Guidelines for better harm reduction: Evaluating implementation of best practice recommendations for needle and syringe programs (NSPs)
Article Outline
Abstract
Background
The objective of this study was to evaluate needle and syringe program (NSP) policies and procedures before and after the dissemination of a set of best practice recommendations.
Methods
An on-line survey of 32 core NSP managers (100% response rate) and 62 satellite NSP managers (63% response rate). The survey included items about the distribution of needles/syringes, other injection-related equipment and inhalation equipment, and use of a best practice recommendations document.
Results
The majority of NSPs reported following needle and syringe best practice recommendations. Most core NSPs (88%, n
=28) and satellite NSPs (84%, n=52) distributed cookers following the dissemination of the document. All core NSPs (100%, n=32) and nearly all satellite NSPs (97%, n=60) distributed sterile water ampoules in 2008, many more than in 2006. Although more NSPs distributed safer inhalation equipment in 2008, the majority did not distribute these items. More satellite NSPs (44%, n=27) distributed glass stems than the core NSPs (16%, n=5). Commonly cited implementation barriers included funding, senior management and decision-making.
Conclusion
Our findings demonstrate that NSPs will implement empirically based best practice recommendations and welcome such guidance. The managers we surveyed not only reported increased implementation of practices that have been empirically shown to help reduce disease transmission among injection drug users (IDUs), they also used the best practices document for additional purposes, such as planning and advocacy, and expressed interest in having sets of recommendations developed for other areas of harm reduction. Ensuring high-quality and consistent NSP services is essential to prevent transmission of HIV among people who inject drugs and others in the community. Best practice recommendations can assist in achieving these goals.
Keywords: Needle and syringe programs, Best practice recommendations, Harm reduction, Evaluation
Introduction
Three decades of international evidence demonstrates that needle and syringe programs (NSPs) reduce needle sharing, HIV incidence and prevalence, and are cost effective when compared with the costs of treating individuals with HIV/AIDS (Holtgrave et al., 1998, Laufer, 2001, Reid, 2000, Wodak and Cooney, 2005). Given this evidence, the World Health Organization (2004) states that access to sterile injection equipment for injection drug users (IDUs) is an essential component of HIV/AIDS prevention strategies. NSPs provide needle and syringe distribution and disposal, condom distribution, and HIV prevention education, and many programs provide a wider array of formal and informal services using varied service models (McKnight et al., 2007, Paone et al., 1999, Strike et al., 2002).
While NSPs are an essential component of HIV/AIDS prevention strategies, only a few jurisdictions have developed best practice recommendations and guidelines for NSPs (Burrows, 2006, Buxton et al., 2008, Strike et al., 2006). These documents were developed to encourage the delivery of high-quality and consistent services for IDUs and their communities. These documents also serve the purpose of helping NSPs that are often the target of opposition to justify and defend their services (Strike, Myers, & Millson, 2004). Best practice recommendations may also assist NSP managers and policy makers by informing decisions to direct scarce resources towards effective and efficient practice. Furthermore, best practice recommendations provide benchmarks to evaluate programs and identify targets for improvement at the individual program level and at the systems level.
To date, there have been no evaluations of the extent to which NSPs follow best practice recommendations. Typically, studies do not focus on the full range of NSP practices but evaluate particular areas of policy or practice including, for example, needle/syringe exchange policies and practices, number of NSP outlets, referrals to other services, and hepatitis C screening and management practices (Bluthenthal et al., 2007, Parsons et al., 2002, Pratt et al., 2002). Several studies have enumerated the range of NSP services and supports but not the relationship to best practices (Des Jarlais et al., 2009, McKnight et al., 2007, Paone et al., 1999, Strike et al., 2002). Our goal is to begin to fill this gap by evaluating the implementation of a set of NSP best practice recommendations related to NSP equipment distribution and identifying facilitators and barriers to their uptake. We begin with a brief history of the development of the recommendations.
Development and dissemination of NSP best practice recommendations
In Canada, NSPs have been operational since 1989 (Hankins, 1998). In Ontario, the most populous Canadian province with an estimated 12.9 million residents (Statistics Canada, 2009), NSPs are required public health programs (Ministry of Health and Long-Term Care, 2008) that serve an estimated 41,100 IDUs (Millson, Leonard, Remis, Strike, & Challacombe, 2005). In light of anecdotal evidence pointing to wide variation in NSP practices across Ontario, a team of researchers and NSP managers developed a set of evidence-based best practice recommendations. The goal was to develop recommendations that could be used by NSPs to ensure consistent and high-quality service to all Ontario communities. Following a comprehensive literature review of current scientific evidence supplemented as necessary with input and expertize from well-established NSPs managers, the recommendations were compiled and reviewed by NSP managers for real-world applicability. The document, entitled Ontario Needle Exchange Programs: Best Practice Recommendations (Strike et al., 2006), was released in 2006 and was the only document of its kind in Canada at that time. The Best Practice Recommendations targets all areas of NSP practice and policy (e.g., start-up tasks, needle/syringe distribution, other injection equipment distribution, disposal, program models, education, primary care, relationships with law enforcement, and evaluation). Prior to dissemination, it underwent external peer review by two international scientific experts and two very experienced NSP managers in other parts of Canada.
Varied strategies were used to disseminate the document and encourage uptake of its recommendations including a launch ‘think tank’ meeting with policy makers, presentations to frontline staff, managers, and policy makers, workshops for frontline staff, hard copies mailed to each NSP and its senior decision maker, and on-line availability (http://www.ohtn.on.ca/) in both English and French. A short documentary, The sleeping giant: a day in the life of a needle exchange program (Ontario Needle Exchange Coordinating Committee, 2006) was produced as a supplement for the document. To increase its credibility among provincial decision and policy makers, the authors sought and received endorsement of the document from the Ontario Advisory Committee on HIV/AIDS that reports to the Ontario Minister of Health and Long-Term Care. In 2007, the Ontario Chief Medical Officer of Health and Assistant Deputy Minister of Health endorsed the document and encouraged all regional Medical Officers of Health (MOHs) in Ontario to implement the recommendations. The research team was awarded a 2007 Kaiser Foundation National Award for Excellence in Leadership in harm reduction which also increased exposure for the document.
In 2006, the Ontario Harm Reduction Distribution Program (OHRDP) began to provide injection-related drug preparation materials (i.e., cookers, sterile water ampoules, filters, tourniquets, acidifiers) free of charge to all NSPs in Ontario. In years prior, public health units were required to purchase and distribute needles individually and would decide whether or not to distribute these other pieces of injection-related equipment. This led to variation in the availability of equipment (Strike, 2008). The OHRDP was developed based on the evidence reported in the Best Practice Recommendations and to ensure that there were no financial impediments for NSPs to distribute cookers, sterile water ampoules, filters, tourniquets, and acidifiers. The OHRDP is funded by the Hepatitis C Secretariat at the Ontario Ministry of Health and Long-Term Care and also mandated to provide knowledge transfer and policy support to Ontario NSPs and other harm reduction programs. At the time of this study, the OHRDP provided supplies to 32 NSPs run by or associated with public health units in the province.
Uptake of best practice recommendations
In the fields of addiction and public health, investigations of the uptake of best practice recommendations are lacking. Where researchers have studied the uptake of guidelines, the focus has tended to be on clinical guidelines and clinician adherence rather than programmatic guidelines and program-level implementation (e.g., Cabana et al., 1999, Davis and Taylor-Vaisey, 1997, Strike et al., 2007). The existing literature shows that many guidelines and best practice recommendations are not implemented in the health sector even when they are based on high-quality supporting evidence (Haines, Kuruvilla, & Borchert, 2004). Evidence shows that the facilitators and barriers to uptake of empirically validated guidelines related to health service exist at various levels including the practitioner, the political environment, and the larger healthcare system (Haines et al., 2004).
Our primary objective was to assess NSP policies and practices before and after the publication of the Best Practice Recommendations and to identify the practitioner, system, and political factors that facilitated or impeded implementation.
Methods
All core and satellite NSP managers (n=131) in Ontario were invited to complete an on-line survey about their policies and practices, and facilitators and barriers to implementation of the Best Practice Recommendations. ‘Core’ NSPs were defined as programs that are either directly operated by a public health unit or by another local agency contracted by the health unit to provide needle exchange services. Most core NSPs in Ontario have agreements with other local community agencies and organizations (e.g., community health centres) to offer NSP services as an extension of their existing services. These ‘satellite’ NSP sites thus extend the accessibility of NSP services in communities. Typically, core NSPs provide satellite NSPs with training, supplies, and onsite support, and impose the policies and procedures (Strike et al., 2002). We recruited managers for our study because they play a direct role in policy and procedure development, oversee daily NSP operations, and are, therefore, most knowledgeable about the reasons behind the implementation of the Best Practices or lack thereof.
The Best Practice Recommendations includes nine practice topics with a total of 103 recommendations. For the survey, we primarily focused on practice topics that relate to the primary mandate to prevent disease transmission – needle distribution and disposal, and other injection-related equipment distribution. We also assessed a controversial area of practice, the distribution of glass stems for safer drug inhalation, which has limited empirical evidence yet considerable support from harm reduction workers and their clients (Boyd, Johnson, & Moffat, 2008). Condom distribution, also a best practice, is a mandated practice for Ontario public health programs (Ministry of Health and Long-Term Care, 2008). All NSPs in the province distribute condoms and, therefore, we did not assess this practice. In consultation with the NSP managers on our team, we developed and pilot tested questions about each of the selected practice topics. In this manuscript, we focus on the recommendations related to the distribution of needles, other injection-related equipment, and inhalation equipment; however, we also collected but do not report data concerning needle and syringe disposal, program models, primary care, testing and vaccination, and relationships with law enforcement. As well as assessing the uptake of the recommendations, we also asked participants about how they have used the Best Practices document (e.g., planning, advocacy).
This study was developed in consultation with the core NSPs in Ontario who all agreed to participate and to provide contact information for their satellite NSPs. Using a modified Dillman (2000) approach, we solicited responses to our on-line survey. Prior to the on-line survey launch, all core NSP and satellite NSP managers were sent an e-mail by Hopkins with a notification of the expected start date of the study. Once launched, each manager was sent an e-mail invitation that included a description of the study, confidentiality and consent issues, and a hyperlink to complete the survey. Two weeks after the initial invitations, non-responders were sent a second e-mail invitation to participate in the study. Two weeks after the second invitations, all core NSP non-responders were contacted directly by Strike and invited to participate. All satellite non-responders were contacted by their core NSP managers either by e-mail or telephone and invited to participate. The survey remained open for 12 weeks, from February 28th 2008 until May 22nd 2008.
After closure of the survey website, the data were downloaded and entered into SPSS. The data were analysed using frequencies, χ2 tests, McNemar χ2, and Student's t-tests. Our study was reviewed and approved by the Research Ethics Board at the Centre for Addiction and Mental Health.
Results
We achieved a response rate of 100% (32 of 32) for the core NSPs and 67% (66 of 99) for the satellite NSPs. Combined, the total response rate was 75% (98 of 131) for all Ontario NSPs. Of the surveys submitted, 4 did not contain enough usable data and were removed from the analyses. The findings reported below are based on the data from 94 respondents – 32 core NSP managers and 62 satellite NSP managers.
NSPs were categorized by several characteristics (Table 1). Core NSPs were asked to report annual needle distribution statistics that were categorized into five groups (i.e., less than 25,000; 25,000–49,999; 50,000–99,999; 100,000–499,999; and 500,000 or more). As satellite NSPs do not always collect their own needle statistics, we asked core NSPs to report totals for the core and all satellite programs combined. Using existing estimates, we categorized NSPs by the estimated number of IDUs (Millson et al., 2005) and HIV prevalence (Remis, 2007) in their catchment areas.
Table 1. NSP characteristics.
| % of core NSP programs | |
|---|---|
| Needles distributed in 2007 (n=32) | |
| less than 25,000 | 28.1 |
| 25,000–49,999 | 12.5 |
| 50,000–99,999 | 12.5 |
| 100,000–499,999 | 34.4 |
| 500,000+ | 12.5 |
| Estimated HIV prevalence in catchment area (n=32) | |
| less than 1% | 3.1 |
| 1–4.9% | 59.4 |
| 5.0–9.9% | 31.3 |
| 10% or more | 6.3 |
| Estimated number of IDUs in catchment area (n=32) | |
| less than 500 | 46.9 |
| 500–999 | 37.5 |
| 1000–4999 | 12.5 |
| 5000+ | 3.1 |
| Type of core NSP agency (n=32) | |
| Public health unit | 75.0 |
| AIDS service organization | 12.5 |
| Other (e.g., probation/parole, community health centre) | 12.5 |
| % of satellite NSPs | |
|---|---|
| Type of satellite NSP agency (n=53) | |
| Public health unit | 9.4 |
| Community health centre | 17.0 |
| AIDS service organization | 15.1 |
| Pharmacy | 11.3 |
| John Howard or Elizabeth Fry | 3.8 |
| Youth services | 5.7 |
| Addiction services | 13.2 |
| Shelter/residence | 3.8 |
| Other social service (e.g., family centre) | 7.5 |
| Other | 13.2 |
The core NSP programs varied in terms of the number of needles they distributed, their locations, and HIV prevalence and estimated number of IDUs in their catchments. In 2007, needle distribution varied among core NSPs with 34.4% that distributed between 100,000 and 499,999 syringes and 28.1% that distributed less than 25,000. Most (59.4%) programs operated in a region with an estimated HIV prevalence in IDUs of between 1 and 4.9% and with an estimated IDU population of less than 500. The most common host agencies for satellite NSPs included community health centres (17.0%), AIDS service organizations (15.1%), addiction treatment services (13.2%), and pharmacies (11.3%).
Needle distribution
Needle sharing carries a high risk of transmission of blood-borne pathogens such as HIV and hepatitis C (HCV) and also puts IDUs at risk for other types of infections, as well as skin and vein problems (Strike et al., 2006). The Best Practice Recommendations recommends that NSPs provide needles in the quantities requested by clients without requiring the return of used needles and without placing limits on the number of needles provided to clients. Before and after the dissemination of the document, the vast majority of Ontario programs distributed needles in line with these recommendations. These practices did not change much over time (Table 2).
Table 2. Needle distribution.
| Distribution practice | Core NSPs | Satellite NSPs | ||
|---|---|---|---|---|
| 2006 | 2008 | 2006 | 2008 | |
| Distributed needles without requiring clients to return used needles | 94% (30) | 94% (30) | 93% (55) | 95% (58) |
| Followed a one-for-one exchange policy | 3% (1) | 0% (0) | 0% (0) | 2% (1) |
| Imposed a cap on the number of needles given to clients who did not have any to return | 13% (4) | 3% (1) | 7% (4) | 11% (6) |
| Distributed needles with no limit on the number provided | 84% (27) | 91% (29) | 75% (44) | 86% (50)* |
*p |
In 2008, none of the core NSPs followed a one-for-one exchange policy whereby only one needle is provided for each needle returned. Only one satellite program reported using such an exchange policy. More NSPs were distributing needles in 2008 with no limit on the number provided than was the case in 2006. While fewer core NSPs reported imposing a cap on the number of needles given out to clients in 2008 compared to 2006, more satellite NSPs implemented a cap on the number of needles given to clients who did not have any to return, though these changes were not statistically significant. Among NSPs that reported a change, the three most commonly reported reasons for a change in needle exchange policy were the Best Practice Recommendations (75%, n=9), changes in the approach of staff members (75%, n=9), and changes in client demand (55%, n=6). A manager from one of the satellite NSPs that adopted stricter exchange policies in 2008 explained that the change was the result of, “Community and board pressure due to [a] large amount of needles being found in the community.”
Injection-related equipment distribution
The sharing of injection-related equipment also carries a risk of transmitting blood-borne pathogens such as HIV and HCV (Strike et al., 2006). Table 3 provides a description of the purpose of each piece of equipment. Where evidence is available, the Best Practices recommends specifications for certain items, such as filters with a pore width of 0.22μm (Caflisch, Wang, & Zbinden, 1999) and single-use sachets of citric acid as acidifiers (Garden, Roberts, Taylor, & Robinson, 2003). Similar to the recommendations for needle distribution, the Best Practices advises NSPs to reduce the risks associated with the reuse of other injection-related equipment by offering supplies with every needle and distributing supplies in the quantities requested by clients without placing limits on the number of items provided.
Table 3. Other equipment distributed by NSPs.
| Item | Purpose |
|---|---|
| Cookers | Containers used for mixing and preparing drugs. |
| Filters | Help prevent undissolved drug particles, other debris, and bacteria from being drawn up into an injectable solution. |
| Acidifiers | Convert insoluble drugs into water-soluble form. |
| Sterile water | Used to mix and dissolve drugs prior to injection, and may be used to rinse needles between injections. |
| Alcohol swabs | Clean the injection site to help prevent abscesses and other bacterial infections. |
| Tourniquets | Used to ‘tie off’ and make more accessible the vein used for injecting drugs. |
| Glass stems | Act as pipes, heat drugs and direct vapours toward the user's mouth. |
| Mouth pieces | Protect the lips from burns when using a pipe. |
| Brass screens | Hold rock-type drugs in place in pipes. |
Between 2006 and 2008, NSP injection-related equipment practices changed to become more consistent with the Best Practices (Table 4). There was a significant increase in the number of programs distributing cookers in 2008 compared to 2006. All core NSPs that were distributing cookers in 2008 were doing so without limits on the number they provided to their clients. Similar changes in the direction of compliance with the Best Practices were reported for the other types of injection-related supplies as well. Compared to practices in 2006, more core NSPs and satellite NSPs distributed the recommended types of acidifiers and tourniquets in 2008.
Table 4. NSP equipment distribution.
| Distribution practice | Core NSPs 2006 | Core NSPs 2008 | Satellite NSPs 2006 | Satellite NSPs 2008 |
|---|---|---|---|---|
| Cookers | 13% (4) | 88% (28)*** | 34% (21) | 84% (52)*** |
| Cookers without limits | 75% (3) | 100% (28) | 95% (20) | 85% (44) |
| Filters | 41% (13) | 91% (29)*** | 65% (40) | 89% (55)*** |
| Filters without limits | 92% (12) | 90% (26) | 98% (39) | 93% (50) |
| Acidifiers: | ||||
| Recommended type(s) | 13% (4) | 84% (27) | 31% (19) | 76% (47) |
| Different type(s) | 16% (5) | 0% (0) | 18% (11) | 10% (6) |
| Did not distribute | 72% (23) | 16% (5)*** | 52% (32) | 15% (9)*** |
| Acidifiers without limits | 100% (9) | 96% (26) | 83% (25) | 87% (46) |
| Sterile water | 66% (21) | 100% (32)*** | 84% (52) | 97% (60)** |
| Sterile water without limits | 86% (18) | 94% (30) | 87% (45) | 92% (54) |
| Alcohol swabs | 88% (28) | 100% (32) | 90% (56) | 100% (62)* |
| Alcohol swabs without limits | 93% (26) | 94% (30) | 95% (53) | 97% (60) |
| Tourniquets: | ||||
| Recommended type(s) | 47% (15) | 94% (30) | 52% (32) | 89% (55) |
| Different type(s) | 3% (1) | 0% (0) | 16% (10) | 5% (3) |
| Did not distribute | 50% (16) | 6% (2)*** | 32% (20) | 7% (4)*** |
| Tourniquets without limits | 75% (12) | 90% (27) | 98% (41) | 95% (55) |
| Glass stems | 3% (1) | 16% (5) | 33% (20) | 44% (27)* |
| Mouth pieces | 3% (1) | 16% (5) | 25% (15) | 38% (23)* |
| Brass screens | 3% (1) | 13% (4) | 28% (17) | 41% (25)* |
*p |
**p |
***p |
Among managers who reported changes in practice, the three most commonly reported reasons for change included the availability of the OHRDP, the Best Practice Recommendations, and decisions by NSP managers (Table 5). Other reported reasons for change in cooker (46%, n=15), filter (39%, n=11), and acidifier (36%, n=14) distribution practices included the ‘decision by the local Medical Officer of Health or Executive Director’ and, for sterile water (30%, n=9), the ‘decision by the Ontario Ministry of Health and Long-Term Care.’
Table 5. Reasons for changing injection-related equipment distribution.
| Reported changes in the distribution of: | Most commonly reported reason for change | Second most commonly reported reason for change | Third most commonly reported for change |
|---|---|---|---|
| Cookers | OHRDP (92%, n=35) | Best Practice Recommendations (67%, n=24) | Decisions by NSP managers (49%, n=16) |
| Filters | OHRDP (83%, n=25) | Best Practice Recommendations (66%, n=19) | Decisions by NSP managers (43%, n=12) |
| Acidifiers | OHRDP (80%, n=36) | Best Practice Recommendations (70%, n=28) | Decisions by NSP managers (46%, n=18) |
| Sterile water | OHRDP (73%, n=27) | Best Practice Recommendations (70%, n=23) | Decisions by NSP managers (45%, n=14) |
| Alcohol swabs | Best Practice Recommendations (75%, n=6) | OHRDP (67%, n=6) | Decisions by NSP managers (43%, n=3) |
| Tourniquets | OHRDP (82%, n=23) | Best Practice Recommendations (70%, n=19) | Decisions by NSP managers (44%, n=11) |
Inhalation equipment distribution
It is hypothesized that sharing equipment used to smoke crack and other ‘rock-type’ drugs can lead to transmission of HCV and HIV. The empirical evidence regarding the route of transmission is mixed and limited (DeBeck et al., 2009). Existing evidence shows that pipes are often crudely constructed from metal items such as pop cans and from glass materials that can lead to lip burns and cuts from sharp edges (Haydon & Fischer, 2005). These cuts and burns around the mouth and hands can contaminate inhalation equipment with blood and potentially lead to transmission. One recent study has identified the presence of HCV RNA on used crack pipes (Fischer, Powis, Cruz, Rudzinski, & Rehm, 2008). In light of elevated risk for HCV among non-injecting drug users and people who smoke crack (Macías et al., 2008, McMahon and Tortu, 2003, Nyamathi et al., 2002, Tortu et al., 2004, Tortu et al., 2001) and with the public health goal of reducing transmission, the Best Practice Recommendations encourages NSPs to distribute glass stems, rubber mouth pieces, and brass screens in the quantities requested by clients and without placing limits on the number of items provided. Distribution of inhalation equipment may help reduce other potential harms from smoking crack as well. For example, people who smoke crack will make screens for their smoking devices out of materials (e.g., brass wool cleaning pads) that tend to break apart and can cause respiratory damage (Porter, Bonilla, & Drucker, 1997).
More NSPs reported distributing inhalation equipment in 2008 than in 2006 and these increases were statistically significant for the satellite NSPs (see Table 4). However, most programs do not distribute these supplies. Among NSPs that do not distribute glass stems, mouth pieces, or brass screens, the three most commonly reported reasons for lack of implementation were the ‘decision by the local Medical Officer of Health or Executive Director’ (46%, n=23), the ‘decision by the Board of Health/Board of Directors/City Council’ (27%, n=13), and ‘opposition from law enforcement’ (18%, n=9). There were no statistically significant differences between the core NSPs and the satellites. Other reasons for not distributing inhalation equipment included lack of funding and NSPs not receiving such supplies from their health unit or the OHRDP. One core NSP manager wrote in their survey, “Safer inhalation equipment is only distributed when we can obtain kits from outside sources. We do not currently have money in our NEP budget to purchase these items.” Some managers also mentioned an unfavourable or controversial climate surrounding the distribution of inhalation equipment. Another core NSP manager wrote, “At the moment, we do not want to jeopardize the current harm reduction program by distributing safer inhalation equipment.” According to a satellite NSP manager, “Small town mentality/I’ve had to give my word that I would not distribute glass stems behind their backs.” In short, there were numerous reasons behind the lack of implementation of the recommendations for inhalation equipment.
Use of the best practice recommendations
Compared to the core NSP managers (94%, n=30), significantly fewer satellite NSP managers (76%, n=44; p≤.05) reported having read the Best Practice Recommendations. Among those who read the document, 90% (n=28) of the core NSP managers rated the document as ‘very helpful’ overall, and 58% (n=29) of the satellite managers gave the same rating. The remaining satellites rated the Best Practice Recommendations as either ‘somewhat helpful’ (24%, n=12) or ‘neither helpful nor unhelpful’ (18%, n=9). None of the programs provided negative ratings of the document.
Core NSPs and satellite NSPs reported using the document for a variety of purposes including making planning decisions about program practices and policies, making changes to program practices and policies, advocacy, and training (Table 6).
Table 6. Use of the best practice recommendations document.
| Program has used the Best Practice Recommendations to: | Core NSPs % (#) | Satellite NSPs % (#) |
|---|---|---|
| Make planning decisions about program practices and policies | 97% (30) | 59% (32)*** |
| Make changes to program practices and policies | 94% (29) | 54% (29)*** |
| Advocate to change program practices and policies in the community | 97% (30) | 46% (25)*** |
| Defend the program in the community | 80% (24) | 59% (32) |
| Explain the program to outsiders | 87% (26) | 67% (37) |
| Evaluate the program | 63% (19) | 42% (23) |
| Train with new staff | 90% (27) | 67% (36)* |
| Train with staff at other agencies | 80% (24) | 47% (26)** |
*p |
**p |
***p |
When asked to recommend future content for other best practice documents, NSP managers expressed interest in recommendations for specific substances (methamphetamine, Oxycontin™), types of medication-assisted treatment (Buprenorphine, prescription heroin), supervised injecting facilities, and prison-based NSPs (Table 7). Other suggestions for improving the Best Practice Recommendations included keeping the empirical evidence updated and creating a shorter or quick-reference version.
Table 7. Recommendations for future editions of best practices.
| Would like to see a best practices document for: | Core NSPs % (#) | Satellite NSPs % (#) |
|---|---|---|
| Methamphetamine | 97% (28) | 94% (51) |
| Oxycontin™ | 97% (28) | 94% (51) |
| Buprenorphine | 79% (22) | 84% (42) |
| Heroin substitution | 86% (24) | 89% (47) |
| Supervised injecting facilities | 89% (25) | 86% (42) |
| Prison-based NSPs | 89% (23) | 80% (40) |
Discussion
This is the first study to report on the uptake of best practice guidelines by NSPs and our findings demonstrate that NSPs will implement such recommendations. With the exception of distributing inhalation equipment, our findings demonstrate that NSPs changed their practices to be consistent with a set of recommendations. As a result, NSPs in Ontario are now in a better position to respond to the health needs of their clients. Our findings point to several important considerations.
While core NSPs determine the needle exchange policies for their satellites, a few satellite programs reported moving further away from greater needle distribution. The number of satellite NSPs that imposed stricter policies (e.g., one-for-one exchange policy, cap on the number of needles given to clients who do not have any to return) than their core programs was small, but points to the potential of satellites to undermine core NSP efforts as well as the potential for serious risks and health consequences for IDUs who do not receive equipment in sufficient quantities. We know from our data that one satellite that adopted one-for-one exchange and was imposing a cap on the number of needles given out in 2008 experienced pressure from both its board and community due to concerns over publicly discarded needles. The other programs did not provide a rationale for their policies. However, given what we know from informal interactions with satellite NSPs, we might surmize that their ‘stricter’ policies for needle distribution reflect the beliefs amongst the staff, agency board, and/or community that limits or caps are important controls on clients to reduce opportunities for reuse and/or improper disposal of used equipment, despite the best practice recommendations.
To try to motivate change in policy and practice, we undertook many varied dissemination strategies for the Best Practice Recommendations. We cannot isolate the influence of any one strategy; however, our experience suggests that targeting dissemination activities to the frontline workers and their senior managers is a very important component to achieving the desired changes. When asked why NSPs had changed their injection-related distribution practices, most managers reported that the Best Practice Recommendations was an important factor driving change. Equally important is our finding that when supplies are available at no cost to programs, NSPs will distribute them according to recommendations. As well, decisions by NSP and more senior agency managers greatly influenced changes in these practices. However, we also observed that even when supplies are available at no cost to NSPs, complete uptake of recommended practices did not always occur. Prior to 2006, any NSP distributing injection-related equipment (i.e., cookers, filters, tourniquets, sterile water, and/or alcohol swabs) did so at its own expense. From ongoing informal interactions with NSP managers, we knew that the Medical Officers of Health of some programs were opposed to the distribution of these pieces of equipment. Among many, one of the reasons for developing the Best Practice Recommendations was to provide NSPs with the evidence necessary to advocate for a change in this area of policy and practice. In an environment where the senior decision maker is ideologically opposed, our findings suggest that both best practice recommendations and access to a free source of supplies may be vital to motivate changes in policy and practice.
Few Ontario NSPs follow the recommendations regarding the distribution of glass stems, mouth pieces, and brass screens. Interestingly, more satellite than core NSPs reported doing so. This finding is likely the result of one core NSP that provides glass stems for distribution by its satellite NSPs and, at the time of the study, had nearly 30 satellites. Distribution of glass stems continues to be a highly controversial area of practice because, in part, the evidence base on smoking crack and risk of disease transmission is small (DeBeck et al., 2009, Fischer et al., 2008). Some NSP managers identified, among other reasons, decisions by the local MOH or Executive Director, Boards of Health or city council, and boards of directors as impeding the distribution of inhalation equipment. Somewhat surprising given recent experience in one of Ontario's larger cities (Leonard, DeRubeis, Pelude, et al., 2008), opposition from law enforcement did not emerge as a major reason behind lack of inhalation equipment distribution (nor was law enforcement noted by any respondents as a reason for failure to distribute cookers, filters, acidifiers, sterile water, or tourniquets). Nevertheless, this finding should not discount the potential influence law enforcement may have over NSP activities. For example, Ontario NSP clients have reported having their new glass stems confiscated and destroyed by police officers (Leonard, DeRubeis, Germain, et al., 2008). Lack of funding has also presumably played a role as many NSPs in the province have not secured stable resources to purchase inhalation equipment.
Our findings suggest that NSPs will welcome guidance in the form of empirically based best practice recommendations. The managers we surveyed not only reported increased implementation of practices that help reduce disease transmission among IDUs, they also used the document for additional purposes, such as planning and advocacy, and expressed interest in having sets of recommendations developed for other areas of harm reduction. The Best Practice Recommendations were developed for Ontario; however, these recommendations have applicability outside of this jurisdiction. With modifications, other NSPs can have recommendations that fit their local circumstances (Strike, 2008). Our study suggests that to implement best practice recommendations, NSPs in other jurisdictions would be well served to remove financial impediments to the distribution of all types of equipment and build partnerships with senior decision makers.
In terms of limitations, this study was conducted in Ontario where provision of NSP services is a mandated public health program (Ministry of Health and Long-Term Care, 2008) and where the NSPs are connected through a coordinating committee comprised of NSP managers from varied regions. Although we cannot say for certain, the connectedness of the NSPs provided a direct channel through which we could communicate to the NSPs and may have influenced uptake. Furthermore, Hopkins, Lavigne, Shore, and Young were members of this coordinating committee who were also directly involved in the production of the Best Practice Recommendations which may have increased the credibility of the document amongst their peers and their willingness to implement the recommendations. Our findings, therefore, reflect the particulars of the Ontario context and may not be readily generalizable to jurisdictions without a similar mandate and context. Second, our data were based on self-report and were not externally verified. Third, we surveyed NSP managers at one point in time; that is, we asked them to report on current practices as well as recall their program's practices 2 years earlier. There may have been instances where NSP managers were not accurate in their recollection or were not as involved in their managerial roles in the period just prior to the dissemination of the document. Lastly, although we heard from two thirds, one third of satellites in the province did not respond to our survey. It is possible that this one third has experienced some trends in policies and practices that were not captured by our study.
Acknowledgements
We are very grateful for the time and effort of many individuals who helped us to complete this project. When we first began planning this project, the team was very grateful to receive assistance from Robb Travers and Colleen McKay. Our on-line survey was greatly improved by the efforts and feedback of three pilot testers: Suzanne Newmark from The Van and Street Health Program, Hamilton Public Health; Beth Whalen from Project X Change, John Howard Society of Durham; Lori Brooks from Northern Points Exchange, North Bay Parry Sound District Health Unit. We would also like to extend our thanks to Cathy Cleary at the Ontario Harm Reduction Distribution Program (OHRDP) for helping us with some issues of interpretation. This project was funded by the Ontario HIV Treatment Network (OHTN). Salary and infrastructure support for Dr. Carol Strike were provided by the Ontario Ministry of Health and Long-Term Care. The views expressed in this paper do not necessarily reflect those of the Ministry.
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PII: S0955-3959(10)00061-7
doi:10.1016/j.drugpo.2010.03.007
© 2010 Elsevier B.V. All rights reserved.
