Research paperCommunity attitudes towards harm reduction services and a newly established needle and syringe automatic dispensing machine in an inner-city area of Sydney, Australia
Introduction
Needle and syringe programs (NSPs) were initially introduced to prevent the transmission of HIV among people who inject drugs (PWID) and data from early ecological studies suggest that they were successful in achieving this aim (Des Jarlais et al., 1995, Hurley et al., 1997). NSPs distribute sterile injecting equipment to PWID with the aim of preventing blood-borne virus (BBV) transmission by reducing the reuse/sharing of contaminated needle and syringes. There is considerable evidence that NSPs are effective in reducing injecting-related risk (Palmateer et al., 2010) and they have been found to be cost-effective in the Australian context (Kwon et al., 2012).
Currently in Australia there are more than 3000 NSP sites (Victorian Department of Human Services, 2010). While operational policies vary, the mode of distribution can generally be classified as either fixed-site, mobile or outreach (World Health Organization, 2007). The three main types of fixed-site NSP services include primary (standalone) public NSPs, secondary public NSPs (offered as part of a range of other community services) and pharmacy-based programs (Dolan, MacDonald, Silins, & Topp, 2005). There are also automatic needle and syringe dispensing machines (ADMs) that dispense equipment at no cost or for a small fee (Victorian Department of Human Services, 2010).
Despite the benefits of NSP overall, a sterile needle and syringe is required for every injecting episode to prevent BBV transmission. In most contexts, however, coverage of NSPs is inadequate to achieve this outcome (Mathers et al., 2010, Vickerman et al., 2006). One potentially cost-effective approach to increasing NSP coverage is to provide sterile injecting equipment via ADMs that can operate over extended hours and offer anonymity to clients (Islam and Conigrave, 2007). ADMs have been found to be acceptable to users and complementary to existing services (Islam et al., 2009, McDonald, 2009), effective for providing sterile injecting equipment to younger (Islam et al., 2008a, Moatti et al., 2001) or marginalised (Obadia, Feroni, Perrin, Vlahov, & Moatti, 1999) PWID, and those who may be reluctant to attend staffed NSPs due to stigma and discrimination concerns (Islam, Wodak, & Conigrave, 2008). Yet despite enhanced access and potential cost-benefits, implementation internationally has not been widespread (Islam and Conigrave, 2007). Even in Australia, which is renowned for embracing harm reduction (Mathers et al., 2010) and boasts approximately 150 machines, implementation has been limited in many areas and ADMs are absent in three out of eight states and territories (Victorian Department of Human Services, 2010).
Harm reduction is a key component of the Australian National Drug Strategy and is supported by the general public in this country (Treloar and Fraser, 2007). Despite being a key harm reduction initiative, NSPs remain controversial and vulnerable to localised community opposition, which in some instances has resulted in service closures (Körner and Treloar, 2003, Southgate et al., 2000). Concern regarding NSP services include public amenity and discarded syringes, perceived drug-related and other crime, attracting drug users from outside the area into the neighbourhood and concern that children might access needles from the machine (Davidson and Howe, 2014, Körner and Treloar, 2003). While there is no published evidence to support these concerns, such misconceptions can undermine public confidence in this important public health intervention.
In Australia, the introduction of an ADM in an inner-city area of Sydney led to similar concerns being raised by the local community. Traditionally a working class area, the suburb had a long history of aboriginal settlement and racial tensions (Anderson, 1993, Shaw, 2007) and during the 1980s and 1990s developed a reputation as a major drug market (Gibson et al., 2003). While it has recently undergone intense gentrification given its proximity to the city centre and increased engagement with, support of and autonomy for the local aboriginal population, it has nevertheless remained an area with ongoing social issues and drug problems.
In early 2012, in response to ongoing drug-related issues, the local health district announced that an ADM would be introduced to supplement existing harm reduction services, which had been operating since 1995. The community response to this announcement was reported in the local print and state-wide radio and television media (Channel 10 News, 2013, Day et al., 2014, Fordham, 2013a, Fordham, 2013b, Fordham, 2013c, Fordham, 2013d, White et al., 2014). Media attention was largely focused on perceptions of a “honey-pot” effect, a perceived increased in crime, reduced public amenity and a poor understanding of the aims of harm reduction imbued with a sense of NIMBYism (‘not in my back yard’), remarkably similar to that described in San Francisco by Davidson and Howe (2014). Although there were multiple objections from both residents and business groups, it appeared at least some of the negative community sentiment arose from one particularly well-organised group. How much the opposing sentiments of the more active and vociferous members of this group represented the broader community remained unclear.
This study aimed to examine community-level attitudes to harm reduction services in an inner-Sydney neighbourhood known for high levels of drug use which had received media coverage of the community opposition to the implementation of an ADM. Specific aims were to determine (1) community awareness and support for harm reduction services in general and locally; (2) the proportion of community members who had observed discarded needle and syringes in the local area; and (3) factors associated with indicating support for the newly implemented ADM.
Section snippets
Methods
In April 2013, the ADM commenced operation, located within 50 metres of existing NSP services. In February 2014, 10 months following ADM installation, a face-to-face survey was undertaken, with both local residents and nominated representatives of local businesses (typically the owner or site manager) interviewed. All homes, units and businesses located on the streets directly surrounding the NSP services were approached. If no contact was made at the first attempt, the home or business was
Results
During February 2014, contact attempts were made with 463 street-accessible homes, 406 units and 87 businesses, with 241, 82 and 72 contacts made, respectively. The response rate varied but was highest among businesses (43/72, 60%) followed by residents living in street-accessible dwellings (102/241, 42%), with only 8/82 residing in units contacted via intercom agreeing to participate (10%). Overall, the survey was completed by 153 community members, including 103 residents, 35 businesses and
Discussion
This survey of households and businesses conducted 10 months following the installation of a needle and syringe automatic dispensing machine found high levels of support for harm reduction programs among a community affected by drug use. Support for fixed-site NSPs in general was particularly high, with 83% of participants indicating support for these programs. While support for the local ADM was somewhat lower at 60%, this finding nevertheless suggests that a majority of the local residents
Conflict of interest
The authors declare that they have no financial or personal relationship with people or organisations that could inappropriately influence this work.
Acknowledgments
We are grateful to the Redfern residents and businesses who participated in the survey. The authors also acknowledge Shannon Less, Sian Woodmore and Lucia Evangelista who conducted the interviews. We thank all members of our Advisory Committee for their commitment, time and contribution to the development of the study protocol. This study was funded by Sydney Local Health District.
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