Unmet need for recommended preventive health services among clients of California syringe exchange programs: Implications for quality improvement
Introduction
Injection drug users (IDU) suffer high morbidity and mortality due to preventable conditions, including human immunodeficiency virus (HIV), hepatitis B virus (HBV), hepatitis C virus (HCV), sexually transmitted infections (STIs), tuberculosis (TB), and accidental overdose (Kral et al., 2003, Kral et al., 2004, Kuo et al., 2004, Friedman et al., 2003, Murrill et al., 2002, Seal et al., 2001, Davidson et al., 2003, Coffin et al., 2003; CDCP, 2003b, CDCP, 2004; Perlman et al., 1995). In the United States (US), the Centers for Disease Control and Prevention (CDC) recommends that IDUs receive comprehensive preventive services to address these multiple sources of risk, including screening for infectious diseases, vaccinations, risk reduction counseling, drug treatment/counseling, and access to sterile syringes (Academy for Educational Development, 2000). Yet, these preventive services cannot result in improvements in health if at-risk IDUs do not receive them.
Recent studies have documented significant deficits in the quality of care provided by the US health care system (Schuster et al., 1998), with Americans receiving on average only about 50% of recommended preventive services (McGlynn et al., 2003). While the quality of preventive care received by vulnerable populations such as IDUs has not been systematically evaluated, there is reason to believe that IDUs may fail to receive recommended preventive care. For example, IDUs have poor access to traditional sources of preventive care, including primary care providers (Chitwood et al., 1999, Chitwood et al., 2001, Chitwood et al., 2002, French et al., 2000, Riley et al., 2002c) and drug treatment programs (Wenzel et al., 2001, Wu et al., 2003). And although providers have adopted a variety of low threshold community-based approaches to delivering preventive services to marginalized IDUs, including providing preventive services via street outreach, and at homeless shelters, drop-in centers, and syringe exchange programs (SEPs), few studies have determined if IDUs using these low threshold services are receiving recommended preventive care. As a result, studies to identify unmet need for preventive care among IDUs, as well as successful strategies for delivering preventive services to IDUs, are needed.
Of low threshold providers, SEPs, which distribute sterile syringes to IDUs in order to reduce HIV transmission via syringe sharing, are uniquely positioned to deliver preventive services to IDUs due to their ability to successfully attract highly marginalized IDUs with frequent high-risk behaviors (Hahn et al., 1997, Hagan et al., 2000, Miller et al., 2002) and therefore high need for preventive care. While multiple studies have established the effectiveness of SEPs in preventing transmission of HIV via syringe sharing (Gibson et al., 2001), less is known about the role of SEPs in providing preventive services to IDUs.
Previous studies evaluating preventive services available at selected SEPs have found delivery of preventive services to IDUs at SEPs to be feasible and effective, including vaccinations (Stancliff et al., 2000, Des Jarlais et al., 2001), screening for HIV and STIs (Liebman et al., 2002), and screening for tuberculosis (Perlman et al., 1997, Perlman et al., 2001, Riley et al., 2002b). But other studies suggest that these findings may not be generalizable to SEPs and IDUs in other communities. For example, a national survey of US SEPs found that availability of preventive services at SEPs varies, with on-site HIV testing and counseling available at 64% of SEPs, but HCV testing available at only 24% of SEPs, HBV vaccinations at only 16%, and STI testing at only 13% (Centers for Disease Control and Prevention, 2001). While SEP preventive services may be potentially effective, IDUs may still fail to receive needed services if services are not available from the SEP and are not received from other sources, suggesting that additional studies examining use of preventive services among IDUs from multiple SEPs, and including services from SEPs and non-SEP sources, are needed. In addition, a study comparing use of a variety of preventive services among SEP clients and methadone maintenance patients in Rhode Island found that although the majority of IDUs in both groups had received screening for HIV and TB, many SEP clients had not received testing for HCV, HBV, and STIs or vaccination against HBV (McGarry et al., 2002). Previous studies have focused on selected preventive services and therefore studies examining a variety of preventive services are necessary in order to insure that IDUs receive the comprehensive preventive care that is recommended. Finally, little is known about factors that may facilitate use of preventive services among IDUs, such as use of primary care or drug treatment services, or more frequent SEP visits, which may provide greater access to preventive services provided at the SEP. Studies to identify these factors are needed in order to best design interventions to increase use of preventive services and improve the quality of preventive care received by IDUs.
In order to address these gaps in the literature we asked the following research questions using data from a sample of clients from 23 SEPs throughout California: Do SEP clients receive recommended preventive services from any source, including SEPs and non-SEP sources? What portion of recommended services are received from SEPs versus from non-SEP sources? Are specific services more likely to be underused? Are SEP client characteristics, specifically having health insurance, use of primary care or drug treatment, or more frequent SEP visits, associated with receipt of recommended preventive services, after controlling for demographics, drug use, and risk behaviors?
Section snippets
Participants and data collection
Data for this paper came from a larger study of changes in statewide policy regarding legalization of SEPs in California (Riehman et al., 2004). A convenience sample of 560 SEP clients was recruited from 23 SEPs throughout California (approximately 25 clients per SEP) from March to September 2003. The 23 SEPs in the study represent approximately two-thirds of California SEPs in 2003, and all but one were in existence in 2000 when the larger study began. The SEPs were located in 16 different
Characteristics of sample
SEPs in the study included a variety of different organization types and ranged from very small programs with several hundred client contacts to very large programs exchanging more than 500,000 syringes per year (Table 2). The mean age of SEP clients in the sample was 43 years (standard deviation 10.7 years), 68% were male, 51% were white, 51% reported current homelessness and 56% were uninsured. The majority reported injecting heroin (76%) but use of other drugs was also common. A considerable
Discussion
Multiple studies support the effectiveness of preventive health services in preventing harmful consequences of injection drug use. Yet, effective services will not result in improved community health if IDUs in these communities do not receive needed services. We examined use of preventive services among IDUs using SEPs in California, and found that despite high need for preventive services, SEP clients failed to receive the majority of recommended preventive services, with unmet need for
Acknowledgements
The authors would like to thank the Centers for Disease Control and Prevention for funding the California Syringe Exchange Program Study (Grant #RO6/CCR918667). Support for writing this paper was also provided by the National Institute on Drug Abuse (Grant #R01DA14210), the Universitywide AIDS Research Program (Grant #IS02-DREW-705) and the Robert Wood Johnson/VA Clinical Scholars Program. The authors also thank the following project staff: Christopher Buck and Ellyn Bloomfield in Santa Monica
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