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International Journal of Drug Policy 23 (2012) 103–110

Contents lists available at SciVerse ScienceDirect

International Journal of Drug Policy

journa l homepage: www.e lsev ier .com/ locate /drugpo

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lients are central to any independent and rigorous evaluation of the serviceshey use

ames Rowe ∗

chool of Global Studies, Social Science and Planning, RMIT University, Melbourne 3001, Victoria, Australia

In 2005, I spent a year onsite at a newly established primaryealth centre (PHC), designed to meet the needs of street-based

njecting drug users (IDUs) – as well as homeless individuals andex workers attracted to the area due to the nearby street sex mar-et and the long-established needle and syringe program (NSP) inhe adjoining building. The NSP – managed by the same organisa-ion – had served as the site for preliminary research conductednto the health care needs of those who would become the centre’slients.

Engaged to conduct an on-going evaluation of the service, I doc-mented a service accessible, welcomed and thoroughly embracedas opposed to merely accepted – by the clientele, several of whoartook in regular interviews throughout the year in addition to the50 who filled in quarterly surveys as a key component of quarterlyeports provided to the centre’s management. The final evaluationas a number of valuable findings for health planning but was ofost value to the service that commissioned the research and to

he health authorities who are the facility’s key source of funding.he report (Rowe, 2006) – a 205-page document with objectiveeasures in addition to a focus on client contributions – may hold

eneral lessons for health design – but there is a need for anyttempt to draw on such evaluations to appreciate the specific cul-ural and political influences that have shaped the service and theentrality of clients to evaluate the success – or otherwise – ofHCs.

The continued nature of my on-site evaluation allowed the ser-ice to evolve to address issues raised by clients that affected theervice operating as proficiently as possible. For example, femalelients with histories of physical, sexual and emotional abuse com-unicated the (unintended) intimidation they experienced when

haring spaces with large, physically imposing men. This wasnstrumental in establishing separate spaces for women and female

nly service hours.

The philosophy of clients’ serving as key informants, best placedo inform the primary health centre’s management, from its initial

∗ Tel.: +61 3 9925 2319; fax: +61 3 9925 3088.E-mail address: james.rowe@rmit.edu.au

955-3959/$ – see front matter © 2011 Elsevier B.V. All rights reserved.

design and staffing, to the continued evolution of the PHC appearsunder-valued by Islam, Topp, Day, Dawson, and Conigrave (2012);one of a number of issues compromising their ability to meet theirambitious objectives.

The authors suggest that certain evaluations lack objective, eval-uative merit. Noting the high rates of client satisfaction, they state,‘however, none of the studies employed rigorous, independentmeasures’ but cited client reports. I can only speak for my delib-erate reliance on client input: unless clients of PHCs are central totheir design and operation, then these services may well not prove‘acceptable’ to those whose needs they are established to meet. Thenotion that client contributions to evaluations of services estab-lished to meet their needs robs an evaluation of objectivity andrigour is misjudged.

Further, an understanding of comparative studies demands anawareness of the fact that policy responses – including the designand operation of PHCs – are shaped by political structures andinstitutions that define government and its roles in different juris-dictions, as, indeed, they are shaped by the means and effectsof political socialisation on the public, prevalent cultural values,religious influence, and ever-evolving local attitudes. Seeking tosynthesize the findings of evaluations of PHCs from Melbourne andSydney may be achievable given the relatively comparable politicaland cultural context of Australia’s populous south-eastern states atthis time. But the authors’ attempt to draw on ‘common modelsof IDU-targeted PHC’, is greatly weakened by a failure to acknowl-edge the vast cultural and political differences that limit a narrativesynthesis of services across as broad an international spectrum asAustralia, Finland, Iran, Nepal, the United States and the UK (across aperiod of 15 years). The authors’ admit the ‘mainstreaming’ of PHCsin health services is perhaps too great a challenge given geograph-ical, cultural, policy and practice variation. This applies equally foran international review of PHCs (and one that only uses those pub-lished in English).

There is insufficient evidence on the effectiveness of the PHC

using the means employed by the paper in question. This doesnot mean that valuable lessons cannot be drawn from evaluativestudies in the appropriate cultural context in which each is set.Perhaps, in future, complete evaluation reports, as provided to the

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04 J. Rowe / International Journal of Drug Policy 23 (2012) 103–110

ey health services that fund and seek to build on such research,hould be sought out for such attempted reviews. This would bear more productive than an analysis that, the authors’ admit, isimited by a reliance on papers restricted by just what can be com-

unicated in journals given editorial demands for brevity. In doingo, they might find there is not so much a dearth of rigorous eval-ations, but that these are not found via a search of academicatabases.

References

Islam, M. M., Topp, L., Day, C. A., Dawson, A. & Conigrave, K. M. (2012). The accessi-bility, acceptability, health impact and cost implications of primary healthcareoutlets that target injecting drug users: A narrative synthesis of literature. Inter-national Journal of Drug Policy, 23(2), 94–102.

Rowe, J. (2006). Access health: Towards best practice in the delivery of primary healthcare. Melbourne: Salvation Army Crisis Services.

doi:10.1016/j.drugpo.2011.09.009

ne stop shopping – Bringing services to drug users

. Douglas Bruce ∗

ale University School of Medicine, Yale University School of Public Health, Yale University AIDS Program, 135 College Street, Suite 323, New Haven, CT 06510-2283, United States

Drug users often come into contact with healthcare systems,ut this care is episodic and not specific to the unique needs ofrug users. A visit to an emergency department for an abscess orn urgent care clinic for STI screening, for example, may be the mosthat many drug users encounter. A failure to provide comprehen-ive healthcare for drug users is a failure to provide a service to aroup that should be a public health, and therefore a primary care,riority. One reason for the failure to deliver needed primary careervices to drug users has been the requirement that drug usersccess normal primary care services – services which are unlikelyo be organized to meet the specific needs of drug users. In thisssue of IJDP, Islam and colleagues report on several models ofrimary healthcare delivery to injection drug users that resulted

n increased healthcare utilisation, improvements in health statusnd overall cost savings (Islam, Topp, Day, Dawson, & Conigrave,012). Embedded in that discussion are a few key themes on serviceelivery for drug users.

In any healthcare environment, individuals solicit services theyerceive to be of value. Drug users are no different and will seekut services that are of value and provided in a convenient andespectful manner. If the service is quite valuable, the drug user mayndergo some measure of inconvenience and disrespect in order tobtain the service. Attendance at the emergency department is oneuch example. As the perception of service value declines, how-ver, convenience and respect become the main determinants ofccessing services. A drug user, for example, may not see hepati-

∗ Tel.: +1 203 737 6133; fax: +1 203 737 5143.E-mail address: robert.bruce@yale.edu

tis B vaccination as worth travelling across town to obtain from aclinic that may or may not be respectful. If, however, that same vac-cine is given on a mobile unit in the neighbourhood where the druguser lives and is provided in a respectful manner with other services(e.g., clean syringes and condoms), then the drug user is often morethan willing to benefit from the service. The key to service deliveryfor drug users then, is to find what is valuable to the drug user andthen to add public health interventions to that service. This was therationale for adding HIV testing or hepatitis B vaccination to nee-dle and syringe programme sites. This was the rationale for addinghepatitis C and HIV treatment into methadone clinics, creating ‘onestop shopping’ – multiple services that a drug user may need in aplace where the drug user already frequents. And this should be theguiding principle for primary health care services directed towardsdrug users. Behaviour change is very difficult even for the mostmotivated of people – this is something the 12 steps has taught fordecades. So if behaviour change is difficult, the key to the successfulcreation of primary care services to drug users is to ascertain themotivation for the drug user and to capitalize on that motivation.And this all starts with a nonjudgmental conversation with a druguser, because how else can we know someone’s motivations?

Reference

Islam, M. M., Topp, L., Day, C. A., Dawson, A., & Conigrave, K. M. (2012). The accessi-bility, acceptability, health impact and cost implications of primary healthcareoutlets that target injecting drug users: a narrative synthesis of literature. Inter-national Journal of Drug Policy, 23(2), 94–102.

doi:10.1016/j.drugpo.2011.09.008