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Self-reported changes in drug use behaviors and syringe disposal methods following the opening of a supervised… Kinnard, Elizabeth N; Howe, Chanelle J; Kerr, Thomas; Skjødt Hass, Vibeke; Marshall, Brandon D Oct 28, 2014

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RESEARCH Open AccessSelf-reported changes in drug use behaviors andsyringe disposal methods following the openingsyringe disposal). As a public health intervention, Copenhagen’s SIF has successfully reached PWID engaging in riskKinnard et al. Harm Reduction Journal 2014, 11:29http://www.harmreductionjournal.com/content/11/1/29USAFull list of author information is available at the end of the articlebehavior. To fully characterize the impacts of this and other Danish SIFs, further research should replicate this studywith a larger sample size and prospective follow-up.Keywords: Supervised injecting facility, Drug consumption room, People who inject drugs, Injection drug users, Harmreduction, Risk behaviors, Syringe disposal, Denmark* Correspondence: Elizabeth_Kinnard@brown.edu1Department of Behavioral and Social Sciences, Brown University School ofPublic Health, 121 South Main Street, Box G-S-121-4, Providence, RI 02912,reduce harm and promote health among PWID, as well asof a supervised injecting facility in Copenhagen,DenmarkElizabeth N Kinnard1*, Chanelle J Howe2, Thomas Kerr3,4, Vibeke Skjødt Hass5 and Brandon DL Marshall2AbstractBackground: In Denmark, the first standalone supervised injecting facility (SIF) opened in Copenhagen’s Vesterbroneighborhood on October 1, 2012. The purpose of this study was to assess whether use of services provided by therecently opened SIF was associated with changes in injecting behavior and syringe disposal practices amongpeople who inject drugs (PWID). We hypothesized that risk behaviors (e.g., syringe sharing), and unsafe syringedisposal (e.g., dropping used equipment on the ground) had decreased among PWID utilizing the SIF.Methods: Between February and August of 2013, we conducted interviews using a survey (in English and Danish)with forty-one people who reported injecting drugs at the SIF. We used descriptive statistics and McNemar’s test toexamine sociodemographic characteristics of the sample, current drugs used, sites of syringe disposal before andafter opening of the SIF, and perceived behavior change since using the SIF.Results: Of the interviewed participants, 90.2% were male and the majority were younger than 40 years old (60.9%).Three-quarters (75.6%) of participants reported reductions in injection risk behaviors since the opening of the SIF,such as injecting in a less rushed manner (63.4%), fewer outdoor injections (56.1%), no longer syringe sharing(53.7%), and cleaning injecting site(s) more often (43.9%). Approximately two-thirds (65.9%) of participants did notfeel that their frequency of injecting had changed; five participants (12.2%) reported a decrease in injecting frequency,and only two participants (4.9%) reported an increase in injecting frequency. Twenty-four (58.5%) individuals reportedchanging their syringe disposal practices since the opening of the SIF; of those, twenty-three (95.8%) reported changingfrom not always disposing safely to always disposing safely (McNemar’s test p-value < 0.001).Conclusions: Our findings suggest that use of the Copenhagen SIF is associated with adoption of safer behaviors thatpractices that benefit the Vesterbro neighborhood (i.e., safer© 2014 Kinnard et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the CreativeCommons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly credited. The Creative Commons Public DomainDedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article,unless otherwise stated.Kinnard et al. Harm Reduction Journal 2014, 11:29 Page 2 of 8http://www.harmreductionjournal.com/content/11/1/29BackgroundSupervised, or safer, injecting facilities (SIFs) — alsoknown as supervised injecting rooms (SIRs), supervisedinjecting sites (SISs), and drug consumption rooms(DCRs) — have historically been implemented in re-sponse to public health and safety concerns that arisefrom street-based injecting in urban areas [1]. The pri-mary objectives of SIFs are to reduce morbidity andmortality that would otherwise occur from syringe shar-ing, public injecting, and other activities [1], specificallyinfectious disease transmission and fatal overdose, andto connect people who inject drugs (PWID) to varioushealth and social programs. These facilities are oftenviewed as complementing other harm reduction inter-ventions [2], by allowing for the consumption of pre-obtained illicit substances in the most hygienic way pos-sible under the supervision of healthcare professionals(e.g., nurses), and thus resulting in improved health andsocial equity for PWID [3,4].SIFs around the world typically provide a calm, well-lit, health-oriented venue to inject, as well as access toclean injecting equipment, referrals to external services,and emergency assistance in the event of an overdose.Some SIFs are highly comprehensive in their approach[2,5], providing a host of medical, legal, and social ser-vices, such as extensive counseling, subsidized food,showers, lockers, and laundry services [1,2,4-6]. Overall,by addressing addiction as a chronic, relapsing healthcondition, SIFs have been found to reduce barriers toaccessing health-centered care for PWID [7-11].Beyond promoting the health of PWID, SIFs have alsoproven beneficial for the larger communities surround-ing them. Municipalities that have implemented SIFshave seen reduced rates of drug injection in publicspaces, reduced burden of illegal drug use on the com-munity, and expanded opportunities to work with PWID[2,12,13]. Specifically, results from Sydney, Australia andVancouver, Canada have shown reduced public injectingand discarded needles, as well as decreased drug over-dose mortality rates in neighborhoods in which SIFs arelocated [11,13-18]. Moreover, the European MonitoringCentre for Drugs and Drug Addiction (EMCDDA) haspublished two comprehensive reports on SIFs, conclud-ing that they reach and are accepted by vulnerable targetpopulations, reduce high-risk drug using behavior, pre-vent drug use in open spaces and related public disorder,and improve the health of PWID, and are thus recom-mended as part of local public health strategies [3,14,19].Gaining broad-based community support for SIFs isfrequently a key component of implementing these in-terventions [2]. This was true in Denmark, where thereexisted a clear need to reduce mortality rates amongPWID, and to reduce public injecting and discardedparaphernalia [20-22]. In September 2011, Fixerum, anongovernmental organization (NGO), opened a mobileSIF in Copenhagen, which provided services for PWIDwithout police or government interference for ten months[14]. In June 2012, the Danish parliament adopted a newamendment (Executive order no. 606) to an existing lawon psychoactive substances that gave municipalities a legalmandate allowing them to implement and operate standa-lone SIFs, with permission from the Minister of Health[14,23]. The Danish parliament included language in thenew law that instructed police and prosecutors not tosearch, seize, and prosecute users who were in possessionof “small quantities” of controlled substances for personaluse “in and nearby” SIFs [24]. Copenhagen’s first standa-lone (non-mobile) SIF was subsequently established onOctober 1, 2012 in the Vesterbro neighborhood, wheredrug dealing and public injection drug use have historic-ally been concentrated [20,25]. Users of the SIF are re-stricted to injecting inside the facility, but clients arepermitted to smoke or sniff illicit drugs in the designatedoutside area; thus, Danes often refer to the greater healthfacility as a more all-encompassing drug consumptionroom (DCR) [26].To date, no peer-reviewed article evaluating behaviorsand practices among PWID accessing the CopenhagenSIF, and how the facility may affect the greater Vesterbrocommunity, has been published. However, MændenesHjem (the Men’s Home) in Copenhagen has conducteda survey administered among users of the SIF to investi-gate their experiences and satisfaction with the facility[27]. The purpose of our study was to assess whetheruse of the services provided by the recently opened SIFin Copenhagen was associated with changes in injectingbehavior and syringe disposal practices among PWID.We hypothesized that risk behaviors (e.g., syringe shar-ing), and unsafe syringe disposal (e.g., dropping usedequipment on the ground) decreased among PWID util-izing the SIF.MethodsStudy populationMembers of our research team approached individualsseated in the outdoor area adjacent to the SIF to ask ifthey would be willing to take part in a study regardingtheir use of SIF services. Due to a limited timeframe forprimary data collection in Copenhagen, convenience sam-pling approaches were employed. Eligible persons werethose who reported having injected drugs at the SIF inCopenhagen, Denmark at least once since its opening onOctober 1, 2012. Participants were excluded if they onlyused drugs at the Copenhagen SIF via routes of adminis-tration other than injecting (i.e. snorting, smoking, etc.).Individuals who were eligible and agreed to participate inthe study were asked to complete a survey aimed at gain-ing insight into injecting behaviors and syringe disposalKinnard et al. Harm Reduction Journal 2014, 11:29 Page 3 of 8http://www.harmreductionjournal.com/content/11/1/29practices prior to and following the opening of the SIF. In-dividuals who completed the survey were asked to refertheir acquaintances who also used the SIF for studyparticipation. All interviews were conducted betweenFebruary and August of 2013.Survey measures and administrationParticipants completed a structural behavioral survey inDanish or English, and either self-administered the sur-vey or were interviewed by a member of the researchteam. If participants chose to self-administer the survey,a research assistant was available to answer any ques-tions. All interviews were completed in person at theSIF, directly outside the building in an adjacent sittingarea. Privacy during the interview sessions was ensuredto the greatest extent possible by sitting in a secludedsection of the outdoor seating area. At any point, partici-pants could choose to skip a question or terminate theinterview. Participants were given consent forms explain-ing the goals of the study, with contact information for theproject supervisor at Brown University.The survey included questions about sociodemo-graphic characteristics, current drugs used, most com-mon sites of injecting, frequency of use at the SIF,quality of relationships with the community and thepolice, as well as other activities and behaviors (e.g.,overdose). We assessed the presence and absence ofinjecting risk behaviors such as rushed/stressful inject-ing, outdoor injecting, needle and syringe sharing, clean-ing injection site(s), difficulty in finding a vein, reusingone’s own needles/syringes, using clean water to inject,and requiring assistance injecting. Specifically, we askedparticipants whether they felt they had changed any oftheir reported injecting behaviors that they practiced be-fore using the SIF. Finally, participants were also askedwhether they felt their frequency of injecting had chan-ged since using the SIF.We also assessed primary sites of syringe disposal be-fore and after the opening of the SIF to determinewhether use of the SIF was associated with safer syringedisposal methods. Specifically, if participants endorsedone or more of the following choices when asked aboutprimary sites of syringe disposal — returned them (sy-ringes) to the needle exchange (or SIF), put them in myown sharps container, or put them in an outdoor sharpscontainer — they were coded as “always safe”. If theyendorsed any of the following choices — threw them inthe garbage, dropped them on the ground, gave them toanother user, flushed them down the toilet, or other —they were coded as “not always safe.” This method ofcoding was used to produce two dichotomous variables —which indicated “always safe” vs. “not always safe” beforethe opening of the SIF, and “always safe” vs. “not alwayssafe” after the opening of the SIF.Statistical analysisDescriptive statistics were used to examine demographiccharacteristics of the sample, current drugs used, enroll-ment in treatment in the last six months, frequency ofuse at the SIF, and primary site(s) of injecting before theSIF opened. Next, sites of syringe disposal before andafter the opening of the SIF were compared to assesswhether participants’ primary sites of syringe disposalchanged following the facility’s opening. McNemar’s testwas used to assess whether participants who reportedchanging their syringe disposal practices were signifi-cantly more likely to change from “not always safe” to“always safe” after the SIF’s opening. Finally, we evalu-ated perceived behavior change and perceived frequencychange using descriptive statistics. All p-values are two-sided at α = 0.05, and all analyses were conducted inSPSS (version 22.0).This research was conducted as part of a Global Inde-pendent Study Project (GLISP) through Brown University.Based on Brown University’s Human Research ProtectionProgram Policy and Procedure Manual, Section 11, (http://www.brown.edu/research/human-research-protection-program-policy-and-procedure-manual-section-11), thisresearch project did not meet the definition of research(i.e. the data collected was part of an undergraduate pro-ject and did not receive external funding), and thereforeIRB review was not required. At no point during thestudy was personally identifiable information collected, andsurveys were kept strictly anonymous and confidential.ResultsAs shown in Table 1, of the 41 eligible and interviewedparticipants, 37 (90.2%) were male, and the median ageof participants was 37 years old (25th; 75th percentiles =30; 43). A total of 33 participants (80.5%) were born inDenmark, while the remaining 8 (19.5%) were bornabroad. When asked about their current housing situ-ation, 11 participants (26.8%) reported being homeless,12 (29.3%) had temporary housing, and 18 (43.9%) re-sided in a permanent residence. The median age of firstinjection was 18 years old (17; 22). Seventeen partici-pants (41.5%) had been arrested or charged with a crimein the past six months.Also shown in Table 1, cocaine was the most fre-quently used drug at the SIF, reported by 30 participants(73.2%), followed by heroin, reported by 25 participants(61.0%). Twenty-four participants (58.5%) reported anyenrollment in substance abuse treatment in the last sixmonths. The primary injecting location before the SIFopened was outdoors (e.g. street, park, parking lot), re-ported by 25 participants (61.0%), followed by their owndwelling (56.1%). Since the SIF opened, the majority ofparticipants (61.0%) reported using the facility at leastonce a week.As shown in Table 2, the number of people who re-Table 1 Characteristics and drug use behaviors reportedby a sample of people who inject drugs at a supervisedinjecting facility in Copenhagen, Denmark (n = 41)Characteristic n (%)bAge (median, 25th; 75th) 37 (30; 43)22 – 30 11 (26.8)31 – 40 14 (34.1)41 – 49 13 (31.7)50 – 57 3 (7.3)SexFemale 4 (9.8)Male 37 (90.2)Born in DenmarkYes 33 (80.5)No 8 (19.5)Current housingHomeless 11 (26.8)Temporary 12 (29.3)Permanent 18 (43.9)Age of first injection (median, 25th; 75th) 18 (17; 22)12 – 17 16 (39.0)18 – 23 17 (41.5)24 – 29 4 (9.8)30 – 43 4 (9.8)Drugs currently used at SIFCocaine 30 (73.2)Heroin 25 (61.0)Methadone 11 (26.8)Speedball 4 (9.8)Ritalin 4 (9.8)Other 8 (19.5)Enrolled in treatmentaAny substance abuse treatment 24 (58.5)Opioid replacement therapy 20 (48.8)24 hour treatment 3 (7.3)Other 6 (14.6)Frequency of use at SIFaEvery day 12 (29.3)Every couple of days 10 (24.4)Once a week 3 (7.3)Every couple of weeks 5 (12.2)Once a month 3 (7.3)Less than once a month 5 (12.2)Arrested/charged with crimeaYes 17 (41.5)No 22 (53.7)Table 1 Characteristics and drug use behaviors reportedby a sample of people who inject drugs at a supervisedinjecting facility in Copenhagen, Denmark (n = 41)(Continued)Primary site of fixing before SIFOutdoors (street, park, lot, etc.) 25 (61.0)Own place 23 (56.1)Other’s place 16 (39.0)Public washroom 16 (39.0)Other 2 (4.9)Note: n’s do not sum to 41 and proportions do not sum to 100% due tomissing values or the possibility of endorsement of more than one option forsome questions.Note: all data collected between February and August, 2013.a= refers to activities or behaviors in the last 6 months.b= n (%) unless otherwise specified.Kinnard et al. Harm Reduction Journal 2014, 11:29 Page 4 of 8http://www.harmreductionjournal.com/content/11/1/29ported disposing of their used syringes by returning themto the needle exchange or SIF increased from 14 partici-pants (34.1%) before the SIF opened to 36 participants(87.8%) after the SIF opened. The only unsafe disposalmethod that was still reported by participants after theopening of the SIF was throwing syringes in the garbage,but this behavior decreased from 23 participants (56.1%)before to 5 participants (12.2%) after the opening of theSIF. All other unsafe methods (i.e. dropped them on theground, gave them to another user, flushed them downthe toilet, or other) were reported infrequently before theSIF opened, but were not reported by any participant afterthe SIF opened. In total, twenty-four individuals (58.5%)reported changing their syringe disposal practices follow-ing the opening of the SIF; of those, twenty-three (95.8%)reported changing from not always disposing safely toTable 2 Primary locations for disposal of used syringesamong a sample of people who inject drugs before andafter the opening of a supervised injecting facility inCopenhagen, Denmark (n = 41)Disposal mechanism/site Before SIFopened n (%)After SIFopened n (%)Returned to the needle exchange(or SIF)14 (34.1) 36 (87.8)Put them in an outdoors sharpscontainer19 (46.3) 8 (19.5)Put them in their own sharps container 11 (26.8) 6 (14.6)Threw them in the garbage 23 (56.1) 5 (12.2)Dropped them on the ground 5 (12.2) 0 (0.0)Gave them to another user 2 (4.9) 0 (0.0)Flushed them down the toilet 4 (9.8) 0 (0.0)Other 3 (7.3) 0 (0.0)Note: n’s do not sum to 41 and proportions do not sum to 100% becauseparticipants may have identified more than one location as primary site ofused syringe disposal.Note: all data collected between February and August, 2013.always disposing safely, (McNemar’s test, p < 0.001) whileonly one individual (4.2%) reported the reverse behavior.As shown in Table 3, 31 individuals (75.6%) believedtheir behaviors had changed since utilizing the servicesat the SIF. As compared with their behaviors before theSIF opened, 26 participants (63.4%) reported less rushed/stressful injections, 23 participants (56.1%) reported lessinjecting outdoors, 22 participants (53.7%) reported nolonger sharing needles, and 18 participants (43.9%) re-ported cleaning the injecting site on their skin more often.Other types of behavior change reported by participantsare shown in Table 3. The majority (65.9%) did not feelthat their frequency of injecting had changed; however,five participants (12.2%) reported a decrease in injectingfrequency, while only two participants (4.9%) reported anincrease in injecting frequency.DiscussionOur results from interviews with a small sample of PWIDsuggest that use of the SIF in Copenhagen was associatedwith positive self-reported behavior change and safer syr-Any perceived behavior change 31 (75.6)Kinnard et al. Harm Reduction Journal 2014, 11:29 Page 5 of 8http://www.harmreductionjournal.com/content/11/1/29Less rushed/stressful 26 (63.4)Less injecting outdoors 23 (56.1)No longer share needles 22 (53.7)Clean injection site more often 18 (43.9)Easier to get vein first time 16 (39.0)Reuse own needles less often 11 (26.8)Use clean water more often 11 (26.8)No longer need help injecting 6 (14.6)Other 3 (7.3)Perceived frequency changeNo change 27 (65.9)Decreased (inject less often) 5 (12.2)Increased (inject more often) 2 (4.9)Unsure 4 (9.8)inge disposal practices. Given that the majority of partici-pants reported unstable housing and outdoor injectingbefore the SIF opened, we conclude that the SIF has beensuccessful in engaging a hard-to-reach population thatwould otherwise inject primarily outdoors in the Vesterbroarea. Furthermore, the majority of participants (61.0%) re-ported using the SIF at least once a week, which demon-strates that the SIF can serve as a low-threshold healthTable 3 Perceived behavior and frequency change among asample of people who inject drugs at a supervised injectingfacility since its opening in Copenhagen, Denmark (n = 41)Characteristic n (%)Note: n’s do not sum to 41 and proportions do not sum to 100% due tomissing values or where participants endorsed more than one option.Note: all data collected between February and August, 2013.service to engage PWID [27]. Finally, our results suggestthat the SIF fills an important gap of other harm reductioninterventions in Copenhagen, which do not engage PWIDbeyond provision of injecting equipment [2].Three-quarters of our sample believed their behaviorshad changed since using the SIF, such as injecting in aless rushed manner, injecting outdoors less often, nolonger syringe sharing, and cleaning injecting site(s)more often. Of particular interest is the reduction inpublic injecting, known to be associated with an elevatedrisk of blood-borne virus acquisition [28] and overdose[29,30]. Injecting in public (and in other settings inwhich maintaining a hygienic drug-using environment isdifficult), has also been associated with vascular harmand bacterial infection [31-33]. By providing a nonjudg-mental, low-threshold venue, (i.e. use of SIF services re-quires little bureaucracy, no payment, and is not linkedto an obligation of the client to be or to become drug-free) [34] for PWID to consume pre-obtained substances,the Copenhagen SIF has the potential to significantlylower the frequency of deleterious injecting episodes forlocal drug users. Overall, our finding that users of the SIFhave reported a reduction in public injecting, as well as areduction in publicly discarded syringes, supports theharm reduction framework and goals that the SIF aimedto achieve [30,31].Our study adds to the SIF literature, which consists ofmany reports showing that public drug use has declinedsince the implementation of SIFs in Vancouver, Sydney,and multiple western European cities [11,13,15,17,18,35-39],as well as reports of fewer discarded syringes found in allSwiss cities that have implemented SIFs [2,14,40].Finally, we found associations between use of the SIFand decreased equipment sharing, as well as improvedinjecting hygiene and technique, in accordance with theexisting literature [31,35,41-43]. There was no evidencethat use of the SIF significantly changed self-reportedinjecting frequency. This supports previous researchdemonstrating that SIFs do not result in increasedinjecting frequency among PWID accessing such facil-ities [44,45]. We conclude that, overall, utilization of theSIF has resulted in positive behavior change towardhealthier injecting hygiene and reduced risk of blood-borne disease transmission among study participants.Regarding the capacity of the facility, findings from theMen’s Home’s survey found that approximately 22% ofreported injections take place in the users' own homes,and 22% still in the public domain [27]. According toour data, before the SIF opened, 61% of injections tookplace in the public domain (outdoors) and 56.1% inusers’ own homes. Although we did not ask specificallyabout primary locations of injecting after the opening ofthe SIF, 56.1% of our sample reported injecting outdoorsless frequently. The capacity of the current SIF toKinnard et al. Harm Reduction Journal 2014, 11:29 Page 6 of 8http://www.harmreductionjournal.com/content/11/1/29accommodate just over half of users’ daily injections isan important finding [27]. Aside from the sheer numbersof injections that the SIF can accommodate, the interviewsfrom the Men’s Home indicate that users choose the SIFfor their drug consumption rather than elsewhere becauseof the security in knowing that there is a health profes-sional to help them should they require medical attentionfor an overdose or other health issue. Since the data col-lection phase of both studies, an additional drug con-sumption room, “Skyen”, or “The Cloud”, has openednearby in The Men’s Home itself, which can seat eight in-dividuals for injecting and six for smoking, augmentingthe overall capacity of SIFs in Copenhagen [27,46].To assess whether we reached a sample of PWID simi-lar to that of the Men’s Home’s study, we comparedsociodemographic characteristics across the two studies[27]. Their questionnaire, administered in spring 2013,was answered by 56 newly registered users. Their samplecomprised 30% female users, while our sample com-prises 10% females. Thus, it appears that women may beunder-represented in our study. However, the age distri-bution of the two samples are similar: the participants ofthe Men’s Home survey were between 22 and 53 years,with a mean age of 38 years, while the ages in our sam-ple spanned 22 years to 57 years, with the mean age at37 years. We also note that the Men’s Home’s samplecomprised a very frequent group of users; nearly half ofsurvey participants presented at the SIF several times aday. Our survey also captured frequent users, as overhalf came every day or a few times a week, although wealso captured infrequent users, as 20% reported comingonce a month or less.One of the primary limitations of our study is a smallsample size and limited power to conduct bivariable stat-istical tests. Further research with a larger sample size isrecommended to confirm the observed findings. More-over, convenience sampling approaches, which wereused in this study to recruit participants who presentedat the SIF, may prevent generalization to a wider drug-using population in Denmark. As the registry of users atthe SIF is completely anonymous, there was no avail-able sampling frame from which to draw for this study.Now that Denmark has implemented additional SIFs inCopenhagen and other cities, it would be beneficial forpublic health professionals to conduct a multisite studyto examine how PWID’s demographics vary among thesites, or how particular programmatic elements of eachsite have proven successful or unsuccessful.Our study is subject to a number of additional limita-tions. First, we relied on self-reported behavior changeassessed at one point in time, rather than measuringthese variables prospectively at multiple time points,which could introduce bias due to measurement error.The cross-sectional structured behavioral survey alsodoes not allow for inferences about temporal associa-tions and causal pathways between measured factors.However, as our questions were posed in a way thatasked about behaviors before and after the opening ofthe SIF, we believe that our conclusions regarding theassociation between use of the SIF and behavior changehave merit. Second, this study only assessed the short-term effect of the SIF; thus, additional studies shouldaim to assess longer-term impact on the health behav-iors of PWID. Third, a further limitation of our study re-lates to the sociodemographic characteristics of thesample (e.g., comprised predominately of men). Thus,our results are not entirely representative and may notcapture the true lived experiences and behavior changesof women who use the SIF.Fourth, the survey instrument was not delivered uni-formly to all participants; the survey was either self-administered or read aloud by a research assistant, anddelivered in either English or Danish. Some members ofour research team were not bilingual in English andDanish, and participants may have opted to have thesurvey read aloud in English even though their primarylanguage was Danish, which could have led to misinter-pretations and misreporting of personal information andbehavior change. It is therefore possible that some be-haviors could be under-reported, over-reported, or mis-reported. Finally, ascertainment of stigmatized behaviorsmight have introduced social desirability biases, espe-cially when research assistants read the survey itemsaloud. This may have been mitigated by providing par-ticipants with the opportunity to self-administer thesurvey, an option they would have most likely chosenhad they felt the questions were too sensitive or stig-matizing [47].ConclusionsOur findings indicate that utilization of services pro-vided by the first standalone SIF in Copenhagen is asso-ciated with self-reported adoption of safer behaviors thatreduce harm and promote health among people whoinject drugs (e.g., less rushed/stressful injections, lessinjecting outdoors, and no longer sharing needles). Useof the SIF was also associated with changes in practicesthat benefit the Vesterbro neighborhood (i.e., safer syr-inge disposal). As a public health intervention, the SIF inCopenhagen has successfully reached PWID engaging inhigh-risk behavior, has not led to an increase in overallfrequency of injecting, and has resulted in benefits forthe greater community. Since the data collection phaseof this study, there have been additional SIFs imple-mented in Copenhagen and across Denmark, whichmerit their own research and evaluation. However, thispilot peer-reviewed evaluation provides the first evidencethat the expansion of Danish SIFs is likely a positive,Kinnard et al. Harm Reduction Journal 2014, 11:29 Page 7 of 8http://www.harmreductionjournal.com/content/11/1/29effective strategy towards improving the health and so-cial equity for people who inject drugs.AbbreviationsDCR: Drug consumption room; PWID: People who inject drugs;SIF: Supervised injecting facility.Competing interestsThe authors declare that they have no competing interests.Authors’ contributionsENK carried out the design of the survey instrument, data collection, datacoding and entry, and writing the scientific manuscript. CJH assisted inconceptualizing and revising the manuscript. TK assisted in designing thesurvey instrument and revising the manuscript. VSH assisted with surveytranslation into Danish, data collection, back-translation, and revising themanuscript. BDLM assisted in designing the survey instrument, communicatingwith Brown University IRB, advising from abroad (U.S.A.) during data collection,data coding, and revising the manuscript. All authors read and approved thefinal manuscript.AcknowledgementsWe would like to thank Nanna W. Gotfredsen and Anja Plesner Bloch,who both participated in key informant interviews, survey administration,and data collection; Michael Lodberg Olsen and Emil Kiørboe, who wereboth interviewed as part of key informant interviews; and Rasmus KobergChristiansen, who was interviewed as part of key informant interviews andaided in revision of the survey instrument.Author details1Department of Behavioral and Social Sciences, Brown University School ofPublic Health, 121 South Main Street, Box G-S-121-4, Providence, RI 02912,USA. 2Department of Epidemiology, Brown University School of PublicHealth, 121 South Main Street, Box G-S-121-2, Providence, RI 02912, USA.3Faculty of Medicine, University of British Columbia, 317 - 2194 HealthSciences Mall, Vancouver, BC V6T 1Z3, Canada. 4Urban Health ResearchInitiative, British Columbia Centre for Excellence in HIV/AIDS, 608 – 1081Burrard Street, Vancouver, BC V6Z 1Y6, Canada. 5The Saxo Institute, Faculty ofHumanities, University of Copenhagen, Karen Blixens Vej 4, DK-2300Copenhagen, Denmark.Received: 3 July 2014 Accepted: 22 September 2014Published: 28 October 2014References1. 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Harm ReductionJournal 2014 11:29.Submit your manuscript at www.biomedcentral.com/submit


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