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More than just needles: An evidence-informed approach to enhancing harm reduction supply distribution… Buxton, Jane A; Preston, Emma C; Mak, Sunny; Harvard, Stephanie; Barley, Jenny Dec 24, 2008

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ralssBioMed CentHarm Reduction JournalOpen AcceResearchMore than just needles: An evidence-informed approach to enhancing harm reduction supply distribution in British ColumbiaJane A Buxton*1,2, Emma C Preston1, Sunny Mak1, Stephanie Harvard1, Jenny Barley and BC Harm Reduction Strategies and Services CommitteeAddress: 1Epidemiology Services, British Columbia Centre for Disease Control, 655 West 12th Avenue, Vancouver, Canada and 2School of Population and Public Health, University of British Columbia, 5804 Fairview Avenue, Vancouver, CanadaEmail: Jane A Buxton* - jane.buxton@bccdc.ca; Emma C Preston - emma.preston@bccdc.ca; Sunny Mak - sunny.mak@bccdc.ca; Stephanie Harvard - stephanie.harvard@bccdc.ca; Jenny Barley - jbarley@interchange.ubc.ca; BC Harm Reduction Strategies and Services Committee - jane.buxton@bccdc.ca* Corresponding author    AbstractBackground: The BC Harm Reduction Strategies and Services (HRSS) policy states that eachhealth authority (HA) and their community partners will provide a full range of harm reduction(HR) services to their jurisdictions and these HR products should be available to all who need themregardless of where they live and choice of drug. Preliminary analysis revealed wide variationsbetween and within HAs.Methods: The objective of this study is to analyze distribution of HR products by site usingGeographic Information Systems (GIS) and to investigate the range, adequacy and methods of HRproduct distribution using qualitative interviews. The BC Centre for Disease Control pharmacydatabase tracks HR supplies distributed to health units and community agencies. Additionally,eleven face-to-face interviews were conducted in eight mainland BC communities using an open-ended questionnaire.Results: There is evidence in BC that HR supplies are not equally available throughout theprovince. There are variations within jurisdictions in how HR supplies are distributed, adequacy ofcurrent HR products, collection of used needles, alternative uses of supplies and communityattitudes towards HR. GIS illustrates where HR supplies are ordered but with secondarydistribution, true reach and availability of supplies cannot be determined.Conclusion: Currently, a consultant is employed to develop a 'best practice' document; relevanthealth files, standard training and protocols within HAs are also being developed. There is a needto enhance the profile and availability of culturally appropriate HR services for Aboriginalpopulations. Distribution of crackpipe mouthpieces is being investigated.Background each of the 5 regional health authorities, the BC MinistryPublished: 24 December 2008Harm Reduction Journal 2008, 5:37 doi:10.1186/1477-7517-5-37Received: 4 August 2008Accepted: 24 December 2008This article is available from: http://www.harmreductionjournal.com/content/5/1/37© 2008 Buxton et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 7(page number not for citation purposes)The British Columbia (BC) Harm Reduction Strategiesand Services (HRSS) committee has representation fromof Health and the BC Centre for Disease Control(BCCDC). The BC HRSS policy states that each healthHarm Reduction Journal 2008, 5:37 http://www.harmreductionjournal.com/content/5/1/37authority and their community partners will provide a fullrange of harm reduction (HR) services to their jurisdic-tions and that the HR products should be available to allwho need them regardless of where they live and choice ofdrug [1]. The HR products distributed include condomsand lubricants, needles and syringes, alcohol swabs andsterile water and are funded by the BC Ministry of Healthand subsidized by the Provincial Health Services Author-ity.The HR product distribution is coordinated by BCCDC;the BCCDC pharmacy database tracks HR productsordered by health units and community agencies(approved by the health authorities) that distribute thesupplies. Over 20 products are currently available for dis-tribution to the more than 150 ordering sites in BC. Pre-liminary analysis of the data revealed wide variationsbetween and within health authorities. As a result of thesediscrepancies we identified a need to evaluate currentproduct supply distribution, identify gaps, cost-savingmeasures and potential future demands.The objective of this study is to:1) Analyze distribution of HR products by site using geo-graphic information systems2) Investigate the range, adequacy and methods of HRproduct distribution using qualitative interviews.Much of the current information and knowledge sur-rounding HR in BC is derived from Vancouver; thereforewe sought to include the perspectives of distribution sitesoutside Vancouver.MethodsProduct distribution by site was obtained from theBCCDC pharmacy database. We used a period of 19months (May 2006-November 2007) to ensure inclusionof sites that placed infrequent orders i.e. less than annu-ally. All needles with syringes attached (0.5 and 1 cc) andindividual needles (but not individual syringes) were col-lated to produce the total volume of needles distributedand were analyzed using geographic information systems.Interview sites were selected purposively from BCCDCpharmacy database to ensure a range of geographic factorsand volume of supplies distributed. An invitation letterwas sent to the contact at each selected site. A researchassistant contacted potential participants to arrange anapproximately one-hour in-person interview.The semi-structured interviews consisted of open-endedlection progressed [2]. Interviews were audio-taped andthe research assistants made field notes of their observa-tions.Questionnaire domains included:1) How HR supplies are distributed2) Perspectives on the adequacy of current harm reductionproducts3) Collection of used needles4) Alternative uses of supplies5) Perceived community buy-inThe interviews were transcribed verbatim and analysedusing standard qualitative methods. Members of theresearch team reviewed the transcripts and independentlyidentified themes within the pre-determined domainsand from open-ended comments. Transcripts and fieldnotes were reviewed in an iterative manner to ensure allemergent themes were captured. Representative quoteswere selected from the transcripts to illustrate the mainthemes identified.To inform the findings, the mapping and qualitative anal-ysis were presented to HRSS committee members for fur-ther input; notes of the discussions were taken. Ethicalapproval was received from the University of BritishColumbia Behavioural Research Ethics Board.ResultsSupply distributionSupply orders were tabulated into reports to illustrate dateand quantity of each category of products ordered by eachindividual site, collated into 5 regional health authoritiesand the 16 health service delivery areas in BC. Input wasreceived from HRSS committee regarding the report for-mat and utility. Committee members agreed to use theinformation to provide feedback to their health authori-ties and distribution sites with regard to appropriateordering frequency and product quantity to improve fiscalresponsibility. Some sites supplied only condoms; othersprovided a full range of products. Single use water vialsordered varied from 0% – 70% of quantity of needles sup-plied.Figure 1 shows the results of geographic information sys-tem mapping of the distribution of needles and syringesin the province of British Columbia between May 2006and November 2007. Each dot represents a site wherePage 2 of 7(page number not for citation purposes)questions developed by the research team. The questionswere modified to explore emerging concepts as data col-harm reduction supplies are ordered and distributedthrough public health nursing and other communityHarm Reduction Journal 2008, 5:37 http://www.harmreductionjournal.com/content/5/1/37health organizations. The smaller white dots representcommunities where harm reduction supplies are distrib-uted but not needles and syringes (i.e. condoms only).Qualitative interviewsEleven face-to-face interviews were conducted in eightmainland BC communities. All selected interview sitesagreed to participate. Interviews occurred with providersat health units, community health centers, AboriginalYouth and Friendship Centers, and HIV/AIDS agenciesand organizations; three of the interview sites did not dis-tribute needles.1) How HR supplies are distributedThe themes that emerged included: a) variations in how'exchange' versus a needs basis distribution; c) data collec-tion and d) trends in demand. Availability of supplies wasitem and site dependent. Some health units reported dis-tributing sex products only, as injection supplies wereavailable from a nearby agency. Some sites have condomsin a basket at the reception desk and in washrooms so cli-ents can help themselves; other sites required clients toask for all supplies, which were provided by the reception-ist or the nurse on call. One site requested the client to callahead to place their order in advance. A few sites providedharm reduction items in brown bags; clients selected bagA or B from a list or picture, which showed number ofitems in each, depending on their needs. A number of thehealth units had designated rooms in which supplies werestored and where the client met privately with the pro-Distribution of needles and syringes in British Columbia May 2006–November 2007Figure 1Distribution of needles and syringes in British Columbia May 2006–November 2007.Page 3 of 7(page number not for citation purposes)the supplies were made available to the clients and thedegree of client engagement; b) one-for-one needlevider to obtain supplies and return used needle.Harm Reduction Journal 2008, 5:37 http://www.harmreductionjournal.com/content/5/1/37The degree of client engagement was highly variable.Some providers routinely engaged clients and reportedregular referrals to 'detox' or clinics for sexually transmit-ted infections and blood borne pathogen testing. Nostandard protocols or training of the HR supplies provid-ers were reported to be available in the rural sites.All but one respondent reported giving supplies to indi-viduals or agencies for distribution at that site i.e. "second-ary distribution." Although individuals from First Nationscommunities obtain their supplies from the provider sites,no supplies were reported to be obtained for secondarydistribution on reserve by nurses or other representatives.One site reported a female who came in for supplies totake to the working girls and at other sites clients took sup-plies in large quantities to share.We have a regular exchange user who is male. And he'sbeen coming for years and he exchanges for his group aswellAll sites encouraged needle exchange; but only one sitereported trying to ensure one-for-one exchange. However,even this site supplied a single clean needle and some-times 4 or 5, even if no needles were returned. This wasperceived to prevent people from 'tossing' needles andencouraged people to collect discarded needles found onthe ground to exchange for clean ones.Data collection also varied considerably from site to site.No systematic data collection of supplies obtained for"secondary distribution" was reported. One site registeredindividual clients by birthday; this site also tracked demo-graphic information, drug of choice, HIV testing etc.Other sites collected no client information and had notracking system.We don't collect any demographic information from clientsin any way. It is supposed to be anonymousThe demand for supplies fluctuated. For example, thedemand for needles was reported to be highest around thetime welfare checks were issued. A large lower mainlandsite reported a considerable decrease in needle distribu-tion over time; it was estimated the number of needles dis-tributed per month had almost halved to 15,000–18,000a few years ago when smoking crack cocaine became thedrug of choice. Although some rural sites reported adecline in needle distribution others noted a steadyincrease in demand as 'word got around'.2) Perspectives on the adequacy of harm reduction productsThis section discusses input regarding current supplies, byeach site; lubricated condoms were generally preferred tonon-lubricated and one distributor reported providing ina ratio of about 5:1. Clients usually did not specify a pref-erence of condom type although younger clients preferredflavoured condoms.Female condoms were not widely used, some sitesrequired women to ask specifically for them, as theybelieved this ensured provision of adequate educationregarding use. The two sites with the greatest distributionreported actively engaging the women and teaching aboutfemale condom use. One site sent the female clients to aclinic next door as...... this is a good way to get the girls 'checked over' [testedfor sexually transmitted infections]Most clients use 0.5 or 1 cc syringes with needles attached.Larger syringes and needles were reportedly used forinjecting steroids. There was general consensus that clientswere not using sterile water for every injection, thoughsome sites thought the demand for water was increasing.The demand of water is not comparable, in terms of, peoplewill take more needles than they will take water, in fact weask them specifically every time they... ask for needles, doyou want water?One site reported distributing no sterile waterWe don't ever get asked for water... It's just the needlesRequests for additional supplies include those used forinjecting drugs e.g. cookers, filters, tourniquets and sharpscontainers; miscellaneous e.g. paper bags in which tohand out supplies and drinking water for clients, andfinally those related to crack use e.g. crack pipes, mouth-pieces and screens. Crack was perceived as the most com-monly used drug in many of the areas, and that anincreasing number of clients were asking for crack smok-ing paraphernalia. Some sites reported purchasing theirown additional items for injection or crack use.3) Collection of used needlesAll sites reported encouraging clients to return used nee-dles.Users bring in used needles and...we have a large sharpscontainer that they put them intoSome sites provided clients with individual sharp contain-ers, which varied between official yellow biohazard con-tainers to empty rigid shampoo bottles. Sites distributingPage 4 of 7(page number not for citation purposes)item category, and then will explore what is perceived tobe missing from the list. Male condoms were available atsharps containers requested that they be returned to theprovider site when full. Others stated that clients reportedHarm Reduction Journal 2008, 5:37 http://www.harmreductionjournal.com/content/5/1/37concern about collecting and keeping needles in the homewhen there were children in the household.4) Alternate uses of HR suppliesCondoms had a number of different alternate uses. Non-lubricated condoms were reported to be used as tourni-quets for injection drug use, and also by crack smokerswho hold exhaled smoke in the condom to share orinhale it 'for a second take'. One site removed the condombasket from the front desk and washrooms in the summeras teenagers were using them as water balloons, leavingbroken condoms on the sidewalk outside the office.Providers in Vancouver revealed that the plungers ofsyringes were being used as a pusher for crack pipes torecover the crack resin dried on the inside of the pipe as itcools. When this was explored further with Vancouverfront line staff it was estimated about 1 in 5 syringes werebeing used for this purpose, and the needle and barrel ofthe syringe discarded.5) Community buy in/readinessParticipants reported few community development initia-tives regarding HR or pick-up of discarded needles. Therewas a perception that HR philosophy was new to manyhealth care workers and the general public.The community with professionals and the public the fla-vour is currently stop the drug use. If we stop the drug usewe could clean up the mess kind of thing... we all know...that doesn't work.However some interviewees felt their community was ripeto hear the messages because 'there's been a few drug relatedtragedies [recently]'.DiscussionAvailability of clean needles (via needle exchange pro-grams) has been shown to decrease the rates of transmis-sion of HIV and hepatitis C (HCV) [3]. A recent studyfound that full participation in HR programs, includingmethadone, could decrease the risk for HIV and hepatitisC [4]. Therefore it is important, as stated by HRSS policy,that HR supplies are available to all who need them. How-ever, there is evidence in BC that supplies are not equallyavailable throughout the province. Spittal et al foundAboriginal youth in Northern BC had more difficultyaccessing clean syringes than Vancouver youth [5]. Noofficial harm reduction distribution on First Nationsreserves was reported. Several barriers to comprehensiveharm reduction services for First Nations persons havebeen identified by Wardman et al. These include culturaldifferences, stigma, limited service infrastructure andis considered the norm in many First Nations communi-ties, it is acknowledged that it is possible to enhance theprofile and availability of culturally appropriate HR serv-ices in this context. This may include incorporating tradi-tional Aboriginal practices, providing additional servicessuch as education and counseling in conjunction with HRprograms, and integrating into existing reserve publichealth programs [6,7]Geographic information systems illustrated sites and thevolume of HR supply distribution in BC, and by inferencewhere availability may be lacking. However without sec-ondary distribution information, the true reach and avail-ability of supplies cannot be determined. Productdistribution by population can be calculated for eachhealth authority, but the variations within each jurisdic-tion are vast. It is interesting to note that Fraser Healthwith the largest health authority population in BC hasonly eight communities where supplies are delivered.Harvard et al found regional variations of BC harm reduc-tion product distribution. However using reported HCVcases, as a proxy for injection drug use, variation in prod-uct distribution could not be attributed to variations ofestimated prevalence of injection drug use [8].Qualitative research seeks to explore process, opinions,attitudes and actions. It is the best method to answer ques-tions about a topic, which may be sensitive and/or aboutwhich little is known. Sampling in qualitative studies ispurposeful; so we explored the perspectives of HR distrib-utors in sites outside Vancouver including rural areas.Qualitative interviews do not aim to be representative orgeneralizable; however we found recurrent commonthemes from different sites.To improve the understanding of HR for health care pro-viders and the public a generic 'Understanding HarmReduction' health file [9] has been recently published.Despite the provincial policy of HR distribution on aneeds basis, one site interviewed maintains one-for-oneexchange. A health file discussing 'needle distribution vs.exchange and community engagement' is therefore indevelopment.Training of volunteers and staff to give HR advice andreferrals for services and testing can increase client engage-ment. Sites where women received instruction on the useof female condoms distributed more of these items. Bestpractice guidelines suggest that distribution of needlesand syringes should be comparable to the rates of sterilewater, as both products should be used for every injection.However there is a wide variation in the request and offer-ing of water for injection; some sites encouraged the usePage 5 of 7(page number not for citation purposes)financial resources, and community size [6] While theabstinence model for the treatment of addictive disordersof water vials for each injection whereas others distributedno water because they were not asked for it.Harm Reduction Journal 2008, 5:37 http://www.harmreductionjournal.com/content/5/1/37Although flavored condoms were not in great demand itwas felt important to continue, as these were popular withthe younger population who should be encouraged to usesafer sex products. Many sites requested sharps containers.However advice re safe collection of needles using rigidplastic containers such as shampoo bottles could improvethe safety in the household and transportation andenhance needle return to the sites.The use of syringe plungers to push the resin through thehot crack pipe, may lead to melting the plastic plungerand discarding of the needle and syringe barrel. The distri-bution of wooden push sticks through the HR supplies iscurrently being investigated. Clients at many sitesrequested crack pipes and mouthpieces. Two infectiousdisease outbreaks have been reported in BC associatedwith crack use. In 2006 an outbreak of Streptococcuspneumonia in the DTES of Vancouver was identified, [10]and a Tuberculosis outbreak in a crack using populationwas reported elsewhere in BC [11]. A recent study detectedhepatitis C virus on a crack pipe from an infected host,and therefore supports the possibility of transmissionthrough sharing crack paraphernalia [12]. Crack usersmay have open mouth sores due to burns and cuts fromhot and broken pipes therefore sharing crack pipes cantransmit respiratory infections and blood-borne patho-gens, including HCV and HIV [13]. Crack pipe mouth-pieces are now available through the provincial BC HRsupplies and each HA is undergoing consultation to deter-mine if, and how, to provide these.One HA has developed a training module; all urban siteproviders must participate in the training before they candistribute supplies, and is willing to share with otherregions. Standard training and protocols within healthauthorities can lead to improved client engagement andawareness of the client needs. It may also encourage peersto be involved in distribution and needle collection.Community engagement is uncommon in rural areas,regions that have developed the process can share theirexperiences and lessons learned to enhance public under-standing of harm reduction.The mapping of needle distribution sites provides a highlyvisual way to show the limitations of primary distributionsites and enables health authorities to assess the reach ofsupplies in their regions. The qualitative research high-lighted the lack of standardization between and withineach health authority in BC. Therefore a consultant hasbeen employed to develop a 'best practice' document toassist regions in employing standardized evidence-basedprocess and protocols to improve access of supplies andclient and community engagement. Development of awork is continued it is critical that the risk environment istaken into account in order to address issues at the com-munity level and create 'enabling environments' for harmreduction [14].ConclusionThis study has contributed to the evidence that HR sup-plies are not equally available throughout the province ofBritish Columbia. The use of GIS in this study illustrateswhere availability of HR supplies may be lacking. How-ever; with secondary distribution, true reach and availabil-ity of supplies cannot be determined. Variations withinjurisdictions must also be taken into consideration.Development of standard training and protocols withinHAs will play a important role in ensuring optimal utili-zation of HR supplies through BC and will lead toincreased client awareness and engagement. Additionally,further research is needed to gain a better understandingof HR supply distribution, to enhance the profile andavailability of culturally appropriate HR services for Abo-riginal populations, and to create enabling environmentsfor harm reduction across the province.Competing interestsThe authors declare that they have no competing interests.Authors' contributionsJBu is the primary investigator for this study and wasinvolved in the interview analysis and manuscript writing.Emma Preston contributed to the qualitative interviewsand manuscript writing. SM was responsible for the GISanalysis. SH performed qualitative interviews and aidedin manuscript writing. JBa reviewed qualitative interviewsand assisted in manuscript writing. All have read andapproved the final manuscript.AcknowledgementsWe are grateful to Carolin Timms and Pamela Tan for their assistance and to the interviewees who provided their time, experience and insights. Fund-ing for this study was provided through the BC harm reduction budget.References1. British Columbia Harm Reduction Supply Services Policyand Guidelines.  2004. Ref Type: Generic2. Glaser BG: Theoretical Sensitivity: Advances in the Methodology ofGrounded Theory Mill Valley, CA: Sociology Press; 1978. 3. McKnight CA, Des Jarlais DC, Perlis T, Eigo K, Krim M, Ruiz M, et al.:Syringe exchange programs – United States 2005, 56(44):1164-1167.11-9-2007. Mortality and Morbidity Weekly. 6-11-2008. Ref Type:Report4. Van Den BC, Smit C, Van Brussel G, Coutinho R, Prins M: Full par-ticipation in harm reduction programmes is associated withdecreased risk for human immunodeficiency virus and hepa-titis C virus: evidence from the Amsterdam Cohort Studiesamong drug users.  Addiction 2007, 102:1454-1462.5. Spittal PM, Craib KJ, Teegee M, Baylis C, Christian WM, Moniruzza-man AK, et al.: The Cedar project: prevalence and correlatesof HIV infection among young Aboriginal people who usePage 6 of 7(page number not for citation purposes)secondary distribution data collection tool and sharing oftraining modules will be explored. Additionally, as thisdrugs in two Canadian cities.  Int J Circumpolar Health 2007,66:226-240.Publish with BioMed Central   and  every scientist can read your work free of charge"BioMed Central will be the most significant development for disseminating the results of biomedical research in our lifetime."Sir Paul Nurse, Cancer Research UKYour research papers will be:available free of charge to the entire biomedical communitypeer reviewed and published immediately upon acceptancecited in PubMed and archived on PubMed Central Harm Reduction Journal 2008, 5:37 http://www.harmreductionjournal.com/content/5/1/376. Wardman D, Quantz D: Harm reduction services for BritishColumbia's First Nation population: a qualitative inquiryinto opportunities and barriers for injection drug users.Harm Reduct J 2006, 3:30.7. Dell CA, Lyons T: Harm reduction for special populations inCanada: Harm reduction policies and programs for personsof Aboriginal descent. 6-1-0007.  Canadian Centre for SubstanceAbuse . 6-11-2008. Ref Type: Report8. Harvard SS, Hill WD, Buxton JA: British Columbia Harm Reduc-tion Product Distribution.  Can J Public Health 2008, 99:446-50.9. British Columbia Ministry of Health: Understanding Harm Reduc-tion (BC Health File # 102).  2007. 12-6-2007. Ref Type: Generic10. Buxton J: Canadian Community Epidemiology Network onDrug Use (CCENDU) Vancouver Site Report.  2007. Ref Type:Report11. Caranci J: TB outbreak tied to crack users.  Alberni Valley Times .10-2-0007. Ref Type: Newspaper12. Fischer B, Powis J, Firestone CM, Rudzinski K, Rehm J: Hepatitis Cvirus transmission among oral crack users: viral detection oncrack paraphernalia.  Eur J Gastroenterol Hepatol 2008, 20:29-32.13. Haydon E, Fischer B: Crack use as a public health problem inCanada: call for an evaluation of 'safer crack use kits'.  Can JPublic Health 2005, 96:185-188.14. Rhodes T: The 'risk environment': a framework for under-standing and reducing drug-related harm.  Int J Drug Policy 2002,13:85-94.yours — you keep the copyrightSubmit your manuscript here:http://www.biomedcentral.com/info/publishing_adv.aspBioMedcentralPage 7 of 7(page number not for citation purposes)


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