First-Step Project
An Assertive Community Outreach Program
to Minimise the Harm Associated with Illicit
Intravenous Drug Use
First-Step:
An assertive community outreach program to minimise the harm
associated with illicit intravenous drug use
Miriam O’Toole
Michelle Hudoba
Brin Grenyer
Centre for Research and Education in Drugs & Alcohol
Illawarra Institute for Mental Health
University Of Wollongong, NSW
December 2000
A report for the NSW Department of Health
Acknowledgment: To Jennifer Grey for her valuable ideas and support on this project.
Additional copies of this report can be obtained by contacting:
The Secretary, Illawarra Institute for Mental Health
University of Wollongong, Wollongong, NSW, 2522, Australia
Suggested citation:
O’Toole, M., Hudoba, M., and Grenyer, B. F. S. (2000) First-Step: An assertive community
outreach program to minimise the harm associated with illicit intravenous drug use. (Report for
the NSW Department of Health.) Wollongong, NSW: University of Wollongong, Illawarra
Institute for Mental Health, Centre for Research and Education in Drugs and Alcohol.
© 2000
IBSN: 0 864 18 709 2
Table of Contents
TABLES AND FIGURES ......................................................................................................iii
EXECUTIVE SUMMARY ......................................................................................................1
INTRODUCTION ....................................................................................................................3
OVERALL CONTEXT..........................................................................................................11
The Illawarra Needle and Syringe Program Geographic Area ................................... 11
Role of the Needle and Syringe Program.................................................................... 12
The First-step Project .................................................................................................. 13
Objectives of First-step ............................................................................................... 14
Development of First-step........................................................................................... 14
Performance Indicators ............................................................................................... 15
SERVICE DESCRIPTION....................................................................................................16
Service Provision ........................................................................................................ 16
Secondary Outlets ....................................................................................................... 17
Primary Outlets ........................................................................................................... 17
Mobile Service ............................................................................................................ 18
Outreach Service ......................................................................................................... 18
Special Projects ........................................................................................................... 18
MEASURE OF STAFF PERCEPTIONS ............................................................................20
Clients ......................................................................................................................... 20
Service Structure ......................................................................................................... 20
Experience of Staff...................................................................................................... 21
Staff Recommendations for Change ........................................................................... 21
NEEDLE DISTRIBUTION RATES.....................................................................................23
CLIENT STATISTICS .........................................................................................................27
TRAINING..............................................................................................................................32
Development ............................................................................................................... 32
Training Program ........................................................................................................ 34
Placements................................................................................................................... 36
Placement Tasks.......................................................................................................... 37
OUTCOMES...........................................................................................................................38
TRAINING ................................................................................................................. 38
Knowledge Test ....................................................................................................... 38
Confidence/Knowledge scale .................................................................................. 38
Evaluation of the Modules...................................................................................... 39
PROCEDURAL OUTCOMES ................................................................................... 41
Client Contact.......................................................................................................... 41
Tracking System...................................................................................................... 42
Planning .................................................................................................................. 42
RECOMMENDATIONS .......................................................................................................44
REFERENCES .......................................................................................................................46
APPENDICES.........................................................................................................................51
APPENDIX 1: ILLAWARRA NEEDLE AND SYRINGE PROGRAM BUSINESS
PLAN 2000 ................................................................................................................. 51
APPENDIX 2: REFERRAL CARDS ......................................................................... 55
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First-Step Project
TABLES AND FIGURES
Table 1
Population by local Government Areas in the Illawarra , 1994.............. 11
Table 2
Average Number of Needles per Month by Year ................................... 12
Table 3
Referral rates for the six months Jan to June 1999 ................................. 29
Table 4
Number of group NSP education by month............................................ 30
Table 5
Number of sexual health education sessions by month .......................... 31
Table 6
Responses to community needs by month .............................................. 31
Table 7
Knowledge Score .................................................................................... 38
Table 8
Confidence/Knowledge task scores ........................................................ 39
Table 9
Confidence/Knowledge subject scores ................................................... 39
Table 10
Modules .................................................................................................. 40
Figure 1
Needle and syringe data before training……………….………….....…23
Figure 2
Needle and syringe data after training………..……………………...…24
Figure 3
Needle and syringe data for Wollongong secondary outlets………..….25
Figure 4
Needle and syringe data for Nowra secondary outlets……………..….25
Figure 5
Total needle and syringe data by month…………………………….…27
Figure 6
Client data……….…………………………………………………….28
Figure 7
Gender of clients by month……….………………….……………….28
Figure 8
Referrals to other services………….………………………………....30
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First-Step Project
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First-Step Project
EXECUTIVE SUMMARY
Engaging drug users into treatment has long been recognised as a problem that
needs to be addressed. In 1999, the NSW Department of Health AIDS Bureau provided
funding for the “First Step” Project, a Needle and Syringe Program (NSP). The overall
aim of the project was to reduce the incidence of harm associated with drug use. The
goals of the First Step Project were to help clients stabilise their lifestyle; potentially
reduce drug use or harmful drug use behaviours; and assist clients to access other
relevant health and community services. It was envisioned that NSP workers could also
provide a point of transition for those clients wishing to enter treatment programs.
The main service provided by an NSP in general is the pro-active provision of
safe injecting equipment and safe sexual products to intravenous drug users (IDU). In
addition to this, the First Step project involved educating both IDU and the general
population about transmission, and the provision of assertive outreach training for NSP
workers. Although engaging IDU into treatment was the primary objective of this
project, the importance of reducing the transmission of HIV and other blood born
viruses was also acknowledged. Data was collected from January to June 1999 and then
from January to June 2000 to map changes due to the First Step implementation. A
substantial number of needles were distributed and returned at both primary and
secondary outlets, and this number increased post-training. Data was also collected on
when and why clients were seen, and the number of participants at NSP and sexual
health education sessions. These education sessions were judged by participants to be
useful and relevant. The most common requests from clients were about risk behaviour,
community services, legal and financial help, referrals to treatment and health care. 784
people (41 groups) attended the NSP education sessions, and 1356 (80 groups) attended
the sexual health sessions over a six month period.
The nature of the initiative was to increase the ability of the NSP to meet the
health and social needs of clients either through enhancing existing staff skills through
relevant training programs, or alternatively, to employ staff members with specific
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First-Step Project
skills. By improving the skills of the NSP staff, it was anticipated they could better help
clients reduce harmful drug behaviours by providing clients with information, referring
them to community services, and engaging more clients into treatment services.
Through a process of consultation with staff and management, a training
package was developed to improve the skills of staff in both the theory and practice of
client intervention. The training was conducted over a three-month period, and involved
didactic, interactive and placement based learning. Pre and post training assessment of
staff confidence and knowledge was completed. The results from the evaluation of the
training showed significant increases on the knowledge test from 17% to 66% and on
the confidence/ knowledge scales (average increase of 17% and 47% respectively) for
the majority of the tasks and across all subjects.
Once the training was completed, the team designed a system whereby client
referrals would be tracked through the service to enhance engagement. The most
referrals were to Drug and Alcohol Services, followed by health services. Record
keeping was also reviewed and new instruments were designed to increase the level of
information about client needs and treatment preferences.
The First Step project was successful in reducing drug related harm with an
increase in the number of needles distributed and returned. There was also an increase
in the number of participants in educational sessions, which were also judged by the
clients to be particularly relevant to their concerns. The staff training program was
successful in increasing staff knowledge and confidence about tasks and subjects that
are vital for assessing and engaging clients into treatment. The evidence from this study
is that an assertive community outreach role for properly trained NSP workers is an
effective additional way to reduce harm from IDU by educating and engaging these
users into treatment.
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First-Step Project
INTRODUCTION
It is estimated that there are approximately 3 million illicit drug users aged 14
years and older in Australia (1998 National Drug Strategy Household Survey, 1999). Of
this group, 100,000 regularly use intravenous methods of administration. In addition,
there are 175,000 occasional intravenous drug users (IDU) (Wodak, 1999). As a result
of different sampling methods, the quality of information available on the nature and
size of the IDU population may be under-represented. For example, a study may not
include an adequate sample of IV drug users who are not enrolled in a treatment
program (Watters & Biernacki, 1989; Watters, Downey, Case, Lorvick, Cheng &
Ferguson 1990). Such findings would therefore not be generalised to IDU who are not
in treatment (Baker, Kochan, Dixon, Wodak & Heather 1994b). Studies in which heroin
addicts in the community were compared with heroin addicts in treatment show the two
groups to be different in both their characteristics and risk taking behaviour (ElandGoossensen, van de Goor & Garrestsen 1997). In addition, accurate estimates about the
population of IDU cannot be extrapolated to the wider population using studies based
on IDU samples as this group is a very small percentage of the overall population
(Rounsaville & Kleber, 1985). Although chain referral and targeted sampling are
commonly used in evaluating IDUs, these methods do not allow a representative
characterisation of IDU in the community as a whole, because IDUs who keep
themselves separate from the heroin-using community (eg. addicted physicians and
pharmacists) are not reached (Rounsaville & Kleber, 1985). For accuracy of
information, further research is required (Hando, Hall, Rutter & Dolan 1999). The rate
of IDU increase has been estimated at 7 % per annum since the 1960’s and if this rate is
accurate it represents a doubling every ten years (Wodak, 1999). Between 1994 and
1996, the opioid overdose rate has doubled (Joint Selection Committee into Safe
Injecting Rooms, 1998).
The National policy toward illicit drug use in Australia is to pursue a balanced
approach between supply reduction, demand reduction and harm minimisation
strategies (National Drug Strategic Framework 1998-99 to 2002-3, 1998). In 1997, a
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First-Step Project
United Nations World Drug Report estimated that of the total amount budgeted toward
addressing the drug problem in Australia, 84 % had been directed to law enforcement,
but only 6 % to treatment and 10 % to prevention and research. (Wodak, 1999).
Australia adopted a harm minimisation policy in 1985, largely in response to the
HIV threat (National Drug Strategic Framework 1998-9 to 2002-3, 1998). One of the
strategies instigated under harm minimisation was the Needle and Syringe Program
(NSP) which was trialed in Australia in 1988 and has been operating and expanding
since then (Schwartzkoff, Spooner, Flaherty, Braw, Grimsely, Scanlon & Stewart
1990).
Needle and Syringe Programs were established to assist in the prevention of the
spread of blood born viruses in the community by providing new needles to IDUs (thus
reducing the need to share), and by distributing condoms. From 1984 to 1991, 189 cases
of HIV infection due to IDU (not including those possibly due to sexual intercourse)
were reported in NSW (NSW Public Health Bulletin, 1992). However, this does not
include cases where no source of exposure data was given. Also, studies show that HIV
infection is commonly under-reported, or falsified when self-reported (Guydish et al.,
1998). From 1994 to 1998, of the 2,734 clients of selected NSW NSPs who volunteered
to be tested, 11.6% were HIV positive (National Centre in HIV Epidemiology and
Clinical Research, 1999). As of December 1997, 36% of the 641, 086 cases of AIDS
reported to the Centres for Disease Control (CDC) in the US were directly or indirectly
associated with injecting drug use (Centres for Disease Control and Prevention, 1998).
In 1997, 96 out of the 100 NSPs in the US that participated in a survey reported
exchanging approximately 17.5 million syringes (median: 57,343 syringes per NSP).
Ninety nine per cent offered instruction in the use of condoms to prevent STDs, 96%
provided information about safer injection techniques and/or the use of bleach to
disinfect injection equipment, and 94% referred clients for substance abuse treatment
programs (Centres for Disease Control and Prevention, 1998). Thus, workers in NSP
provide education and information about behaviours and strategies that if employed
reduce the chance of infection. Overseas studies have shown that the estimated average
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First-Step Project
annual HIV seroprevalence is 11 % lower in cities with a NSP (Joint Selection
Committee into Safe Injecting Rooms, 1998). A report into the efficacy of NSP in North
America estimates that infection from HIV has decreased by 33 % as a result of contact
with a NSP (Vlahov & Jungle, 1998). HIV infection among IDUs in Australia has
remained one of the lowest in the world, at less than 2%, compared to up to 50% in
those countries without NSPs (Davies, 1998). The strongest evidence for the efficacy of
NSPs was obtained by an Australian analysis of over 3000 articles in the research
literature. Hurley, Jolley and Kaldor (1997) identified 81 cities worldwide where HIV
seroprevalence had been assessed over time. In the 29 cities that had NSPs, HIV
prevalence decreased by 5.8% per year, compared to a 5.9% increase in the 52 cities
without NSPs. (Hurley, Jolley & Kaldor, 1997). A decrease in the rate of infection of
other blood born viruses has also been reported with a seven fold increase in Hepatitis C
Virus infections in IDU who were associated with non-use of NSP (Vlahov & Jungle,
1998).
In 1995, there were 718 NSP outlets in Australia and 15 million needles
distributed annually at a cost of $1 each (Hando et al., 1999). Findings suggest that in
comparison to a range of other health interventions, NSP is an extremely cost effective
measure (Kahn 1993; Joint Select Committee into Safe Injecting Rooms, 1998). An
independent evaluation of the National HIV/AIDS Strategy 1993- 1996 reported that in
1991, Australian NSPs had prevented approximately 2900 cases of HIV infection,
saving $266 million in avoided treatment costs (Davies, 1998). Research has
demonstrated that NSP have been successful not only in reducing the rates of infection
but also in changing the risk behaviours related to injecting (Darke, Ross & Hall 1996).
Sampling of the Australian population has demonstrated a high degree of community
support for harm minimisation approaches such as NSP (Community Attitudes to
Needle and Syringe Exchange and to Methadone Programs, 1990; National Drug
Strategy Household Survey, 1998). In some communities, NSPs remain controversial
and unpopular, being blamed for discarded needles, beliefs that NSP condone and
enable drug use thereby increasing the illicit drug problem, and even for economic
decline (Broadhead, van Hulst & Heckathorn 2000). However, one study found that
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First-Step Project
following a needle exchange closure, former clients increased their drug-related risk
behaviours, the number of discarded syringes increased, and the level of illicit drug use
remained the same (Broadhead et al., 2000). In addition, the percentage of clients
reporting their primary source of new syringes were from unreliable sources (family,
friends, diabetics, or street sources) increased from 14% to 51%; the number of times
syringes were re-used increased from an average of 3.5 times to 7.7 times; the rates of
sharing syringes also increased significantly from 16% to 34%; the rate of discarded
syringes increased from 26.1 to 39.8 per month in the fall, and from 11.2 to 17.9 per
month in the winter following closure (Broadhead et al., 2000). Thus, the closure of the
needle exchange deprived drug injectors of a reliable and economic way of obtaining
new syringes and a convenient means of proper disposal. Guydish, Bucardo, Clark and
Bernheim (1998) also report that clients who receive a higher proportion of their
needles from NSPs were less likely to report sharing of needles or rinse water, less
likely to re-use needles, and more likely to clean their skin prior to injection.
A study into the characteristics of IDUs reported that about 80 % were male and
57 % were between 20 and 29 years old. The study also reports that IDUs cannot be
identified as such by appearance and generally had very low levels of support (Stowe &
Ross, 1992). The average age of first injection was between 18-19 years of age (1998
National Drug Strategy Household Survey, 1999). It is possible that many IDUs do not
consider their drug usage as an important component of their self-identity. A study in
Sydney reported that when those IDU sampled where asked to describe themselves,
75.3 % did not mention their drug use (Stowe & Ross, 1991). In a US study NSP clients
have also been found to have a greater baseline severity of drug use, to be significantly
older, and more likely to be male, African American and unemployed (Brooner et al.,
1999). Guydish et al. (1998) report 72% of IDUs are male, they have a mean age of
38.2, 25% are homeless, and 34% are unemployed. Heroin users in general tend to be
young (mean age = 30.9), single (75.5%), unemployed (51.3%) males (80%) (ElandGoossensen et al., 1997;1998). Specifically, those not receiving treatment (no treatment
contacts that lasted more than two weeks in the last two years) had the longest heroin
careers, probably related to the fact that they were slightly older on average (33 years)
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First-Step Project
(Eland-Goossensen et al., 1998). However, reports on city populations may not
generalise to other populations of IDUs (Lenton & Tan-Quigley, 1997; Roberts &
Crofts, 1999). Characteristics and behaviours of IDUs have been found to differ in rural
areas, particularly in the absence of a methadone maintenance program (Roberts &
Crofts, 1999).
The majority of people who inject in most countries are not in contact with
treatment and office-based services. There is evidence that long term injectors not in
touch with services have higher levels of risk behaviour (White, 1992; Baker et al.,
1994b). This trend is supported by reports conducted in Sydney, where 20.3% and
41.9% of the populations sampled had never sought treatment (Dobison & Poletti, 1989;
Stowe & Ross, 1991).
Recommendations to improve access of IDU into formal interventions include
researching the barriers to treatment, and improving the attractiveness of treatment by
using creative approaches to developing new methods, settings and types of intervention
(Mattick & Hall, 1993). Wodak (1999) argues that retention into treatment can only be
improved through offering treatments which IDU find accessible and attractive (Wodak,
1999). In the case of IDU, intervention needs to be timely in order to not risk loss of
motivation, with an emphasis on engagement as opposed to lengthy information
gathering (Mattick & Hall, 1993). For example, in one trial, vouchers were given out for
immediate free detoxification. This approach brought in drug users who were less likely
to have been in treatment, had higher levels of risk behaviour, were older, and from
ethnic minorities (White, 1992). While delays in treatment remain more difficult than
obtaining illicit drugs, poor outcomes are to be expected (Wodak, 1999).
NSPs have been reported as being instrumental in increasing treatment contacts
(Drug Problems in our Society, 1992). Findings also suggest that NSPs give health
workers access to high-risk groups in the community who would not normally use
health services (Joint Select Committee into Safe Injecting Rooms, 1998). This finding
provides support for a UK study which found about one in three clients using a NSP had
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First-Step Project
no previous contact for help with their drug problems (White, 1992). In a London
sample of poly-drug users in which 51.2% were injecting daily, NSPs were also the
most commonly used drug services in the last six months (Hunter et al., 1998). In
addition, NSPs have acted as referral agents to drug and alcohol services. NSP staff are
often the referral point to main stream health services and provide a range of health
education including disease prevention, vein care, nutritional advice and living with
Hepatitis C, HIV or AIDS.
One possible reason for the success of NSPs in encouraging IDUs to enter
treatment may rest with these educative opportunities. In a comparison between IDUs
who were either seeking or not seeking treatment, those IDUs not seeking treatment
were found to be a substantially impaired group who generally misunderstood the
severity of their drug use and the treatment opportunities available (Rounsaville &
Kleber, 1985). Contact with a NSP may serve to educate this group on both risks and
options available. A study comparing 1) heroin addicts in the community with those in a
2) methadone program and 3) those receiving inpatient detoxification found that the
community group had the least concern over their drug use (Eland-Goossensen et al.,
1997; 1998). However, the community group had more concern and need for help with
legal problems, occupational functioning, and physical health compared to the other
groups. Perhaps offering assistance in these areas might entice IDUs into NSPs, even
though they are not “triggers” for seeking help from treatment programs. Conversely,
the inpatient group had the most social and psychological problems, which motivated
them to seek treatment (Eland-Goossensen et al., 1997). This study also showed that the
most important reason for asking for help is concern about problems with drug use
(Eland-Goossensen et al., 1997). In summary, using NSP as an opportunity to educate
IDUs on the risks involved in drug use, and for motivational interviewing, (a technique
which focuses on increasing the client’s level of concern regarding their behaviour,
(Baker et al., 1994a)) may assist engagement with treatment services. Also, educational
techniques aimed at alerting families to the need for addicted relatives to seek treatment
might encourage those not seeking treatment to do so. Schutz, Rapiti, Vlahov and
Anthony (1994) found that IDUs enrolled in a methadone maintenance program were
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First-Step Project
more likely to be married or living with a partner. Therefore, the spouse or living
partner plays a role in the treatment process that starts prior to admission to treatment
and continues through recovery.
Brooner et al (1999) argue that stronger links should be formed between NSPs
and more comprehensive drug treatment services. Treatment responses were compared
between clients referred from NSPs and those who had entered a program through
standard referrals. Both groups achieved comparably good short-term treatment
outcomes (Brooner et al., 1998; 1999). There have been no large-scale comparative
studies of treatment outcomes for illicit drug problems in Australia. NSPs can facilitate
entry into drug treatment because the relationship between IDUs and staff is often
ongoing and non-judgmental, and treatment referrals are provided on request (Sorenson
& Laurie, 1993). Heimer (1998) found that NSP acted as a conduit to bring drug users
into substance abuse treatment programs, but that such gains are easily lost by
impediments to the implementation of a complete harm reduction program.
One of the threats and current barriers to developing strong links between NSP
and drug and alcohol treatment services may rest in differing ideologies. In a
government report, treatment is defined as “A deliberate person to person intervention
that provides counselling and/or specific procedures that aim to assist individuals to
reduce drug consumption or to minimise the harm associated with continued drug use”
(Mattick and Hall, 1993). A study conducted in Wales reported that HIV prevention
varied according to policy. Those services with an abstinence policy rejected NSP and
prevention developed on an ad hoc basis, whereas drug agencies with a pre-existing
harm minimisation model easily integrated syringe exchange into their work (Keene et
al., 1997).
In summary, evidence overwhelmingly supports the use of NSP for preventing
the spread of blood borne viruses in the community. An additional advantage is that
IDUs come into contact with an NSP worker who can provide psycho-education and
harm minimisation strategies and can probably act as a conduit for the IDU to enter
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treatment. There is very little research investigating this expanded role for the NSP
workers. The aim of the current study was to train NSP workers for a more assertive
community outreach role in addition to their usual work dispensing needles, syringes
and condoms. It also aimed to investigate utilisation rates of the NSP and study rates of
referral into treatment.
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First-Step Project
OVERALL CONTEXT
The Illawarra Needle and Syringe Program Geographic Area
The Illawarra Area Health Service (IAHS) covers the geographic region of the
coastal plains south of the Sydney metropolitan area. The area covered by the Illawarra
NSP incorporates the four local government areas of Wollongong, Shellharbour, Kiama
and Shoalhaven and extends over a distance of 242 kilometres.
The region contains the highly urbanised and industrial areas of Wollongong and
Port Kembla and largely rural areas of Kiama and Shoalhaven further to the south. The
population within the Illawarra area is steadily growing resulting in increased demand
for services and resources. In comparison to the rest of NSW the Illawarra is an area of
relative socio-economic disadvantage with residents more likely to have low incomes,
to be unemployed and to have completed formal education early.
Table 1.
LGA
Population by local Government Areas in the Illawarra , 1994
Estimated Resident
% of Population in each LGA
Population 1994
Wollongong
182,530
55.7
Shellharbour
50,840
15.5
Kiama
17,970
5.5
Shoalhaven
76,150
23.3
327,490
100.0
IAHS
Source : Australian Bureau of Statistics, 1994
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First-Step Project
Role of the Needle and Syringe Program
The primary role of the NSP is to decrease the transmission of HIV and other
blood borne viruses. The core task of the program is the provision of safe injecting
equipment and safe sexual products to IDUs, as well as education about transmission to
both IDU and the general population. The Illawarra NSP has operated continuously
since its establishment in 1988. Its primary outlet is located in Wollongong and it has
established 11 secondary outlets throughout the area. The NSP currently employs four
full-time and one half-time staff, a further part time member of staff works exclusively
in outreach for the sex work industry.
In the Illawarra HIV and Drug and Alcohol Services are organisationally
linked into one department (DAHIV). Managers of HIV services and Government
and Non-government Drug and Alcohol Services meet every fortnight and all staff
from these agencies meet three to four days per year at DAHIV service planning days.
During the last four years, there has been a doubling in the amount of safe
injecting equipment distributed by the Illawarra NSP. This finding may indicate that
intravenous drug use is escalating in the Illawarra region.
Table 2.
YEAR
Average Number of Needles per Month by Year
AVERAGE NUMBER OF NEEDLES
DISTRIBUTED PER MONTH
1996
17, 072
1997
24,217
1998
35,917
1999
35,415
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First-Step Project
Other indicators are:
♦ Number of opioid deaths 1987-1995 = 47 deaths.
♦ Clients registered in Methadone treatment in 1997 = 508
♦ Cumulative hepatitis C Virus notifications to 1997 = 2,226
The NSW Department of Health used these indicators to estimate that in 1999
there were approximately 1,500 IDU in the Illawarra region. Due to the hidden nature of
this population, any report about size can only reach an approximation based on current
indicators.
The First-step Project
In 1999, the Illawarra Area Health Service was awarded a grant from the NSW
Department of Health to establish the First-step Program.
In 1999, the Department of Health offered funding grants to needle and syringe
programs in NSW to support initiatives aimed at reducing the incidence of harm
associated with drug use. The objectives were to help clients stabilise and/or reduce
drug use and harmful drug use behaviours, and to assist clients to access other relevant
health and community services. It was also envisioned that NSP workers could facilitate
referral for those clients who wished to enter a treatment program. Hopefully, those that
enter treatment would then respond better, through increased retention in maintenance
programs and reduced relapse rates after detoxification.
The nature of the initiative was to increase the ability of the NSP to meet the
health and social needs of clients by enhancing staff skills through training, or
alternatively, to employ staff members with the specific skills required.
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First-Step Project
The differing nature and structure of NSPs around the state was acknowledged
and the initiatives were individually designed to reflect local needs and resources.
Objectives of First-step
1
Improve the ability of NSP staff to assist Injecting Drug Users to reduce harmful
drug using behaviours.
2
Improve the ability of NSP staff facilitate the referral of Injecting Drug Users to
drug and alcohol treatment services.
3 Improve the ability of NSP staff at the primary outlet to facilitate the referral of
Injecting Drug Users to health and community welfare services.
4
Improve the ability of NSP staff to provide a staged transition for clients wishing to
enter drug treatment programs.
Development of First-step
The first phase of the project was to develop a baseline measure of the Illawarra
NSP and to conduct meetings with the team to establish the best method of establishing
the objectives of the project. During this initial phase, the capacity of the team to
complete the project was examined in more detail and the objectives were reworked to
enable the team to complete the project so that the essential services of the NSP were
not impaired by hosting the pilot.
Through a process of consultation with staff and management, a training
package was developed to improve the skills of staff in both the theory and practice of
client intervention. Staff were pre and post tested on both confidence and knowledge
skills specific to the training. The training was conducted over a three-month period,
and involved didactic, interactive and placement based learning.
14
First-Step Project
Once the training had been completed the team developed a system to track
client referrals into treatment services and to provide feedback on client engagement
with those services. It was important that this remained a relatively informal process so
clients who did not enter treatment were not discouraged from using the NSP for safe
injecting equipment.
Record keeping was also reviewed and new forms were designed to increase the
level of information about client needs and treatment preferences.
Another aim of the project was to improve the quality of client access to NSP
workers. This involved improving the primary outlet reception area to encourage clients
to spend more time with workers and to change the front desk workers duties to enable
them to have more time to engage and respond to clients needs.
Performance Indicators
1. Increase in workers knowledge and confidence about:
♦ Forming a therapeutic relationship with clients
♦ Completing an assessment of clients needs
♦ Taking a drug and alcohol history
♦ Planning interventions with clients
♦ Managing clients in crisis
♦ Referring clients to other services
This was measured using pre and post-test questionnaires.
2. Development of a referral system for IDU clients into mainstream drug and alcohol
services.
3. Increase in the number of referrals of IDU clients to drug and alcohol services.
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First-Step Project
SERVICE DESCRIPTION
Prior to the development and implementation of the assertive community
outreach training, the current service provision and staff attitudes to their roles were
evaluated to provide additional information to target their training needs. All Staff
completed a survey that addressed both their experience of working in an NSP and their
perception of the clients needs. In response to questions about the role of the service,
including duties and tasks, the staff provided the following information.
Service Provision
The Department of Health funds and determines the area of service provision for
Needle and Syringe Programs (NSP). The Illawarra NSP team has been delegated the
area from Helensburgh to Ulladulla.
The Illawarra NSP is located in central Wollongong. Three related services share
the building including the NSP (Rawson St Centre), the Drug/Alcohol and HIV
Community Development Team and, Drug/Alcohol and HIV Administration.
The team has four methods for establishing the distribution of safe injecting
equipment and condoms. The team is entirely responsible for the operation of three of
these methods
1. Running the primary outlet at Rawson St.
2. Delivering a mobile service
3. Providing outreach to the community
These three distribution points are all run within working hours apart from the Sex
Workers Outreach Project (SWOP) that was being conducted during the evenings.
4. The fourth method of distribution is through secondary outlets within the area. There
are 11 secondary outlets within the Illawarra area. One access point operates twenty16
First-Step Project
four hours per day, and is located at the Accident and Emergency Department
Shoalhaven Hospital Nowra.
Secondary Outlets
The aim of the secondary outlets was to ensure the service was available at
geographically, culturally and IDU appropriate locations. This involved community
participation and consultation, and the NSP staff were actively involved in this process,
providing the training of the staff involved.
Having established the secondary outlets, the team were then responsible for
ensuring that they remained stocked, that the returned needles were collected and
disposed of appropriately, and that the distribution rates at the outlet were recorded. The
team was also actively involved with responding to community concerns within that
locality, including complaints and ongoing educational needs.
Primary Outlets
The primary outlet is staffed by at least one staff member between the hours of
8.30am and 5.00pm Monday to Friday. The NSP team also operates the secondary
outlet at the Sexual Health Clinic four hours per day, four days per week. Both these
duties are organised by the team on a rostered basis. Other shared duties include•
The provision of outreach to the community.
•
Community education, training and responding to complaints.
•
Assisting clients with a variety of problems.
•
Distributing resources to clients (eg pamphlets)
•
Telephone switchboard.
•
Collecting needles at hot spots.
•
Community liaison.
•
IDU Education to service users at the Attendance Centre, Drug and Alcohol Inpatient services and at all the methadone clinics.
•
Collection of statistical data.
17
First-Step Project
Mobile Service
The Mobile Delivery Service operates from a van and usually involves one staff
member. The van is also used to stock the secondary outlets (apart from those in the
Shoalhaven), and for the delivery of large supplies of needles in response to requests
from the community. The Mobile service also delivers and picks up all stock from the
packers, and provides outreach where possible on an ad hoc basis. In addition the
mobile worker responds to community requests for the clean up of needles and operates
as a courier for the Drug/Alcohol and HIV Service.
Outreach Service
Outreach is performed to varying degrees by all staff of the NSP, but is not clearly
defined. At present, outreach involves going out to the community to perform a variety
of duties. These include:
•
Forming relationships with intravenous drug users in their own environment.
•
Responding to the needs of clients.
•
The distribution of safe using equipment to people either in their homes or on the
street.
•
The collection of used syringes both at hot spots and in response to community
requests.
•
Responding to general community requests both through phone contact or contact
on the street.
•
Delivering condoms.
Outreach staff work alone or in pairs. The outreach worker determines the place and
time of the outreach, either through their knowledge of the area or through community
requests. During the last three years, the amount of outreach has declined.
Special Projects
In addition, some of the staff are involved in ongoing special projects. Feedback
to other staff about special project progress and findings has no formal review
18
First-Step Project
mechanism within the team. In all instances, projects had been initiated through outside
requests.
19
First-Step Project
MEASURE OF STAFF PERCEPTIONS
Prior to implementing the training staff were surveyed about their current perceptions of
NSP.
Clients
According to this survey, the most common requests from clients apart from safe
injecting equipment and condoms are for:
•
Information about safer injecting and other risk behaviours.
•
Referrals to detoxification and other D&A treatment.
•
Advice about legal issues.
•
Information about services that provide food,
shelter and housing.
•
Financial difficulties including help with benefit forms.
•
Relationship issues including domestic violence.
•
Health care needs including abscesses and vein care.
•
Referral after sexual assault.
•
Information about HIV, AIDS and Hepatitis C.
The number of client contacts range from 20 to 50 per day, with the mobile service
reporting the highest level of contact. Clients most commonly seek help from staff at the
primary outlet, and less commonly some clients arrange appointments by telephone.
Service Structure
The team works within the Ottawa Charter using the Needle and Syringe Policy
Manual as a guide, and harm minimisation as their model of service delivery.
Team meetings are scheduled each week, but are not held regularly. Some members of
the team believe that this is situation is improving. This deficit appears to be a reflection
of the culture of the service where responsiveness to client demand is primary.
20
First-Step Project
Experience of Staff
Experience with NSP work ranged from 2 yrs to 10 years.
In response to the question: “How confident do you feel about your ability to
engage clients?” (10= extremely confident, 1= not confident at all) the teams mean
score was 7.6.
In response to the question: “How confident do you feel about your ability to
successfully encourage clients to enter treatment?” (10= extremely confident, 1= not
confident at all), the mean score was 5.2.
Some staff members commented that their lack of confidence was related to the
availability of treatment services rather than their own ability. Nevertheless, these
responses indicated that additional training was needed to improve staff confidence.
In response to questions about change the staff gave the following information.
Staff Recommendations for Change
All Staff believed that change was needed in some form.
The recommendations for change were as follows:
•
The provision of more outreach
•
Increased knowledge of the role of other services; in particular, Drug and Alcohol.
•
An additional permanent full-time position.
•
Increase in ability to successfully refer clients into treatment services.
•
More access for clients to safe injecting equipment and condoms.
•
More training.
•
To make NSP area more client friendly.
21
First-Step Project
•
At least one additional 24-hour access points to safe injecting equipment
(particularly in Wollongong area).
•
Increased focus on Hepatitis C.
•
For the service to be relocated to an area with a higher proportion of IDUs.
•
Increase in budget.
•
Clearer structures and guidelines with regard to staff duties.
•
More accountability for all staff.
•
Receptionist to answer phones.
•
More adherence to systems.
•
Not as many restraints on choice of safe injecting equipment particularly when it
can be purchased elsewhere for less.
•
Establishing a separate team.
•
Needle and syringe vending machines
The recommendations for what should remain the same were as follows:
•
Access to safe injecting equipment and condoms.
•
Confidentiality and the level of client trust.
•
No reduction in service provision.
•
No reduction in current resources.
•
Staff attitude to clients, which is supportive, helpful, and non-judgmental.
•
Continued ability of clients to access service when they need it.
•
Maintaining current level of client contact.
•
The positive working relationships amongst staff.
•
The degree of flexibility within the team structure.
•
The current support from management.
•
The current criteria for staffing.
•
Continued positive high profile (not to go under cover again).
•
Client focus should not change.
•
Duties continue to have total NSP focus.
22
First-Step Project
NEEDLE DISTRIBUTION RATES
The following statistics were collected on a monthly basis from January 1999 to
June 1999 in order to establish staff workloads before the implementation of the project.
It was envisioned that these statistics when collected post project would demonstrate
any resulting changes to work practice. Some data upon completion of the research had
not been reliably collected and was therefore unavailable for comparison.
Figure 1: Needle and Syringe Data Before
Training (January - June 1999)
Number of Needles and
Syringes
100000
90000
Distributed
Returned
80000
70000
60000
50000
40000
30000
20000
10000
0
Primary
Port Kembla
Sexual Health
Mobile
Outreach
Outlet
The data on the number of needles distributed directly by the NSP staff
demonstrates that the Sexual Health Clinic distributed the most needles (62,274)
followed by the Primary outlet (50,783). The number of needles distributed by the
Outreach service validates staff perception that outreach is declining.
While the highest rates of needles distributed are through the Sexual Health
Clinic the Mobile Service has the highest return rate (43,166). The quantity of needles
collected through the Mobile service was reported by staff to be increasing and time
spent attending to this duty may impact on staff ability to provide assertive outreach.
23
First-Step Project
The Sexual Health Clinic and the Primary Exchange both distributed more
needles than were returned, but the Mobile and Outreach Services both collected more
needle than were distributed. The statistics indicate that Outreach is not a primary
method of needle distribution or return. Overall, more needles were distributed than
returned.
Figure 2: Needle and Syringe Data After Training
(January - June 2000)
Number of Needles and
Syringes
100000
90000
80000
Distributed
Returned
70000
60000
50000
40000
30000
20000
10000
0
Primary
Port Kembla
Sexual Health
Mobile
Outreach
Outlet
The Needle and Syringe data after the training (Graph 2) shows the same trends
as figure 1, except that the total numbers distributed and returned are larger for all
outlets. This increase in the number of needles and syringes distributed at the primary
and the mobile outlets were found to be significant. A significant increase was also
found in the number of needles and syringes returned at the Port Kembla Sexual Health
Outlet.
24
First-Step Project
14000
12000
PRE Distributed
PRE Returned
POST Distributed
POST Returned
10000
8000
6000
4000
2000
W
ar
ra
w
on
g
ha
in
C
la
ar
il
W
D
ap
to
ho
us
e
a
Ke
m
bl
Ba
lla
m
bi
0
Bu
lli
Number of Needles and
Syringes
Figure 3: Needle and Syringe Data for Wollongong
Secondary Outlets
Outlet
Number of Needles and
Syringes
30000
25000
20000
Figure 4: Needle and Syringe Data for Nowra
Secondary Outlets
PRE Distributed
PRE Returned
POST Distributed
POST Returned
15000
10000
5000
0
Ulladulla
Nowra A & E
Nowra CH
Outlet
25
First-Step Project
The data on the secondary outlets show that the Warilla Secondary Outlet had by
far the greatest number of needles distributed and collected. For the Shoalhaven, the
Nowra Community Outlet had the most needles both distributed and returned.
The total needle and syringe data for all outlets demonstrates a clear increase of
needles and syringes both distributed and returned following training from January to
June 2000. However, this increase can not be directly attributed to the training of the
staff as the number of needles distributed has increased steadily every year. Thus, the
increase in the number of IDU accessing the NSP might merely be a result of an overall
increase in the number of IDU.
26
First-Step Project
CLIENT STATISTICS
Note: Data is collected for all clients who present at the service including those
picking up or returning needles. Graph 6 shows that while the number of new clients
and total client visits increased slightly after the training, this difference was not
significant.
Figure 5: Total Needle and Syringe Data By Month
Total Number of Needles and
Syringes
45000
40000
35000
30000
25000
20000
15000
10000
5000
0
Jan
Feb
March
April
May
June
PRE Total Distributed
POST Total Distributed
PRE Total Returned
POST Total Returned
Month
27
First-Step Project
Figure 6: Client Data
5000
4335
4500
4436
pre-training
post-training
4000
Number
3500
3000
2500
2000
1500
1000
500
92
116
0
# client visits
# new clients
Figure 7: Gender of Clients by Month
1400
Number of Clients
1200
1000
800
600
400
Pre-training Male
Pre-training Female
Post-training Male
Post-training Female
200
0
Jan
Feb
March
April
May
June
Month
28
First-Step Project
Figure 7 shows that more male than female clients were seen both in 1999 and 2000,
and this is in accordance with the literature. However, childcare issues may make it
difficult for women to present at the service.
Most clients were seen in March and April, making up 42% of the total clients
seen from January to June 1999. (Note: due to high staff turnover the post training data
for April and May 2000 was not collected. A similar increase in male clients for this
period is predicted.)
Table 3.
Referral rates for the six months Jan to June 1999
Month
Health and
Welfare
Legal
Drug Treatment
Medical
PRE POST PRE POST PRE POST PRE POST
January
0%
9%
0%
7%
0%
3%
0%
21%
February
8%
14%
3%
5%
3%
2% 12%
12%
March
9%
4%
7%
0%
3%
2% 24%
14%
June
6%
1% 11%
2%
6%
2%
9%
3%
Total
23%
28% 21% 14% 11%
9% 44%
49%
Table 3 demonstrates that referral rates were highest in March and May, and the
most common referral destination was drug and alcohol services, followed by health
services. However, there was no breakdown as to what treatment options clients
preferred (eg detoxification, counselling etc.). In accordance with the literature, the
most common requests from NSP clients had to do with information about risk
behaviour, community services, legal and financial help, family issues, referrals to
treatment, and health care (HIV/AIDS, Hepatitis C, and vein care). Figure 8
demonstrates the referral distribution pre and post training as a percentage of the total
number of clients that were referred. The percentage of clients that were referred to
each service remained more or less the same.
29
First-Step Project
Figure 8: Referrals to Other Services
% of Total Clients Referred
60%
Pre-Training
Post-Training
50%
40%
30%
20%
10%
0%
Health and Medical
Table 4.
Welfare
Legal
Drug Treatment
Number of group NSP education by month
MONTH
NUMBER OF
GROUPS
NUMBER OF
PARTICIPANTS
JAN
FEB
MARCH
APRIL
MAY
JUNE
TOTAL
FOR
PERIOD
1
5
18
9
19
8
6
61
163
200
288
66
41
784
April and May were the months in which most group education was provided.
These groups provide information about HIV and other infectious diseases and involve
answering questions in a group format. They also provide information about safe sexual
30
First-Step Project
practices along with risk reducing behaviours for HIV, Hepatitis C, and other blood
borne viruses. These groups are usually provided at other services including
detoxification and rehabilitation centres.
Table 5.
MONTH
JAN
FEB
MARCH
APRIL
MAY
JUNE
TOTAL
FOR
PERIOD
Number of sexual health education sessions by month
GROUPS
3
7
25
26
7
12
80
FACE TO FACE
237
179
296
373
143
128
1356
Sexual education is usually provided at other venues including drug and alcohol
services and especially within the sex industry.
Table 6.
MONTH
JAN
FEB
MARCH
APRIL
MAY
JUNE
TOTAL
Responses to community needs by month
RESPONSES
32
16
25
18
23
23
137
The majority of community needs are in response to telephone reports of needles
left in public places such as parks and car parks. The Mobile Service is then alerted to
the problem and the area concerned is cleared of any apparent needles.
31
First-Step Project
TRAINING
Development
The training program was developed in consultation with all stakeholders. The
staff views were surveyed during meetings and by questionnaire to establish what
training was needed and the level of that training. Work practices were also examined to
establish which models and skills would best fit with the current form of client/worker
interaction. It was agreed that training needed to be easily incorporated into the current
duties to minimise any impact on the core role of the NSP and to maximise training
benefits.
The client/worker relationship was viewed as the core vehicle through which
interventions could be delivered and it was decided that the training would focus on
how best use of this relationship could improve responsiveness to client need. To
achieve this the training needed to introduce staff to some theoretical models through
which they could understand how best to engage and work with clients. The Stages of
Change model was chosen to assist staff to match client’s needs to an appropriate level
of intervention (Prochaska & DiClemente, 1986). The results of the consultation
indicated that the model of clinical management needed to have a strong emphasis on
linking, liaison and referral. In addition, Onyett’s (1992) model of case management
was adopted. These two models became the framework through which specific skill
training was developed and implemented.
Consultation also played an integral role in the development of the methods and
structure of the training. It became apparent that staff needed a semi-structured delivery
model incorporating didactic, interactive and placement methods of learning. The
didactic method involved lectures and readings on the selected topic headings.
Interactive methods utilised role-plays, discussions and set tasks to be completed within
team meetings. Five drug and Alcohol Services were chosen and staff were required to
complete half day placements at each service and were given tasks and log books to
complete. Placements were considered important as both places of learning and as a
32
First-Step Project
means of increasing links with treatment services. The training was structured over a
nine-week period with two half-day sessions per week. Six weeks of the program was
delivered in the training room the other three consisted of placements. The following is
an outline of the training program.
33
First-Step Project
Training Program
Module: 1A The Causes of Drug and Alcohol Problems
Outline
•
The Moral-Legal Model
•
The Disease or Public Health Model
•
The Psycho-social Model
•
The Socio-cultural Model
How Philosophy of cause affects assessment and treatment.
Module: 1B Overview of the Stages of Change Model
Outline
•
Introduction to the Model of Change
•
The Stages Pre-contemplation, Contemplation, Determination, Action Relapse and
Maintenance.
•
The model applied to Drug and Alcohol Problems.
•
Lapse and relapse prevention
Module: 2A Overview of Case Management
Outline
•
Philosophy of Case Management.
•
The Principles of Case Management
•
The tasks and Practices of Case Management
Module: 2B Engagement
Outline
•
Relationship, engagement and therapeutic alliance
•
Research and theory of therapeutic alliance
•
Developing skills of therapeutic alliance
•
Considerations for Particular Client Groups
34
First-Step Project
Module: 3A General Assessment
Outline
•
Theoretical Models of Interviewing and Assessment
•
The Initial Interview
•
Assessment Formats
Module: 3B Assessment of Drug and Alcohol
Outline
•
Use-abuse Continuum
•
How to take a Drug and Alcohol History
•
Assessment and Motivational Interviewing
•
Other aspects to be considered in doing a Drug and Alcohol assessment
Module: 4A Planning with clients
Outline
•
Initial Phase of Case Management
•
Referral and Liaison
•
Initial Case Planning
•
Contracting and Follow-up
Module: 4B Overview of Counselling Skills
Outline
•
Overview of counselling models
•
Attending
•
Exploration
•
Problem Solving
Module: 5A Crisis Intervention
Outline
•
Crisis Identification and Management
35
First-Step Project
•
Managing suicidal Behaviour
Assessment Guidelines
Intervention strategies
Managing Medical Crises
Module: 5B Referral, Liaison and Advocacy
Outline
•
Referral
•
Liaison
•
Advocacy
Placements
Five drug and alcohol services were chosen as placements. The decision of
which services to include was based on the following criteria. The appropriateness for
NSP clients needs, the opportunity for staff to develop skills and to include a variety of
treatment approaches in order to provide as comprehensive an understanding as
possible. The following services participated:
Illawarra Alcohol and Other Drug Service (IOADS), a government outpatient clinic
which provides assessment, referral, counselling and groups.
Bungora Methadone Clinic, a public service to approximately 140 clients at any point in
time.
The Crisis Centre, a non government agency which provides inpatient detoxification
and rehabilitation for illicit drug users.
Youth Drug and Alcohol, a government outpatient clinic for youth, which works on
within a model of outreach.
36
First-Step Project
Orana House, a government inpatient detoxification unit for alcohol, minor
tranquillisers and cannabis.
Staff were encouraged to make the arrangements for the placements with the
managers of each service. This process allowed flexibility for staff to arrange times
around other commitments and to decrease the impact of the training on core duties.
The following is a copy of the tasks to be completed for each placement.
Placement Tasks
Task 1
Obtain a copy of a blank assessment sheet.
Task 2
Identify inclusion/exclusion criteria for entrance into this service
Task 3
What is the best possible method of referral to this service?
Task 4
If possible observe an assessment.
Pay attention to how the worker establishes
Engagement
Therapeutic alliance
Knowledge of client’ stage of change
Need for medical intervention
Risk factors for client
Drug history
Task 5
What do you need to tell a client about his service if they were wanting to go there
Consider: Access, Environment, Rules, What do they need, Admittance to service,
Waiting lists, Opening hours, Types of treatment offered.
37
First-Step Project
OUTCOMES
TRAINING
The staff were pre-tested on two measures. One measure was designed to
directly measure knowledge of the subject matter in the program. The other measure
asked staff to rate their confidence to perform core tasks and estimate their level of
knowledge about subjects covered in the training. Each measure was administered pre
and post training.
Knowledge Test
The knowledge test consisted of a series of questions based directly on material
presented during the training.
Table 7.
Knowledge Score
Mean Score Pre-test
Mean Score Post-test
17.1%
65.8% *
Confidence/Knowledge scale
Question: Please rate how confident you are about your ability to perform the
following tasks by writing a percentage number in the space allocated (0% = not at all
confident, ranging to 100% = extremely confident.)
38
First-Step Project
Table 8.
Confidence/Knowledge task scores
TASK
Dealing with clients in crisis
Mean Score
Pre-test
58.3%
Mean Score
Post -test
79.7 %*
Forming a therapeutic relationship with clients
63.3%
80.7 %*
Doing an assessment of clients needs
59.2%
75.3 %
Taking a drug and alcohol history
65.0%
79.2 %
Planning interventions with clients
60.0%
78.2 %
Referring clients to other services
79.2%
82.0%
Counselling clients
49.2%
74.5 %*
Question: Please rate how much knowledge you have about the following subjects
(0% = no knowledge at all, ranging to 100% = very high level).
Table 9.
Confidence/Knowledge subject scores
SUBJECT
Stages of Change Model
Mean Score
Pre-test
32.5%
Mean Score
Post-test
83.3% *
Case Management
34.2%
79.8 %*
Causes of Drug and Alcohol Problems
50.1%
83.8 %*
Crisis Intervention
45.8%
82.0 %*
Motivational Interviewing
28.3%
81.3 %*
* p<0.05, statistically significant pre-post change.
Evaluation of the Modules
Each module was evaluated on the following points. These items were rated on a
ten point scale 1 being strongly agree 10 being strongly disagree.
1 The material was of sufficient complexity and scope for me to learn.
2 The material was relevant to my professional development needs.
3 I acquired new knowledge or skills.
4 The teaching level was appropriate.
5 Sufficient opportunity was provided for active participation.
39
First-Step Project
6 Audiovisual aids and handouts were legible and relevant.
7 The learning objectives were met as stated.
8 The presenter was well prepared.
9 Concepts were clearly explained.
10 The presenter was a good teacher.
The mean evaluations of each module are presented in the table below.
Table 10.
Modules
MODULE
1A
1B
2A
2B
3A
3B
4A
4B
5A
5B
1
9.4
10
10
10
10
10
9.6
10
10
10
2
9.4
10
10
10
10
10
9.6
10
10
10
3
10
10
9.6
10
9.6
10
9.6
10
10
10
4
10
10
10
10
10
10
9.6
10
10
10
5
9.4
10
9.6
9.6
10
10
9.6
9.6
10
10
6
10
10
10
9.6
10
10
9.6
9.6
10
10
7
9.6
10
10
10
10
10
9.6
10
10
10
8
10
10
10
10
10
10
9.6
10
9.3
10
9
10
10
10
10
10
10
9.6
10
10
10
10
10
10
10
10
10
10
9.6
10
10
10
Total score
97.8
100
99.2
99.2
99.6
100
96.0
99.2
99.3
100
The two questions in the questionnaire designed to measure experience revealed
that although the staff were fairly confident in their ability to engage clients, they were
not so confident in their ability to encourage clients into treatment, as waiting lists in the
services were an issue. Intervention needs to be timely as any difficulty getting
treatment results in a loss of motivation.
Evaluation of the training through pre and post questionnaires showed that the
training did significantly improve staff knowledge on the issues covered in the modules
as their mean scores increased significantly from 17.1% to 65.8% (Table 7). In addition,
40
First-Step Project
staff Confidence/Knowledge Scale scores increased significantly on dealing with clients
in crisis, forming a therapeutic relationship, counselling, Stages of Change Model, case
management, causes of drug and alcohol problems, crisis intervention, and motivational
interviewing (Tables 8 and 9). This is particularly strong evidence that the training was
successful considering the small numbers (n=6).
Therefore, outcomes show that the First Step project was successful in
increasing the number of needles distributed and returned, and the number of
participants in educational sessions, which were also shown to be particularly relevant
to the concerns of the clients. Also, the staff training program was successful in
increasing staff knowledge and confidence about tasks and subjects that are vital in
assessing and engaging clients into treatment.
PROCEDURAL OUTCOMES
Client Contact
Through consultation with the team, it became apparent that the environment in
which needles were distributed did not meet the needs of the first-step project. Staff
argued that successful engagement of clients required the worker on duty to fully attend
to the clients presenting. This was not possible in the current system as the person
distributing needles was also the person performing reception duties for two other teams
within the building, including incoming phone calls for the Community Development
Team. This meant that the worker at the distribution desk was often busy when clients
presented, answering phones etc.
The environment was subsequently reorganised to address this problem. A
receptionist was hired using some of the funds provided by this project. Also, an
additional entrance to the building was reopened leaving the original entrance area for
NSP clients only. The furniture in this area was also reorganised to make it more client
friendly. The result of all these changes meant that NSP clients had access to an area
where they could discuss any problems with the worker uninterrupted and in more
41
First-Step Project
confidential and comfortable surroundings. The only remaining potential interruptions
were from other clients accessing the service.
Tracking System
The development of a tracking system for client referrals into Drug and Alcohol
Treatment Services was a process in which informality and the need for information
came into conflict. NSP success with engagement may be a direct result of the fact that
clients can be seen at times that do not have to be pre-arranged and help is available
when needed. Each crisis (if managed correctly) has the potential to develop trust and
build relationships, further creating the opportunity to move the client into treatment.
Therefore, an over-emphasis on client recording procedures had the potential to impact
on client engagement. Due to these reasons, staff members were reluctant to introduce
lengthy record keeping in favour of continuing to work in a responsive model.
However, in consultation with the team, current recording methods were
adjusted and additional information was added to the statistics sheet, including
information on clients D&A needs. Also, cards were developed for client referrals
(Appendix 2). These cards gave the name and number of the centralised intake service
for the Illawarra with the names of both the client and the caseworker and also included
the date of referral. The receptionist was then to ring and collect information from the
intake service about client attendance. Client outcomes could also be collected through
this system for ongoing assessment and case management needs.
Planning
In an effort to incorporate the training and principals of the First-step project
into work practice, a planning day was held with the team. This day was based on the
principals of consultation and was solution focused. Problems such as staff shortages
were identified and discussed. The planning day was spent identifying implementation
problems. This process involved identifying core duties, prioritising them and allocating
them to appropriate staff members. The outcome of this day was the development of a
twelve-month plan (Appendix 1) in which the principles of The First-step project were
42
First-Step Project
incorporated into the goals of the team. The plan included objectives, strategies,
implementation dates and persons responsible for the implementation.
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First-Step Project
RECOMMENDATIONS
The ability of Needle and Syringe Programs to improve the access of IDU to
treatment, needs to be further investigated. In particular, it is important to clarify the
reasons for the success of NSP to engage IDU.
The success of NSP in engaging IDU over traditional Drug and Alcohol
treatment services may be due to a total commitment to the Harm Minimisation
philosophy. Attendance at NSP outlets is not subject to any underlying premise that
clients change their drug taking behaviour. This approach may provide a psychological
space in which IDU can explore all aspects of their drug usage, both positive and
negative. In the IDU community individuals may be discouraged from contemplating
negative aspects, while in treatment clients may be discouraged from contemplating the
positive aspects of drug usage. According to motivational interviewing, clients will only
begin to change their drug usage when they have considered reasons both for and
against change, believe that their behaviour constitutes a threat to themselves and feel
confident that they can overcome any perceived barriers to change. Due to their regular
contact with IDU, NSP workers are provided with the opportunity to form relationships
with clients, which is not based on intrinsic expectations other than the provision of
needles. As this relationship develops, crisis situations provide an opportunity for
workers to intervene and help clients make connections between drug usage and the
current crisis. As the clients’ concerns accumulate, they can be guided in the
contemplation of their drug usage, develop an understanding of how their behaviour
constitutes a threat to themselves and explore solutions to perceived barriers. Therefore,
the success of NSP to improve access into treatment may be a result of no pressure on
the clients to change, which provides them a greater opportunity to engage, develop
trust, contemplate their drug use behaviours and seek help when ready.
In addition, the success of NSP to engage clients into treatment may also be a result
of responsiveness to client need. Most traditional Drug and Alcohol treatment programs
involve waiting times. Clients can wait anywhere between a few days to weeks before
44
First-Step Project
they can enter treatment. At the Illawarra, NSP workers respond to client need on
demand and can therefore intervene at times when motivation is at its highest level.
In order to facilitate the referral process between NSP and Drug and Alcohol
treatment, liaison between the services should be developed wherever possible. In the
Illawarra region, NSP and Drug and Alcohol treatment services are combined, creating
close links between workers. Therefore, the continuity of treatment for clients increases.
In this project, training was effective in significantly increasing staff’s perceived
confidence in their ability to perform tasks and their knowledge of the subjects.
Training NSP workers in clinical skills may be preferable to hiring drug and alcohol
workers per se. NSP workers have developed attitudes towards drug and alcohol usage
based on harm minimisation. It may be easier to develop their skills than to try and
change the attitudes of more traditional drug and alcohol workers.
Training staff may not address their needs to successfully adopt the First- Step
program. There is potential for staff to become vicariously traumatised through contact
with these clients. Due to the severity of the health and welfare issues of this client
group, support structures need to be developed for workers. Staff may need to be
educated on the need for debriefing and case presentations. Management ought to
ensure that these measures are developed and maintained.
Finally, high staff turnover during this project indicated that training should be
repeated at regular intervals.
45
First-Step Project
REFERENCES
Baker, A., Kochan, N., Dixon, J., Heather, N. & Wodak, A. (1994a). Controlled
evaluation of a brief intervention for HIV prevention among injecting drug users
not in treatment. AIDS Care, 6(5): 559-570.
Baker, A., Kochan, N., Dixon, J., Wodak, A., & Heather, N., (1994b). Drug use and
HIV risk-taking behaviour among injecting drug users not currently in treatment
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Broadhead, R. S., van Hulst, Y., & Heckathorn, D. D. (1999). The impact of a needle
exchange’s closure. Public Health Reports, 114: 439-447.
Brooner R., Kidorf, M., King, V., Beilenson, P., Svikis D. & Vlahov, D. (1998). Drug
abuse treatment success among needle exchange participants. Public Health
Reports, 113 (Suppl 1): 129-39.
Darke, S., Ross, J., Hall, W. (1996). Overdose among heroin users: I. Prevalence and
correlates of non-fatal overdose, Addiction, 91, 405-411.
Davies, S. (1998). NSW Needle and syringe program: Features and public health
benefits. NSW Public Health Bulletin, 9(11): 134-137.
Dobinson, I., & Poletti, P. (1989). Buying and Selling Heroin: A Study of Heroin
User/Dealers. N.S.W. Bureau of Crime Statistics and Research, Attorney
General’s Department.
Eland-Goossensen, M., van de Goor, I., Benshop, A., & Garretsen, H. (1998). Profiles
of heroin addicts in different treatment conditions and in the community.
Journal of Psychoactive Drugs, 30 (1): 11-20.
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First-Step Project
Eland-Goossensen, A., van de Goor, I., & Garrestsen, H. (1997). Heroin addicts in the
community and in treatment compared for severity of problems and need for
help. Substance Use and Misuse, 32(10): 1313-1330.
Guydish, J., Bucardo, J., Clark, G. & Bernheim, S. (1998). Evaluating needle exchange:
A description of client characteristics, health status, program utilization, and
HIV risk behaviour. Substance Use & Misuse, 33(5): 1173-1196.
Hando, J., Hall, W., Rutter, S. & Dolan, K. (1999). Current State of Research on Illicit
Drugs in Australia; An Information Document. National Health and Medical
Research Council.
Heimer, R. (1998). Can syringe exchange serve as a conduit to substance abuse
treatment? Journal of Substance Abuse Treatment, 15(3) 183-191.
HIV in NSW – Changing patterns in major risk factors. (1992). NSW Public Health
Bulletin, 3(3): 33-34.
Hunter, Gillian M., & Judd, Ali. (1998). Women injecting drug users in London: The
extent and nature of their contact with drug and health services. Drug & Alcohol
Review, 17(3): 267-276.
Hurley, D., Jolley J. & Kaldor J. (1997). Effectiveness of needle exchange programs for
prevention of HIV infection. Lancet, 349: 1797-1800.
Jarvis, Tracy J., Tebbutt, Jenny, & Mattick, Richard P. (1996). Treatment Approaches
for Alcohol and Drug Dependence: An Introductory Guide. John Wiley & Sons
Ltd., NY.
Joint Select Committee into Safe Injecting Rooms. (1998). Report on the Establishment
and Trial of Safe Injecting Rooms. Parliament of New South Wales.
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First-Step Project
Kahn, J.G. (1993). Chapter 8. How much does it cost to operate NEPs? In P. Laurie and
A. Reingold (Eds.), The Public Health Impact of Needle Exchange Programs in
the United States and Abroad, Volume I. School of Public Health, University of
California, Berkley, CA, and Institute for Health Policy Studies, University of
California, San Francisco, CA. Final Report prepared for the Centres for Disease
Control and Prevention.
Keene, Jan M. & Stimson, Gerry V. (1997). Professional ideologies and the
development of syringe exchange: Wales as a case study. Medical
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National Centre in HIV Epidemiology and Clinical Research. HIV/AIDS Hepatitis C
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Prochaska, J.O., & DeClemente, C.C. (1986). Toward a comprehensive model of
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First-Step Project
APPENDICES
APPENDIX 1: ILLAWARRA NEEDLE AND SYRINGE PROGRAM BUSINESS PLAN
2000
Goals
Increasing access for clients to clean injecting equipment especially outside normal
hours,
Increase access for clients to staff for support, information and referral and in particular
continue to implement First-step.
Increase links and Liaison with Drug and Alcohol Services and in particular the new
CONTACT service.
Streamline and enhance Needle and Syringe delivery and disposal procedures
Increase and enhance Secondary Outlets
Work together more effectively using proactive systems and procedures.
Work within budget and advocate for budget increase for the purchase of safe injecting
equipment.
Provide more education and support for people infected with the Hepatitis C Virus.
GOAL: Increase Access for Clients to clean injecting Equipment
Objective
Strategy
Increase access of safe
injecting equipment to
Wollongong residents after
move of the primary outlet to
Port Kembla.
Provide mobile access for set
hour each day at convenient
location during methadone
dosing hours.
Increase the ability of
secondary outlet IOADS to
provide equipment including
Barrel kits through liaison and
education.
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First-Step Project
GOAL: Increase client access to Staff for support, information and referral.
Objective
Strategy
Move Primary Outlet to Port
Kembla
Providing primary outlet in
Port Kembla will increase
access for clients to both safe
injecting equipment and NSP
workers as this area has the
largest proportion of IDU’s in
Wollongong region.
Continue to have worker on
front desk sole duty being
client contact
Continued employment of
administrative assistant, which
frees up front desk worker to
concentrate on client needs, and
the development of
engagement.
GOAL: Increase links and liaison with Drug and Alcohol Services and in
particular the new Contact Service.
Objective
Strategy
Increase communication
between services about shared
clients and referral outcomes
Implement new referral
procedure and forms.
Increase Links with the new
CONTACT Service
Conduct Collaborative IDU
outreach projects with
CONTACT.
Rotation of staff through
CONTACT
Main referral point for NSP
clients seeking treatment.
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First-Step Project
GOAL: Streamline and enhance Needle and Syringe delivery and disposal
procedures.
Objective
Strategy
Reduce amount of workers
time spent packing needles
Monitor packers to ensure that
supplies are kept up.
Streamline ordering of needles
GOAL: Increase and enhance Secondary Outlets.
Objective
Strategy
Educate and update all
secondary outlets in the next 12
months.
Organise education times and
dates with all secondary outlets.
Increase Number of Secondary
Outlets and in particular any
with the potential to provide 24
hour access either through
workers or through vending
machines
Liaise with Health and
Community organisations with
the intention of establishing
secondary outlets
GOAL: Work together more effectively using proactive systems and procedures.
Objective
Strategy
Increase communication
Increase regularity of and
attendance at Team Meetings
Development of proactive
systems to improve
effectiveness of work
To Utilise Administrative
assistant to identify tasks which
could be improved through the
development of systemic
procedures
Improve data collection
Develop and implement new
data collection forms
To develop proactive approach
to service delivery
Continued commitment to the
planning process
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First-Step Project
GOAL: Work within Budget and advocate for budget increase for the purchase of
safe injecting equipment.
Objective
Strategy
Develop strategies to work to
budget
Discuss ongoing budget
implications at Team Meetings
and identify cost saving
strategies
Identify budget Shortfalls
Adopt Strategies for the
recording of budget shortfalls
and write report based on data.
GOAL: Provide more education and support for people infected with the Hepatitis
C Virus
Objective
Strategy
Improve coordination of the
treatment of people infected
with the Hepatitis C virus
In conjunction with other
services develop and
implement Hepatitis c
Business plan.
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First-Step Project
APPENDIX 2: REFERRAL CARDS
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First-Step Project