Comparing new participants of a mobile versus a pharmacy-based needle exchange program.

OBJECTIVE: To compare characteristics of first-time needle exchange participants who enrolled at a mobile van-based exchange site versus a fixed pharmacy-based exchange site, in an area where both types of needle exchange programs were available. METHODS: Demographic and drug use data were collected on needle exchange program participants on enrollment. Participants were included if they were first-time participants at the Baltimore needle exchange program between December 1997 and March 1999, and if their first visit was at either one van-based site or at one of two pharmacy-based sites. Descriptive statistics and inferences were based on the type of needle exchange into which participants enrolled. RESULTS: Among 286 first-time participants, 92% were African American, 28% were women, 11% were currently employed, 55% completed high school, and the median age was 40 years. In multivariate analyses, van-based enrollment was more common among frequent injectors (odds ratio [OR] = 2.0), but less common among African American participants (OR = 0.21). CONCLUSIONS: Our data suggest that different venues for needle exchange program settings attract different types of drug injecting participants. This suggests that offering different venue types to reach participants with differing drug use patterns will be important to optimize risk reduction strategies.

Pharmacy access to sterile syringes for injection drug users: attitudes of participants in a syringe exchange program.

OBJECTIVE: To examine attitudes of participants of a van-based syringe exchange program (SEP) toward the hypothetical prospect of pharmacy-based syringe access. DESIGN: One-time, cross-sectional survey. SETTING: Baltimore, Maryland. PARTICIPANTS: 206 injection drug users who participate in the Baltimore SEP. INTERVENTIONS: Face-to-face interviews. MAIN OUTCOME MEASURES: Location preferred for obtaining syringes, drug and syringe use, past experience with pharmacies, and willingness to pay. RESULTS: The sample was 67% men, 95% African American, and 95% unemployed; mean age was 39.8 years. A total of 19% of respondents had bought syringes at a pharmacy during the prior six months. Some 37% reported having been turned down when asking for syringes at a pharmacy, most commonly due to lack of identification to prove diabetic status (50%). If legal restrictions were lifted, 92% of respondents would obtain syringes from pharmacies, and would be willing to pay a mean price of $0.80 (median = $1.00) per syringe. Women were more likely than men to report the intention to switch from van-based SEP to pharmacy (57% versus 38%, p = .045). CONCLUSION: If current legal restrictions were lifted, pharmacies would be a viable syringe source appealing particularly to women, suggesting gender-specific access issues that should be addressed. The per-syringe price that study participants would be willing to pay exceeds typical retail prices, suggesting that pharmacists could charge enough per syringe to recoup operational costs.

Drug abuse treatment success among needle exchange participants.

OBJECTIVE: Although lowering incidence rates of human immunodeficiency virus (HIV) transmission is the primary goal of needle exchange programs (NEPs), other desirable outcomes are possible. Referring exchange participants to more comprehensive drug abuse treatment programs has the potential to reduce or eliminate the use of drugs. This possibility was evaluated by comparing the treatment responses of new admissions with an outpatient opioid agonist treatment program in Baltimore, Maryland. METHODS: New admissions (1994 - 1997) to an opioid agonist treatment program were first grouped by referral source (needle exchange, n = 82 vs. standard referrals, n = 243) and then compared on admission demographic and clinical variables and response to treatment during the first three months. Outcome measures included retention rates, self-reported drug use and injecting frequencies, self-reported illegal activities for profit, and results from weekly urinalysis testing for opioids and cocaine. RESULTS: Patients from the NEP were significantly older and more likely to be male, African American, and unemployed than standard referral patients. Needle exchange patients also had a greater baseline severity of drug use than patients in the standard referral group. Despite these baseline differences, both groups achieved comparably good short-term treatment outcomes (including reduced drug use and criminal activity for profit); treatment retention was also good, although slightly better in the standard referral group (88% vs. 76%). CONCLUSION: These data demonstrate the feasibility and merits of creating strong linkages between NEPs and more comprehensive drug abuse treatment clinics.

Operation Red Box: a pilot project of needle and syringe drop boxes for injection drug users in East Baltimore.

We assessed the acceptability and the use of a community-based needle and syringe disposal project designed to serve injection drug users. In June 1996, three surplus U.S. mail collection boxes were painted red and used as syringe and needle drop boxes in locations with high drug use in East Baltimore. Acceptance of the drop boxes was measured by focus groups of residents, drug users, and police, held before and after project implementation. Use was measured by weekly counts of needles recovered from the red boxes. A sample of all deposited needles was randomly chosen for needle washing and subsequent HIV antibody testing. Community impact was measured by systematic surveys of needles discarded on public sidewalks, in areas with and areas without drop boxes. Before implementation, members of focus groups expressed concerns that drop boxes could convey mixed messages to youth (e.g., seeming to condone drug use), might result in increased loitering, and could further community stigmatization. After project implementation, all focus groups expressed support of project expansion. In the first 10 months, 2971 needles were collected. Of 156 needles tested, 10.9% were positive for HIV antibody. Needle counts on the street showed no significant change in red box areas compared with control areas. In this pilot project, red boxes were accepted by the community and drug users. Police officers also used the boxes to dispose of confiscated needles. Although limited in the number of drop boxes and follow-up time, this pilot project shows promise as a community-based method of safe needle disposal.

Promoting community-based maternal and child health services: a university-health department partnership.

OBJECTIVES: Funded by the Federal Maternal and Child Health Bureau, a partnership between the Johns Hopkins University School of Public Health, Department of Maternal and Child Health (JHU), and the Baltimore City Health Department (BCHD) identifies maternal and child health problems, and develops appropriate interventions. This paper presents the organization and activities of the JHU/BCHD Maternal and Child Community Health Science Consortium as a result of overcoming traditional barriers to collaborative efforts, and discusses what role the Consortium has had in its own collaborative success. METHOD: A review of the literature uncovered a number of barriers to productive interaction. A number of factors contributing to overcoming the barriers was also revealed. The organization and activities of the work of the JHU/BCHD Maternal and Child Community Health Science Consortium has been applied to these barriers and associated factors, and discussed in context of implications for future collaborative efforts. RESULTS: The Consortium has developed a fully integrated administrative structure bridging both the BCHD and JHU. The mission of the Consortium has been translated into four categories of work, each one designed to complement, extend, and augment the other. The infrastructure established in Baltimore, as a direct result of this partnership, has served to overcome traditional barriers to productive academic/agency collaboration, while promoting organizational productivity. This outcome is a result of overcoming the recognized barriers to collaboration. CONCLUSIONS: Health agencies and university public health programs must link resources and collaborate to address public health issues. Commitment to a collaborative approach to the public's health will determine its future.

Discarded needles do not increase soon after the opening of a needle exchange program.

This study examines the effect of a Needle Exchange Program (NEP) on the quantity and geographic distribution of discarded needles on the streets of Baltimore, Maryland, and presents methods to survey discarded needles in the community. A random sample of 32 city blocks located within high-drug-use census tracts, stratified by east and west sides of the city and by proximity to the NEP, was selected for survey. Three teams surveyed the number of needles and the number of drug vials and unbroken glass bottles ("trash") to control for practice effects. Surveillance was conducted prior to initiation of the NEP in August 1994 and 1 and 2 months thereafter. Over the three study periods, the absolute count of discarded needles was 106, 130, and 128, respectively; the number of vials and bottles was 3,048, 3,825, and 3,796, respectively. The initial nonstatistically significant increase in needles (mean change = 0.38, 95% confidence interval (CI) -0.18 to 0.93) was offset by accounting for background trash. Regression models fitted with the generalized estimating equation method, which accounted for within-block correlation over time, showed no significant increase in the number of needles after adjustment for trash during the first 2 months of the NEP's operation. These data suggest that the initiation of NEPs does not result in an increase in the number of discarded needles on the street.

Reductions in high-risk drug use behaviors among participants in the Baltimore needle exchange program.

OBJECTIVE: To determine whether enrollment in the Baltimore Needle Exchange Program (NEP) was associated with short-term reduction in risky injection practices. METHODS: Demographic information was collected on NEP participants upon enrollment. A systematic sample of enrollees was interviewed at program entry, 2 weeks, and 6 months later on recent drug-related behaviors. Comparisons were performed using paired t-tests. RESULTS: Among 221 NEP participants who completed baseline, 2-week and 6-month follow-up visits, significant reductions (p < .01) were reported in using a previously used syringe (21.6%, 11.0%, 7.8%, respectively), lending one's used syringe to a friend (26.7%, 18.4%, 12%, respectively), and several indirect sharing activities. Reductions were reported in the mean number of injections per syringe and the mean number of injections per day (p < .001). CONCLUSIONS: These results show rapid and mostly large reductions in a variety of risky injection drug use behaviors. Study findings are consistent with earlier reports showing an association between behavioral risk reduction and participation in a needle exchange program.

Politics and practice: introducing Norplant into a school-based health center in Baltimore.

As one element of Baltimore's effort to combat its high rate of teenage pregnancy, the Baltimore City Health Department added the implantable contraceptive Norplant to the array of services offered at one of its school-based health centers in early 1993. The initial findings with the adolescents who received this contraceptive at the school were favorable, particularly regarding condom use, parental involvement, and patient acceptance of the contraceptive. This new policy garnered a significant amount of attention, both nationally and locally. It attempts to address problems that have complicated etiologies as well as diverse clinical, social, and ethical ramifications, all complicated by political realities. The Norplant experience offers useful lessons regarding controversial health initiatives that address problems facing public health practitioners today.

Cancer mortality in Maryland: when being a leader is not best.

Maryland has the second highest statewide cancer mortality rate in the nation. This ranking is primarily due to high death rates for the most prevalent cancers: lung, breast, colon, and prostate. Based on the recent literature and the October 1991 preventive medicine grand rounds at the Johns Hopkins University School of Hygiene and Public Health, this paper summarizes several current viewpoints on cancer mortality in Maryland and the progress that has been made by recently instituted state and community initiatives.

When children have children: the teen pregnancy predicament.

Despite developments in contraceptive technology and changes in societal norms, adolescent pregnancy remains a key issue for politicians, social scientists, health care providers, and educators. The adolescent's access to contraception and abortion services continues to spark legal debate. The implications of research call for the development of innovative programs to address larger issues, such as poverty and limited access to health care, in the management and prevention of adolescent pregnancies. Clinical interventions, such as school-linked clinics to provide contraception and prenatal care programs to reduce perinatal morbidity, have varied in their approaches and their subsequent success.

PIP: The birthrate among both white and African-American US young women 15-19 years old declined steadily from 89.1 live births per 1000 women (LB/1000) in 1960 to 51.3 LB/1000 in 1985, as a result of the availability of contraception and abortion. The rate has since risen to 62.1 LB/1000 in 1991. In contrast, the birthrate among unmarried young women 15-19 years old increased from 15.3 LB/1000 in 1960 to 42.5 LB/1000 in 1990. The birthrate among white unmarried adolescents more than tripled over the past three decades. The Johns Hopkins University School of Public Health revealed a rise in overall sexual activity from 28% in 1972 to 50% in 1979 in interviews of a national sample of 15-19 year olds. After the Supreme Court decision in Roe v. Wade, 232,440 abortions were performed in 1973 to 15-19 year olds and that number rose to 444,780 by 1980. Title IX of the Civil Rights Act prohibited the exclusion of girls from schools on the basis of pregnancy. In 1977 the Supreme Court struck down a statute that prohibited the sale of nonprescription contraceptives to minors under 16. Reports by the Centers for Disease Control and Prevention identified 1,559,110 legal abortions in 1987, of which 26.1% were to women younger than 20 years old. The adolescent seeking an abortion faces clinical disclosure and parental consent. According to a 1985 poll, 85% of Americans approve of sex education. Nearly 60% of 12-17 year olds surveyed in 1986 said that they had taken a course or had a class on sex education. However, in a 1988 survey of over 4000 public school teachers, only 84% of teachers were in programs that included sexual decision making, abstinence, and birth control methods. Adolescent childbearing may represent normative behavior for those coping with the stress of poverty. Adolescent pregnancy is associated with low birthweight, preterm labor and delivery, poor maternal weight gain, hypertension, anemia, and sexually transmitted diseases.

Psychosocial factors associated with the use of bicycle helmets among children in counties with and without helmet use laws.

We examined the extent to which psychosocial factors, in addition to the presence of a law, are associated with the use of bicycle helmets. A mailed questionnaire was completed by 3494 children in fourth, seventh, and ninth grades in three Maryland counties: Howard County, which had a law requiring child bicyclists to wear helmets and an educational campaign; Montgomery County, which had an educational campaign but no law; and Baltimore County, which had neither. Overall, 19% of the respondents reported having worn a bicycle helmet on their most recent ride. In a multiple logistic regression, children's use of helmets in all three counties was significantly associated with their beliefs about the social consequences of wearing helmets and the extent to which their friends wear helmets. Significant interactions were also found, suggesting that in the presence of a law, an educational campaign, or both, children's use of helmets was associated more with social concerns than with parental influences or cognitive factors, such as beliefs about the need for helmets or perceptions of risk. To increase helmet use, the issues of stylishness, comfort, and social acceptability of wearing helmets need to be addressed and more widespread adoption of bicycle helmet laws should be encouraged.

Baltimore City Health Department: 200 years of progress and partnership.

The Baltimore City Health Department began its long history of protecting the health of Baltimore citizens in 1793. An outbreak of yellow fever in Fells Point on the northwest branch of the Patapsco River was the impetus for the governor's appointment of the first two health officers. Since that time, the health department has worked closely with the medical community to promote education and preventive measures (e.g., sewer systems, water chlorination, food inspection) in order to stop the spread of communicable diseases. For 200 years, the Baltimore City Health Department has provided "the advocacy and leadership necessary to ensure the protection and promotion of the health of Baltimore's citizens."

Bicycle helmet laws and educational campaigns: an evaluation of strategies to increase children's helmet use.

OBJECTIVES: The passage of a mandatory bicycle helmet law for children in Howard County, Maryland, provided an opportunity to compare legislation and education as strategies to increase helmet use. METHODS: In 1991, a survey was mailed to fourth-, seventh-, and ninth-grade students attending a stratified sample of public schools in Howard County and in two similar suburban/rural counties without helmet laws. RESULTS: Of 7217 students surveyed, 3494 responded (48.4%). Self-reported helmet use in Howard County rose from 11% to 37% after the law and accompanying educational campaign went into effect. Helmet use changed from 8% to 13% in Montgomery County, where educational efforts were undertaken, and from 7% to 11% in Baltimore County, where helmet promotion activities were minimal. Predictors of helmet use included having friends who wore helmets, believing helmet laws are good, being in fourth grade, living in Howard County, and using seatbelts regularly. CONCLUSIONS: Legislation combined with education appears to increase bicycle helmet use substantially more than does education alone. The Howard County law may be considered a successful model of a strategy to increase children's helmet use.

Risk factors for adolescent sexual behavior, fertility, and sexually transmitted diseases.

Current understanding of the risk factors related to adolescent initiation of sexual activity, use of contraception, pregnancy, and STDs is examined. From recent research on adolescent fertility, findings that have particular relevance to school health or reflect new understandings of adolescent sexuality are summarized. In selected cases, prevention programs that build directly on an understanding of these risk factors are cited.

PIP: It is important to understand the risk factors related to adolescent initiation of sexual activity, use of contraception, pregnancy, and sexually transmitted diseases (STD). This understanding is important in identifying and caring for youths at risk and designing primary and secondary prevention programs for schools and communities. The current understanding of these risk factors and recent findings are summarized in this paper. Intermediate determinants of fertility are broadly discussed with closer attention given to specific biopsychosocial risk factors affecting fertility and the potential for contracting STDs. The roles of demographics, geography, poverty and ethnicity, religion, school performance, family factors, peer influences, puberty, risk-taking behavior, drugs, sexual abuse, self-esteem and psychological variables, school health education, and school-based clinics are considered. The social determinants of contraceptive use/STD protection, pregnancy continuation or abortion, and STDs are also discussed.