MOBILISING PUBLIC SUPPORT FOR PROVIDING NEEDLES TO DRUG INJECTORS
A PILOT ADVOCACY INTERVENTION
Simon Lenton, National Centre for Research into the Prevention of Drug Abuse, Curtin University of Technology and Mike Phillips, School of Public Health, Curtin University of Technology
Four hundred members of the general public in Western Australia were surveyed regarding their attitudes to the provision of needles and syringes to drug users as a means reducing the spread of HIV Attitudes were measured before and after the presentation of an audio-taped advocacy intervention which explained the rationale and effectiveness of needle provision. After the intervention fewer respondents agreed with stereotypical negative statements about drug injectors; and more supported needle provision, the role of pharmacists in this, and politicians taking legislative steps to support it. The impact of the advocacy intervention suggested that the public were able to assimilate information about harm reduction with injecting drug users. Providing a data based rationale resulted in an increase in support for needle and syringe provision as a public health strategy for minimising the spread of HIV.
In Australia, as in other countries, one of the main routes of transmission of blood-borne infections, such as HIV and Hepatitis, is the sharing of needles and syringes (N&S) and other injecting equipment by injecting drug users (IDUs). Research has shown that many drug injectors have non-injecting sexual partners (Donoghoe, 1992). Sexual contact, and transmission from mother to child, are considered the main routes for spread of HIV infection from drug injectors into the wider, non-injecting, community. In most western countries where the spread of HIV through IDUs has emerged as an actual or potential problem, the primary public health strategy has been to make new N&S readily available to drug injectors (DesJarlais and Friedman, 1993).
One of the consequences of the 'War on drugs' has been to reinforce a 'them and us' view of drug users. For many members of the public illicit drug users, particularly injectors and users of 'hard drugs', are viewed as a deviant and separate group from the rest of us in the non- injecting 'general' community. Drug injectors are seen in their 'deviancy' as being irresponsible, dependent addicts.
Australia has been noteworthy in its adoption of a nationwide harm reduction strategy. Thus far this approach has succeeded in minimising the spread of HIV among drug injectors and through them to the wider community (Commonwealth Department of Health, 1985; Kaldor, 1992). However, Wodak and Des Jarlais (1993) has suggested that more controversial strategies may be required to contain the epidemic and that this will not be possible without strong community support. Public policies on drug use often involve moral and religious arguments and issues of individual versus collective rights. In democracies there is little incentive for political parties to compete for votes on policies which could undermine their support among the electorate (Makkai and McAllister, 1993). To put it crudely, politicians are 'vote-junkies'. They are unlikely to take actions which they perceive will compromise their supply when their electoral 'fix' is due at each election. Governments often follow public opinion. Therefore, as Wodak and Des Jarlais (1993) note, mass media campaigns about the consequences for the community should HIV become rampant, and the effectiveness of a harm reduction approach in preventing this, will be important components of promoting health in this area.
The Ottawa Charter for Health Promotion (1987) emphasised the place of health promotion advocacy in making favourable the political, economic, social, cultural environmental, behavioural and biological factors that can be favourable or harmful to health. Chapman (1994) describes public health advocacy as involving efforts to shift public opinion to the extent that the desired political action becomes compelling, and inaction a political liability.
HIV, DRUG INJECTORS AND NEEDLE PROVISION IN WESTERN AUSTRALIA
Western Australia (WA) is thought to have one of the lowest rates of HIV infection among IDUs in the western world. Largely due to the provision of N&S to IDUs, the prevalence of HIV among drug injectors in WA is thought robe about I % (Bevanetal., 1996). This compares with rates between 40 and 60% among IDUs in some parts of the USA and Europe (Des Jarlais and Friedman, 1992). It can be argued that HIV was in epidemic proportions among certain populations of IDUs in Europe and the USA well before it became apparent in the Australian IDU populations. However, it remains true that needle provision has to date prevented the 'second wave' of HIV among Australian IDUs. In Australia we have not seen the large numbers of injectors becoming HIV infected as has been witnessed in other countries which failed to introduce comprehensive needle provision schemes as early as possible in the epidemic. Lurie and Drucker (1996) have estimated that if the USA had implemented needle provision from 1987 to 1995 at the same level as was done in Australia, between 8361 and 19 673 HIV infections, among IDUs, their sexual partners and offspring could have been prevented in the USA.
Since July 1987 the Health Department of WA has administered a program of providing new N&S to IDUs. The 'Fitpack' Programme that operates through community pharmacies (often referred to as 'chemists') in WA does not incorporate an exchange component, but rather the emphasis is on providing N&S with a 'safe' disposal container. Five N&S are sold in each 'Fitpack'. These hard plastic containers are designed to enable used syringes to be 'locked-in' for disposal so they cannot be removed for reuse or cause injury to children. During 1993 almost 1.2 million N&S were provided to IDUs in WA, the majority being in the Perth metropolitan area. Over 68% of these were sold through community pharmacies (Government of Western Australia, 1995).
At the time of collecting the data for this Study, the provision of injecting equipment to illicit drug users in WA was still illegal. Pharmacists and other health workers could theoretically be charged for engaging in such activity under the Aiding and Abetting provisions [Sections 7-9,44(l) and44(4)] of the WA Criminal Code] - Draft legislation to make the provision of N&S to drug users no longer illegal was presented to the WA Parliament in October 199 1, but was only passed by both houses of the WA State Parliament in April 1994 as the Poisons Amendment Act 1994.
PREVIOUS COMMUNITY SURVEYS ON HARM REDUCTION
Research into community attitudes to drug injectors and needle and syringe provision to IDUs had previously been conducted in both New South Wales (Schwartzkoff et al., 1989) and WA (Leivers and Medica, 1989). Both studies found general community support for such initiatives. However, no research had been published to look at the effect of advocacy in this area. The present study also investigated community attitudes to the possibility of changing cannabis laws. These data has been reported elsewhere (Lenton and Ovenden, 1996). A paper pertaining to pharmacists' role in the provision of needles has also been published (Lenton and Jacobs, 1995) and a full technical report on the project is available (Lenton, 1994).
This study aimed to measure the existing community attitudes to illicit drug use and strategies to minimise harm. It also attempted to determine whether these attitudes could be shifted in favour of supporting further such measures in a politically salient way. The attitudes of a sample of the Western Australian public were measured regarding illicit drug use, the potential of HIV transmission through the sharing of N&S, their understanding of harm reduction initiatives applying to drug injectors and the level of support for politicians who take steps to further support these initiatives. The study attempted to determine the extent to which a simple advocacy intervention, verbal information, might reinforce attitudes consistent with further steps to minimise harm among drug injectors and the wider community.
Four hundred members of the WA public, aged 17 years and over, were interviewed by telephone between the 26 November and the 5 December 1993. Most (6 1 %) were from the Perth metropolitan area and the remainder were from two regional centres, Bunbury (27%) and Geraldton (12%). These centres had been used in earlier research by Leivers and Medica (1989) into the provision of N&S as a harm reduction strategy with IDUs. The sampling and data collection was conducted by Reark Research Pty Ltd. Survey respondents were selected at random using CD Rom 'Australia on Disk' to select the household. Within households, the person whose birthday was closest to the day of telephoning was used to select the respondent and up to three call backs were made to contact them. No substitution within households was permitted. Most telephone calls were made after 5prn on weekdays and during the day on weekends so as not to bias the sample against those in employment. Thirty-eight per cent of contacts with eligible respondents resulted in a complete interview. Four (I %) of the 404 interviews commenced were terminated by the respondent prior to completion. The data presented below are based on the 400 complete interviews.
On average, the questionnaire took just under 25 minutes to administer by phone. It included both closed and open ended items, which covered knowledge and attitudes to drug use; spread of HIV, methods of reducing spread; demographic information including political and religious affiliation; and questions regarding cannabis decriminalisation. Two sets of Likert scale items pertaining to the provision of N&S to IDUs were also included. One was presented before, and one after, a three-minute standardised audio-taped information module (see Figure 1), played over the telephone, which comprised the advocacy intervention. This taped message was read by a male radio news reader. It attempted to address the 'us and them' construct by appealing to the recipient's self-interest rather than their altruism. Drug injectors were presented as potentially part of the respondent's family or their family members' sexual partners. Realistic figures on the prevalence of injecting drug use in the community were presented and the effectiveness of N&S provision summarised. The aim was to have respondents see provision of N&S as relevant to 'us' (the public), not just 'them' (drug injectors). Political affiliation was measured by asking respondents whom they voted for at the previous state election held on 6 February 1993.
Over half (54.8%) of the sample of 400 respondents were women. The age distribution was 17-19 years 5.8%) 20-29 years 19.3%,30-39 years 28.5%,40-49 years 20.0%, 50-59 years 11.5%, and 14.5% were 60 years or over. The sample did not differ from population figures with regards to gender or voting patterns at the last state election. However, consistent with a sampling strategy based on telephone connections, those in the 30-39 age group were over-represented, and those over 60 years of age were underrepresented in the sample. Consequently, the data were weighted to control for this age effect.
Impact of the advocacy intervention
The impact of the audio-taped information module on respondents' attitudes and beliefs regarding strategies to reduce the harm associated with injecting drug use is presented in Table 1. This shows that the advocacy had little impact on the respondents beliefs about the ease of identifying IDUs. However, the proportion agreeing either 'strongly' or 'somewhat' with the statement that 'most injecting drug users are addicts', was reduced from 66.7% to 5 1.0% by the information. Agreement with the notion that IDUs were capable of acting responsibly to lessen the risk of HIV spread, increased from 35.4% before the tape, to 52.9% thereafter. Approximately four in five respondents agreed prior to the intervention that IDUs came from all sections of the community. This was not affected by the in formation provided. However, agreement with the notion that there were many young people who injected drugs on an occasional basis increased from 64.0% to SO.3% after the intervention.
With respect to the provision of injecting,2quipment, the proportion of respondents who agreed that users of illegal injectable drugs ought to have legal access to new N&S, increased from 75.5% to 86.9%. The proportion who did not agree that provision of N&S would lead more people to inject, increased from 62.8% to 7 1. 1%. Support for the view that provision of N&S was important in stopping the spread of HIV in WA, was initially high (84.9%), but increased after the intervention to 93.2%. The view that health authorities should continue strategies to further reduce HIV spread was supported by approximately nine in ten respondents and was unaffected by the intervention. Just under two-thirds of the respondents believed the only way to reduce the spread of HIV among IDUs was to get them to stop taking drugs. This was not significantly different after the intervention.
Prior to the intervention 73.8% of respondents disagreed that if a young member of their family had been injecting illegal drugs with a needle bought from their local chemist they would hold the chemist partly responsible for any negative consequences. Responses to this item were not significantly different after the tape. Before the tape 89. 1 % of respondents agreed that they could 'understand why some chemists and other health workers may have some worries about providing needles to injecting drug users'. Despite this already high level of support, this increased to 93.7 % of respondents after the information tape was played. The proportion of respondents who agreed that 'it should be legal for chemists and other health workers in WA to make needles available to injecting drug users' increased from 69.0% before the tape, to 84.7% afterwards.
Prior to the tape 54.9% of respondents agreed that if children are trying to purchase needles from chemists they should not be sold them, even if they risked catching HIV by sharing needles. However, after the intervention only 45.4% agreed with the statement. Before the tape, 82.0% respondents agreed that if a young member of their family had been injecting illegal drugs with a needle bought from their local chemist, they would be thankful that at least they had access to clean needles. After hearing the information module, 90.2% agreed with the statement. Initially, 7 5.5 %of the sample agreed that pharmacists and others were providing an important community health service by making needles available to IDUs. This increased to 88.8% after the tape. The proportion of respondents who agreed that 'in WA it was quite likely that a person pricked by a needle dropped in a public place would catch HIV' dropped from 49.9% to 34.4% after the intervention. Agreement with the notion that police were acting responsibly if they exercised their discretion not to 'stake -out' locations where IDUs obtained new needles, increased from 58.8% to 81.7%. The belief that politicians who make it legal to provide needles to injecting drug users in WA were making the right decisions for the health of the community increased from 75.2% prior to the tape, to 85.6% afterwards.
Items measuring similar underlying concepts
To explore which groups of items were measuring similar underlying concepts factor analyses were conducted on the pre, post and change scores. Table 2 shows that there were a group of items (Factor 1) about support of N&S provision, the role of pharmacists in this, and the actions of police and politicians in supporting it. Together these items appeared to measure support for needle provision. The second group of items (Factor 2) represented stereotypically negative attitudes and beliefs regarding IDUs, supported abstinence as the only way to reduce HIV transmission and the belief that the risk was high of contracting HIV through a needle injury in a public place. The third group items (Factor 3) were consistent with a positive view toward IDUs. In particular the view that many young injectors use on a recreational basis. The final group of items (Factor 4) could loosely be described as suggesting the respondents understood the rationale for needle provision.
Differences between supporters and opponents of legal chemist provision of needles to IDUs
Those who who agreed it should be legal for chemists and other health professionals to provide needles to IDUs were no different from those who did not in terms of age, gender, political affiliation, religious affiliation, whether they worked in the medical or allied health area, whether they were from the city or the country, whether they had seen anything in the media regarding provision of N&S to IDUs, or whether they had children under the age of 22. This was true both before and after the presentation of the information module.
The overall response rate for the study of roughly 38% is rather low, but is not surprising given the length of the interview, which was stipulated at the point of seeking the person's involvement in the study. Whilst this maybe considered a limitation of the study, it was decided that given the nature of the material covered in the interview, in particular the inclusion of the information module, the interview could not be shortened substantially without compromising the aims of the research. If the length of the interview did result in a lower response rate it is not apparent that this has systematically biased the sample. The sample was not significantly different to population figures with regards to gender, or right or left wing political affiliation, and although it was significantly different with regards to age, the data were weighted to control for this potentially confounding variable.
It is possible that had we argued in the opposite direction (against N&S provision) we may have been able to move the sample in this direction. However, the purpose of the study was to determine the effect of advocating for N&S provision as a harm reduction strategy. Responses to four of the six items concerning the role of pharmacists in the provision of needles to IDUs were moved by the information module in the direction of support for harm reduction. After the information module was presented there was a significant increase in support for the legalisation of the. provision of N&S, and in recognising that chemists and others were providing an important community health service by providing needles. Even on the more contentious issue of the provision of needles to children, after the information module, roughly equal numbers were in favour as against the proposition.
After the information module an even greater proportion of respondents agreed that, in proving N&S, pharmacists and others are helping to protect family members who may, at some time, inject drugs. The information module apparently reduced the proportion of people who were concerned about the risk of contracting HIV through needle stick injury in a public place. It resulted in a considerable increase in support for police exercising discretion and not staking out locations where IDUs obtain new needles. When the rationale is explained, there appears to be strong community support for this 1--)ragmatic harm reduction strategy, even in the absence of legislative back-up. The support for politicians legalising the provision of needles to drug injectors was high before the information tape, and higher after. Politicians who undertake legislative reform in this area can be assured that the majority of the community is supportive, and that they will be more supportive if an explanation of such policies is provided.
The finding that support for pharmacists and other health workers providing needles to IDUs was independent of political and religious affiliation, whether respondents lived in the city or country and other demographic variables, should be of interest to pharmacists, politicians and policy makers alike as it suggested that taking steps to further support this harm reduction measure is likely to be supported by the majority of the public across the socio-political spectrum.
The impact of the advocacy intervention in the form of the taped information module suggested that members of the community were able to assimilate information about harm reduction with injecting drug users. Providing a data based rationale resulted in an increase in support for needle and syringe provision as a community health strategy for minimising the spread of HIV It is not possible in this study to comment on the durability of this level of support. However, if a community-wide, harm reduction education advocacy campaign was initiated, this could be evaluated. The factor analyses suggest that the issues which need to be addressed in any future advocacy intervention are to increase support for needle and syringe provision by providing a pragmatic rationale for this; and to challenge negative stereotyping of IDUs as dependent addicts who are unable to change their behaviour.
The rationale for needle and syringe provision presented in the current study aimed to undermine the 'us and them' dichotomy, by pointing out that many young people inject and many parents would not be aware if their children injected or had sex with an injector. Thus, the rationale for harm reduction was framed as reducing the harm to 'us' (the individual recipient of the information and their family), rather than as an appeal to altruism towards 'them' (those drug users) out there. The factor analysis indicated that those items which were couched in this manner were heavily loaded on by the 'support for provision' factor, which highlights the saliency of the appeals to self interest. A similar approach may be useful in mobilising the general public to support harm reduction initiatives with drug injectors in the future.
The project was made possible by the funding of the National Centre for Research into the Prevention of Drug Abuse by the National Drug Strategy (Australia). Thanks to Tim Stockwell and Annabel Boys for reading earlier drafts of the paper.
Simon Lenton, Research Fellow, NCRPDA, 1/14 Stone Street, South Perth WA 615 1, AUSTRALIA Email:
Bevan J, LoxleyW, Carruthers S (1996). Getting on and gettin~ offin Perth 1994: Report of the Australian study of HIV and injecting drug use (ASHIDU). Perth: National Centre foi Research into the Prevention of Drug Abuse.
Chapman S (1994). What is public health advocacy? In Chapman S, Lupton D (Eds) The Fightfor Public Health: Principles and Practice of Media Advocacy. London: BMJ Publishing Group.
Commonwealth Departmentof Health (1985). National campaign against drug abuse: campaign document issued following the Special Premiers'Conference Canberra 2 April 1985. Canberra: Australian Government Printing Service. 1985.
Des Jarlais DC, Freidman SR (1992). AIDS and access to sterile drug injecting equipment. Annals of the American Academyof Political and Social Science 521: 42-65.
DesJarlais DC, Freidman SR (1993). AIDS, injecting drug usc and harm reduction. In Heather N, Wodak A, Nadelmann E, O'Hare P (Eds). Psychoactive Drugs and Harm Reductior from Faith to Science. London: Whurr, pp. 297-309.
Donoghoe M (1992). Sex, HIV and the drug user. BritishJournal of Addiction 87: 405-416.
Everitt BS (1977). The Analysis of Contingency Tables. London: Chapman and Hall.
Government of Western Australia (1995). Protecting the Community: Report of the Task Force on Drug Abuse. Perth: Government of Western Australia.
Health Department of Western Australia (1993). Personal communication, 26 October.
Kaldor J (1992). Tracking the course of AIDS. National AIDS Bulletin 6:41-42.
Leivers S, Medica S (1989). Community Attitudes and Knowledge about Needle Exchange Programs and the Safe Disposal of Needles. Perth: Donovan Research.
Lenton S (1994). Illicit drug use, harm reduction and the community: attitudes to cannabis law and needle and syringe provision in WA. Perth: National Centre for Research into the Prevention of Drug Abuse, Curtin University of Technology.
Lenton S, Jacobs S (1995). Selling needles? Public says yes. Australian Pharmacist 14: 285-289.
Lenton S, Ovenden C (1996). Community attitudes to cannabis use in Western Australia. Journal of DrugIssues 26: 783-804.
Lurie P, Drucker E (1996). An opportunity lost: Estimating the number of HIV infections due to the US failure to adopt a national needle exchange policy. Paper presented at the XI International Conference on Al DS, Vancouver, July 7-12.
Makkai T, McAllister 1 (1993). Public opinion and the legal status of marijuana in Australia. Journal of Drug Issues 23: 409-428.
Ottawa Charter for Health Promotion (1987). Health Promotion 1: iii-v.
Schwartzkoff JI NicolasT, Spooner S, Vidic D, WolkJ (1989). Evaluation of the New South Wales Needle and Syringe Exchange Program. Sydney: New South Wales Department of Health.
SPSS Inc. (1990). SPSS (Release 4) Reference Guide. Chicago: SPSS Inc.
WodakA, DesJarlais DC (1993). Strategiesfor the prevention of HIV infection among and from injecting drug users. Bulletin on Narcotics 45: 47-60.