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. 2022 Jul 14;30(6):e4950–e4960. doi: 10.1111/hsc.13907

Level and correlates of social support in a community‐based sample of Australians who primarily smoke methamphetamine

Michael J Leach 1,✉, Bernadette Ward 1,2, Rebecca Kippen 1, Brendan Quinn 2,3,4, Paul A Agius 2,3,5, Keith Sutton 1,2, Joshua Peterson 1, Paul M Dietze 2,3,6
PMCID: PMC10946876  PMID: 35833453

Abstract

Little is known about the level and correlates of social support amongst people who use methamphetamine. We aimed to describe, and determine characteristics associated with, social support amongst a community‐recruited cohort of Australians who primarily smoked methamphetamine. A cross‐sectional study was conducted with data from the Victorian Methamphetamine Cohort Study (VMAX). Adults (aged ≥18 years) who used methamphetamine were recruited from June 2016 to March 2020 across metropolitan and non‐metropolitan areas using convenience, snowball, and respondent‐driven sampling. Social support was measured using the seven‐item Enhancing Recovery In Coronary Heart Disease (ENRICHD) Social Support Inventory (ESSI). Characteristics independently associated with ESSI quartiles were assessed via multivariable partial proportional odds regression. Overall, 718 participants were included for complete‐case analysis. Their mean (standard deviation [SD]) age was 34.7 (9.7) years and 62% were male. The mean (SD) and median (lower quartile‐upper quartile) ESSI scores were 22.6 (7.6) and 24 (16–29), respectively, on a scale of 8 to 34 where higher scores denote better self‐perceived social support. Characteristics independently associated with lower ESSI included past‐year homelessness (adjusted odds ratio [aOR] = 0.49, 95% confidence interval [CI] = 0.36–0.66), moderate/severe depression (aOR = 0.60, 95% CI = 0.42–0.86), increasing age relative to <30 years (aOR[30–39] = 0.61, 95% CI = 0.41–0.91; aOR[≥40] = 0.56, 95% CI = 0.35–0.91) and greater than fortnightly methamphetamine use (aOR = 0.69, 95% CI = 0.52–0.91). Characteristics independently associated with higher ESSI were employment (aOR = 1.51, 95% CI = 1.06–2.14) and female gender (aOR = 1.39, 95% CI = 1.00–1.92). Social support services for people who use methamphetamine could be targeted and tailored to subgroups defined by correlates of social support, such as those who experience homelessness, depression or unemployment.

Keywords: Australia, depression, homelessness, methamphetamine, social support, substance misuse

What is known about this topic?

  • Low levels of social support constitute a potentially modifiable risk factor for poor health outcomes, including reduced health‐related quality of life, morbidity, and mortality.

  • A small number of cross‐sectional studies have shown that, amongst people who used methamphetamine via any route or primarily the injecting route, certain sociodemographic and psychological characteristics are associated with social support.

  • Little is known about how to support consumers who primarily smoke methamphetamine, particularly those in rural areas.

What this study adds?

  • Our cross‐sectional study found that social support amongst Australians who primarily smoked methamphetamine was, on average, 22.6 on the ENRICHD Social Support Inventory (ESSI) scale of 8 to 34.

  • Our cross‐sectional study found novel associations between sociodemographic/psychological characteristics and social support amongst people who primarily smoked methamphetamine, including negative associations for older age, homelessness, depression, and more frequent methamphetamine use as well as positive associations for female gender and employment.

  • Our findings point to the potential importance of interdisciplinary, co‐located models of care in both rural and metropolitan areas—models of care that address social support, other social determinants of health (e.g., housing), and the mental health of people who use methamphetamine.

1. INTRODUCTION

Social support refers to the availability or provision of support through different kinds of informal and formal connections with other people, including distinct typologies such as emotional and instrumental support (Gottlieb & Bergen, 2010). Social support buffers against stress and is, thus, considered to be a social determinant of health (Galea et al., 2011). A low level of social support has been linked to reduced health‐related quality of life (Freak‐Poli et al., 2021; Gallicchio et al., 2007; Hajek et al., 2016), the onset or worsening of disease, and premature death (Galea et al., 2011). Low levels of social support are, therefore, a potentially modifiable risk factor for poor health outcomes.

Amongst people who use drugs, including those with substance use disorders, relationships between social support and health outcomes may be relatively complex and nuanced as an individual's social network likely comprises others who use drugs and influence behaviours (Bathish et al., 2017). For example, in studies of injection drug network characteristics, an increasing number of injection partners has been shown to be associated with a rise in the rate of drug injection frequency—a key variable in relation to a range of harms (Spelman et al., 2019). Similarly, a shift in one's social network composition from mostly people who use drugs to mostly those who are recovering can serve to aid recovery from drug addiction (Bathish et al., 2017).

Research has shown that the availability/provision of social support and the composition of one's social network are important when it comes to methamphetamine use. For example, amongst a community‐recruited sample of metropolitan Australians who primarily injected methamphetamine, lower self‐perceived social support was found to be independently associated with methamphetamine dependence in a cross‐sectional analysis (Lanyon et al., 2019), whilst higher self‐perceived social support was found to be independently associated with subsequent remission from methamphetamine dependence in a longitudinal analysis (Quinn et al., 2016). A Chinese cross‐sectional study found that a longer duration of methamphetamine use (in years) was correlated with lower perceived social support (Cui et al., 2021). Across US cross‐sectional studies, past‐month methamphetamine use amongst adolescents experiencing homelessness was positively associated with the proportion of peers using methamphetamine (Zhao et al., 2018), methamphetamine use by adolescents experiencing homelessness was positively correlated with substance use by parents and others experiencing homelessness (Rice et al., 2011), and 30‐day frequency of methamphetamine use amongst men who had sex with men was negatively associated with the level of social support (Rapier et al., 2019).

Methamphetamine can be administered via various routes. Compared with other routes of methamphetamine administration (e.g., snorting), injecting and smoking have more rapid onsets of effects (Rawson et al., 2006) and lead to greater psychological impairment (Rawson et al., 2007). Different routes of methamphetamine administration also carry specific risks, such as human immunodeficiency virus (HIV) with injecting (Rawson, 2013) and dental problems impacting mental health with smoking (Stanciu et al., 2017). Whilst most known published studies of social support amongst people who use methamphetamine provided no data on routes of administration (Cui et al., 2021; Farnia et al., 2018; Jalali et al., 2019; Rapier et al., 2019; Rice et al., 2011; Semple et al., 2011; Zhao et al., 2018), two past Australian studies measured social support amongst people who primarily injected methamphetamine (Lanyon et al., 2019; Quinn et al., 2016). At the population level in Australia, however, smoking is the most common route of methamphetamine administration (Australian Institute of Health and Welfare, 2020).

International cross‐sectional studies conducted amongst people who used methamphetamine have found that certain sociodemographic and psychological characteristics are associated with social support. In a cohort of 245 US HIV‐positive men who had sex with men and used methamphetamine, employment, lifetime sexual abuse, and risk‐taking behaviours were found to be unrelated to emotional support (Semple et al., 2011). However, amongst this cohort, depression, anxiety, homelessness, and family conflict were independently correlated with less emotional support (Semple et al., 2011). Amongstst a sample of 117 people receiving treatment for methamphetamine addiction in Iran, significant correlations were found between specific personality traits and perceived social support, including a negative correlation for neuroticism (Jalali et al., 2019). This study also found that none of residential location (rural versus urban), gender, educational level, marital status nor age was associated with perceived social support, although potential confounding factors were not accounted for by design nor through adjustment in statistical analysis (Jalali et al., 2019).

Little is known about how to support people who primarily smoke methamphetamine across metropolitan and rural areas, including their social health. No known published studies have assessed sociodemographic, psychological, and drug use characteristics independently associated with social support in a community‐recruited sample of people who smoked methamphetamine. Methamphetamine use is widespread in communities worldwide. In Australia, between 2019 and 2020, methamphetamine was the substance of choice for one‐third of people who used illicit drugs as well as the main illicit substance for which people intended to seek treatment (Peacock et al., 2019, 2021). Knowledge of sociodemographic, psychological and drug use characteristics associated with social support amongst Australians who use methamphetamine could assist with the delivery of targeted social support services: interventions designed to affect positive outcomes for methamphetamine and other drug use in particular population subgroups.

The present study aimed to describe, and determine characteristics associated with, social support amongst a community‐recruited cohort of Australians who primarily smoked methamphetamine. We hypothesised that, amongst people who primarily smoked methamphetamine, lower levels of social support would be associated with a range of sociodemographic, psychological, and drug use characteristics.

2. METHOD

2.1. Study design and sampling

A cross‐sectional study was undertaken using baseline survey data sourced from a prospective cohort study conducted in Victoria, Australia amongst people who primarily smoked methamphetamine: the Victorian Methamphetamine Cohort Study (VMAX). Details of the study methods have been reported elsewhere (Quinn et al., 2020). In summary, convenience, snowball and respondent‐driven sampling were used to recruit participants over the period June 2016–March 2020. The study period ended soon before the World Health Organization (2020) upgraded the coronavirus disease‐19 epidemic to a pandemic on 11 March 2020. Study eligibility criteria included residence in Melbourne or three non‐metropolitan locations, age 18 years or over, at least monthly use of any form of methamphetamine in the preceding 6 months, and using methamphetamine via non‐parenteral routes of administration (e.g., smoking). Due to an initial period of slow recruitment, the latter inclusion criterion was later relaxed to cover all routes of administration. Data were collected via face‐to‐face interviews and entered directly and securely into a mobile device via Research Electronic Data Capture (REDCap) software (Harris et al., 2009). The baseline questionnaire included sociodemographic characteristics, social support, drug use, methamphetamine market information, criminal activity and general and mental health.

2.2. Measures

The outcome of interest, self‐perceived social support, was measured using a tool originally developed for the Enhancing Recovery In Coronary Heart Disease (ENRICHD) trial: the ENRICHD Social Support Inventory (ESSI) (Mitchell et al., 2003). This tool is multidimensional in that it measures social support across four dimensions: emotional, instrumental, appraisal and informational support (Vaglio Jr et al., 2004). ESSI focuses on the availability, as opposed to the provision, of social support. In our study, a total ESSI score was calculated by summing scores across all seven of the instrument's items (Mitchell et al., 2003). The first six items consist of the following questions:

  1. Is there someone available whom you can count on to listen to you when you need to talk?

  2. Is there someone available to give you good advice about a problem?

  3. Is there someone available to you who shows you love and affection?

  4. Is there someone available to help you with daily chores?

  5. Can you count on anyone to provide you with emotional support (e.g., talking over problems or helping you make a difficult decision)?

  6. Do you have enough contact with someone that you feel close to, someone in whom you can trust and confide? (Mitchell et al., 2003, p. 402).

For each of these six questions, responses comprise a five‐point Likert scale ranging from ‘None of the time’ (scored 1) to ‘All the time’ (scored 5). The seventh item is a binary variable for marital status, whereby a score of 4 is applied for people who are married or living with a partner and a score of 2 is applied for those who are not (Mitchell et al., 2003). As such, the seven‐item ESSI score ranges from 8 to 34, with higher scores denoting greater self‐perceived social support. The seven‐item ESSI score has been shown to be both valid and reliable (Vaglio Jr et al., 2004).

Independent variables (Table 1) were chosen based on characteristics previously assessed in relation to social support (Brown et al., 2020; Cui et al., 2021; Jalali et al., 2019; Lanyon et al., 2019; Rapier et al., 2019). Age in years at survey completion was treated as a continuous variable for descriptive purposes and a categorial variable with three groups (<30 years, 30–39 years, and ≥ 40 years) for statistical modelling. Binary sociodemographic variables included: gender (male or female), residential area as per the Modified Monash Model (MMM) geographical classifications (Australian Government Department of Health, 2021) (metropolitan [1] or non‐metropolitan [2–5]), education (≥year 11 or < year 11), employed (yes or no), and homeless in the last 12 months (yes or no). Binary psychological variables included moderate‐to‐severe anxiety measured on the Generalised Anxiety Disorder‐7 [GAD‐7] scale (Spitzer et al., 2006) (yes [≥10] or no [<10]), and moderate‐to‐severe depression measured on the Patient Health Questionnaire‐9 [PHQ‐9] scale (Kroenke et al., 2001) (yes [≥15] or no [<15]). Drug use variables included methamphetamine dependence measured on the Severity of Dependence Scale (SDS) (Gossop et al., 1995) (yes [≥4] or no [<4]), main route of administration (smoked or other [injected/snorted/swallowed/shelved/shafted]), duration of methamphetamine use measured as time since the first use of any methamphetamine (<11 years, 11–19 years, or ≥ 20 years), and frequency of methamphetamine use over the past month (≤fortnightly or > fortnightly). For the purposes of descriptive analysis, the residential area was also defined as a polytomous variable with the following categories: metropolitan (1), regional centres (2), large rural towns (3) and small‐medium rural towns (4–5). Responses of “do not know,” “refuse to answer,” “not applicable,” or “other gender” were set to missing. In line with previously published research (Quinn et al., 2020; Ward et al., 2021), it was necessary to set other gender to missing because the small number (i.e., 2 or 0.3% of the sample) gives insufficient cell sizes for effect estimation in regression analysis.

TABLE 1.

Sociodemographic, psychological and drug use characteristics of participants, overall and by ESSI quartile (N = 718)

n (column %) a n (row %) Mean (SD)
Characteristics ESSI Q1‐Q4 (8–34) ESSI Q1 (8–17) ESSI Q2 (18–24) ESSI Q3 (25–29) ESSI Q4 (30–34) ESSI score
Age, years (Mean, SD) 34.7 (9.7) 36.4 (9.5) 35.9 (9.5) 33.9 (10.6) 32.3 (8.6) –
Age group
<30 years 237 (33.0%) 52 (21.9%) 51 (21.5%) 66 (27.8%) 68 (28.7%) 24.0 (7.2)
30–39 years 259 (36.1%) 80 (30.9%) 71 (27.4%) 49 (18.9%) 59 (22.8%) 22.2 (7.7)
≥40 years 222 (30.9%) 72 (32.4%) 62 (27.9%) 51 (23.0%) 37 (16.7%) 21.5 (7.6)
Gender
Male 445 (62.0%) 125 (28.1%) 129 (29.0%) 97 (21.8%) 94 (21.1%) 22.3 (7.4)
Female 273 (38.0%) 79 (28.9%) 55 (20.1%) 69 (25.3%) 70 (25.6%) 23.0 (7.8)
Residential area (MMM)
2–5 (Non‐metropolitan) 470 (65.5%) 152 (32.3%) 127 (27.0%) 91 (19.4%) 100 (21.3%) 21.7 (7.8)
4–5 (Small‐medium rural towns) 71 (9.9%) 18 (25.4%) 21 (29.6%) 12 (16.9%) 20 (28.2%) 23.2 (7.4)
3 (Large rural towns) 255 (35.5%) 91 (35.7%) 63 (24.7%) 54 (21.2%) 47 (18.4%) 21.1 (7.9)
2 (Regional centres) 144 (20.1%) 43 (30.0%) 43 (30.0%) 25 (17.4%) 33 (22.9%) 22.0 (7.6)
1 (Metropolitan) 248 (34.5%) 52 (21.0%) 57 (23.0%) 75 (30.2%) 64 (25.8%) 24.2 (6.9)
Education
<Year 11 391 (54.5%) 132 (33.8%) 105 (26.9%) 75 (19.2%) 79 (20.2%) 21.5 (7.7)
≥Year 11 327 (45.5%) 72 (22.0%) 79 (24.2%) 91 (27.8%) 85 (26.0%) 23.9 (7.1)
Employed
No 565 (78.7%) 183 (32.4%) 146 (25.8%) 121 (21.4%) 115 (20.4%) 21.8 (7.7)
Yes 153 (21.3%) 21 (13.7%) 38 (24.8%) 45 (29.4%) 49 (32.0%) 25.7 (6.3)
Homeless last 12 months
No 454 (63.2%) 97 (21.4%) 114 (25.1%) 121 (26.7%) 122 (26.9%) 23.9 (7.2)
Yes 264 (36.8%) 107 (40.5%) 70 (26.5%) 45 (17.0%) 42 (15.9%) 20.3 (7.7)
Anxiety (GAD‐7)
Minimal/mild 391 (54.5%) 88 (22.5%) 101 (25.8%) 101 (25.8%) 101 (25.8%) 23.6 (7.2)
Moderate/severe 327 (45.5%) 116 (35.5%) 83 (25.4%) 65 (19.9%) 63 (19.3%) 21.3 (7.8)
Depression (PHQ‐9)
Minimal/mild 511 (71.2%) 124 (24.3%) 126 (24.7%) 132 (25.8%) 129 (25.2%) 23.4 (7.3)
Moderate/severe 207 (28.8%) 80 (38.6%) 58 (28.0%) 34 (16.4%) 35 (16.9%) 20.7 (7.8)
MA dependence (SDS ≥4)
No 245 (34.1%) 63 (25.7%) 50 (20.4%) 60 (24.5%) 72 (29.4%) 23.6 (7.9)
Yes 473 (65.9%) 141 (29.8%) 134 (28.3%) 106 (22.4%) 92 (19.5%) 22.1 (7.4)
Main MA ROA
Smoked 580 (80.8%) 165 (28.4%) 156 (26.9%) 131 (22.6%) 128 (22.1%) 22.5 (7.4)
ROA other than smoked b 138 (19.2%) 39 (28.3%) 28 (20.3%) 35 (25.4%) 36 (26.1%) 22.9 (8.1)
Duration of MA use
<11 years 257 (35.8%) 59 (23.0%) 60 (23.3%) 73 (28.4%) 65 (25.3%) 23.6 (7.3)
11–19 years 231 (32.2%) 61 (26.4%) 65 (28.1%) 48 (20.8%) 57 (24.7%) 22.9 (7.4)
≥20 years 230 (32.0%) 84 (36.5%) 59 (25.7%) 45 (19.6%) 42 (18.3%) 21.1 (7.8)
Frequency of MA use
≤Fortnightly 418 (58.2%) 96 (23.0) 108 (25.8) 109 (26.1) 105 (25.1) 23.5 (7.3)
>Fortnightly 300 (41.8%) 107 (35.7) 77 (25.7) 57 (19.0) 59 (19.7) 21.3 (7.8)
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Abbreviations: ESSI, ENRICHD (ENhancing Recovery In Coronary Heart Disease) Social Support Inventory; GAD‐7, Generalised Anxiety Disorder‐7 scale; Q1, lowest quartile; Q2, lower quartile; Q3, higher quartile; Q4, highest quartile; MA, methamphetamine; MMM, Modified Monash Model; PHQ‐9, Patient Health Questionnaire‐9 depression scale; SD, standard deviation; SDS, Severity of Dependence Scale; ROA, route of administration.

a

Unless otherwise stated.

b

ROAs other than smoked include injected, snorted, swallowed, and shelved/shafted.

2.3. Statistical analysis

Continuous age in years was described using the mean (standard deviation [SD]). All categorical independent variables, including age categories, were described in terms of frequencies and percentages.

The seven‐item ESSI score was described in terms of the mean (SD) as well as the minimum, lower quartile (Q1), median, upper quartile (Q3), and maximum. Furthermore, each of the six individual ESSI items measured on a Likert scale was described in terms of the mean (SD). With regard to a social support outcome for regression modelling, the non‐normally distributed, seven‐item ESSI score was divided into approximate quartiles: lowest (8–17), lower (18–24), higher (25–29), and highest (30–34). Whilst there are no standardised diagnostic cut‐off values for this particular social support measure (Abshire et al., 2018; Lett et al., 2007), the lowest category of our cohort's ESSI score aligns with a criterion for low total ESSI score used by the developers of the instrument: <18 (Burg et al., 2005).

Associations between all independent variables and quartiles of the seven‐item ESSI score were initially assessed using univariable proportional odds (PO) regression models. The PO assumption was tested using the Wald test of parallel lines (Williams, 2006). Given gender and residential area violated this assumption, univariable partial PO regression models were instead fitted for these two independent variables. Unlike standard PO regression, partial PO regression allows the estimation of different (i.e., unconstrained) beta coefficients across ordinal outcome categories (Williams, 2016). Univariable modelling involved the estimation of an odds ratio (OR) and corresponding 95% confidence interval (CI) for the association between each independent variable and the ESSI outcome. All independent variables were also entered into a multivariable partial PO model in which only gender and residential area were unconstrained. This involved the estimation of an adjusted OR (aOR) and corresponding 95% CI for each independent variable‐outcome effect. The Stata package gologit2 (Williams, 2006) was used to fit the univariable and multivariable partial PO models. A complete‐case approach to handling missing data was used. Little's chi‐squared test—specifically the mcartest command in the Stata package st0318 (Li, 2013)—was employed to assess whether data were missing completely at random. A p‐value<0.05 was considered indicative of a statistically significant result at the 5% level.

All statistical analysis was conducted using Stata Version 15.0 (StataCorp, College Station, Texas, USA).

2.4. Ethics

The study was approved by the Alfred Hospital Ethics Committee (project number: 171/16) and the Monash University Human Research Ethics Committee (project number: 2938). Written consent was obtained prior to enrolment. Participants were reimbursed AU$40, in line with accepted practise when conducting research amongst people who use drugs in Australia (Davidson & Page, 2012; National Health and Medical Research Council et al., 2019).

3. RESULTS

3.1. Sample

Of the 848 participants who completed the VMAX baseline survey, 718 were included in the present study. Of the 130 individuals excluded, 45 had missing data on one or more of the seven ESSI items. The remaining 85 individuals had missing data on one or more of the following independent variables: age, gender, past‐year homelessness, residential area, moderate‐to‐severe anxiety, moderate‐to‐severe depression, methamphetamine dependence or main route of administration. Little's chi‐squared test revealed that data were missing completely at random (p‐value = 0.14).

Sociodemographic, psychological and methamphetamine use characteristics of the 718 participants are summarised in Table 1. In terms of the main route of administration, the participants primarily smoked methamphetamine (81%).

3.2. Level of social support

The mean (SD) total seven‐item ESSI score was 22.6 (7.6) (Table 2). The total seven‐item ESSI scores were negatively skewed, with minimum, Q1, median, Q3 and maximum values of 8, 16, 24, 29 and 34, respectively. Table 1 shows the mean (SD) total seven‐item ESSI score for each category of participants' sociodemographic, psychological, and drug use characteristics.

TABLE 2.

Descriptive statistics for individual ESSI items and the total seven‐item ESSI score (N = 718)

ESSI items (Mitchell et al., 2003, p. 402) Mean (SD) a
1. Is there someone available whom you can count on to listen to you when you need to talk? b 3.5 (1.5)
2. Is there someone available to give you good advice about a problem? b 3.5 (1.4)
3. Is there someone available to you who shows you love and affection? b 3.5 (1.5)
4. Is there someone available to help you with daily chores? b 2.7 (1.6)
5. Can you count on anyone to provide you with emotional support? b , c 3.4 (1.5)
6. Do you have enough contact with someone that you feel close to, someone in whom you can trust and confide? b 3.6 (1.5)
7. Are you currently married or living with a partner? d
No—frequency (percentage) 578 (80.5%)
Yes—frequency (percentage) 140 (19.5%)
Total seven‐item ESSI score 22.6 (7.6)
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Abbreviations: ESSI, ENRICHD (ENhancing Recovery In Coronary Heart Disease) Social Support Inventory; SD, standard deviation.

a

Unless otherwise stated.

b

Score: None of the time = 1, A little of the time = 2, Some of the time = 3, Most of the time = 4, All the time = 5 (Mitchell et al., 2003, p. 402).

c

e.g., talking over problems or helping you make a difficult decision.

d

Score: No = 2, Yes = 4.

Out of the six individual ESSI items measured on a Likert scale, the lowest mean score (2.7 out of 5, SD = 1.6) and highest mean score (3.6 out of 5, SD = 1.5) were observed for the items ‘Is there someone available to help you with daily chores?’ and ‘Do you have enough contact with someone that you feel close to, someone in whom you can trust and confide?’ (Mitchell et al., 2003), respectively (Table 2). In terms of the ESSI item about marital status, 19.5% of the 718 participants indicated that they were married or lived with a partner (Table 2).

3.3. Correlates of social support

Table 3 shows univariable and multivariable associations between participant characteristics and quartiles of the seven‐item ESSI score, as determined via partial PO regression modelling. Unconstrained effects are shown as the PO assumption was violated for the variables female gender (Wald test p‐value = 0.03) and residential area (Wald test p‐value = 0.02). The adjusted odds of having higher levels of social support were reduced by 51% for participants who had experienced homelessness in the past year, 40% for those with moderate‐to‐severe depression, 39% for those aged 30–39 years, 44% for those aged ≥40 years, and 31% for those with greater than fortnightly use of methamphetamine. The adjusted odds of having higher levels of social support were increased by 51% for participants who were employed. Relative to the lowest and lower quartiles of social support, the adjusted odds of highest or higher social support were increased by 39% for female participants. In the univariable setting, but not the multivariable setting, non‐metropolitan residence and education to year 11 or beyond were associated with significantly higher levels of social support whilst moderate‐to‐severe anxiety, 20 or more years of methamphetamine use, and methamphetamine dependence were associated with significantly lower levels of social support. The main route of administration was unrelated to social support in both the univariable and multivariable settings.

TABLE 3.

Associations between participant characteristics and social support as measured by the seven‐item ESSI (N = 718)

Proportional odds Unconstrained effects
≤ESSI Q1 (8–17) ESSI Q2 (18–24) ≥ESSI Q3 (25–29)
Factor OR (95% CI) aOR a (95% CI) OR (95% CI) aOR a (95% CI) OR (95% CI) aOR a (95% CI) OR (95% CI) aOR a (95% CI)
Age group
<30 years 1.00 1.00 – – – – – –
30–39 years 0.62 (0.45, 0.85)* 0.61 (0.41, 0.91)* – – – – – –
≥40 years 0.54 (0.39, 0.75)* 0.56 (0.35, 0.91)* – – – – – –
Gender
Male – – 1.00 1.00 1.00 1.00 1.00 1.00
Female – – 0.96 (0.69, 1.34) 0.90 (0.63, 1.29) 1.38 (1.02, 1.87)* 1.39 (1.00, 1.92)* 1.29 (0.90, 1.84) 1.26 (0.87, 1.83)
Residential area (MMM)
2–5 (Non‐metropolitan) – – 1.00 1.00 1.00 1.00 1.00 1.00
1 (Metropolitan) – – 1.80 (1.25, 2.59)* 1.29 (0.87, 1.90) 1.86 (1.36, 2.54)* 1.18 (0.83, 1.67) 1.29 (0.90, 1.84) 0.74 (0.49, 1.10)
Education
<Year 11 1.00 1.00 – – – – – –
≥Year 11 1.68 (1.29, 2.19)* 1.26 (0.94, 1.69) – – – – – –
Employed
No 1.00 1.00 – – – – – –
Yes 2.20 (1.60, 3.03)* 1.51 (1.06, 2.14)* – – – – – –
Homeless last 12 months
No 1.00 1.00 – – – – – –
Yes 0.43 (0.33, 0.57)* 0.49 (0.36, 0.66)* – – – – – –
Anxiety (GAD‐7)
Minimal/mild 1.00 1.00 – – – – – –
Moderate/severe 0.59 (0.45, 0.77)* 0.82 (0.59, 1.14) – – – – – –
Depression (PHQ‐9)
Minimal/mild 1.00 1.00 – – – – – –
Moderate/severe 0.51 (0.38, 0.69)* 0.60 (0.42, 0.86)* – – – – – –
MA dependence (SDS ≥4)
No 1.00 1.00 – – – – – –
Yes 0.66 (0.50, 0.87)* 0.92 (0.67, 1.25) – – – – – –
Main MA ROA
Smoked 1.00 1.00 – – – – – –
ROA other than smoked b 1.19 (0.85, 1.66) 1.14 (0.80, 1.61) – – – – – –
Duration of MA use
<11 years 1.00 1.00 – – – – – –
11–19 years 0.82 (0.60, 1.13) 1.29 (0.88, 1.89) – – – – – –
≥20 years 0.55 (0.40, 0.76)* 0.97 (0.61, 1.56) – – – – – –
Frequency of MA use
≤Fortnightly 1.00 1.00 – – – – – –
>Fortnightly 0.60 (0.46, 0.79)* 0.69 (0.52, 0.91)* – – – – – –
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Abbreviations: aOR, adjusted odds ratio (with adjustment for all other factors included in the multivariable model); CI, confidence interval; ESSI, ENRICHD (ENhancing Recovery In Coronary Heart Disease) Social Support Inventory; GAD‐7, Generalised Anxiety Disorder‐7 scale; MA, methamphetamine; MMM, Modified Monash Model; OR, odds ratio; PHQ‐9, Patient Health Questionnaire‐9 depression scale; POOLR, proportional odds ordinal logistic regression; PPOOLR, partial proportional odds ordinal logistic regression; ROA, route of administration; SDS, Severity of Dependence Scale.

a

ROAs other than smoked include injected, snorted, swallowed, and shelved/shafted.

b

Unless otherwise stated.

*

Statistically significant at the 5% level (p‐value <0.05).

4. DISCUSSION

This study examined social support in a community‐based sample of people who primarily smoked methamphetamine. Self‐perceived social support in our sample was, on average, 22.6 on the seven‐item ESSI scale of 8 to 34. Our sample's median, minimum, and maximum ESSI scores of 24, 8, and 34, respectively, equal those observed amongst a community‐based cohort of metropolitan Australians who primarily injected methamphetamine (Quinn et al., 2016). The ESSI item about marital status revealed that approximately one‐fifth of our study's participants were married or living with a partner. This proportion is approximately a third of the corresponding proportion for all Australians aged 30–34 years in 2016 (Qu, 2020).

Social support amongst people who use methamphetamine is an understudied yet nuanced topic. In general, social support is considered to be a positive social determinant of health (Galea et al., 2011; Gallicchio et al., 2007; Hajek et al., 2016). The particular social support scale used in the present study—the ESSI—comprises items measuring positive aspects of interactions with social contacts (e.g., the item ‘Is there someone available to give you good advice about a problem?’ [Mitchell et al., 2003, p. 402]). This helps explain why, in line with the literature (Rapier et al., 2019), more frequent methamphetamine use was associated with significantly lower social support in our sample. Nevertheless, those participants who recorded a high level of social support on the ESSI scale may have still had contact with family members or friends who negatively influenced their drug use behaviours. People's use of methamphetamine may be influenced by members of their social network who use this or other illicit substances, as suggested by the results of past US cross‐sectional studies (Rapier et al., 2019; Rice et al., 2011; Zhao et al., 2018). Studies exploring social support and social networks amongst people who use methamphetamine are needed to better understand the nature and function of social support and to inform the design of tailored social interventions.

In the present study, characteristics associated with social support are partially consistent with the US, Iranian, Chinese, and Australian studies described above (Cui et al., 2021; Jalali et al., 2019; Lanyon et al., 2019; Rapier et al., 2019; Semple et al., 2011). Potential explanations for contrasting findings include methodological differences such as sampling, sample size, choice of social support measure, and whether or not effect estimates were adjusted for covariates in multivariable analysis.

We found that past‐year homelessness and moderate‐to‐severe depression were independently associated with lower ESSI scores amongst people who primarily smoked methamphetamine. These findings are unsurprising and in agreement with the literature (Harvey et al., 2002; Jalali et al., 2019; Mejia‐Lancheros et al., 2020; Semple et al., 2011). People who experience homelessness or depression are prone to pronounced stigmatisation, discrimination, and social withdrawal (Harvey et al., 2002; Mejia‐Lancheros et al., 2020), which may reduce an individual's social support. Our study shows that the homelessness‐social support and depression‐social support associations observed in past studies (Jalali et al., 2019; Semple et al., 2011) extend to a broader population and a more comprehensive social support measure than previously investigated.

Although past research on people who use methamphetamine found that neither age nor gender was associated with social support (Jalali et al., 2019), the present study found that increasing age and male gender were associated with less social support. Nevertheless, our findings are consistent with studies of broader populations. For example, the significant effect of age is consistent with evidence from a study conducted on a general US population (Jiang et al., 2018). Here, it was suggested that, as people age, they may be less inclined to seek explicit social support because of perceived costs to themselves and others (Jiang et al., 2018). Past studies conducted amongst younger people (e.g., university students in Poland [Adamczyk, 2016]) support our finding of higher perceived social support amongst women than men. A number of potential explanations for this finding have been highlighted in the literature, including women's greater tendency to confide in family members and friends (Day & Livingstone, 2003).

The present study also found that employment was associated with significantly greater social support whilst education to year 11 or higher was unrelated to social support. The observed association between employment and greater social support contrasts with the literature (Semple et al., 2011), and may reflect the more comprehensive nature of our measure. Employment typically involves social interaction with co‐workers and, thus, the potential for greater social support. Whilst international evidence suggests that education is associated with greater social support in general populations (Cutler & Lleras‐Muney, 2010; Lee et al., 2021), our null finding for education is consistent with that observed in a past sample of people who used methamphetamine (Jalali et al., 2019).

Our study found further non‐significant multivariable associations between characteristics and social support amongst people who primarily smoke methamphetamine. We found that metropolitan residential area was unrelated to social support—a finding that agrees with the literature (Jalali et al., 2019). Methamphetamine dependence, duration of methamphetamine use, and anxiety were not independently associated with social support in our study, but were in broadly relevant past studies (Cui et al., 2021; Lanyon et al., 2019; Semple et al., 2011). The residential area, methamphetamine dependence, duration of methamphetamine use, and anxiety variables in our study were, however, associated with social support in univariable analyses. A potential explanation for this loss of significance in the multivariable model is that other factors investigated in our study, such as depression, are in fact stronger correlates of social support amongst those who primarily smoke methamphetamine.

Whilst the present study had a large sample size relative to past analyses of factors associated with social support amongst people who used methamphetamine (Jalali et al., 2019; Semple et al., 2011), a number of limitations ought to be considered when interpreting our results. Due to the use of a cross‐sectional study design, the significant effects of participant characteristics on social support should be interpreted as associations and not causal relationships. The directionality of these associations is unknown. For instance, it is unclear whether depression led to poor social support or vice versa (Swami et al., 2021). Future longitudinal studies could help unpack the underlying causal paths. The present study is also limited by the utilisation of convenience and snowball sampling approaches, which reduce the likelihood of our sample being representative of all Australians who use methamphetamine. Given that self‐reported VMAX survey data were obtained via face‐to‐face interviews, social desirability and recall biases may have influenced the results reported here (Quinn et al., 2020). Moreover, unmeasured factors such as family conflict (Semple et al., 2011), childhood adversity, and comorbidities could have confounded the observed associations between participant characteristics and social support.

5. CONCLUSION

Overall, in our community‐based sample of Australians who primarily smoked methamphetamine, social support scores averaged 22.6 on the seven‐item ESSI scale of 8 to 34. The present study has identified previously unreported associations between sociodemographic/psychological/drug use characteristics and social support amongst people who primarily smoked methamphetamine, including negative associations for older age, homelessness, depression, and more frequent methamphetamine use as well as positive associations for female gender and employment. These associations should be further investigated in future observational studies, including longitudinal studies conducted in the same cohort as the present study. Nonetheless, as the identified correlates highlight population subgroups for which social support services should be prioritised, the present study could help inform the development and evaluation of policies and service models aimed at addressing the needs of people who use methamphetamine. In particular, our findings point to the potential importance of interdisciplinary, co‐located models of care in both rural and metropolitan areas—models of care that address social support, other social determinants of health (e.g., housing), and the mental health of people who use methamphetamine.

AUTHOR CONTRIBUTIONS

All authors contributed to the conception of the study or the study design/sampling. MJL conducted the analysis and drafted the manuscript. All authors contributed to the writing of the manuscript and approved the final version.

CONFLICT OF INTEREST

There are no potential conflicts of interest to declare.

ACKNOWLEDGEMENTS

The VMAX study was established with a grant from the Colonial Foundation and is now funded by the National Health and Medical Research Council (NHMRC, 1148170). PMD is supported by an NHMRC Senior Research Fellowship. PMD has received investigator‐driven funding from Gilead Sciences and Indivior for work unrelated to this study. Open access publishing facilitated by Monash University, as part of the Wiley ‐ Monash University agreement via the Council of Australian University Librarians.

Leach, M. J. , Ward, B. , Kippen, R. , Quinn, B. , Agius, P. A. , Sutton, K. , Peterson, J. , & Dietze, P. M. (2022). Level and correlates of social support in a community‐based sample of Australians who primarily smoke methamphetamine. Health & Social Care in the Community, 30, e4950–e4960. 10.1111/hsc.13907

DATA AVAILABILITY STATEMENT

Data available on request due to privacy/ethical restrictions: The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

Data available on request due to privacy/ethical restrictions: The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

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