opportunities for learning and work, and a safe and flexible structure. Core components of an effective recovery program identified by women themselves stand in contrast to the views of service providers and policymakers, particularly in regard to the need for a rural location for residential programs, low threshold access, multidisciplinary service provision of conventional and complementary modalities and therapies for integrated healing, long-term multi-phase recovery, and variety and choice of programming.A key barrier to the addiction recovery of women is the present framework of addiction treatment, as well as current drug laws, policies and service delivery systems. The expectation of women is that harm reduction-based recovery services will facilitate safe, supportive transitioning from the point of the decision to access services, through independent living with community integration. This article presents the results of a qualitative research project examining the perspective of 28 low income substance using women on the core components of a harm reduction-based addiction recovery program. In-depth interviews were completed with women living in Vancouver’s Downtown Eastside neighborhood, an area with the lowest per capita income and highest level of problem substance use in Canada, yet also at the vanguard of harm reduction programming on a global level.The goals of the study were to learn about the primary addiction recovery needs and other core issues of women in their struggle with substance addiction , and to establish priorities for the development of a harm reduction-based addiction recovery program from the perspective of the women themselves. This data may be used to inform and guide policymakers, program developers and service providers in the development of such programs.When we speak of “harm reduction” as a foundation to addiction recovery, we refer to a user-directed approach focused on the reduction of substance use-related harm without requiring abstinence from substances. This does not preclude abstinence for those women struggling with addiction who choose this option.In this article we join the pillars of harm reduction and addiction recovery , and concur with the women who participated in our study that women seeking recovery from “hard drugs”  should have a menu of choices made available to them in their recovery journey, including the options of both non-abstinence and abstinence-based recovery. In the opinion of the women we interviewed, abstinence should not be required for entry into recovery programs, as low threshold access is essential; abstinence was, however, seen to be to be a key element in ensuring women’s safety within residential recovery programs. Thus our definition of harm reduction also includes the option of abstinence-based recovery for women who choose it.The most common services currently available to women struggling with substance addiction include detoxification, residential intensive treatment, residential supported recovery/community reintegration facilities, outpatient services, and mutual-aid groups -3. DetoxTrends in addiction recovery over the past decade include approaches that are harm reduction-based; that is, strength-based, client-centred, and respectful of self-determination and individuality ,6, in plAlthough trends are slowly changing due to an increase in woman-focused research, the majority of current treatment supports and services are still misinformed by research with a “male-as-norm” bias ,2,10,11.Estimates reveal a total of 5,000 active intravenous drug users (IDU’s) in the Downtown Eastside (DES) area of Vancouver ,15. In 1Also fuelling the epidemic are inadequate detoxification facilities, lack of treatment facilities, deinstitutionalization of the mentally ill with inadequate community supports, the increasing geographical concentration of IDU’s in Vancouver, inadequate housing, the lower use of the supervised injection site by women as compared to men, and the lack of availability of heroin prescription for long-term users. Poverty is the overriding concern of women struggling with drug addiction in the DES, as social assistance payments are inadequate and welfare ineligibility is a core concern for many women. Low-income female drug users are regarded as “suspect tenants” and homelessness remains an issue for many. Women are routinely exposed to violence, and health issues include communicable disease, mental heath challenges, and lack of accessible health care .The relationship between drug addiction and sex work is strong among women in the DES. Twenty of the 28 women in our sample, for example, had been involved in long-term sex work. The cost of drugs has a profound effect on the frequency of sex work, because as prices rise, women become more desperate to earn income and competition for dates increases. Exposure to violence and increases in the rate of sexually transmitted disease also rises ,17.The history of women’s addiction treatment and recovery reveals some interesting patterns, including the fact that women’s dependence on drug-abusing men has long been a key factor in their addiction . Women’sFrom the 1800’s until today, women have been seen as needing longer treatment than men, and mostly addiction treatment for women has been an offshoot of men’s treatment, including Alcoholics Anonymous, as well as inebriate asylums (in the 1800’s); psychiatric asylums and sanitoriums (late 1800’s/early 1900’s); criminal justice-based treatment centres and psychiatric wards (mid-1900’s); and in-patient treatment and rehabilitation units (from the 1960s inwards).It is now recognized that women have different addiction recovery needs than men, and that recovery processes for women should be gender- or women-sensitive to address their unique needs -4,19-26:In general, chemically dependent women have been found to have lower expectations for their lives than male addicts, and they express greater preoccupation with simply surviving and minimizing discomfort than getting ahead in life .As a group, women struggling with drug addiction have less education, fewer marketable skills, fewer work experiences, and diminished financial prospects compared to substance dependent men .Most chemically dependent women who enter treatment are unemployed and have not been employed within the preceding year .Chemically dependent women are more likely than men to be dependent on a family member or on public assistance for survival, yet they are also more likely to be primary caretakers of children ,26,28-30Prescription drugs are more abused by women ,26. WomeWomen are underrepresented in alcohol and drug recovery programs , and notBeckman  developeOther studies have stressed that women’s addictions are frequently correlated to issues of trauma including a history of repetitive childhood physical and/or sexual assault including incest and rape ,23,36,37Covington  proposedOther important principles related to the recovery of women struggling with drug addiction include:-Recognizing drug and alcohol use as a coping response ,6-Promoting awareness of and actively countering women’s oppression; taking into account gender roles and female socialization  ,20,29-Linking recovery with physical and spiritual transformation, and encouraging a richer spiritual life ,31,41-Replacing addiction with a healthy lifestyle, an expanded self-concept, and focusing on healthy relationships  and then examine the problem and situation; avoid the tendency to label or define women as “addicts”—rather, see women as individuals with strengths and capacities; recognize heterogeneity among women and use individualized recovery plans; and match recovery to different subgroups . In addition, it is important to focus on physical, psychological and emotional, social, and spiritual needs, including safety and violence concerns, physical and mental health, housing and homelessness, financial and vocational needs, family and relationship challenges , and basic life skills.The study sought to provide an enumeration of the core needs of women struggling with drug addiction, including those related to addiction recovery, and to establish priorities for the development of a harm reduction-based women’s recovery program, from the perspective of women themselves. The views of low-income women in particular are lacking. Thus we designed an exploratory and descriptive qualitative study that utilized narrative inquiry  as the main approach to data collection. It is rooted in grounded theory that leads to the discovery or generation of theory derived directly from the data provided by the stories, and informed and guided by harm reduction practice principles that emphasize the importance of individual experience in knowledge construction. It adopts a biopsychosocial-spiritual – or holistic – approach to understanding women’s needs, which postulates that substance misuse is the net result of a complex interaction between a combination of biological, psychological, social, environmental and spiritual determinants. We draw on May’s  definitiThe project received approval from the Behavioural Research Ethics Board at the University of British Columbia. Low-income women with substance addiction problems were purposively recruited and selected via posters placed variously in the DES neighborhood, in medical clinics and drug user associations, and with outreach and addiction-related service providers. The posters announced the focus of the project as seeking the input of women on core components of an effective addiction recovery program. Potential participants made initial contact directly by collect telephone call or indirectly through a service provider. The goals of the project were then explained, and consent form provided. No financial remuneration was offered to elicit participation. Every participant indicated that her decision to contribute to the study was driven by a desire to influence the direction and development of recovery programs that would effectively meet her needs and the needs of other women in the future.Details of the study and the legal limits of confidentiality were explicated to all parties. Participants were informed that participation was voluntary and that the decision whether or not to participate would be known only to the investigators and was separate from, and would in no way jeopardize their participation in, any programs or services with which they may have been involved.Each woman participated in one audio-taped face-to-face interview of approximately one hour in duration. Methodological instrumentation included two phases that consisted of narrative storytelling about each woman’s personal history as it relates to addiction, and a semi-structured interview with open-ended questions pertaining to needs, what has helped and what has hindered in meeting needs, and the principal components of a harm reduction-based addiction recovery program. The stories of the first phase were invited to provide context, and to assist the participants in accessing the memories that would help to inform their responses to the questions in the second phase.The research data - consisting of audio-recordings, their transcriptions and a field journal of ongoing notes - was approached using elements of a reflexive grounded theory approach of a constant comparative method and content analysis. This multi-modal approach involved switching between deductive and inductive reasoning and contextualization and decontextualization throughout analysis:is not a specific technique, but rather a methodological orientation that seeks to base theorizing in the data rather than imposing a pre-determined hypothesis…a reflexive stance requires acknowledgement of the knowledge the researcher inevitably brings to the data…Such an approach involves examining the data with existing influences made explicit, but with an openness to the theoretical implications of the raw data. .In this study, a single-case analysis was conducted with each transcript. The classification system of Lieblich et al.  was usedCoding occurred at three levels: open coding ; axial coding ; and selective coding (integrating and refining of categories). To begin, each interview was read several times by the two researchers, with patterns summarized and exceptions, complexities and contradictions noted. The next step for each interview was to code the data into text units that represented a single “thought” or meaning. Each “thought” was numbered in consecutive order on the main body of the text, with labeled “thoughts” remaining close to the original language. The meaning units were then reviewed and a list of key words was made. If the words seemed to be important to the participant’s meaning and were not isolated references, the researchers considered whether or not they could be a part of a theme within that transcript. Key words were grouped and regrouped with other key words.Discovering themes required more in-depth breakdown of the data. Each transcript was broken down into parts of various foci and the meaning units relating to each focus were listed. The meaning units were then examined to see what specifically occurred in each woman’s experience. The core themes in each transcript were identified by breaking down the data in this manner.The next step was to create a theme matrix using cross-study analysis. All themes were listed and checked to see which ones were common across the transcripts; patterns and relationships between patterns were identified through constant comparative analyses among cases. Some of the final themes were of different wording than the originals; the wording of themes was changed to clarify, avoid repetition, or create an umbrella term that connected a number of sub-themes.After studying the theme matrix, recontextualizing and attempting to discredit as well as link together the themes and potential metathemes, the final, higher-order themes were identified. Categorical-content analysis entailed the selection of subtext that corresponded to categories derived from the interview questions. This multi-modal approach involved switching between deductive and inductive reasoning and contextualization and decontextualization throughout the analysis.Participants included 28 women who were either active or former users of “hard drugs”  who self-identified as being of low or marginal income, and as being residents of Vancouver’s Downtown East Side. Both women in active use and in various stages of recovery were included in the study in order to ascertain which aspects of addiction recovery hindered or supported them in meeting their goals, and in recognition of the fact that substance use and recovery occur along a continuum, with constant changes in direction along the continuum. The women ranged in age from 22 to 59, with a mean age of 41. Half of the women were living in the DES or were homeless, while the remaining women had previously lived in the DES or were previously homeless. Five of the women identified as being of First Nations heritage, and 24 of the 28 participants were mothers. Five identified alcohol as their drug of choice and all of these identified as having a severe co-occurring mental health illness. Ten of the women were currently clean of drugs, five were using prescribed methadone only, eight were actively using drugs excluding methadone, and five were actively using drugs in addition to methadone. Five of the ten women who were clean had been so for a minimum of 6 months; two of these were clean for eight months, one for 9 months and two for several years.Thus the majority of our participants were still actively using alcohol, heroin, cocaine, crack cocaine, and metamphetamines. Most did not have long-term sobriety. All but one of the women had experiences with one or more addiction recovery programs including inpatient and outpatient detoxification, residential treatment, day treatment programs, mutual support groups and programs within correctional facilities.Pseudonyms were used for each participant to protect anonymity, which were chosen by the participants themselves.The majority of the study participants were women for whom addiction services and programs had not proven helpful in overcoming addiction. Recruitment did not attract women with long-term sobriety who were completely satisfied with services. It seems likely that those women for whom services were helpful were not sufficiently motivated to volunteer as participants. This study attracted women who wanted to see changes in services.More than half of the women in the study were actively using drugs, and were or had been both severely addicted and socially marginalized, homeless and engaged in illicit activities. As such, they are not representative of all women with addictions. However, the intention of this qualitative study was to learn more about the needs and experiences of the most socially marginalized women who struggle with substance addiction. Due to the highly personal and individualized nature of addiction, this data may also not be indicative of the experience of every woman of marginal income with addiction problems, but there is nothing to indicate that the most salient features of the results are unique to this sample. The commonalities and parallel experiences between the respondents support the conclusion that they are representative of the population in question.Due to the lifestyles and situation of the majority of the women, the researchers were unable to conduct member checks.Our findings are organized into the following sections: recovery needs, what hinders recovery, what helps, and core components of an effective harm reduction-based recovery program.Women’s self-identified primary needs vis-à-vis addiction recovery were as follows, in order of importance: normalization, the need for residential recovery facilities, an open door, biopsychosocial-spiritual safety, time, ongoing support, a home, and financial assistance.The most fundamental need of women struggling with drug addiction is to “be normal”. Within the context of our findings the word denotes a state of being that is free of the “slavery” and affliction of drug addiction. The women reflected an ongoing preoccupation with thoughts around becoming “normal,” even while they were actively using substances:I always used to look out the window and see people and wonder why they’re laughing, jumping, skipping rope, and throwing balls to their kids, and - you know - wondering, “Why God? Why don’t I? Why am I not like that?”… I just wanted to be a human being… A normal human being. (Susan).All except one woman indicated a need for more residential recovery facilities. An unexpected finding was that 26 of the 28 women felt that such facilities need to be rurally-based, well away from the atmosphere of the DES and the urban environment, and that a core component of harm reduction-based recovery was the healing afforded amidst nature within a rural setting.Every woman in the study indicated that she wanted women-only group work in residential programming, and some preferred a women-only residence. Leigh said, “I think it should be strictly women. I think there’s a huge part in a woman addict helping another woman addict…I just think it’s amazing. It’s like a miracle. Magic happens…” Others indicated that some family or couples group counselling would also be beneficial in the later stages of recovery.Participants without children who lived with life partners wanted to see more residential centers for couples, and participants currently living with minor children wanted residential facilities that could accommodate the entire family. Participants with adult children or with children living permanently in care did not indicate whether or not a family inclusive centre would have been of benefit to them in the past.Throughout the interviews the women expressed a profound need for time to focus on oneself without distraction, and that the capacity to focus on self could be complicated by familial and marital concerns, including the pain of separation itself. Women fear for their children’s safety when they are placed in temporary foster care for the duration of an addiction recovery program, and are afraid that their children may be permanently removed. However, women also recognized the need for some separation. The women interviewed wanted separate living quarters from their spouses in the stages of early recovery, and while they would like access to their children, they wanted the option to be apart from their children. They did not want to assume full responsibility for their children’s care. Some suggested that child care be provided within the facility according to the needs of the mother; others wanted regular contact with their children, with their spouses or other family members assuming responsibility for child care.A number of women expressed ambivalence around the issue of life partners in recovery together when both parties are struggling with addiction. They acknowledged that they each had the capacity to both help and hinder the other’s progress.If I want to stay clean, I have to be able to walk through that door right now, push that button and say, “I’m high. I have no drugs on me. I need a bath and I want to get clean.” And not turned away…[I need] recovery on demand. That means that I don’t have to be clean for 72 hours or 48 hours – even 24 hours. Because when you turn somebody down that’s dope sick, and say “No. We won’t help you stay clean”, I’m going to the dope dealer. (Marina).The need and inability to access detoxification and recovery programs upon demand were consistently topics of passionate and animated discussion. The women recounted numerous experiences of repeated and frequently desperate attempts to gain access to services that failed because of various admission criteria or lack of space. Another identified barrier to access was the daunting process of navigation to the location of the service when the route is wrought with difficulties, pitfalls, temptations, and triggers of many forms, including, but not limited to, poor health, dope sickness, cravings, drugs, drug pushers, using friends, and lack of money, transportation and energy. For women living in the DES, such navigational difficulties are extreme. They may find it impossible to leave a hotel room without immediately encountering drugs in the hallway, and will most certainly encounter them on the street.There’s so many barriers, you know, so many barriers…that some things have to be made easy. (Joni).Addiction treatment centers had not proven to be safe places of recovery for many of the women. Drugs were sometimes smuggled in by clients or visitors and the women indicated that they had been subject to violations in varying degrees from both clients and staff that included manipulation, indoctrination, coercion, and physical, mental, and sexual abuse and exploitation.[We need] a safe place where there is no use, where there is no abuse, where there’s no one trying to hurt us…change our minds…someone who’s there to see us heal physically, mentally and spiritually…Someone who’s there to promote our health with rules. I have total respect for rules, however…not someone who’s trying to push a religion on me, or a belief system. Someone who may want me to try that system and that I will try with an open mind, but not when someone cuts down every other method. (Athena).Trust was a major issue for women in recovery programs and some women found it extremely difficult to open up in a group. Some women suggested that intensive group work should not commence until trust has been established. This may require time and/or it may require a specific trust-building component to be structured into the programming.I think being really, really clear and having a definite process of trying to build trust among a group of people…I’m not sure exactly what you do to build trust but it has to be explicit. It has to be a primary focus because you’re not just building trust with those people who are in the group with you, you’re ultimately building trust in the other people you encounter in your life. (Joni).The women talked about needing time for their recovery process. They need time to wean off drugs, to come “back down to earth,” to stabilize, for their “brains to recover,” to think straight, to build back up, to learn to trust, to learn to live in new worlds, to develop a new lifestyle, to reintegrate into the workforce, to work on life issues, to reach a place where triggers are not overwhelming, to move from chaos into peace, and to replace old experiences with new. While the majority of participants emphasized that stays in detoxification and residential centers should have flexible timelines according to the unique needs of the individual, and that access to aftercare should be open and ongoing as needed, it was frequently suggested that a two-year period could be a viable time frame in which to realize many of these goals.We are disrupting a whole history… (Joni).Ongoing support refers to any and all physical, psychological, social and spiritual supports that the women find helpful in the maintenance of their well-being after they leave a residential center. These include, but are not limited to, professional aftercare services, mutual support groups, and natural supports such as family and friends.I would say my biggest need right now is support. Just to know that if I needed somebody to be there that they would be. I think it’s more empowering to know that there’s groups that you can go to, people that you can talk to, and when situations get a little out of control you don’t have to turn to a drug - that there’s somebody there who would listen to you. (Dee-Dee).Once you’re on your own, even if you’ve gotten yourself an apartment and if you’ve gotten yourself a job - to be able to keep going back - maybe not to stay and reside, but if you need to go back and talk about relapse or whatnot. (Grace).The women say they need “homes,” as opposed to merely “housing.” There is a qualitative difference between the two that the women made clear using descriptors like ‘safe’, ‘warm’, and ‘comfortable,’ to describe the former. They need homes from which to successfully access recovery programs, and in which they can stabilize after a residential program.We move out [of residential programs]. We’re clean; sober; we don’t have any money. We get stuck with roommates and they’re using. We get stuck in shit holes ‘cause we don’t have enough money. Low income [housing] is synonymous with crack shacks. You’re living in places of squalor and drug addiction. So if we had places subsidized and really strictly no using, no partying, no this, no that…you’d have maybe a better chance. Because I don’t care - you can be as strong as you want – if you’ve got somebody doing an eight ball in your living room, it’s not conducive to staying straight. (Athena).Women need assurances that their rent, bills and other financial obligations will be provided for while they are in recovery programs, and provisions to reestablish themselves within communities afterwards. “…I wasn’t just giving up a drug. I was giving up a kind of income.” (Joni).What hindered successful recovery in the women’s experience were: an inner urban location, prescriptive recovery, invidious treatment, lack of safety, distress-derived distraction, problem-focused treatment, aspects of mutual support groups, and social marginalization.Locating recovery programs and residential centers in areas where drug users congregate was considered absurd by the respondents, due to excessive exposure to triggers and access to drugs. One participant described her reaction to the surroundings of a treatment facility upon her arrival as follows:At first I was like “Excuse me? Are you sure?” I’ve sat on that corner before and I wasn’t in treatment – that’s for damn sure. So I asked about it. “What the hell are you guys thinking making a treatment center right here? I mean, there are crack-heads in the alley and drunks everywhere, and drug dealers everywhere”. They explained to me that the reason they chose that location was because that’s where they got the funding for it…I just found it kind of stupid to be there. (Leigh).Prescriptive recovery may be understood as a recovery method that is imposed, enforced or sanctioned with exact rules, directives or instructions about how it must occur. A major theme throughout the interviews was the dehumanizing effect of prescriptive recovery with its disregard for individual difference and self-determination. Jewel complained of expectations that she be “just like a robot”. The word “robot” appeared in several interviews in reference to such an approach. Ginger was representative of the women when she stated, “Everybody’s recovery is going to be different, you know. Different things work for some people that don’t work for other people.”Past experiences of invidious treatment by caregiving professionals was reported as negatively impacting desire and decisions to seek help for addiction. Deficit-based and confrontational methods of counselling, judgmental attitudes, omniscient demeanors, and “pushy” behaviors are barriers to successful engagement and retention in addiction recovery programs.A description of safety issues and corresponding harms are discussed in the above section on “Needs,” under the sub-heading “Biopschosocial-spiritual and Environmental Safety”.Personal anguish or suffering can interfere with women’s abilities to focus on their personal needs in the change process and hence impede progress. Such anguish cited included boredom, depression, general anxiety, low self-esteem, fear, and interpersonal concerns . Several women recommended that telephone calls and visitation be strictly limited or prohibited during the early phases of recovery to shelter them from outside concerns, and thus support them in focusing on their own recovery needs.Problem-focused treatment, with an emphasis on problems, deficits, weakness, illness and even an over-emphasis on substance use, may prove debilitating and ultimately defeating. Treatment or supports in which personal accounts of addiction struggles and “war stories” dominate discourse can be triggering and detrimental to a recovering substance user. The women overwhelmingly indicated a preference for a positive, strengths-based, and balanced approach to addiction recovery. “Life is supposed to be balanced. If it’s too one-sided – recovery, recovery, recovery – it’s too much for a person and it’s all about all my problems and my life history. It’s too much.” (Athena). Joni’s hard-won struggle with addiction taught her that, “To look beyond a substance is the way to be okay.” (Joni).Nineteen of the women shared their experiences of step-based, mutual aid support groups, including Narcotics Anonymous (NA) and Alcoholics Anonymous (AA). While certain aspects of mutual support groups were considered helpful, every participant but two spoke emphatically about negative elements of AA or NA attendance, and of how such groups have the capacity to hinder as opposed to support women. Eight of the eleven women who had participated in NA found it more harmful than helpful while three found it to be helpful. Seven of the fourteen women who had participated in AA found it more harmful than helpful while five found it to be helpful overall, with two ambivalent about the experience. While two of the women were strong proponents of these programs, they also acknowledged dangers. Negative aspects cited included prescriptive methods of recovery including pressure to embrace each of the 12 Steps, the use of fear tactics and confrontation, a problem focus, unstable and unsafe members, judgmental attitudes, lack of confidentiality, war stories, emphasis on trusting a higher power when they found it difficult to trust at all, unhealthy romantic entanglements, deleterious attacks on self-esteem and increased exposure to drugs. Michelle described NA as “a social club for users.” Offence was taken by many women to AA and NA on the perceived grounds that the groups purported to be “the only way”; if one did not accept the tenets of the program she was often dismissed as “not ready” to seriously address her addiction.Marginalization can be understood as a process in which people who are relatively different from the dominant norm are moved to the periphery of society because of their identities, associations, experiences or environment. Women spoke in a desultory manner about “exclusion being a big part of addiction” (Michelle) and of being “treated like an outcast” (Melissa), or like “rats” . Some of the women described how they were not permitted to sit in certain public areas or were singled out of crowds and harassed by police. “They don’t tell normal society to leave” (Grace). “Just because you’re a junkie doesn’t mean you’re a bad person” (Athena). The stigma and marginalization experiences of the women were linked to prevailing drug laws and policies which blame, stereotype and isolate low-income women struggling with illicit drug addiction in particular.What helped women in their recovery process included: connection in counselling; multidisciplinary service provision; spirituality; keeping busy; an experience of exploration, learning, and discovery; work; a safe and flexible structure; nutritious food; and aspects of mutual support groups.The women were unanimous in reporting that access to a peer or professional counsellor who had a history of addiction recovery was essential, and each First Nations woman stated that she felt more comfortable with a First Nations counsellor.Counsellors with similar histories to the women are role models who represent hope and can share personally informed knowledge on how they were able to overcome their struggles and offer practical suggestions. The women reported being more likely to find them empathetic and compassionate, to trust them and to feel understood because of their commonalities. They appreciated the interpersonal insight that came from being “street-wise” and avoiding “bullshit” (Joni), or in other words, dishonesty in themselves or others. Such counsellors are favored over pedantic “textbook”  helpers. The women needed to “feel connected” to a counsellor.…there have been so many times when the very first person I’ll sit down and talk to, I don’t have that initial connection with. There seems to be a barrier…And yet the next time I’ll try again or go a different avenue and meet somebody completely different who I do connect with, and makes me feel like, “Yeah. I am a valuable person. I do belong here. I do need help, and you’re here, and I’m glad.” (Dee-Dee).Some of the adjectives used to describe the attributes of the people who helped the women were: “positive,” “professional,” “well-trained,” “compassionate,” “understanding,” “genuine,” “street-wise,” “warm,” “loving,” “tender,” “approachable,” “honest,” “respectful,” “accepting” and “welcoming.” Some appreciated a spiritually mindful counsellor who “knows how to bring you to that place - whatever you want to call it - closer to your higher power…” (Susan).While most of the women appreciated group work in varying degrees, many indicated that they had a preference for one-on-one counselling, and several asserted that 24 hour access to a counsellor is critical. Some participants discussed the potential benefits of an informal approach to counselling that could occur while participating in ordinary activities like swimming, walking, and television viewing.Most of the women in the study had complex needs and required multidisciplinary service provision. Several had physical disabilities and health problems, including HIV, AIDS, hepatitis C, diabetes and other serious illnesses. Several women were on medication for severe and persistent mental health issues like chronic depression, anxiety and bi-polar disorder.The main thing I needed to feel was that there was a team that was in control…for me to be able to let go and trust. There was a system in place. (Sophie).Spirituality (as opposed to dogmatic religiosity) was a major theme in the healing process. Leigh summed it up by saying, “I couldn’t understand how anyone could go through recovery and not have spirituality of some kind.” Spirituality presents in many forms while having an association with nature for a number of these women. Joanne described her own experience as follows.I think I was always spiritual. I just kind of lost that in my life along the way. I’m getting that back and I feel more. I just don’t feel lonely all the time. My best friend was my bottle or whatever. Spirituality slowed me down, so I can at least focus. I can read now…and now can sleep. I don’t think I slept in four years…I find my spirituality in myself, kind of, and just, I don’t know, like, whether you want to call it God or whatever. It’s almost like something’s embracing me. It’s everywhere – like the forest. Like, I go for walks and it’s absolutely beautiful in there and I take the girls and it’s just peaceful – which I’ve never had in my life – where I felt peaceful and safe. With those two things, I feel like I could sort of conquer everything. That and, with sobriety, being peaceful and safe.First Nations women and Caucasian women both talked about the benefits of First Nations cultural teachings and ceremonies, such as sweat lodge and burning ceremonies. Other cited sources of spiritual benefit including 12-step and 16-step groups, and feminist spiritual teachings. Kasl’s  16-step Several women indicated that “keeping busy” alleviates preoccupation with drug use and facilitates the process of normalization.…not just keeping busy by going to group therapies and things like that. But keeping busy doing normal things…I really think trying to do normal things really, really helps and makes a difference because it gets you back into the track of what it’s like to live a normal life. And when you start doing stuff like that, you start to remember how much it actually was enjoyable. You know, when you get into this kind of lifestyle, you kind of forget how straight people actually have fun. (Ginger).The experience of exploration with learning and discovery was a key to the success of recovery for these participants. The following were identified by the women as essential:* Body-mind exploration: walking; yoga; meditation; acupuncture; fitness/ recreational therapy; massage; tai-chi; self-hypnosis; touch therapies; expressive therapies; horticultural therapy.* Self exploration: self-knowledge/honesty; trust building; grief and loss; physical, mental, sexual abuse; other trauma; relationships; self-esteem/self-empowerment; anger; thought management.* Life exploration/education: drug and alcohol education ; basic living skills; relationship skills; parenting skills; employment counselling; job training; alternative behaviors and activities; family and community reconnection and integration; spiritual paths.Many of the women liked the idea of having healthy community members attend residential recovery programs to interact and give classes, workshops, lectures and to otherwise share of their time and knowledge, covering a wide range of topics.Work – whether it is volunteered or remunerated – was seen to provide stability, a meaningful role, a sense of belonging and increased self-esteem.…I like the routine of it…the getting up in the early morning with the sunrise, and getting your shower, and making your bed before breakfast, and helping and…doing the chores was phenomenal…I needed that…like I had been a really good housewife but I hated it. But this was different. This was me not having all the jobs but having a role. So I felt like I belonged. I was helping. (Athena).One of the dominant themes was that an effective recovery program must respect individual differences, and that the program structure must incorporate mechanisms that allow for self-determination. The women wanted a safe, flexible structure that has not only a set routine and clear rules, but many programming options. The women were adamant that while strict rules are necessary for safety, alternatives should be offered in programming, timelines should be dependent on needs and goals, and concessions need to be made for individuals, dependent upon their physical, mental, emotional, social, and spiritual needs and abilities. Brenda summed it up neatly, “Everybody is individual, you know, what works for one doesn’t work for another”. (Brenda).Nutritious, tasty food is essential to nurture the health and well-being of women who have been chemically addicted. Several mentioned that they would like access to food 24 hours a day in a residential center. Access is especially important in early recovery when they may be sick and unable to eat during scheduled mealtimes.Some mutual support groups were found to be helpful to some for establishing a peer community with common bonds, as they provide accessible and low threshold access, attention to core needs including trauma support, and in some cases a spiritual pathway of recovery while providing support toward abstinence. In more empowerment-based and less prescriptive mutual aid groups, women found emotional support, respite from loneliness and an opportunity to learn from and with peers. Some found spiritually-based programming particularly helpful, and some of the women who had utilized support groups stated a preference for Kasl’s  16-step Our development of the core components of a harm reduction-based women’s recovery program draws on the wisdom and experiential knowledge of the participants in this study, and considers their stated recovery needs, and what has helped and hindered in meeting these needs in their past experience. Although the women did not use the term, “harm reduction” in their vision of the main components of an effective substance addiction recovery program, the components they identified are in fact core elements of a harm reduction approach. The women’s expectation is that recovery services include a residential component to facilitate safe, supportive transitioning from the point of the decision to access services, through independent living with community integration.Every woman ardently asserted that residential recovery programs in particular should not be situated in areas that are frequented by people with addictions, or by drug dealers. With the exception of two women who preferred suburban residential neighborhoods, all stated that residential programs must be located in a rural location. For the vast majority of the women interviewed, the ideal location for a residential center would be in a quiet, safe rural area - preferably on an acreage - near water, trees and wilderness; away from cities’ dense population and traffic noise; far enough away to present as a barrier to an impulsive return to one’s former lifestyle, and a barrier to unwelcome individuals; close enough to a community to allow for weekly outings and community interaction; in a natural environment with walking areas and a garden. A number of women described a farm-like setting with animals.They always say you can’t run from your problems, or move from your problems - which is true - but taking a break doesn’t hurt either. (Melissa).It’s just easier to clear your mind… (Rose).…I think it’s partly that noise and cars and living on top of other people and dull roar…traffic and stuff in the background…kind of interferes with your own inner feeling or awareness. So, for me, being outside of this makes a huge difference. I mean I can hear myself and think and be open in a way that I can’t be otherwise…A lot of times in the city I’m so closed off just to minimize the battering feeling of all that, that it takes away from being able to be open to other things. (Joni).The following is the list of core components of a rural harm reduction-based women’s recovery facility as identified by the respondents:* An overall approach that is holistic; respectful; positive; strengths-based; person-centred; supportive of self-determination and choice; balanced* Low threshold access* Safety •Free from danger, including but not limited to, coercion, indoctrination, invasive and invidious contact and treatment•Regulated•Supervised* Serene and home-like environment* Multidisciplinary service provision of conventional and complementary modalities and therapies for integrated healing* Long term multi-phase recovery program* Flexible structure/timelines in consideration of individual need, ability and stage of growth* Counselling readily available•Therapeutic relationships•One-on-one as needed•Women-only group work in the early phases•Non-confrontational approach and promotion of honesty•Access to counsellors and support workers of similar culture and personal history * Variety and choice of programming/therapies/activities* An experience of physical-psychosocial-spiritual exploration, learning, discovery, and fun•Body-mind therapies•Sports, play and hobbies; self-defense training•Personal self-development•Spiritual paths•Life skills•Employment and educational counselling•Work •Trust-building programs•Drug and alcohol education•Community interaction/integration•Family counselling/education* Connection with resources for ongoing support•Supported homes•Financial assistance•Healthy mutual support groupsIn regard to mutual aid groups, the participants in our study emphasized the importance of adopting a biopsychosocial-spiritual understanding of addiction, and a non-judgmental and non-hierarchical approach; a strengths and capacity-based approach emphasizing self-efficacy; low threshold access; social support; and the safety and structure of abstinence.From the perspective of low income women struggling with addiction, a harm reduction orientation is essential to the effectiveness of substance addiction recovery programs, and the two “pillars” of harm reduction and addiction treatment are inextricably linked. Although the women in our study did not necessarily use the term, “harm reduction-based” in their description of the core components of an addiction recovery program and center, the main elements they identified were first, the reduction of harm via attending to the basic needs of women in recovery (a needs hierarchy from their own perspective); and second, women-directed programs, both goals and strategies of a harm reduction approach ,6,46. FuThe women were forthright and keen to articulate their experiences and insights toward the goal of providing information that would make a positive and significant difference in the provision of what are essentially harm reduction-based recovery programs and services to marginalized women struggling with addiction. Our findings report women’s stated recovery needs, what hindered their recovery in past programs, what helped, and the core components of an effective harm reduction-based recovery program. These results not only complement existing theoretical and empirical formulations of the unique needs of women struggling with substance addiction, but add new data to our collective understanding of what is most salient to these women in their recovery process.Central to an understanding of the core components of a model harm reduction-based recovery program is the adoption of a “kaleidoscopic” lens that does not view a constructed model as immutable, but understands that it provides a framework for systems of variation that reflect and respond to the complex and shifting states of the diverse entities it serves. Core concepts and principles comprise the girders of a framework and a guide to program activity, without assuming or insisting that every harm reduction-based recovery program based on these components be identical.Our findings indicate that the three core needs identified by low income women struggling with drug addiction are normalization/structure, safety, and social connection. An effective recovery program must first and foremost address these needs, and a residential recovery program is essential for those who choose an abstinence-based approach, best located in a rural, natural setting. Recovery programs based on harm reduction principles need to have a safe, supportive, and flexible structure that responds to women’s’ unique needs and abilities, and supports individuality and self-determination. The intervention approaches used need to be positive, client-centered and strengths-based, as opposed to problem-focused, prescriptive, and deficit-based. They must provide a variety of biopsychosocial-spiritual experiences and education to assist the women in the discovery, development and/or remembrance of integral and core internal and external organizational constructs, processes, beliefs, behaviors and activities that will holistically facilitate the normalization of health, experience and lifestyle with personal and social integration. Such healing requires time, timeliness of intervention, and a safe, supportive and stable environment.In keeping with a harm reduction orientation, the women in our study also identified the following key components of an effective addiction recovery program: immediate attention to reducing the harms associated with substance use and containing the adverse consequences of use; low threshold access to residential and out-patient services as needed; client-directed recovery tailored to the unique needs of each individual woman; a menu of choices and options in regard to intervention strategies, to maximize self-efficacy and develop a sense of mastery over what initially seem to be insurmountable obstacles. The recognition among service providers that there exists a continuum of substance use from non-problematic to problematic was seen as critical; when substance use becomes problematic to the degree that addiction is a concern, the need for long-term residential programs in particular was identified, and in the interests of women’s safety in residential addiction treatment, an abstinence requirement was seen to be fundamental . From thIn sum, according to the women, the process of addiction recovery should direct attention to immediate needs, with women then co-constructing a hierarchy of their needs with the service provider, along with a menu of choices in regard to intervention, the provision of different interventions for women at different stages of addiction recovery, and service provider transparency in regard to the use of specific intervention strategies. These are essentially the core elements of harm reduction as a psychotherapeutic approach in addictions .A notable finding is this study was that a residential recovery program should be located well away from an urban environment, where accessibility to drugs is a constant threat. A rural, nature-based residential setting was identified as crucial for addiction recovery by 26 of the 28 women. Women with substance use problems have talents, abilities and resiliencies that must be built upon so that they may empower themselves as self-effective agents of change, and a rural recovery setting would allow these strengths to re-emerge. Strengths-based practitioners in such a setting would look for and try to nurture the ‘gleam’ that is often hidden by misery, protective strategies, and the failure to achieve goals set by others [People’s lives are lived through both subjective and objective transactions between inner and outer realities that are constantly developing processes rather than static structures  . A persoThe assumption inherent in a biopsychosocial-spiritual – or holistic – approach to harm reduction-based recovery is that problems arise when individual characteristics combine with biological, psychological, social, environmental and spiritual factors to produce unwanted or harmful states and behaviors. The unique qualities of each individual in interaction with these factors and the unique manifestations of these interactions in the form of substance use and addiction construct a heterogeneous population of substance users with multi-varied needs and desires ,50.The complexities of the interactions that occur within unique ways in each individual demand a wide range of intervention options. There is no universal approach appropriate for everyone, and so it is desirable to match interventions with an individual’s characteristics, values, beliefs, strengths, needs and wishes within the context of her situation, and respecting social differences in race, class, gender, sexual orientation, religion, age, ability and ethnicity. Variety and options are critical and require harm reduction-based recovery programmers to be creative and resourceful in developing methods to offer a diverse group meaningful and effective experience. More interdisciplinary research should be conducted to develop a stronger knowledge base around body-mind science and the implications for addiction recovery. Drawing on this knowledge, policymakers will be in a better position to develop best practice guidelines that will meet the needs of women as efficiently and efficaciously as possible. Long-term and multidisciplinary service provision is essential in order to offer both conventional and complementary programming in relation to trauma and addiction (,21; GregOur research results also indicate a need for further examination and discussion of women’s experiences in AA and NA groups . It is eFinally, the implications of our findings for programs developers and policymakers are profound. Although the feasibility of establishing the type of recovery programs envisioned by the women may be argued to be unrealistic and not feasible, it seems clear that an alternative approach to addiction recovery is urgently needed in the case of highly marginalized women struggling with addiction, who remain in constant danger of death and disease, and for whom existing recovery approaches have limited utility ,16. LongThe authors declare that they have no competing interests.Both authors conceived of the study. EK designed the instrument for the study, and led the study’s design and coordination. KS carried out the interviews and qualitative data analysis. Both authors contributed to the drafting of the manuscript, and read and approved the final manuscript.