Stages of Behavioral Change and Associated Factors Among Female Injecting Drug Users in Imphal, Manipur, India: An Explanatory Sequential Mixed-Methods Study

Background: Female injecting drug users (FIDUs) remain a vulnerable and understudied group in Manipur’s drug-use and human immunodeficiency virus (HIV) context. Despite access to harm-reduction services, they experience gender-based stigma, unsafe injecting practices, and high health risks. Assessing readiness for change is critical for designing gender-responsive interventions. Methods: An explanatory sequential mixed-methods design was used. Quantitative data were collected from 125 FIDUs selected using simple random sampling without replacement through a structured questionnaire incorporating the Stages of Change Readiness and Treatment Eagerness Scale-8D (SOCRATES-8D). Based on the quantitative findings, qualitative data were obtained through in-depth interviews with participants demonstrating high and low readiness for change. Quantitative data were analyzed using descriptive and inferential statistics, while qualitative data were analyzed thematically. Results: Over half of the participants were female sex workers (53.6%), with a mean age of 29.9 ± 8.17 years. Peer pressure was the most common reason for initiating injecting drug use (48%). Low recognition of substance use as a problem was observed in 71.2%, while moderate to high ambivalence was present in 73.6%. Medium to high taking-steps scores were seen in 57.6%. In multivariable linear regression, significant predictors emerged only for the Taking Steps domain. Higher scores were associated with older age (β = 0.38, p = 0.002), being currently married (β = 0.62, p = 0.014), and earlier age at initiation of drug use (β = -0.28, p = 0.027). Daily injecting was negatively associated with taking-steps scores compared with less-than-daily injecting (β = -0.58, p = 0.019). Qualitative findings revealed normalization of drug use contributing to low recognition, persistent ambivalence related to emotional and functional dependence, and fragile action efforts undermined by withdrawal symptoms and perceived inadequate support. Conclusion: Although motivation to change was evident, recognition remained low, and behavior change efforts were often unstable. Ambivalence, dependence, and structural barriers limited sustained change, underscoring the need for stage-matched, gender-sensitive counseling and strengthened early support within harm-reduction services.