Drug addiction stigma in relation to methadone maintenance treatment by different service delivery models in Vietnam

Xuan Bach
Tran
Phuong Bich Vu
Long Hoang Nguyen
Sophia Knowlton Latkin
Cuong Tat Nguyen
Huong Thu
Thi Phan
Carl A Latkin
Drug addiction stigma in relation to methadone maintenance treatment by different service delivery models in Vietnam
10.1186/s12889-016-2897-0R E S E A R C H A R T I C L E Open Access
Background: The rapid expansion of methadone maintenance treatment (MMT) services has significantly improved health status and quality of life of patients. However, little is known about its impacts on addiction-related stigma and associated factors.Methods:A cross-sectional survey was conducted in 2013 in Vietnam's capital, Hanoi, and Nam Dinh province among 1016 methadone maintenance patients; 26.6 % at provincial AIDS centers (PAC) and 73.4 % at district health centers (DHC), respectively. Drug addiction history and related stigma, health status, MMT-related covariates, and sociodemographic characteristics were interviewed. Results: More than one-sixth of the sample reported experiencing felt or enacted stigma, including Blame or Judgement (17.2 %), Shame (19.9 %), or Others' fear of HIV transmission (17.1 %). These proportions were higher in PACs than in DHCs, which are integrated with other HIV or general health care services. Very few patients reported being discriminated at the workplace (2.5 %) or at health care services (1.7 %); however, 15.6 % of patients at PACs and 10.6 % of patients at DHCs reported discrimination in their communities. Drug users taking MMT for longer periods were less likely to report felt stigma. Other factors associated with stigma against MMT patients included the lack of comprehensive services, higher education, presence of pain/discomfort, and anxiety/ depression, self-reported HIV positive, and number of previous drug rehabilitation episodes.Conclusion: The study shows a high level of stigma against MMT patients and emphasizes the necessity to integrate MMT with comprehensive health and support services. Mass communication campaigns to reduce stigma against people with drug addiction and HIV/AIDS, as well as vocational trainings and jobs referrals for MMT patients, are needed to maximize the benefits of MMT programs in Vietnam.

Background

Illicit drug use has been recognized as a major global public health issue and continues to drive HIV epidemics in various low and middle-income countries. In 2013, an estimation of 213 million people still used illicit drugs, with 27 million having health problems and approximately 1.65 million living with HIV making it one of the leading attributable factors to the global burden of disease [1]. In Vietnam, along with sex workers, people who inject drugs (PWID) have been labelled "social evils" due to their high prevalence of perceived immoral behaviors such as criminal activities or deteriorating health, which could threaten the safety of the population [2,3].

Methadone is a highly effective medication for opioid dependence [4] and methadone maintenance treatment (MMT) has been found to improve health status and promote access to health care among drug users [5][6][7]. Moreover, MMT helps to reduce the frequency of illicit drug use [7][8][9], HIV-related risk behaviors [10,11] and illegal activities [12,13]. Expanding the coverage of MMT has a major role as a cost-effective strategy in planning HIV/AIDS prevention and control programs in both lower and upper-income countries [7,14,15].

However, drug users might confront stigmatization even when they enroll in MMT programs [14]. Those infected with HIV/AIDS may suffer from drug use and HIV stigma. Discrimination may occur at multiple locations, such as health care facilities and family, community, or work places. For example, a study of Ahern et al. showed that 75.2 % of drug users experienced discrimination in their family [16]. Stigma attached to drug use has been found to have negative effects on the health status of drug users and to hinder treatment adherence and health improvement [14,17,18]. Therefore, understanding influential factors and identifying strategies to reduce drug addiction-related stigma are essential for maximizing the effectiveness of MMT programs.

In Vietnam, PWID are one of the most-at-risk populations and account for about a half of the total number of people living with HIV/AIDS [6]. To respond, the government of Vietnam has developed comprehensive HIV/AIDS policies and programs, including a plan for expanding MMT programs to 80,000 drug users [19]. In 2015, there were only 170 MMT clinics nationwide with 31,200 patients [20,21]. MMT service has been delivered in stand-alone or integrative models, which are colocated or managed with other HIV-related or general health care services. The MMT services are organized with trained specialists and standardized facilities following national guidelines established by the Vietnam Ministry of Health. There have been studies that examined the experiences of MMT patients and sources of stigma [14,[22][23][24] as well as the role of services providers. Very few studies, however, have focused on different service delivery models or have been conducted in the context of a large drug injection-related HIV epidemic. This study examines the differences in levels of felt and enacted stigma that MMT patients may experience across different service delivery models and levels of health administration.

Methods

Survey design and sampling

A cross-sectional survey was performed from June to August 2013 in Hanoi and Nam Dinh provinces. There were five MMT clinics involved, four of which were located at district health centres (DHC), namely Tu Liem, Ha Dong, Long Bien, and Xuan Truong, and one clinic was at Nam Dinh Provincial AIDS Center (PAC). The characteristics of study sites are listed in Table 1. We selected the two provinces in consultation with program managers at the Vietnam Authority of HIV/AIDS for a purposive comparison of an experienced setting, Hanoi, and a new setting, Nam Dinh Province. The MMT sites were primarily selected for the comparison of various service delivery models in different level of health administration. In general, drug users register at the nearest MMT clinics and these clinics provide treatment regardless of patients' HIV status. In the organization of Vietnam's health services delivery system, the regional polyclinic is providing primary health care for an area that combines several communes and is linked to commune health stations [25,26]. Therefore, the criteria for enrolling drug users in selected MMT were indifferent.

Eligibility criteria for recruiting participants included: 1) taking or initiating MMT in selected sites; 2) presenting at clinics during study periods; 3) being 18 years old or above; 4) having the capacity to answer questionnaire within 20 min and 5) agreeing to participate. A convenient sampling technique was used to enroll a total of 1016 patients in this study. Patients were invited into a designated room for face-to-face interviewing. Before the interview, participants were introduced to the study and asked to provide written informed consent. The response rate was 80-90 % across sites. Interviewers were master's students of public health at Hanoi Medical University. The students were working in HIV study and had no affiliation with the clinics in which they invited patients to participate.

Measures and instruments

A structured questionnaire was developed to use in this study. Data on socioeconomic characteristics, drug use behaviors, HIV status was interviewed. Drug use information included age at initial drug use, time since first drug injection, times of previous drug rehabilitation, and duration of MMT treatment. Health status of respondents was measured in five dimensions (mobility, self-care, usual activities, pain/discomfort, and anxiety/ depression) using the five-level EQ-5D (EQ-5D-5 L) instrument that has been validated and widely used in Vietnamese populations [6,27,28]. Responses were then recorded to the EQ-5D dimensions as either having any health problems or no problems. It has been well-documented that the stigma against HIV and drug use in Vietnam has been fueled by both the fear of HIV infection and social values and by judgements on addiction and other risk behaviours [3,18,[29][30][31][32]. In some settings that contain large drug-using populations with generalized HIV epidemics, the stigma and discrimination against HIV/AIDS and addiction are intertwined [3,33,34]. We referred to the Substance Abuse Self-Stigma Scale by Luoma and measures of HIV-related stigma [35,36]. In addition, we adapted the conceptual framework by Parker and Aggleton to construct the measure of drug addiction-related stigma among MMT patients [37]. We then piloted the measures in drug users and people living with HIV/AIDS. The final measure of stigma included five dimensions: (1)Blame/Judgement, (2) Shame, (3) Discrimination in various settings (work place, health care services, family, and community), (4) Disclosure of addiction or health status (including HIV-positive if seropositive), and (5) Other's fear of HIV transmission among those patients who self-reported being HIVpositive [36]. Respondents were asked if they had experienced any of the above types of stigma within the last month. The measure, for example, included the following questions with the response options: Yes/No/Not answer.

Statistical analysis

T-test and χ2 tests were used to compare differences of characteristics among different services models. Multivariate logistic regression was employed to determine the associated factors with self-stigma, discrimination, and disclosure. In this study, a stepwise backward selection strategy was applied along with multivariate regression to have reduced models. This strategy used threshold with the log-likelihood ratio test to have predictors with p-values of < 0.1 included.

Ethics, consent and permissions

The protocol of this study was reviewed and approved by the Vietnam Authority of HIV/AIDS Control's Scientific Research Committee. Written informed consent was obtained from all participants. Patients could withdraw at any time without the influence on their current treatment.

Results

In total, 1016 patients participated in this study; 746 were receiving MMT at one of four DHCs, and 270 others were receiving MMT at Nam Dinh PAC. Among those, 98.7 % were male and the mean age was 36.8 years (SD = 7.7). The majority lived with a spouse or partner (67.7 %) and had high school education or below (93.4 %). The percentage of patients who were currently working was 74.6 %, and of these, 53.4 % were selfemployed, 9.8 % were workers or farmers, and 11.4 % had other jobs (white collars, students, and other) ( Table 2). Table 3 presents health status, history of drug addiction, and MMT utilization of participants. The average age of drug use initiation was 24.5 years (SD = 6.7), corresponding to an average duration of drugs use of 13.3 years (SD = 5.9) and drug injection duration of 10.2 years (SD = 4.9). Enrolled patients experienced approximately 5 episodes (mean = 4.8) of drug rehabilitation prior to MMT. The duration of MMT utilization was 16.5 months on average (SD = 11.0); patients from PAC experienced an average of 11.4 months (SD = 7.2) while patients from DHC had undergone a longer duration on MMT (mean = 18.4 months, SD = 11.5). Regarding health status of patients, we found homogeneity in outcomes between provincial and district health facilities, except a higher prevalence of pain or discomfort among patients at DHCs. The prevalence of patients who reported any health problem was highest in the anxiety/depression dimension (20.7 %), followed by pain/discomfort (19.2 %).4.8 % of patients reported concurrent drug use during MMT and the percentage of self-reported positive HIV status was 8.1 %.

In Table 4, the proportion of stigma and discrimination among MMT patients is shown. More than one-sixth of the sample population reported experiencing different types of stigma or discrimination related to their addiction or health status, including Blame/Judgement (17.2 %), Shame (19.9 %), or Fear of HIV transmission by others (17.1 %); these percentages were higher in PAC than in DHCs. There were very few patients who reported discrimination at the workplace (2.5 %) or at health care services (1.7 %); however, 15.6 % patients at PAC and 10.6 % patients at DHCs reported discrimination from their communities. The proportion of respondents who disclosed their addiction or health status to others was low (with spouse (58.3 %), parents (50.4 %), health workers (37.3 %), and peer educators (14.3 %)). Patients who were taking MMT at DHCs reported less discrimination and more disclosure of their status to others. Table 5 presents the factors that are associated with stigma and discrimination against drug users. Drug users taking MMT for longer periods were less likely to report being blamed or judged (OR = 0.98, 95 % CI = 0.97-0.99), but they were also less likely to disclose their health condition to others (OR = 0.96, 95 % CI = 0.95-0.98). A higher likelihood of disclosing health conditions was associated with people living with a spouse (OR = 1.56, 95 % CI = 1.14-2.15) versus patients living alone. Other factors that contributed to perceived stigma and discrimination among MMT patients included higher education, presence of pain/discomfort and anxiety/depression, selfreported HIV positive, and number of previous drug rehabilitation episodes. Moreover, these factors also increased the likelihood of disclosing addiction and any health problem among MMT patients.

Discussion

To date, this is the first study comparing drug addictionrelated stigma among MMT patients across different service delivery models and levels of administration. The findings showed that though MMT has been known to improve health behaviors among drug users, a high proportion of users suffered from stigma and discrimination due to their previous drug addiction or health status. Although felt stigma decreased among patients who were enrolled in MMT for longer periods and discrimination was rarely seen in health facilities, workplace, and family life, felt stigma remained high in communities where patients live, especially in urban areas and in areas of higher level of health care service administration.

Stigma in relation to MMT and different service delivery models

Our findings highlight the encouraging progress in quality improvement and stigma reduction in HIV-related health care services in Vietnam. Previously, stigma was commonly reported in health care services, which reduced the access and use of health care and support services among people with HIV/AIDS [18], and was burdensome to health workers in HIV facilities [30]. In this study, just about 2 % of respondents reported experiencing any discrimination at health care services. Meanwhile, the high level of discrimination from communities against drug users is consistent with a previous qualitative analysis in Thai Nguyen Province by Rudolph et al. [31] In addition to previous studies, we found that not only socioeconomic status and history of drug rehabilitation significantly predicted stigma and discrimination among drug users taking MMT, but also other major factors included health status and the availability of comprehensive HIV/AIDS and general health care services.

In Vietnam, a DHC is the closest health care facility providing methadone medication for drug dependence treatment. In this study, patients at DHCs or regional polyclinics were less likely to be stigmatized compared to those at PAC. One study by Mukora et al. showed that patients were concerned about stigma and loss of privacy if they received treatment in decentralized clinics [38]. However, a study by Odeny et al. found that decentralized HIV-related services that were integrated into primary health care did not worsen stigma [39]. The differences in patients' preferences and perceived stigma highlighted the importance of understanding contextual factors and stages of the epidemics in each setting. In this study, fewer patients felt ashamed or experienced discrimination at MMT clinics with other HIV-related and general health care services; nonetheless, these results may not apply to those living in rural areas.

In addition, we found that drug users taking MMT for longer periods of time felt less blamed or judged (OR = 0.98, 95 % CI = 0.97-0.99). This may be due to the effects of MMT on the improvement of health status and the reduction of risk behaviors and illegal activities, which may promote positive attitudes of family and others toward MMT patients. Previous studies have shown that MMT patients improved substantially  in physical health; however, the changes in mental and social status were moderate and small, respectively [7,40]. Participants reporting anxiety and depression were also much more likely to report feeling blamed/judged and shame. In addition, drug users who currently used drugs during MMT were more likely to suffer from discrimination than those who did not. Collectively, these results indicated the importance of maintaining MMT to reduce drug use behaviors, as well as the importance of providing comprehensive mental health care for patients.

The study also suggests that the use of MMT is preferred more than traditional drug rehabilitation in Vietnam. Less effective drug rehabilitation was significantly associated with higher stigma. Drug detoxification is available in Vietnam [6] , but with high episodes of failure rehabilitation, patients may believe that they cannot be successfully treated, and therefore, blame themselves for relapsing. In this study, the proportion of felt stigma was lower than in other settings. This coincides with findings from previous studies that MMT helps improve social and economic status of patients and their families [5,7,[40][41][42].

Notably, the proportion of MMT patients' felt stigma in communities was significantly higher than in families, health facilities, or workplaces. This result suggested that although participating in MMT program could reduce stigma in those latter place, stigma remained a great  Tomori et al. in Vietnam showed that even when a person successfully detoxifies from illicit drugs, they had to confront the drug-related stigmatization in their community [2]. Therefore, mass media campaigns are necessary to reduce stigma against people with HIV/AIDS and history of drug addiction in settings with large drug injection related HIV epidemics.

In this study, we also found that patients who were HIV positive or unknown status were more likely to report self-stigmatization. Literature suggests that drug users report shameful attitudes and think that HIV might be a punishment for their past [2]. On the other hand, it is noteworthy to find that people who were employed were less likely to feel self-stigmatization. Vocational training and job referrals should be considered in local planning to maximize the benefits of MMT programs.

Disclosing MMT patients' status

Disclosure of status among HIV-positive people and PWID has been considered a potential method to reduce the spread of HIV/AIDS. Although the drawbacks of self-disclosure may include stigma, loss of privacy, and blame, it may help those high-risk populations to reduce HIV risk behaviors and increase access to HIV-related care, as well as being related to better adherence for those receiving treatment [18]. In present study, patients receiving MMT at DHC reported a higher percentage of disclosing their condition to spouses, relatives, health workers, and friends than patients at PAC. This association can be partially explained by the fact that in order to hide their conditions and avoid discrimination, drug users tended to receive treatment at a health center far from their hometowns [43].

People taking MMT in long duration were less likely to disclose their health status to other people. There may several reasons be for this finding. First, as we observed, with the improvement in health status due to long duration of treatment, MMT patients might feel confident about their health and therefore may think that they do not need to share their status with other people. Second, information about MMT patients' treatment or their past may be used against them at work or in the community [44].

Most patients shared their status with their spouse (58.3 %) and parents (50.4 %), who were the closest relatives of patients. People living with a spouse also were likely to disclose. Families are a critical source of financial, physical, and emotional supports, which facilitate re-entry into the community for drug users [45]. Therefore, support from family has a central role in encouraging patients' disclosure.

Implications

There were several implications that can be drawn from this study. First, MMT clinics should be integrated with other health services and decentralized as satellite model to provide patients with accessible and friendly health care, which in turn may reduce stigma of patients. Strategies to optimize the effectiveness of this model should be considered for the scale-up plan of MMT programs. Second, mass media campaigns in television or on the internet should be conducted to reduce stigmatization in the community for MMT patients. Third, the role of parents/spouses should be heightened to help combat difficulties encountered when patients participate in MMT treatment. Lastly, physical and mental health conditions of patients should be acknowledged and addressed.

Limitations

Several limitations in this study should be under consideration. First, this cross-sectional design could not establish causal relation between stigma outcomes and MMT delivery models. In addition, a qualitative study should be conducted to understand how different models can impact on the feeling of stigma in accordance to patients' perceptions and experiences. Second, Self-report information may be subject to recall bias. Finally, the convenient sampling technique limited the generalization of this study.

Conclusions

In conclusion, the study highlighted significant higher levels of stigma among MMT patients at PAC as compared to people at DHC. The findings suggested the need to integrate MMT with the satellite model (DHC, regional poly-clinics, etc.) to reduce stigma. Moreover, the study emphasized the importance of maintaining MMT adherence and effectiveness and the importance of intervening on stigma amongst drug users, family, health care workers, and community.

Availability of data and materials

Data are available from the Authority of HIV/AIDS Control (VAAC). However, since the Government of Vietnam issued the Law on HIV/AIDS, information of HIV-affected people is confidential and cannot be shared. Requests for data on this study may be submitted to VAAC and go through a review process by the Scientific and Ethical Research Committee. The contact for requesting data use is Dr. Phan Thi Thu Huong, email firstname.lastname@example.com, Deputy Director in Research of the Vietnam Authority of HIV/AIDS Control, Ministry of Health, Vietnam.

Table 1
1Study settings and sample sizeLevel
Settings
Site Name
Type of services
Sample size

Province
Nam Dinh City
Provincial AIDS Center
MMT+ VCT
270

District (rural)
Xuan Truong District
District Health Center
MMT+ VCT + ART + GH
151

District (urban)
Tu Liem District
District Health Center
MMT+ VCT + ART + GH
201

District (urban)
Long Bien District
District Health Center
MMT+ VCT + ART + GH
184

District (urban)
Ha Dong District
Regional Polyclinic
MMT+ GH
210

Table 2
2Socioeconomic characteristics of MMT patients by level of health services administrationProvincial
District
All
p-value

Mean SD
Mean SD
Mean SD

Age
36.8
7.7 36.8
7.7 36.8
7.6 0.52

N
%
N
%
N
%

Sex (Male)
266
98.5 737
98.8 1003 98.7 0.73

Educational attainment

Illiterate
4
1.5 13
1.7 17
1.7 0.03

Elementary
21
7.8 98
13.1 119
11.7

Secondary
103
38.2 323
43.3 426
41.9

High
121
44.8 266
35.7 387
38.1

Vocational
12
4.4 20
2.7 32
3.2

University
9
3.3 26
3.5 35
3.4

Marital status

Single
101
37.4 150
20.1 251
24.7 <0.01

Live with
spouse

148
54.8 537
72.0 685
67.4

Live with partner 0
0.0 3
0.4 3
0.3

Divorced
19
7.0 53
7.1 72
7.1

Widow
2
0.7 3
0.4 5
0.5

Religion

Cult of
ancestors

247
91.5 649
87.0 896
88.2 0.17

Buddhism
13
4.8 46
6.2 59
5.8

Catholic
10
3.7 46
6.2 56
5.5

Protestant
0
0.0 5
0.7 5
0.5

Employment

Unemployed
76
28.2 183
24.5 259
25.5 <0.01

Self-employed
159
58.9 383
51.3 542
53.4

White collars
5
1.9 17
2.3 22
2.2

Workers, Farmers 10
3.7 90
12.1 100
9.8

Students
0
0.0 2
0.3 2
0.2

Other jobs
20
7.4 71
9.5 91
9.0

Table 3
3Health status and history of drug addiction and MMTProvincial
District
All
p-value

Mean
SD
Mean
SD
Mean
SD

Age at first drug use
24.3
7.0
24.6
6.7
24.5
6.7
0.10

Time since 1st drug use (yr.)
13.5
5.1
13.2
6.1
13.3
5.9
0.07

Time since 1st drug inject(yr.)
10.9
4.4
9.9
5.1
10.2
4.9
0.12

# previous drug rehabilitation episodes
5.7
7.2
4.5
5.9
4.8
6.3
<0.01

Duration on MMT (month)
11.4
7.2
18.4
11.5
16.5
11.0
<0.01

N
%
N
%
N
%

Self-reported health problems

Mobility
19
7.04
55
7.37
74
7.28
0.86

Self-care
10
3.7
30
4.02
40
3.94
0.82

Usual Activities
18
6.67
42
5.63
60
5.91
0.54

Pain or Discomfort
37
13.7
143
19.17
180
17.72
0.04

Anxiety or Depression
56
20.74
154
20.64
210
20.67
0.97

Concurrent drug use
15
5.56
34
4.56
49
4.82
0.51

History of drug injection
222
82.22
524
70.24
746
73.43
<0.01

Self-reported HIV status
0
0
0

Negative
239
88.52
637
85.39
876
86.22
0.15

Positive
22
8.15
60
8.04
82
8.07

N/A
9
3.33
49
6.57
58
5.71

Table 4
4Proportion of stigma and discrimination among MMT patientsProvincial
District
All
p-value

N
%
N
%
N
%

1. Blame, judge
46
19.7 119 16.4 165 17.2 0.25

2. Shame
66
28.5 124 17.2 190 19.9 <0.01

3. Discrimination

Work place
12
4.4
13
1.7
25
2.5
0.01

Health care services 9
3.3
8
1.1
17
1.7
0.01

Family
8
3.0
16
2.1
24
2.4
0.45

Community
42
15.6 79
10.6 121 11.9 0.03

4. Disclosure

Spouse
109 40.4 483 64.8 592 58.3 <0.01

Parents
133 49.3 379 50.8 512 50.4 0.66

Relatives
53
19.6 229 30.7 282 27.8 <0.01

Friends
59
21.9 237 31.8 296 29.1 <0.01

Health workers
72
26.7 307 41.2 379 37.3 <0.01

Peer educators
38
14.1 107 14.3 145 14.3 0.91

5. Others' fears of HIV 5
22.7 9
15.0 14
17.1 0.41

Table 5
5Factors associated with stigma and discrimination against drug usersBlame, judge
Shame
Discrimination
Disclosure of addiction or health status

OR
95 CI
OR
95 CI
OR
95 CI
OR
95 CI

Duration on MMT (months)
0.98 a 0.97
0.99 1.00
0.98
1.02 0.99
0.96
1.01 0.96 a
0.95
0.98

MMT model (MMT+ PAC -ref)

Rural MMT-ART-VCT-DGH
1.67
0.99
2.82

Urban MMT-ART-VCT-DGH
0.36 a 0.22
0.58 0.51 a 0.31
0.84 3.21 a
2.13
4.83

MMT + Regional poly clinic
0.39 a 0.24
0.63

Education (High school or Lower -ref)

College/University
1.82
0.93
3.57
1.96 a 1.02
3.74

Marital status

Live with spouse vs. Single
1.56 a
1.14
2.15

Religion

Buddhism vs. Cult of ancestors 0.43
0.15
1.22

Employment (Unemployed -ref)

Self-employed
0.72
0.49
1.04

White collars
0.30
0.06
1.44

Workers, Farmers
0.42 a 0.19
0.93 0.50 a 0.25
0.99 0.52
0.24
1.13 0.49 a
0.30
0.80

Other jobs
1.65
0.93
2.95

Self-reported health problems

Mobility
1.82
1.00
3.31
0.39 a
0.20
0.74

Self-care
2.12
0.94
4.81

Usual Activities
2.22
0.90
5.47

Pain or Discomfort
2.01 a
1.16
3.47

Anxiety or Depression
1.79 a 1.19
2.70 2.39 a 1.62
3.53 1.49
0.95
2.32 1.66 a
1.02
2.69

Self-reported HIV status (Negative -ref)

Positive
1.74 a 1.01
3.04

N/A
2.15 a 1.04
4.47

# previous drug rehabilitation (None -ref)

1-5 times
2.27
0.88
5.88
0.73
0.49
1.08 1.86 a
1.21
2.86

6-10 times
2.89 a 1.07
7.80
1.73 a
1.03
2.89

> 10 times
2.75
0.85
8.83

Ever inject drug vs. None
1.53
0.94
2.48

Concurrent drug use vs. None
2.44 a 1.11
5.37

a

significant at 5 % level

Competing interestsThe authors declare that they have no competing interests.Authors' contributions BXT, CL and HTTP conceived of the study, and participated in its design. BXT, HTTP, LHN, CTN, CL, SKL and PBV implemented the survey and complied the data. LHN and BXT analyzed the data. BXT, LHN, HTTP, CTN, SKL and PBV helped to draft the manuscript. All authors read and approved the final manuscript. Submit your next manuscript to BioMed Central and we will help you at every step:
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The RiBaTox web tool: selecting methods to assess and manage the diverse problem of chemical pollution in surface waters

Kees J M Kramer
Frank Sleeuwaert
Guy Engelen
Christin Müller
Werner Brack
Department of Ecosystem Analysis
ABBt-Aachen Biology
Institute for Environmental Research
AachenGermany

Leo Posthuma
RIVM
National Institute for Public Health and the Environment
P.O. Box 13720 BABilthovenThe Netherlands

Department of Environmental Science
Radboud University
NijmegenThe Netherlands

for Environmental Research UFZ
Permoserstr. 1504318LeipzigGermany

The RiBaTox web tool: selecting methods to assess and manage the diverse problem of chemical pollution in surface waters
10.1186/s12302-019-0244-7Received: 3 June 2019 Accepted: 16 August 2019PDF hosted at the Radboud Repository of the Radboud University Nijmegen The following full text is a publisher's version. For additional information about this publication click this link. http://hdl.handle.net/2066/208581 Please be advised that this information was generated on 2020-05-08 and may be subject to change. Kramer et al. Environ Sci Eur (2019) 31:68 POLICY BRIEF
Chemical pollution of water bodies is a complex problem around the globe. When described by the extremes of the range of problem definitions, water bodies can be chemically polluted by a single compound that is emitted from a point source or an incidental spill, or by chronic diffuse emissions from local and upstream land uses. The resulting mixture exposures can vary in space and time, e.g. due to the use of pesticides in the crop growing season. The environmental management objectives are commonly to protect and restore surface waters against human influences. Currently, chemical pollution is globally judged for a selected set of compounds, by judging each of these individually in comparison with protective environmental quality standards. Research has provided a novel assessment paradigm (solution-focused risk assessment) and novel data, measurement methods and models to improve on current practices. Their adoption and application require establishing novel linkages between the diverse problem definitions and the novel approaches. That would assist water quality professionals to select the most effective option or options to protect and restore water quality. The present paper introduces the RiBaTox (River Basin Specific Toxicants assessment and management) web tool. It consists of short descriptions of the novel approaches (made available as Additional file 1) and a decision tree for end-users to select those. The overview of novel approaches collated in RiBaTox is relevant for end-users ranging from local water quality experts up till strategic policy developers. Although RiBaTox was developed in the context of European water quality problems, the methods provided by RiBaTox are relevant for users from (inter)national to local scales. This paper is part of a series of Policy Briefs from the EU-FP7 project SOLUTIONS (http://www.solut ions-proje ct.eu), which provide backgrounds on chemical pollution of surface waters and policy practices and proposed improvements.© The Author(s) 2019. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creat iveco mmons .org/licen ses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

Challenge

Chemical pollution in European water resources is of growing societal concern due to the potential risks to ecosystems and human health [1,2]. The pollution problem can vary from simple and local, to complex and basin-wide. In 2010, the EU funded a substantial body of research activities to improve on the approaches for diagnosing and managing chemical pollution for surface waters in Europe [3]. In response, the SOLUTIONSproject (http://www.solut ions-proje ct.eu) undertook fundamental research in water pollution. Results were evaluated in the context of, and aligned with, the current regulatory framework (the EU-Water Framework Directive [4]). This resulted in (a) a proposal to improve the utility of chemical risk assessments, a (b) suite of improved or novel technical tools and services to diagnose water quality problems with chemicals, and (c) a proposal of a strategy and a solutions database to translate diagnostic results in a programme of measures [5].

The results may lead to changes to current practices. As yet, the methods to assess chemical pollution problems are commonly applied in a straightforward way. That is, monitoring efforts yield data on measured concentrations of chemicals, and the observed values are compared on a per-chemical basis to a protective environmental Open Access *Correspondence: email@example.com 3 Helmholtz Centre for Environmental Research UFZ, Permoserstr. 15, 04318 Leipzig, Germany Full list of author information is available at the end of the article quality standard. Amongst others, this involves an analysis of pressures and impacts [6] and the classification of the chemical and ecological status on the basis of chemical and ecological monitoring data and the quality standards [7,8]. The current approach does not sufficiently cover the chemical pollution problem, as both societal concerns and scientific research asks consideration of far more chemicals and their mixtures [9,10]. The results of the research encompass a suite of tools to characterize the pollution problem, as described in associated Policy Briefs of the SOLUTIONS-project. Due to the diversity of the new opportunities and the need to change the current practice, their practical implementation might be challenging for experts involved in chemical pollution assessment and management. These challenges might be faced by experts who are involved in the day-to-day practices of monitoring, assessment and management at the level of a water board up till decision makers working on the long-term strategic planning to prevent and reduce chemical pollution via, e.g. improved regulations or the provision of applicable guidance documents. Building forth on the current practices, the new opportunities for diagnosis confronts them with the choice to address the chemical pollution problem diagnosis, e.g. with improved component-based methods [11], or effect-based methods [12], or ecological methods [13], or any combination thereof.

Given the project results, the practical challenge boils down to the question of how to support the process of matching the novel assessment approaches to the diverse chemical pollution problems for the diverse end-users.

To address this problem, the SOLUTIONS-project designed the RiBaTox (River Basin Toxicants assessment and management) web tool. Despite the tools' name suggest a limitation to river basin-specific pollutants (a group of chemicals specifically considered within a river basin) in the EU-WFD context, the web tool provides information for any spatial level and for all surface waters globally. The WFD itself has no scale limitation, as any chemical may locally threaten the ecological status; if so, that chemical is identified as 'specific chemical' against which measures much be taken to reduce those impacts (see also [6]).

The RiBaTox web tool was designed to provide a decision tree and fact sheets that describe the novel assessment methods. Despite the EU-context of the SOLUTIONS research, the applicability of the methods is not limited to the EU only. The contents of RiBaTox are applicable to any water management situation, whether local, regional or (inter)national. The decision tree and the methods were derived in the context of the solutionfocused risk assessment paradigm [5,14]. This paradigm is used to improve the utility of the risk assessments and has been the basis for a strategy and a database that provides end-users with solutions options for water quality management planning. The fact sheets can be updated in response to novel practical needs or results of research. RiBaTox is available via https ://solut ions.marvi n.vito.be/.

Recommendations

To assist water quality protection, monitoring, assessment and management in practice, water quality managers and policy makers are recommended to:

• Use the SOLUTIONS conceptual framework for protecting, assessing and managing surface water pollution with complex mixtures, and consider RiBaTox as operational tool to use this conceptual framework in practice; • Use RiBaTox to navigate from the specifications of a (likely) water pollution problem towards the diagnostic tools and services with which that problem can potentially be assessed and managed, and to identify the best (combination of ) tool(s) that serves the purposes best; • Apply RiBaTox for making decisions on the design of monitoring campaigns, on prioritizing chemicals, sites and abatement options, on the use of models to bridge data gaps and to prioritize them for the need of experimental efforts to fill them; • Use RiBaTox as a basis for the development of a longstanding and regularly updated information platform that reflects the newest knowledge and further develop the structure of solutions-oriented decision trees with informative fact sheets as end points.

Requirements

Any tool or service needs to be useful, known, accessible by stakeholders and actual. The requirement of potential usefulness is that the web tool allows stakeholders to find science-based proposals to address the wide array of chemical pollution problems, beyond the methods currently known and frequently used. The set of tools and services can be used by experts at any level of organization-be it those that are responsible for local water quality management or those working as strategic policy designers at the level of countries or the EU. The other requirement of 'being known' is reflected in the web tool (and the present paper). Scholars and practical end-users can find and use the available knowledge on approaches to investigate surface water chemical pollution.

The requirement of accessibility of the web tool has been arranged until at least 2020 via the SOLU-TIONS Web site (https ://www.solut ions-proje ct.eu/). Longer-term maintenance and regular updates are achieved with the European science-policy network on emerging pollutants NORMAN (https ://www.norma n-netwo rk.net/), which acts as RiBaTox host.

The requirement of actual information is organized via the potential to update to information in RiBaTox. Active management of RiBaTox is recommended to continue that assessors can identify contemporary tools and services for their chemical pollution problem specification. Such management could be based on testing and implementing continuous improvements as needed. Systematic management would advance the system and its utility for water quality assessment and management beyond the duration of the SOLUTIONS-project, aligned with the longer-term requirements of the WFD and/or of other (inter)national water management schemes.

Achievements

RiBaTox as versatile and actual web tool

The goal that novel and diverse science-based approaches for chemical pollution assessment and management can be found by end-users has been achieved by creating the RiBaTox web tool.

The web tool concerns a specific policy area, which is chemical pollution of surface waters. The web tool assists end-users in understanding solution-focused risk assessment (with early focus on the 'solution space' when a pollution problem is encountered), in identifying potential diagnostic tools and services to diagnose the relevance of mixtures and individual chemicals in affecting water quality, and in the combination of both in selecting measures to prevent or reduce chemical pollution. The latter are required for the programmes of measures, which are the key management step in the assessment/management cycle for improving water quality.

The web tool supports the recommended changes of chemical pollution protection, assessment and management that have been proposed in associated Policy Briefs (e.g. on using holistic approaches considering chemical pollution from a water-system level point of view [5], for vastly more chemicals and their mixtures [10][11][12], via both monitored and modelled environmental concentrations of chemicals [15], with early consideration of the 'solution space' [16,17], and with associated improvements on, e.g. monitoring data management [18]).

The web tool consists of a decision tree (to identify and select available tools and services for diagnosis) and of a set of fact sheets (available also as Additional file 1 to this paper). RiBaTox supports end-users in applying the novel science-based tools and services, fully in line with the obligations of the regulations to protect and restore surface water quality. For example, if an end-user is confronted with evidence for chemical pollution-e.g. from an analysis of the drivers of chemical emissions in an area-and is specifically interested in impacts, the web tool shows potential approaches to be component-based methods, effect-based methods or ecological tools. All three can be used from a scientific perspective, as all three are a line of evidence on the presence of impacts. All three can also be used from the regulatory perspective of water quality management, as most regulations specifically suggest collecting data on multiple lines of evidence for this (e.g. WFD, Annex II). The assessor can select either individual methods or combinations of methods for the specific conditions of the pollution case. The web tool and the fact sheets can be updated to novel scientific insights or societal/regulatory needs if needed.

Alignment between the solution-focused approach and RiBaTox

The research achieved to use the solution-focused risk assessment paradigm as basis for the design of RiBatox decision tree and the fact sheets on the diagnostic tools and services. According to the conceptual framework for solution-focused risk assessments [16], the problem of-and solutions for chemical pollution can be explored from different angles (chemicals, environment, abatement and society, see also [5]). The RiBaTox web tool reflects the different angles of the conceptual framework in the decision tree and the presence of fact sheets related to all the framework angles. It provides information on, e.g. monitoring strategies, modelling strategies, prioritization strategies, abatement strategies and policy strategies. Those strategies not only enable to find approaches or models for the various purposes, but also the data sets that have been compiled to serve as a harmonized volume of information for the different uses, available to all.

The compilation of current diagnostic tools and services in RiBaTox

More than 80 potentially relevant tools and services were identified in the research. This expands vastly on the current practices, in which classification of chemical and ecological status on the basis of monitoring data is common [2], but where the consideration of multiple lines of evidence and comprehensive diagnosis of causes of impacts as suggested, e.g. in WFD Annex II is relatively rare [5]. To support end-users in applying the novel approaches, RiBaTox provides a decision tree and fact sheets on methods that end-users can apply. The idea for stepwise guidance to most-profitable approaches helps in the selection of methods from the available options. For example, for a local or regional diagnosis of the role of chemical pollution in affecting water quality in the European context (WFD Annex II) or for the design of monitoring approaches (WFD Annex V). The latter is illustrated in Table 1.

The full set of current fact sheets is shown in Additional file 1. Fact sheets contain contact information, so that end-users can contact scholars for more information on use and implementation or on novel developments of the methods, if needed.

End-user evaluation

The RiBaTox web tool is one of the three major achievements of the recent research activities, next to the conceptual framework for solution-focused risk assessment and the provision of a strategy and a database to support management planning. RiBaTox collates the final results of the research in a user-oriented format, but as yet no extensive practice validation of its utility in case studies was feasible. It is clear, however, that the gaps between diverse chemical pollution cases, diverse diagnostic methods and diverse stakeholders need to be bridged. However, positive evaluations on the concept and approaches of RiBaTox have been received in both the planning phase (from the EU as commissioning body) and on the final product (the web tool). The latter was apparent from a dedicated stakeholder meeting in Paris, 2018, and from a memorandum of members of the stakeholder board [19]. This result can be understood in the context of 11 RiBaTox-dedicated stakeholder interactions, three dedicated RiBaTox surveys on draft web tools and the workshop with water managers, co-hosted together with stakeholder board member Veolia, June 2018.

Table 1 Illustration representing some elements of the RiBaTox decision tree and fact sheets, in relation to the conceptual framework for solution-focused risk assessment and end-user needs

The table shows a part of the decision tree that users are offered regarding monitoring strategies (column 1, WFD, Annex V). Column 2 shows the systematic subgrouping of main actions that can be applied. Column 3 identifies specific techniques and provides detailed fact sheets
 AcknowledgementsThis article has been prepared as an outcome of the projects SOLUTIONSSupplementary informationSupplementary information accompanies this paper at https ://doi. org/10.1186/s1230 2-019-0244-7.Additional file 1. RiBaTox fact.Abbreviations NORMAN: Network of reference laboratories, research centres and related organisations for monitoring of emerging environmental substances; RiBaTox: Web tool on River Basin Specific Toxicants; WFD: Water Framework Directive.Authors' contributionsKJMK, FS and LP conceptualized and drafted the manuscript. The other authors helped to further elaborate the manuscript and contributed specific aspects. All authors read and approved the final manuscript.FundingNot applicable.Availability of data and materialsRiBaTox fact sheets are available as Additional file 1.Ethics approval and consent to participateNot applicable.Consent for publicationNot applicable.Competing interestsThe authors declare that they have no competing interests.1Mermayde, Groet, The Netherlands. 2 VITO, Mol, Belgium.3Helmholtz CentreAuthor details
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High-resolution mass spectrometry to complement monitoring and track emerging chemicals and pollution trends in European water resources. W Brack, 10.1186/s12302-019-0230-02-019-0230-0Environ Sci Eur. Brack W et al (2019) High-resolution mass spectrometry to comple- ment monitoring and track emerging chemicals and pollution trends in European water resources. Environ Sci Eur. https ://doi.org/10.1186/s1230 2-019-0230-0

Mixture risks threaten water quality: the European Collaborative Project SOLUTIONS recommends changes to the WFD and better coordination across all pieces of European chemicals legislation to improve protection from exposure of the aquatic environment to multiple pollutants. A Kortenkamp, 10.1186/s12302-019-0245-6Environ Sci Eur. Kortenkamp A et al (2019) Mixture risks threaten water quality: the European Collaborative Project SOLUTIONS recommends changes to the WFD and better coordination across all pieces of European chemicals legislation to improve protection from exposure of the aquatic environ- ment to multiple pollutants. Environ Sci Eur. https ://doi.org/10.1186/ s1230 2-019-0245-6

Improved component-based methods for mixture risk assessment are key to characterize complex chemical pollution in surface waters. L Posthuma, 10.1186/s12302-019-0246-5Environ Sci Eur. Posthuma L et al (2019) Improved component-based methods for mixture risk assessment are key to characterize complex chemical pol- lution in surface waters. Environ Sci Eur. https ://doi.org/10.1186/s1230 2-019-0246-5

Effect-based methods are key. The European Collaborative Project SOLUTIONS recommends integrating effect-based methods for diagnosis and monitoring of water quality. W Brack, Environ Sci Eur. 3110Brack W et al (2019) Effect-based methods are key. The European Collabo- rative Project SOLUTIONS recommends integrating effect-based methods for diagnosis and monitoring of water quality. Environ Sci Eur 31:10

Assessing the ecological impact of chemical pollution on aquatic ecosystems requires the systematic exploration and evaluation of four lines of evidence. T Backhaus, Environ Sci Eur. in pressBackhaus T et al. Assessing the ecological impact of chemical pollution on aquatic ecosystems requires the systematic exploration and evalua- tion of four lines of evidence. Environ Sci Eur (in press)

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The European Collaborative Project SOLUTIONS developed models to provide diagnostic and prognostic capacity and fill data gaps for chemicals of emerging concern. J Van Gils, 10.1186/s12302-019-0248-3Environ Sci Eur. Van Gils J et al (2019) The European Collaborative Project SOLUTIONS developed models to provide diagnostic and prognostic capacity and fill data gaps for chemicals of emerging concern. Environ Sci Eur. https ://doi. org/10.1186/s1230 2-019-0248-3

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Exploring the 'solution space' is key. SOLUTIONS recommends an early-stage assessment of options to protect and restore water quality regarding chemical pollution. L Posthuma, 10.1186/s12302-019-0253-6Environ Sci Eur. Posthuma L et al (2019) Exploring the 'solution space' is key. SOLUTIONS recommends an early-stage assessment of options to protect and restore water quality regarding chemical pollution. Environ Sci Eur. https ://doi. org/10.1186/s1230 2-019-0253-6

Establish data infrastructure to compile and exchange environmental screening data on a European scale. J Slobodnik, 10.1186/s12302-019-0237-6Environ Sci Eur. Slobodnik J et al (2019) Establish data infrastructure to compile and exchange environmental screening data on a European scale. Environ Sci Eur. https ://doi.org/10.1186/s1230 2-019-0237-6

. L M Hewitt, R M Burgess, SOLUTIONS External Stakeholder Board Memorandum. Environment Canada and U.S.EPA Publisher's NoteHewitt LM, Burgess RM (2018) SOLUTIONS External Stakeholder Board Memorandum. Environment Canada and U.S.EPA Publisher's Note

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