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Summary
Background
In December 2002, Scotland's Lord Advocate reviewed the
Guidelines that govern the number of needles and syringes (
n/s) dispensed at any one visit to a needle
exchange. The new Guidelines increased the number that
could be distributed to a maximum of 20 sets (previously 5
sets) on the first visit; a maximum 60 sets (previously 15
sets) on subsequent visits; and an exceptional upper limit
of 120 sets (previously 30 sets) for holiday periods when
facilities are closed or are difficult to access. These
exchanges are subject to the return of used equipment for
safe disposal. This study set out to evaluate the effects
of this change on
IDUs' risk behaviours.
Aim
The aim of the evaluation was to determine if increasing
the supply of sterile needles and syringes to injectors
reduces the frequency of needle and syringe sharing.
The main objectives of the study were to ascertain if
the lifting of the Lord Advocate's restriction on the
number of needles and syringes distributed to
injectors:
1. reduces the frequency of needle and syringe sharing
among injectors;
2. causes any other behavioural changes among injectors,
either beneficial or detrimental,
e.g. frequency of visits to needle
exchange
The evaluation also sought to determine the views of
needle exchange and pharmacy workers on the increase in
supply of needles and syringes.
Methodology
Evaluating the impact on risk behaviours
The study originally set out to evaluate the effects of
the new Guidelines by comparing the risk behaviours among
recent initiates to injecting (i.e had injected for six
years or less) among Glasgow
IDUs in 2004 with the behaviours of
recent initiates to injecting who had been interviewed in
2001-2002. Recruitment of
IDUs commenced a year after the
introduction of the new Guidelines. However it very quickly
became apparent that most
IDUs were unaware that they could now
obtain an increased number of sterile
n/s per visit. It was clear that the aim of
determining if the increase in supply had reduced risk
behaviours could not be achieved.
An awareness campaign was incorporated into a new study
design. This campaign, consisting of cards and posters
displayed in, and distributed through, pharmacies, needle
exchanges and drug treatment centres, aimed to inform
IDUs that they could now collect more
n/s and also included harm reduction
advice.
The new study design changed to include all current
injectors
i.e. those who had injected at least once in
the four weeks prior to interview. This allowed the
recruitment of a more representative sample of injectors
than in the original proposed method. Injectors within the
sample who had begun injecting within the previous six
years would still be compared to the respondents in
2001-2002 study to determine if there had been any change
in behaviours over this longer period.
Between February and May 2004, prior to the introduction
of the awareness campaign, 296
IDUs, all of whom had injected in the
previous month, were recruited to the study from a variety
of venues including street sites, pharmacies, needle
exchanges and drug treatment centres. They were interviewed
with a structured questionnaire that contained questions on
their drug use habits and risk behaviours. The results of
this phase of the study formed a baseline against which any
changes in behaviour following the implementation of the
awareness campaign could be measured.
Six weeks after the introduction of the awareness
campaign, recruiting for the post awareness sample began
and 299
IDUs were interviewed over a three-month
period.
Evaluation of the views of needle exchange and
pharmacy workers
Two members of staff from each pharmacy and needle
exchange from which
IDUs were recruited were interviewed.
Staff members were asked a series of structured, open-ended
questions about their views on the increase in supply of
needles and syringes. These included their perceptions of
any impact the Lord Advocates guidance had on their service
including frequency of attendance by drug users and any
impact on return of used
n/s.
Results
The impact on risk behaviours
The characteristics of the participants in the pre and
post campaign phases were comparable with respect to
proportion of males (86% and 83% respectively); age at
interview (mean 32 years in both); age at first injection
(mean 21 years in both); length of injecting career (mean
11 years in both); recruitment setting (79% and 86%
recruited in street respectively); type of residence in the
six months prior to interview (hostel accommodation 37% and
36% respectively); and having ever been in treatment for
drug use (93% and 88% respectively). Heroin was the most
common drug injected (by 93%) in both samples.
A significantly higher proportion of participants from
the post awareness campaign phase (54%) injected drugs
twice daily or more compared to those recruited
pre-campaign (44%).
There were no significant differences in injecting risk
behaviours in the four weeks prior to interview. Almost 80%
in both sweeps reported never having injected with a
n/s previously used by someone else.
There was no significant difference in the number of
n/s obtained in an average week from a
pharmacy or needle exchange between the pre and post
awareness surveys. Pre-awareness respondents obtained an
average of 26
n/s (median=20) and post awareness
IDUs received an average of 27
n/s (median=30) per visit.
There was a significant decrease in the number of
respondents obtaining sterile
n/s from non-exchange sources (
i.e. friends, other drug users, on street,
sexual partner, family, theft and drug dealers) in the post
awareness phase.
The maximum number of needles and syringes that
IDUs believed could be obtained per
visit from a pharmacy or needle exchange increased
significantly from a median of 20
n/s to a median of 25
n/s, an increase of 25%, between the pre and
post awareness surveys. Few injectors, however, knew that
the limit had been changed in either the pre or post
surveys (20% in both).
The majority of
IDUs in both surveys did not want to
obtain as many as 60
n/s per visit and they were, moreover,
generally satisfied with the number they were currently
receiving (a mean of 19 and 21 (median 15 and 15), pre and
post awareness campaign respectively). In both samples, the
main reason for not wishing to obtain a greater number was
that this was enough for their injecting needs (206/359,
57%). Despite this claim, half of these respondents
(181/359, 50%) stated that, on average, they injected with
the same needle more than once. Among
IDUs who did wish to receive more
n/s than they were currently receiving
(236/595, 40%) the most common reason was to cut down the
number of visits to the needle exchange (74/236, 31%).
In the 2004 survey, 170
IDUs had begun injecting in the previous
six years and their behaviours were compared with those of
385
IDUs with the same length of injecting
careers who had been interviewed in 2001-2002.
Injecting of cocaine (on its own) had increased with
just over half of recent initiates reporting use of cocaine
in the previous months in 2004 compared with just under
two-fifths of
IDUs in 2001-2002. With the increase of
cocaine use it might have been expected that the frequency
of injecting would also increase, however there was a
significant decrease in the frequency of injecting in the
previous six months in the 2004 sample compared with the
2001-2002 survey
.
Moreover, those interviewed in 2004 were significantly
less likely to inject with a
n/s previously used by someone else; just over
half of the 2001-2002 sample had injected in the previous
six months with a
n/s previously used by someone else compared
with a quarter in 2004.
Views of needle exchange staff
Forty staff were interviewed about their views on the
new Guidelines. This included 19 pharmacy assistants, 14
pharmacists, 2 nurses and 5 team workers.
The majority of staff (37/40) knew about the new
Guidelines and nearly two-thirds (25/40) could correctly
cite the maximum number of
n/s that could be given out per visit.
Almost all (36/40) said that they had informed clients
of this change. However, it appeared that, apart from
displaying information about the new Guidelines, some staff
directly told
IDUs of the change only if asked. Other
staff were more pro-active and explained the change to
clients and encouraged them to take more
n/s.
Just over a third of staff approved of the new
Guidelines, with one third disapproving and the remainder
having mixed views. Furthermore, whilst just under
two-thirds said that the number of
n/s that they dispensed depended on the number
of returns they received, some respondents said that they
decided what to dispense according to how well they knew
the client
There were mixed views on the impact that the Guidelines
had on exchanges. A third felt that the change in guidance
had no impact on the pharmacy/exchange while nearly a
quarter believed that the frequency of visits by
individuals had reduced. The remainder cited a variety of
changes including an increase in numbers of clients (7/40),
a decrease in clients (6/40) and an increase in frequency
of visits (3/40).
Conclusion
More than a year after the introduction of the Lord
Advocate's new Guidelines, very few
IDUs in Glasgow were aware of the
increase in the maximum number of
n/s that could be obtained per needle exchange
visit; even a specially designed, targeted campaign failed
to raise awareness.
After the introduction of the new Guidelines, needle
exchanges and pharmacies displayed information and informed
IDUs. The results of the staff survey,
however, indicated that some staff did not actively promote
the increase to services users. Moreover, only one-third of
staff approved of the new guidelines and some used their
own judgement in deciding how many
n/s should be given out.
It may be that the reluctance to implement, or
disapproval of, the Guidelines among some staff was one
reason for the low level of awareness among
IDUs. Needle exchange and pharmacy staff
need, therefore, to be made more aware of the necessity to
actively provide oral advice and information to their
clients.
The attitude of some staff, however, does not explain
why the targeted awareness campaign also failed to inform
the majority of
IDUs. Posters and cards were distributed
to all exchange outlets and the cards were inserted in all
n/s packs. Yet this strategy, too, failed to
increase knowledge among
IDUs.
One of the study findings indicated that
IDUs did not, generally, wish to have
any more
n/s than they were currently receiving. The
message contained in the awareness campaign (or imparted by
pharmacists) that more
n/s were available was therefore meaningless
to them. The main reason for not wanting more
n/s was that the current level was sufficient
for their needs. However it was noted that half of these
IDUs were re-using their own
n/s; yet the awareness campaign cards alerted
IDUs to the risks involved in this.
Due to time constraints, the time period for the
awareness campaign was six weeks. After this period,
recruitment for the post awareness group began. Cards and
posters were distributed to agencies throughout the city
and were placed inside the packs of
n/s that are distributed through the pharmacy
exchanges. The cards placed within the packs, however,
would not have reached some injectors until towards the end
of the recruitment period. It may be that if the campaign
had run for a longer period it would have had more
impact.
There is some evidence, however, that leaflets are not
successful in communicating messages to
IDUs (Wright et al). Some
IDUs may, for example, have literacy
problems that render written material ineffective. There is
perhaps a need to evaluate the readability of written harm
reduction materials and to design and evaluate new ways of
delivering harm reduction messages to
IDUs.
Nevertheless, there have been some positive changes in
behaviours among
IDUs in Glasgow since the introduction
of the awareness campaign and since 2001.
The maximum number of
n/s that
IDUs believed could be obtained per
visit from a pharmacy or needle exchange increased
significantly. Respondents were also less likely to obtain
sterile
n/s from non-legitimate sources in the post
awareness phase. Whilst frequency of injecting had
increased, there was no increase in sharing behaviour. A
comparison between recent initiates to injecting in
2001-2002 and 2004 found a decrease in both frequency of
injecting and sharing in 2004.
These changes cannot definitely be proved to arise
directly from the increased availability of
n/s; other factors may have influenced
behaviour between 2001-2002 and 2004. Nevertheless, the
association between the introduction of the new Guidelines
and behaviour changes suggests that the former may be
having a positive impact. It would seem prudent to continue
with the current policy on
n/s distribution. However, the findings from
this study suggest that further work needs to be done among
needle exchange staff to inform
IDUs of their entitlement to a greater
number of
n/s and to encourage them to make use of their
entitlement.
Chapter 1: Introduction
Background
The hepatitis C virus (
HCV) was discovered in 1988 and, in the
UK, antibody testing became available in
1991.
HCV infection causes a silent and
progressive disease of the liver. While a minority of those
who become infected with
HCV will clear the virus naturally
without intervention or treatment, an estimated 60-85% of
infected people will continue to carry the virus and are at
risk of developing cirrhosis. A systematic review of the
worldwide literature indicated that 4%-10% of those with
chronic
HCV will develop cirrhosis after 20
years of infection (Freeman et al, 2001); higher rates of
progression have been reported among heavy alcohol users
and those co-infected with
HIV. Although the efficacy of anti-viral
treatment has improved (Manns et al, 2001), prevention of
HCV transmission remains a high
priority.
Injecting drug use is the most common risk factor for
HCV with transmission associated with
injecting with infected injecting equipment. Throughout the
world, rates of infection exceeding 50% have been detected
among populations of injecting drug users (
IDUs) (Wodak et al, 1996). In 1999, the
prevalence of
HCV among drug injectors undergoing a
named
HIV test was 44% and 62% in Scotland and
Glasgow, respectively (Hutchinson et al, 2000).
Needle and syringe exchange, which was introduced
principally to prevent
HIV infection, had become well
established in the
UK in the early 1990s. There is
considerable evidence that this intervention has helped to
control
HIV transmission among injectors, and
injectors' incidence of
HIV has been low during the 1990s.
However, evidence suggests that needle exchange has been
less effective in preventing the spread of
HCV. In 1999 a community wide study in
Glasgow found an
HCV prevalence of 53% among 436
IDUs who had commenced their injecting
careers post 1989 (
i.e. after the introduction of needle
exchange) (A. Taylor, personal communication). Among those
who had commenced injecting in the previous two years,
HCV antibody prevalence was 23%. A
further community wide study carried out in Glasgow in
2001-2002 found an
HCV antibody prevalence of 58% among 466
IDUs who had begun their injecting
careers in the previous five years (A. Taylor, personal
communication). Thus, it was clear that
HCV was continuing to spread among
injectors.
Unless safe injecting is practised throughout an
injector's entire injecting lifespan, he or she will be at
high risk of acquiring
HCV. However, 51% of injectors recruited
in the Glasgow study during 2001-2002 had injected with a
used needle and syringe (
n/s) in the six months prior to interview (A.
Taylor, personal communication). In Scotland, 34% per cent
of injectors reported to the Scottish Drug Misuse Database
in 2003/2004 had injected with a used needle and syringe (
n/s) in the previous month (
ISD, 2004).
Not enough is known about the reasons why injectors
continue to share used needles and syringes. It is,
however, possible that sub optimal access to clean needles
and syringes is one reason why sharing continues to be
practiced. Community wide surveys in Glasgow have shown
significantly lower levels of needle/syringe sharing by
IDUs who had obtained needles and
syringes from a needle exchange compared with those who
obtained no sterile equipment from this source (Hutchinson
et al 2000).
A survey conducted in the
UK in 1997 estimated that needle
exchange schemes in Scotland distributed between 40 and 80
syringes per injector per annum (Hickman et al, 2001). If
the target is to provide one sterile needle and syringe per
injecting episode and if it is assumed that injecting
occurs on average three times per day, then this represents
a serious shortfall in supply. In comparison, in England
and Wales, where the prevalence of
HCV among injectors is much lower than
that in Scotland and where there is no restriction on the
number of needles and syringes distributed, each injector
receives an average of 180-380 needles and syringes per
annum.
Evidence such as this led to recommendations that the
number of needles and syringes allowed to be dispensed in
Scotland should be increased (
SCIEH 2001,
HEBS 2002). In the light of these
recommendations, the Lord Advocate reviewed the Guidelines
that govern the number of needles and syringes that may be
dispensed at any one visit to a needle exchange (
NHSHDL (2002) 90). Previously, the Lord
Advocate's Guidance on the distribution of sterile needles
and syringes allowed five sets to be offered to clients
attending a needle exchange for the first time. On
subsequent visits, up to 15 sets could be given as long as
the same number of sets was returned for disposal.
Exceptions to this guidance included when: i) an injector
was collecting equipment for a partner and ii) distribution
occurred in a rural area or around a public holiday. On
such occasions, a maximum of thirty sets could be issued.
The new Guidelines allow a maximum 20 sets on the first
visit, a maximum 60 sets on subsequent visits and an
exceptional upper limit of 120 sets for holiday periods
when facilities are closed or are difficult to access.
These exchanges are subject to the return of used equipment
for safe disposal. These new Guidelines came into effect in
December 2002.
The Effective Interventions Unit (
EIU) provided funding through the
Scottish Executive's Drug Misuse Research Programme to
undertake an evaluation of the impact of the new
Guidelines. The study forms part of the
EIU's programme of research in the area
of hepatitis C prevention (Effective Intervention Unit,
2003).
Aim
The aim of the evaluation was to determine if increasing
the supply of sterile needles and syringes to injectors
reduces the frequency of needle and syringe sharing.
Objectives
The main objectives of the study were to ascertain if
the lifting of the Lord Advocate's restriction on the
number of needles and syringes distributed to
injectors:
- reduces the frequency of needle/syringe sharing
among injectors.
- causes any other behavioural changes among
injectors, either beneficial or detrimental,
e.g. frequency of visits to needle
exchanges.
The evaluation also sought:
- to determine the views of needle exchange and
pharmacy workers on the increase in supply of needles
and syringes.
The report is divided into four chapters. Chapter 2
describes how the study was undertaken. Chapter 3 provides
the results from the study. Chapter 4 discusses the results
and draws conclusions.
Chapter 2: Methodology
Evaluating the impact on risk
behaviours
The original proposal aimed to recruit 500 injectors who
had begun injecting in the previous six years and interview
them about their injecting behaviours, in particular
frequency of needle/syringe sharing and frequency of visits
to needle exchange, in the previous six months. All
respondents would be recruited at least six months after
the introduction of the Lord Advocate's new Guidelines on
the number of needles and syringes distributed to
injectors. The behaviours of these 500
IDUs would then be compared with those
reported by a sample of 500 injectors with the same
eligibility criterion of recent injecting, who had been
interviewed in 2001-2002. The 2001-2002 study found that in
the six months prior to interview 51% had injected with
needles and syringes previously used by someone else. The
results from the 2001-2002 study would provide a baseline
against which to evaluate the effects of the increase in
the Lord Advocate's restriction on the number of needles
and syringes distributed to injectors.
Recruitment of the sample began in December 2003, almost
one year after the introduction of the new Guidelines. It
very quickly became apparent to the interview team that
most injectors were unaware that they could now obtain an
increased number of sterile needles and syringes per visit
to needle or pharmacy exchange. Accordingly, it was clear
that the aim of the study, to determine if the increase in
supply reduced the frequency of sharing among injectors,
could not be achieved. In consultation with the
EIU a new method to determine the effect
of the Guidelines was developed. The method was as
follows:
- an awareness raising campaign would be introduced
throughout Glasgow, consisting of posters displayed in
pharmacies, needle exchanges and drug treatment
services providing information on the new minimum and
maximum limits and re-emphasising the message about not
sharing injecting equipment. Credit card size cards
containing the same information would also be given to
injectors when they attended needle exchanges,
pharmacies and drug treatment services;
- prior to the launch of the awareness campaign 300
injectors would be recruited and interviewed. The
results of this phase would form the pre awareness
baseline data. A further 300 would be recruited
approximately six weeks after the introduction of the
awareness campaign. Comparison would then be made
between behaviours pre and post campaign;
- the eligibility criterion of having started to
inject in the last six years would be changed to
include all individuals who had injected at least once
in the month prior to interview. This would allow the
recruitment of a sample representative of all current
injectors and not just recent initiates to injecting as
in the original proposed method. Injectors within this
sample who had begun injecting within the previous six
years would still be compared to the respondents in
2001-2002 study to determine if there had been any
change in behaviours over this longer period;
- the questionnaire would be altered so that
respondents could be asked about their behaviours in
the last four weeks as well as the last six months, the
period asked about in the 2001-2002 questionnaire.
Apart from this change, the questions would remain the
same as those in the 2001-2002 questionnaire.
The study proceeded on the basis of this new
methodology. The pre awareness recruitment phase took place
between February and May 2004. Recruiting then ceased and
the awareness campaign was put into operation. This ran for
approximately six weeks and then recruitment of the
post-awareness sample took place from mid July to October
2004.
A multiple site recruitment strategy was used to
generate as representative a sample as possible of
IDUs in Glasgow. Sites included 16
pharmacy exchanges, Turning Point needle exchange and
treatment service, Easterhouse
GDPS needle exchange, the four needle
exchanges operating in hostels for the homeless, the
addiction teams located throughout Glasgow, Red Tower drug
project, the Homeless Health & Social Care Centre,
Wayside Day Centre, the Big Issue office and various street
sites throughout Glasgow.
After obtaining permission from each exchange and
treatment service, interviewers either sat inside or stood
outside the premises and approached
IDUs. Interviews took place either in a
private area of the premises or in a mobile campervan that
was parked nearby.
For the street sample recruitment the mobile campervan
was parked in streets in all areas throughout Glasgow in
which
IDUs were known to frequent.
Interviewers explained the study to all respondents and
assured them that all information provided by them was
anonymous and confidential. Only the initials, date of
birth and first part of postcode were collected from each
respondent and these were used only to identify respondents
who had inadvertently been interviewed more than once.
After obtaining informed consent, the interviewers
administered a structured questionnaire.
The questionnaire covered demographics, injecting
patterns, sharing of needles and syringes and other
injecting equipment, time spent in prison, access to needle
exchanges, knowledge of entitlement to a greater number of
needles and syringes, frequency of needle exchange
attendance and number of needles acquired per visit. Each
interview took between 20 and 45 minutes to complete.
Evaluation of the views of needle exchange and
pharmacy workers
All of the pharmacies and needle exchanges from which
IDU respondents were recruited to the
study were included in the exchange workers' evaluation.
Two members of staff from each establishment were
interviewed either inside the exchange or outside in the
mobile campervan during a four-week period in June/July
2004.
Respondents were asked a series of structured,
open-ended questions about their views on the new
Guidelines. These included their perceptions of any impact
the Lord Advocates' guidance had had on their service
including the frequency of attendance by drug users.
Interviews took between five and ten minutes to
complete.
Data analysis
The behaviours (
i.e. uptake and sharing of
n/s) of
IDUs interviewed pre and post the
awareness raising campaign were compared using univariate
analysis (see footnote to table 1 for further details).
Univariate and multivariate logistic regression analyses
were used to compare the behaviours (
i.e. uptake and sharing of
n/s) of pre and post awareness
IDUs interviewed in 2004 with
IDUs interviewed in 2001-2002; these
analyses were restricted to
IDUs who had begun to inject in the six
years prior to recruitment. The multivariate logistic
regression analysis was adjusted for age, gender,
recruitment setting, frequency of injecting and hostel
residence in the previous six months.
Descriptive statistics were used to analyse the views of
pharmacy and needle exchange workers on the new
Guidelines.
Chapter 3: Results
Sample characteristics (Table 1)
Questionnaires were obtained from 296 and 299 injectors
recruited pre and post awareness campaign respectively.
The characteristics of the participants recruited in the
pre and post campaign phases were comparable with respect
to proportion of males (86% and 83%, respectively), age at
interview (mean 32 years in both), age at first injection
(mean 21 years in both), length of injection career (mean
11 years in both), recruitment setting (79% and 86%
recruited in street, respectively), type of residence in
the six months prior to interview (hostel accommodation 37%
and 36% respectively), having ever been in treatment for
drug use (93% and 88%, respectively) or in prison since
onset of injecting (81% and 78%, respectively). Heroin was
the most common drug injected (by 93%) in both samples.
A significantly higher proportion of participants from
the post campaign phase (54%) injected drugs twice daily or
more in the previous six months compared to those recruited
pre campaign (44%) (p=0.03).
Table 1 Comparison Of Key Characteristics Of
Current Injectors Interviewed Before And After The
Awareness
Characteristics | | Interview Undertaken | P
1 |
|---|
| Pre campaign (N=296) | Post campaign (N=299) |
|---|
Age (years) (1
NR) | Mean/median (
SD) | 31.9/31.6 (6.0) | 32.0/31.5 (6.0) | NS |
|---|
Males | n (% of N) | 253 (85.5%) | 249 (83.3%) | NS |
|---|
Age at first injection | Mean/median (
SD) | 20.5/19.0 (5.5) | 20.8/20.0 (5.4) | NS |
|---|
Time since onset of injection (1
NR) | Mean/median (
SD) | 11.0/9.3 (7.2) | 10.7/9.0 (7.2) | NS |
|---|
Frequency of injecting drugs in previous 6
month (1
NR) | < twice/day _ twice/day | 164 (55.6%) 131 (44.4%) | 138 (46.2%) 161 (53.8%) | 0.03 |
|---|
Drugs injected in previous 6 months (three
most reported drugs) | Heroin Cocaine Heroin + Cocaine | 275 (92.9%) 179 (60.5%) 115 (38.9%) | 277 (92.6%) 169 (56.5%) 112 (37.5%) | NS |
|---|
Recruitment setting | Street Needle exchange Treatment | 234 (79.1%) 53 (17.9%) 9 (3.0%) | 256 (85.6%) 37 (12.4%) 6 (2.0%) | NS |
|---|
Glasgow residence (17
NR) | East North/North West South Central Outside Glasgow | 69 (24.1%) 61 (21.3%) 26 (9.1%) 126 (44.1%) 4 (1.4%) | 57 (19.5%) 51 (17.5%) 39 (13.3%) 136 (46.6%) 9 (3.1%) | NS |
|---|
Type of residence in past six months | Hostel Other
2 | 110 (37.2%) 186 (62.8%) | 108 (36.1%) 191 (63.9%) | NS |
|---|
Ever treated for drug use | n (% of N) | 273 (92.2%) | 264 (88.3%) | NS |
|---|
1 c 2 test, t-test or where appropriate Mann
Whitney U-test,
NS is not significant at the 5%
level
2 other includes own home, someone else's home,
residential drug treatment, hospital, B & B, rented
accommodation and at work
NR non-response;
SD Standard deviation
Risk behaviours pre and post awareness campaign
(Table 2)
There were no significant differences in injecting risk
behaviours in the four weeks prior to interview nor in the
number of
n/s obtained in an average week from the
needle exchange or pharmacy between the pre and post
awareness surveys. Almost 80% in both samples (78% and 79%
in pre and post samples, respectively), reported never
having injected with a
n/s previously used by someone else in the
four weeks before interview; just under half of each sample
had shared a spoon (47% and 49%, respectively) and filter
(44% and 44%, respectively) in the same time period.
Table 2 Injecting risk behaviours prior to
interview 4 weeks
| | Interview Undertaken | P
1 |
|---|
| | Pre campaign (N=296) | Post campaign (N=299) | |
|---|
Injected with
N/S previously used by someone
else (4
NR) | Never Once/month 2-5 times/month >5 times/month | 229 (77.9%) 13 (4.4%) 31 (10.5%) 21 (7.1%) | 237 (79.8%) 19 (6.4%) 27 (9.1%) 14 (4.7%) | NS |
|---|
Injected with
N/S previously used by self (6
NR) | Once/month 2-4 times/month >4 times/month | 128 (43.7%) 139 (47.4%) 26 (8.9%) | 148 (50.0%) 126 (42.6%) 22 (7.4%) | NS |
|---|
Source of used
N/S (5
NR) | Never shared Either family, friend or sexual partner
only Casual acquaintance
2 | 228 (77.8%) 40 (13.7%) 25 (8.9%) | 237 (79.8%) 46 (15.5%) 14 (4.7%) | NS |
|---|
Number of different people from whom
obtained used
N/S (26
NR) | Never shared One person 2 or more people | 228 (80.7%) 37 (13.1%) 18 (6.4%) | 137 (82.9%) 37 (12.9%) 12 (4.2%) | NS |
|---|
Shared spoons (3
NR) | Never Once/month 2-5 times/month >5 times/month | 155 (52.7%) 27 (9.2%) 65 (22.1%) 47 (16.0%) | 151 (50.7%) 26 (8.7%) 56 (18.8%) 65 (21.8%) | NS |
|---|
Shared filter (1
NR) | Never Once/month 2-5 times/month >5 times/month | 165 (55.7%) 25 (8.4%) 45 (15.1% 61 (20.5%) | 168 (56.4%) 22 (7.4%) 42 (14.1%) 66 (22.1%) | NS |
|---|
Passed on previously used
N/S (4
NR) | Never £ 5 times 6-20 times > 20 times | 221 (75.4%) 50 (17.1%) 12 (4.1%) 10 (3.4%) | 231 (77.5%) 50 (16.8%) 10 (3.4%) 7 (2.3%) | NS |
|---|
1 c 2 test, t-test or where appropriate Mann
Whitney U-test,
NS is not significant at the 5%
level
2 Casual acquaintance includes drug dealer,
someone in a shooting gallery, a fellow prisoner or a
stranger
NR Non response
Source and uptake of sterile needles and
syringes (Table 3)
The majority of participants in both surveys obtained
their sterile needles and syringes from a reliable source
(including needle exchange, pharmacy, drug agency, hospital
or
GP). The number of
IDUs obtaining needles and syringes from
only a non-reliable source reduced significantly between
the pre and post surveys (17% to 9%, respectively;
p<0.001).
The frequency of visiting a needle exchange increased
significantly between the pre and post awareness surveys
(33% and 45% visited a needle exchange at least twice
weekly, respectively;
p=0.018).
Table 3 Uptake of needles and syringes in the
four weeks prior to interview
| | Interview Undertaken | P
1 |
|---|
| | Pre campaign (N=296) | Post campaign (N=299) | |
|---|
Source of needles and syringes (11
NR) | RS2 only RS and elsewhere elsewhere | 226 (77.4%) 18 (6.1%) 50 (16.9%) | 228 (76.3%) 36 (12.0%) 26 (8.7%) | <0.001 |
|---|
Frequency of using needle exchange in an
average week
3 (14
NR) | < twice/week 2-3 times/week > 3 times/week | 163 (67.4%) 62 (25.6%) 17 (7.0%) | 145 (55.1%) 95 (36.1%) 23 (8.7%) | 0.018 |
|---|
Number of
N/S obtained from needle exchange
and /or pharmacist in average week
4 (1
NR) | None 1-5 6-15 16-30 >30 | 38 (12.9%) 36 (1.2%) 63 (21.4%) 72 (29.2%) 86 (29.2%) | 31 (10.4%) 28 (9.4%) 61 (10.4%) 74 (24.7%) 105 (35.1%) | NS |
|---|
1 c 2 test, t-test or where appropriate Mann
Whitney U-test,
NS is not significant at the 5%
level
2RS refers to reliable source, which
includes needle exchange scheme, pharmacist, drug agency,
hospital and
GP; elsewhere includes friends, other
drug users, bought on streets, sexual partner, family,
theft from legitimate source and drug dealer
3 Excludes 76 participants who obtained
N/S from non legitimate source
4N/S obtained by self and/or someone else for
own use
NR Non-response
IDUs' awareness of change in
Guidelines, views on ideal numbers of needles/syringes
per visit to needle exchange and actual numbers
obtained (Table 4)
The maximum number of needles and syringes that
IDUs believed could be obtained per
visit from a pharmacy or needle exchange increased
significantly between the pre and post awareness surveys
(mean 26 and 37, median 20 and 25, respectively;
p<0.001). Few injectors, however, knew that the
limit had been changed in the pre and post surveys (20% in
both samples).
In both the pre and post awareness surveys, the majority
of
IDUs stated that they would like to
obtain up to a maximum of 30
n/s per visit to an exchange. The actual
number of
n/s they obtained on average were 19 and 21,
(median 15 and 15), pre and post awareness campaign,
respectively.
Table 4
IDUs' perceptions of maximum numbers
of needles/syringes available and actual
uptake
| | Interview Undertaken | P
1 |
|---|
| | Pre campaign (N=296) | Post campaign (N=299) | |
|---|
Reported Max number of
N/S available from needles
exchange per visit (166
NR) | mean/median (
SD) | 25.7/20 (18.5) | 37.2/25.0 (30.0) | <0.001 |
|---|
Awareness of change in maximum number of
N/S available (232
NR) | n (% of N) | 58 (19.6%) | 61 (20.4%) | NS |
|---|
Number of sterile
N/S would like to get per visit to
pharmacy or
NE | 1-5 6-15 16-30 >30 | 34(13.0%) 78(29.8%) 84(32.1%) 66(25.2%) | 39(13.9%) 83(29.5%) 82(29.2%) 77(27.4%) | NS |
|---|
Number of sterile
N/S on average obtained by self
per visit to pharmacy of
NE2 (22
NR) | 1-5 6-15 16-30 >30 | 32 (13.3%) 103 (42.9%) 73 (30.4%) 32 (13.3%) | 43 (16.7%) 108 (42.0%) 69 (26.4%) 37 (14.4%) | NS |
|---|
1 test, t-test or where appropriate Mann Whitney
U-test,
NS is not significant at the 5%
level
2 Excludes 76 participants who obtained
N/S from non legitimate source
NR Non responsive;
SD Standard deviation
Reasons for wanting/not wanting more
needles/syringes (Tables 5 and 6)
Sixty-three per cent (186/296) and 58% (173/299) from
the pre and post awareness surveys, respectively, stated
that they would not wish to obtain a greater number of
needles than they were currently receiving (data not
shown). In both samples, the main reason for not wishing to
obtain a greater number was that what they were receiving
already was enough for their injecting needs (206/359, 57%)
(Table 5); however half of these respondents (181/359, 50%)
stated that, on average, they injected with the same needle
more than once (data not shown).
Among those
IDUs who did wish to receive more
needles and syringes than they were currently receiving
(236/595, 40%) the most common reason was to cut down on
the number of visits to the needle exchange (74/236, 31%)
(Table 6).
Table 5 Reasons given by
IDUs for not wanting any more
needles than they were currently receiving.
(N=359)
Current number enough for injecting
needs | 206 | 57.4% |
|---|
No reasons/don't know | 46 | 12.8% |
|---|
Don't like to carry them about | 24 | 6.7% |
|---|
Don't want them lying around | 22 | 6.1% |
|---|
I want to stop using | 18 | 5.0% |
|---|
The more I have the more I would use | 19 | 5.3% |
|---|
Other | 14 | 3.9% |
|---|
No response | 10 | 2.8% |
|---|
Table 6 Reasons given by
IDUs for wanting to receive more needles than they were
currently receiving (N= 236)
So I can go to the needle exchange less
often | 74 | 31.4% |
|---|
So I could use a fresh needle every time I
inject | 56 | 23.7% |
|---|
So I don't run of
N/S | 32 | 13.6% |
|---|
No Reason | 34 | 14.4% |
|---|
So I wouldn't have to share
N/S | 13 | 5.5% |
|---|
So I could give
N/S to others | 9 | 3.8% |
|---|
In case I run into problems when
injecting (Blunt needle, missed hit) | 4 | 1.7% |
|---|
Other/Don't know/ no response | 14 | 5.9% |
|---|
Comparison of behaviours in
IDUS injecting for less than six
years in 2001-2002 and 2004 (Tables 7 and 8)
In the 2001-2002 and 2004 surveys, 385 and 170
IDUs, respectively, had begun injecting
in the six years prior to interview and had injected at
least once in the four weeks prior to interview.
Comparison of key characteristics between participants
in the 2001-2002 and 2004 surveys showed that the two
groups were statistically significantly different with
respect to age, gender, frequency of drugs injected,
recruitment setting and area of residence. Those
interviewed in 2004 were significantly more likely to be
older, male, recruited from a street site and to reside in
the centre of Glasgow, and significantly less likely to
inject drugs more than twice daily than those interviewed
during 2001-2002 (Table 7).
While heroin was the most common drug injected in both
the 2001-2002 and 2004 surveys (98% and 89%, respectively),
the proportion injecting cocaine (on its own) increased
significantly from 38% in 2001-2002 to 54% in 2004 (
p=0.001).
Univariate and multivariate logistic regression analyses
were used to compare behaviours between the 2001-2002 and
2004 samples (Table 8). In univariate analysis, those
interviewed in 2004 were significantly less likely than
those interviewed in 2001-2002:
- to use a needle exchange at least twice a week (
OR 0.5, 95%
CI 0.4-0.8),
- to obtain more than sixteen
n/s from an exchange in an average week (
OR 0.6, 95%
CI 0.4-0.9) and
- to have injected with a
n/s previously used by someone else in the
six months prior to interview (
OR 0.3, 95%
CI 0.2-0.5) than those interviewed
in 2001-2002.
In the multivariate analysis, those interviewed in 2004
were significantly less likely than those interviewed in
2001-2002:
- to obtain more than sixteen
n/s from an exchange in an average week in
the six months prior to interview (adjusted
OR 0.4, 95%
CI 0.2-0.6) and
- to have injected with a
n/s previously used by someone else in the
six months prior to interview (adjusted
OR 0.3, 95%
CI 0.2-0.5).
Another multivariate analysis (not shown) also found a
significant reduction in the proportion who reported
injecting with a used
n/s in the four weeks prior to interview among
those interviewed in 2004 compared to 2001-2002 (adjusted
OR 0.3; 95%
CI 0.2-0.6).
Table 7 Characteristics of current injectors,
with an injecting career of less than six years,
recruited in Glasgow 2001/2002 and 2004
Sample Characteristics | | Interviewed | P
1 |
|---|
2001/02 (N=385) | 2004 (N=170) |
|---|
Age (years) (1
NR) | Mean/median (
SD) | 27.27/26.82 (5.34) | 28.29/27.98 (5.37) | 0.033 |
|---|
Males | n (% of N) | 278 (72.2%) | 140 (82.4%) | 0.014 |
|---|
Age at first injection | Mean/median (
SD) | 23.87/23.00 (5.37) | 24.85/24 (5.50) | 0.046 |
|---|
Time since onset of injection (1
NR) | Mean/median (
SD) | 2.99/3.23 (1.64) | 3.07/3.3 (1.80) | NS |
|---|
Frequency of injecting drugs in previous 6
month (3
NR) | <2 times daily 2-3 times daily > 3 times daily | 132 (34.3%) 150 (39.0%) 100 (26.0%) | 93 (54.7%) 47 (27.6%) 30 (17.6%) | <0.001 |
|---|
Drugs injected in previous 6 months (three
most reported) | Heroin Cocaine Heroin + Cocaine | 377 (97.9%) 148 (38.4%) 132 (34.3%) | 152 (89.4%) 91 (53.5%) 54 (31.8%) | 0.028 |
|---|
Recruitment setting | Street Needle exchange Treatment | 119 (30.9%) 204 (54.0%) 62 (16.1%) | 136 (80.0%) 32 (18.8%) 2 (1.2%) | <0.001 |
|---|
Glasgow residence (17
NR) | East North/North West South Central Outside Glasgow | 132 (34.2%) 65 (16.9%) 93 (24.2%) 42 (10.9%) 29 (7.5%) | 36 (21.2%) 26 (15.3%) 20 (11.8%) 78 (45.9%) 7 (4.1%) | <0.001 |
|---|
Type of residence in past six months | Hostel Other
2 | 122 (31.7%) 263 (68.3% | 44 (25.9%) 126 (74.1%) | NS |
|---|
Ever treated for drug use | n (% of N) | 312 (81.0%) | 139 (81.8% | NS |
|---|
1 c 2 test, t-test or where appropriate Mann
Whitney U-test,
NS is not significant at the 5%
level
2 other includes own home, someone else's home,
residential drug treatment, hospital, B & B, rented
accommodation and at work
NR non-response;
SD Standard deviation
Table 8 Univariate and multivariate analysis of
injecting risk behaviours for current injectors, with
an injecting career of
six years or less, recruited into the community-wide
studies in Glasgow 2001/02 and 2004
| | | Interview year | Odds ratio (95%
CI) |
|---|
Characteristics | | Total | 2001 | 2004 | Univariate | Multivariate * |
|---|
Frequency of using
N/S exchange in average week in the previous 6
months (40
NR) | once or less/week | 282 (50.8%) | 180 (46.8%) | 102 (60.0%) | 1.00 (baseline) | 1.00 (baseline) |
|---|
2 or more/week | 233 (42.0%) | 179 (46.5%) | 54 (31.8%) | 0.53 (0.36-0.79) | 0.83 (0.52-1.32) |
Number of sterile
N/S obtained from
NE or pharmacy in average
week in previous 6 months* (4
NR) | 15 or less | 309 (56.1%) | 201 (52.8%) | 108 (63.5%) | 1.00 (baseline) | 0.38 (0.24-0.60) |
|---|
more than 15 | 242 (43.9%) | 180 (47.2%) | 62 (36.5%) | 0.64 (0.44-0.93) | 1.00 (baseline) |
Injected with
N/S previously used by someone
else in previous 6 months (6
NR) | No | 311 (56.6%) | 186 (48.8%) | 125 (74.4%) | 1.00 (baseline) | 1.00 (baseline) |
|---|
Yes | 238 (43.4%) | 195 (51.2%) | 43 (25.6%) | 0.32 (0.22-0.49) | 0.30 (0.19-0.49) |
Number of individuals borrowed previously
used
N/S from (40
NR) | one person | 116 (62.4%) | 88 (61.5%) | 28 (65.1%) | 1.00 (baseline) | 1.00 (baseline) |
|---|
2 or more people | 70 (37.6%) | 55 (38.5%) | 15 (37.6%) | 0.86 (0.42-1.75) | 0.92 (0.41-2.04) |
* Odds ratios 4 separate multivariate analysis are
presented; odds ratios were adjusted for age, gender,
recruitment setting, frequency of injection and hostel
residence in previous 6 months
Views of needle exchange staff (Table
9)
Forty exchange staff were interviewed about their views
on the new Guidelines. This included 33 pharmacy exchange
staff from 16 pharmacies and 7 needle exchange staff from
Turning Point exchange, Easterhouse
GDPS needle exchange and the Homeless
Health and Social Care Centre. From the pharmacy needle
exchanges, 19 pharmacy assistants and 14 pharmacists were
interviewed. Two nurses and five team members were
interviewed from the remaining services.
Half of the exchanges had been operating for more than
three years. The mean number of staff working in exchanges
was five, ranging from two to 24 (data not shown).
Three members of staff had received no training in
needle exchange. Just under half (19/40) had been given
informal training, which included being shown what to do by
the pharmacist and other staff, on the job training,
reading information and discussions with the pharmacy
needle exchange co-ordinator. The remainder of respondents
(17/40) had had formal training in the form of lectures and
courses.
Most staff (37/40) knew about the new Guidelines but
only 25 could correctly cite the maximum number of
n/s that could be given out per visit.
When asked what the exchange had done to implement the
new Guidelines, almost all staff (39/40) said that staff
had been informed and 36 said that clients had been
informed.
Staff reported that the most frequent way in which
IDUs had been informed of the changes
was by word of mouth and distributing information cards
(cited by 14/40). This was closely followed by the pharmacy
displaying all information that they had received about the
change (cited by 12/40).
The way in which
IDUs were informed of the change
differed between exchanges. Some staff commented that they
would inform clients only if asked directly about the
numbers that could be distributed.
"Clients are told of the change if they ask. Most just
want five to 20…never had any wanting upper limit."
(Pharmacist)
"If clients asked, we would inform them." (Pharmacy
assistant)
Other exchanges were more pro-active.
"We encourage clients to take more." (Pharmacy
assistant)
Just under two-thirds of respondents (25/40) reported
that the exchange had changed their policies or the way in
which the exchange was run after the introduction of the
new Guidelines. The changes in policy included verbal and
written policies on the number of needles and syringes to
be given out per visit, how many
n/s to be given when none were returned and
how many
n/s to give to new users.
As the change in the Lord Advocate's guidance is only a
recommendation, respondents were asked how they
individually, or as an exchange, decided on how many
needles and syringes were given out to
IDUs. Respondents reported that the
decision was based on a number of factors. Twenty-four
staff stated that it was dependent mainly on the number of
returns the individual brought back.
"If they don't have returns then we give them five."
(Pharmacy assistant).
"If equipment is not returned then only two sets will be
provided." (Pharmacy assistant).
"If people were not bringing back returns we would give
out less. We try to make people responsible." (Drug
worker)
Half of the respondents (20/40) said that the number of
n/s distributed per visit was dependent on
what the service user requested and 17 said that they used
their own experience and the exchange's policies to guide
them. Respondents also reported that all these factors
could change dependent on how well or otherwise they knew
the individual
IDU who was requesting needles and
syringes (data not shown).
There were mixed views on the impact that the Guidelines
had had on exchanges. A third (12/40) felt that the change
in guidance had no impact on the pharmacy/exchange. Nine
staff believed that the frequency of visits by individuals
had reduced and three respondents claimed that visits had
increased. Six staff felt there had been a decrease in the
number of clients who visited the exchange.
When asked their opinion on any impact on returns of
used needles and syringes, 24 had not noticed any
change.
Over a third of staff (15/40) were totally in favour of
the new Guidelines.
"I think it is a good idea, a definite improvement,
keeps them safe to have fresh needles. If they were a heavy
user the old guidance meant that they had to reuse
needles." (Nurse)
"It's better that they are getting more so that they are
not reusing them." (Pharmacy assistant)
"I think it is positive; we need to get more needles out
there. Just need to be sure that they are being safely
disposed of." (Drug worker)
"Good idea so that they are not sharing as much."
(Pharmacist)
A third of staff (14/40) did not personally approve of
the new Guidelines and nine had mixed views about the
change.
"Ridiculous, it's way too much, it's just encouraging
them. Needles would be lying all over the place. They're
not safety conscious." (Pharmacy assistant)
"I don't agree with the change, the numbers are too big.
The fact that they can ask for 20 without returns is
awful……….The old guidelines were better, even then maybe
too many." (Pharmacist)
"Think it's a bad thing, encourages them to take more
drugs. To have them lying around could be dangerous."
(Pharmacy assistant)
"In some ways it is a bad thing as it encourages them
but at the same time it reduces risks of catching viruses
so it has its good and bad points." (Pharmacy
assistant)
"Good in some ways, stops sharing, but why should we
give out so much for free?" (Pharmacy assistant)
Table 9. Views of pharmacy and needle exchange
staff on new Guidelines (n=40)
| | n |
|---|
Amount of time operating as an exchange | Under 1 year | 6 |
|---|
1-2 years | 9 |
3-7 years | 12 |
>7 years | 8 |
DK | 5 |
Training received (1 Non-response) | Informal training | 19 |
|---|
Formal training | 17 |
No training | 3 |
Aware of Lord Advocate's new Guidelines | Yes, can state new guidance | 25 |
|---|
Yes, but not sure of details | 12 |
No | 3 |
What exchange has done to implement
changes | Informed staff | 39 |
|---|
Informed clients | 36 |
Changed policies | 25 |
How exchange informs service users of
change | Word of mouth and cards | 14 |
|---|
Displays information | 12 |
Word of mouth | 7 |
Nothing has been done | 4 |
Distributes cards | 3 |
How exchange decides how many
n/s to distribute per visit | Number of returns | 24 |
|---|
Give client number requested | 20 |
Use own experience or pharmacy policy | 17 |
Impact of change on exchange | No Impact | 12 |
|---|
Decrease in frequency of visits | 9 |
Increase in number of service users | 7 |
Decrease in number of service users | 6 |
Increase in frequency of visits | 3 |
Other | 3 |
Impact on number of
n/s returned | No Change | 24 |
|---|
Increase in returns | 6 |
Decrease in returns | 4 |
Unsure | 4 |
Varied | 2 |
Personal opinion of change | In favour | 15 |
|---|
Not in favour | 14 |
Mixed opinion | 9 |
Unsure | 2 |
Chapter 4: Discussion
The results of the study indicate that, more than a year
after the introduction of the Lord Advocate's new
Guidelines, very few
IDUs in Glasgow were aware of the
increase in the maximum number of
n/s that could be obtained per needle exchange
visit; even a specially designed, targeted campaign failed
to raise awareness. Only one-fifth of injectors in both the
pre and post awareness surveys knew that the limit had been
changed.
However, despite the failure of the awareness campaign
and continuing lack of knowledge of the new Guidelines
among many
IDUs, there were some positive changes
in behaviour between the pre and post awareness
surveys.
The maximum number of
n/s that
IDUs believed could be obtained per
visit from a pharmacy or needle exchange increased
significantly between the pre and post awareness surveys
from a median of 20
n/s to a median of 25
n/s. There was a decrease in the number of
respondents obtaining sterile
n/s from non-reliable sources (
i.e. friends, other drug users, on street,
sexual partner, family, theft from reliable source and drug
dealer) in the post awareness phase.
These findings could, perhaps, indicate that although
the pre and post awareness
IDUs did not appreciate that a change in
policy had occurred, apropos the numbers of
n/s being made available to them, this may be
because the change happened gradually from the beginning of
2003. In the pre awareness phase in early 2004,
IDUS reported that they were receiving a
median of 20
n/s, more than the 15 sets recommended in the
old Guidelines, suggesting that the new Guidelines had
already increased the numbers of
n/s dispensed to individual
IDUs. If it is accepted that it may have
been difficult for
IDUs to perceive any obvious change
between the pre and post awareness period (see Conclusion),
the median increase, from 20 to 25, is impressive (
i.e. a 25% increase). However, it still falls
far short of the permitted maximum of 60
n/s per visit.
Whilst there was no difference in
n/s sharing behaviour between the pre and post
awareness periods, the proportion indicating that they had
never shared in the previous four weeks was nearly 80% in
both phases. Detecting any changes within such a short time
period among a group who, during the pre awareness period,
generally, did not share, would be very difficult. Although
non-significant, however, the proportion sharing more than
five times per month did decline from 7.1% to 4.7%.
There was a significant increase in the frequency of
injecting in the post awareness sample, however over such a
short comparative period it is difficult to say whether
this was a result in the increase in
n/s or merely a coincidence. Importantly, the
findings show that the increase in availability did not
lead to an increase in sharing of
n/s.
About three-fifths of
IDUs in both pre and post awareness
surveys said that they did not want to obtain as many as 60
n/s per visit and they were, moreover,
satisfied, generally, with the number they were currently
receiving (a mean of 19 and 21 (median 15 and 15), pre and
post awareness campaign respectively). In both samples, the
main reason for not wishing to obtain a greater number was
that this was enough for their injecting needs. Despite
this claim, half of these respondents stated that, on
average, they injected with the same needle more than once.
It is clear that many
IDUs do not yet know of the risks
involved through re-use of their own needles, nor are they
perhaps aware of the danger of inadvertently re-using a
n/s previously used by someone else if they
store their used
n/s along with those of an injecting partner
(Taylor et al 2004).
Among the two-fifths of
IDUs who did wish to receive more
needles and syringes than they were currently receiving,
the most common reason was to cut down on the number of
visits to the needle exchange. As the role of needle
exchanges and pharmacies extends beyond the dispensing of
n/s to encompass imparting harm reduction
messages,
IDUs may fail to benefit from this if
awareness and uptake of the increase reduces contact time
with health care workers. However, this does not yet appear
to have happened as reported frequency of visits to a
needle exchange in an average week also significantly
increased between pre and post awareness phases.
A further aim of the study was to determine changes in
behaviours among recent initiates to injecting in 2001-2002
and in 2004. In the 2004 survey, 170
IDUs had begun injecting in the previous
six years and their behaviours were compared with those of
385
IDUs with the same length of injecting
careers who had been interviewed in 2001-2002.
There were some demographic differences between the two
samples. In particular those in the 2004 sample were more
likely to be male and reside in the city centre. After
changing the design of the study to include an awareness
campaign, there was limited time for recruitment and the
running of the campaign. Recruitment was targeted more
towards sites where the interview team knew they could
recruit larger numbers in a short period of time. In
comparison with the 2001-2002 study, more respondents were
recruited from street sites, including homeless hostels,
most of which housed male
IDUs, and the city centre where larger
numbers of injecting drug users are known to frequent. This
may account for the significant difference in gender,
recruitment setting and area of Glasgow residence from the
study undertaken in 2001/2002.
After controlling for these demographic differences in
the analysis, injecting of cocaine (on its own) had
increased with just over half of recent initiates in 2004
reporting use of cocaine in the previous six months
compared with just under two-fifths of
IDUs in 2001-2002. With the increase of
cocaine use it might be expected that the frequency of
injecting would also increase. However there was a
significant decrease in the frequency of injecting in the
previous six months in the 2004 sample compared with the
2001-2002 sweep.
Moreover, those interviewed in 2004 were significantly
less likely to inject with a
n/s previously used by someone else; just over
half of the 2001-2002 sample had injected in the previous
six months with a
n/s previously used by someone else in
comparison with a quarter of the 2004 cohort. While it
cannot be said with certainty that there is a causal link
between the introduction of the new Guidelines and these
behaviour changes (other factors may have influenced the
changes between 2001-2002 and 2004), nevertheless, it is
encouraging to note that both frequency of injecting and
frequency of sharing used
n/s has reduced among new injectors
interviewed in 2004 in comparison with their peers in
2001-2002.
A third aim of the study was to ascertain the views of
needle exchange and pharmacy staff about the change in
Guidelines. The survey of 40 staff members showed that
almost all knew about the change in Guidelines and almost
all had informed clients of this change. However, it
appeared that, apart from displaying information about the
new Guidelines, some staff directly told
IDUs of the change only if asked. Other
staff were more pro-active and explained the change to
clients and encouraged them to take more
n/s.
Just over a third of staff approved of the new
Guidelines, one third disapproved of them and the remainder
had mixed views. Furthermore, whilst just under two thirds
said that the number of
n/s that they dispensed depended on the number
of returns they received, some respondents said that they
decided what to dispense according to how well they knew
the client.
These findings - that some staff were less forthcoming
in telling
IDUs of the change in guidelines; that
two-thirds were either opposed to or had mixed views of the
change; and that dispensing can sometimes depend on the
individuals requesting
n/s - may help explain why there was so little
awareness of the new Guidelines among the
IDU population.
Over one-fifth of staff members believed that frequency
of visits by individual
IDUs had reduced since the change. This
contrasts with the results of the
IDU survey, which indicated that visits
to needle exchanges had increased. However the opening of
more pharmacy exchanges since the new Guidelines had been
implemented could have been a reason for a drop in the
frequency of visits that some exchanges were
experiencing.
The majority of staff believed that the guidelines had
had no impact on the number of needles returned to the
exchange.
Conclusion
More than a year after the introduction of the Lord
Advocate's new Guidelines, very few
IDUs in Glasgow were aware of the
increase in the maximum number of
n/s that could be obtained per needle exchange
visit; even a specially designed, targeted campaign failed
to raise awareness.
After the introduction of the new Guidelines, needle
exchanges and pharmacies displayed information and informed
IDUs. The results of the staff survey,
however, indicated that some staff did not actively promote
the increase to services users. Moreover, only one-third of
staff approved of the new guidelines and some used their
own judgement in deciding how many
n/s should be given out.
It may be that the reluctance to implement, or
disapproval of, the guidelines among some staff was one
reason for the low level of awareness among
IDUs. Needle exchange and pharmacy staff
need, therefore, to be made more aware of the necessity to
actively provide oral advice and information to their
clients.
The attitude of some staff, however, does not explain
why the targeted awareness campaign also failed to inform
the majority of
IDUs. Poster and cards were distributed
to all exchange outlets and the cards were inserted in all
n/s packs. Yet this strategy, too, failed to
increase knowledge among
IDUs.
One of the study findings indicated that
IDUs did not, generally, wish to have
any more
n/s than they were currently receiving (about
20 per visit). The message contained in the awareness
campaign (or imparted by pharmacists) that more
n/s were available was therefore meaningless
to them. The main reason for not wanting more
n/s was that the current level was sufficient
for their needs. However it was noted that half of these
IDUs were re-using their own
n/s; yet the awareness campaign cards alerted
IDUs to the risks involved in this.
Due to time constraints, the time period for the
awareness campaign was six weeks. After this period,
recruitment for the post awareness group began. Cards and
posters were distributed to agencies throughout the city
and were placed inside the packs of
n/s that are distributed through the pharmacy
exchanges. The cards placed within the packs, however,
would not have reached some injectors until towards the end
of the recruitment period. It may be that if the campaign
had run for a longer period it would have had more
impact.
There is some evidence, however, that leaflets are not
successful in communicating messages to
IDUs (Wright et al). Some
IDUs may, for example, have literacy
problems that render written material ineffective. There is
perhaps a need to evaluate the readability of written harm
reduction materials and to design and evaluate new ways of
delivering harm reduction messages to
IDUs.
Nevertheless, there have been some positive changes in
behaviours among
IDUs in Glasgow since the introduction
of the awareness campaign and since 2001.
The maximum number of
n/s that
IDUs believed could be obtained per
visit from a pharmacy or needle exchange increased
significantly. Respondents were also less likely to obtain
sterile
n/s from non-legitimate sources in the post
awareness phase. Whilst frequency of injecting had
increased, there was no increase in sharing behaviour. A
comparison between recent initiates to injecting in
2001-2002 and 2004 found a decrease in both frequency of
injecting and sharing in 2004.
These changes cannot definitely be proved to arise
directly from the increased availability of
n/s; other factors may have influenced
behaviour between 2001-2002 and 2004. Nevertheless, the
association between the introduction of the new Guidelines
and behaviour changes suggests that the former may be
having a positive impact on
IDUs behaviours. It would seem prudent
to continue with the current policy on
n/s distribution. However, the findings of
this study also suggest that further work may need to be
done by needle exchange staff to inform
IDUs of their entitlement to a greater
number of
n/s, and to encourage them to make use of
their entitlement.
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