ESAP Evaluation: Harlem and the Bronx

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Harlem Community Academic Partnership
Community Based Participatory Research A
Multilevel Outcome Analysis Following a
Multi-component Intervention in Treatment and
Comparison Communities David Vlahov, PhD
Center for Urban Epidemiologic Studies,New
York Academy of MedicineMailman School of Public
Health, Columbia University
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Overview of HCAP Process

• Mission Statement to Promote Health in Harlem.
• Principles of Partnership e.g., Reciprocity
• Bylaws Organization for a Sustained Effort
  Steering Committee meets monthly Intervention
  Work Groups (IWG) more often
• Conceptual Model Social Determinants of Health
• Multilevel Influences, Multi-component
  Interventions
• Needs Assessment Qualitative, Quantitative,
  Priority Setting
• HCAP Goal Should be easier to get help for
  problems with drugs
• than it is to get drugs themselves.

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Social ecological model of health
Kaplan 2000
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General Model of Social Determinants
Galea et al. Health Educ Behav 200229(3)296-311
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Background of Problem Addressed

• Substance abuse and HIV are major problems in
  Harlem. While syringe exchange programs provide
  limited access to sterile syringes in some major
  cities across the U.S., the U.S. federal ban on
  funding for SEPs has limited their ability to
  meet the needs of HIV prevention.
• Some have urged the use of pharmacies for HIV
  prevention by virtue of convenience in hours and
  locations providing a safe supply of sterile
  needles that would supplement existing SEPs.
• For HIV prevention, New York State enacted public
  health legislation permitting pharmacy sales of
  syringes
• requiring no prescription.

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Expanded Syringe Access Program (ESAP)

• As of January 1, 2001, State Program started and
  involved
• Providers (pharmacies and health care facilities)
  registered with the New York State Department of
  Health to participate in ESAP.
• Registered providers may sell or furnish up to 10
  syringes per transaction, only to persons 18
  years or older.
• Registered providers may not advertise but
• must provide the ESAP safety insert.
• State mandated an independent evaluation that
  assessed pharmacy response, and impact on drug
  users and public. This evaluation, performed by
  NYAM, was the official program evaluation for
  legislature and needs assessment for HCAP.

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ESAP Program Findings Widespread Pharmacy
Registration but Utilization in Harlem is Low.

• Following early State Health Department-directed
  educational efforts, NYAM survey shows that while
  pharmacies registered and needle sales began to
  increase overall in NYC, early findings
  identified that
• utilization lower in black and Hispanic than
  white IDUs,
• lower in Harlem than other parts of city.
• NYAM partner in HCAP presents these results to
  HCAP.
• HCAP reviews information and moves to designate
  an Intervention Work Group to design and
  implement the ESAP IWG Project which is a
  multi-level, multi-partner community-based
  intervention in East and Central Harlem with
  educational outreach efforts to IDUs, pharmacists
  and community residents.

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Harlem ESAP Evaluation Design

• Design Pre-Intervention Intervention Post-In
  tervention
• Communities East Central East Central
• Harlem, Brooklyn, East Central Harlem,
  Brooklyn,
• South Bronx Harlem South Bronx
• (Intervention Control) (Intervention) (Interv
  ention Control)
• Levels
• IDU Survey Outreach Survey
• Pharmacy Phone Survey Outreach Phone Survey
• Community RDD Outreach RDD

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Methods Pre- Post- Assessments

• Community residents of Harlem, South Bronx, and
  Brooklyn underwent a RDD telephone survey which
  ascertained knowledge and opinions of drug use,
  HIV, ESAP and other harm reduction strategies in
  their community.
• A random sample of ESAP participating and
  non-participating pharmacists in Harlem, South
  Bronx, and Brooklyn underwent a random sample
  telephone survey which ascertained ESAP
  knowledge, attitudes and practices.
• Injection drug users were recruited using
  targeted and respondent driven sampling methods
  in Harlem, South Bronx, and Brooklyn, and
  underwent a behavioral risk survey which
  ascertained pharmacy use, injection behaviors,
  and ESAP knowledge (only Harlem and South Bronx
  are presented for this analysis).

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Community Attitudes and Perceptions of ESAP, Pre
and Post Harlem Intervention in Harlem (n980),
and South Bronx (n391)Aware of ESAP ESAP
is a Good Idea
Increase Syringes on Street
Increase Spread of HIV
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Pharmacists Attitudes and Perceptions of ESAP,
Pre and Post Harlem Intervention in Harlem
(n52), Brooklyn, and South Bronx
(n77) Support ESAP Not Good
for HIV Prevention
Increase Syringes on Street
Increase Drug Use
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IDUs Injection Practices, Pre and Post Harlem
Intervention in Harlem (n340), and South Bronx
(n377)
Use Pharmacy at Last Injection
Knowledge of ESAP
Syringe Re-Use
Syringe Disposal-Ground or Bushes
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Discussion

• Academic part of Partnership brought key
  information to HCAP
• Survey data to present a problem of interest to
  partnership.
• Content expertise to help frame design of
  intervention
• Content expertise in evaluation
• (sampling, measurement, analysis)
• Community part of Partnership brought key
  information to HCAP
• Definition of community
• Buy in from community
• Community directed intervention creation and
  selection of components (e.g., pharmacy purchases
  to identify friendly pharmacies that was then
  built into outreach materials)
• Interpretation of Results

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Conclusion

• Community Academic Partnerships can move beyond
  process to accomplish broad scale mobilization
  efforts.
• Outcome Effectiveness of mobilization efforts
• can be designed, measured and summarized.
• Pre- and Post Intervention/Comparison
• Such partnerships provide academic challenges as
  well as practical public health experience,
  e.g.,
• 1. Interdisciplinary Development of Multi-level,
  Multi-component Approaches to Intervention
• 2. Multi-level Analyses for Program Evaluation.
• 3. Novel methods e.g., Improved Sampling
• of Hidden Populations.

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HCAP members

• Community residents
• Clients
• Community based organizations (CBOs)
• NYC Department of Health
• Hunter College, City University New York
• Mount Sinai School of Medicine
• Mailman School of Public Health,
• Columbia University

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CBOs involved in HCAP activities

• Association to Benefit Children (ABC)
• Association for Drug Use Prevention and Treatment
  (ADAPT)
• ACCESS
• Boriken Health Center
• Central/East Harlem HIV Care Networks
• Harlem branch YWCA
• Harlem Dowling West Side Center
• Harlem East Life Plan
• Harlem United Community AIDS Center
• Latino Organization for Liver Awareness (LOLA)

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CBOs involved in HCAP activities

• Little Sisters of the Assumption
• Mount Sinai School of Medicine
• Institute for Medicare Practice
• Department of Community Medicine
• New York City Department of Health
• North General Hospital alcohol Treatment Center
• The Riverside Church
• Settlement Health Center
• Union Settlement
• Veritas Therapeutic Community
• Womens Information Network

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Funding for CBPR is possible. This research was
supported byRobert Wood Johnson
FoundationCenters for Disease ControlNational
Institute on Drug Abuse

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Implications for public health training

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• Faculty development training
• in CBPR competencies
• Post doc training in CBPR
• Coursework in CBPR
• Institutional recognition and support for
  faculty engaged in CBPR

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