University of Southern Cultural Characteristics and A Cultural Tailoring HW

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There will be a brief written 5 page paper (double-spaced) on how to tailor an evidence based intervention to fit the population and health issue you are focusing on in your photovoice project.In this case, tailoring the attached article for the population of homeless people in Downtown, Los Angeles. Your paper will (1) briefly summarize and identify the active intervention components of the EBI, (2) briefly summarize the health disparity, (3) summarize 2 to 4 cultural characteristics of your target population in your photo-voice (homeless people of Downtown, LA) that will be used to tailor your intervention, (4) briefly outline how you will adapt the intervention to this population using those cultural characteristics and a cultural tailoring framework, maintaining the health topic and active ingredients of the evidence based intervention.

Make sure to tease out the key components and the key significant outcomes for your summary in the individual paper.

Further instructions and grading rubric is provided in attachments, as well as the attached article on the evidence based intervention that will be used for this paper.

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HP420 Photovoice Assignment Fall 2019 Please complete a brief individual written assignment (5 pages max) reflecting on the health disparity you covered in this project and a possible solution. • Your written piece should include the following: • Title Page (not counted in 5 page total) • Brief summary of the disparity: briefly summarize the disparity in your community based on data about the issue and this community, risk factors, prevalence for this health problem in this population (About 1/2 page.) • Evidence-based intervention (EBI): o Find an EBI that uses a community or population based approach to reduce the health problem you are working on in your photovoice project (See Cultural Tailoring Lecture Slides 3, 6, 7, 26). Check with group-mates to make sure you are not duplicating the EBI of another team member. Bring it to class to discuss on 10/23/19 to review in a small group, and to make sure it is an EBI. Please note that it does not have to be for the same population as your photovoice population. That’s why the next part of the paper is about tailoring it to fit your population. o In your paper, briefly identify and summarize one evidence-based (research tested) intervention from the research literature or evaluation literature that addresses this health problem or a closely similar health problem and, most important, the key intervention components that make it work and, briefly, the significant outcomes. (About ½ to one page.) • Cultural tailoring: suggest how the intervention could be tailored to fit this health problem, community context and population using course concepts on tailoring. (About 3 pages) o First, identify which cultural tailoring model you will use: Framework for Cultural Tailoring – Surface Structure Deep Structure Adaptation Model, CBPR, Cancer Control Guidelines, or Van Duyn’s Social Marketing Approach. (Cultural Tailoring Lecture, slides 17-20). Come to class on 10/23/19 prepared to discuss which tailoring approach you will use and how you will use it to adapt your EBI. o Then, in your paper, summarize 3 to 5 known cultural indicators (values, beliefs, etc., for your population found in the Cultural Tailoring Lecture, slides 9-11) that you will be using to tailor the intervention. Document your research sources. o Finally, explain how you will adapt the key components of the EBI to your target population/community using your 5 or more components of your tailoring model and the 3 to 5 known cultural indicators for your population. • Conclusion: Discuss strengths and limitations of your tailored approach and why you think this is a good approach. (About ½ page) • References (additional page, not counted in page total): Please cite your sources using APA format throughout the text and in a separate reference page at end. 9-15-19 • Format: 5 pages in length, double-spaced, 12 point font, 1 inch margins, with title page and references, American Psychological Association (APA) in-text citation and reference format, and numbered pages. Individual Paper Grading Rubric • Pts Possible EBI article submitted Submitted 10-23-19 in class. Meets criteria of a community or population based EBI: sound test of intervention effects, showing significant differences in key outcomes, for health topic that fits the photovoice health topic. Peer discussion of cultural tailoring model, indicators and tailoring approach in class. Discussed EBI (journal article), Tailoring Model, and cultural indicators in class on 1023-19 to discuss in small group. Title Page: required, and not counted in 5 page total 3 Introduction (about ½ page): • Briefly summarize the health disparity that your group is focusing on your community, including the prevalence in your population. • Briefly discuss: what makes it a disparity according to Braveman’s or Healthy People 2020 definition? • Cite an appropriate source to document your data about this disparity. Evidence-based Intervention (EBI) (about 1/2 to 1 page) • Identify one community or population level evidence-based intervention from the research or evaluation literature that addresses this health problem or a health problem that is very similar to your photo-voice disparity (and cite your source); • Cite an appropriate source. It can be aimed (and probably should be aimed) at a different population or location than your photovoice group presentation. • Briefly summarize the key components of the intervention (i.e., the active ingredients) • Summarize (very briefly) what it was able to change (i.e., the significant outcomes relevant to your health disparity) Cultural Tailoring Strategy (about 3 pages) • State which tailoring framework or model you are using (and cite source) • Identify 3 to 5 relevant cultural indicators for this population that you are going to use to adapt the EBI (cite your sources) • Note how your intervention will be tailored using at least 5 components of the tailoring model to fit your specific population and context, based on your cultural indicators. Summary/Discussion (about 1/2 page) • Discuss the strengths and limitations of this tailored approach and why you think it’s a good approach. 4 9-15-19 3 8 20 4 Comments Individual Paper Grading Rubric References (separate page at end, not counted in 5 page limit) • Appropriately cite sources throughout the text • Appropriately cite sources in a reference section at the end of the paper • Use American Psychological Association (APA) citation and reference guidelines (e.g., references are cited by authors not by number) Overall Organization (note this may also be reflected in grades for sections above) • Clearly written • Well-argued and integrated • Depth of discussion in each section rather than a simple listing of features. • Formatted appropriately (1 inch margins, 12 point font, 4-5 page double spaced text, separate title page and reference page not counted in 5 page limit) Total 9-15-19 Pts Possible 5 3 50 Comments Health Policy 45 (1998) 209 – 220 Syringe and needle exchange as HIV/AIDS prevention for injection drug users in Puerto Rico Rafaela R. Robles a,b,*, Héctor M. Colón a,b, Tomás D. Matos a,b, H. Ann Finlinson a, Aileen Muñoz b, C. Amalia Marrero a,b, Myriam Garcı́a a, Juan C. Reyes a a Center for Addiction Studies, School of Medicine, Uni6ersidad Central del Caribe, Call Box 60 -327, 00960 -6032 Bayamón, Puerto Rico b Research Institute, Mental Health and Anti-Addiction Ser6ices Administration, Puerto Rico Department of Health, Box 21414, 00928 -1414 San Juan, Puerto Rico Received 15 April 1998; accepted 27 August 1998 Abstract This study evaluated the effectiveness of the first needle exchange program (NEP) established in Puerto Rico. The data for this study were collected during the first months of the NEP from July 1995 to March 1996 in 13 communities of the San Juan metropolitan area. Subjects were the participants of two modalities of the NEP: a mobile team and a community-based drug treatment program. During the 3-week evaluation period, 2401 injection drug users (IDUs) were recruited, resulting in a total of 19195 exchange contacts and 146323 syringes exchanged. No significant change in drug injection was observed. However, the program was effective in reducing sharing of syringes and cookers. The study suggests that the NEP did help in reducing needle sharing in Puerto Rico. However, the HIV seropositivity in returned syringes suggests the need to continue aggressive prevention programs to arrest the epidemic among IDUs. However, factors related to the socio-cultural environment as well as cultural norms and traditions need to be considered when planning and expanding NEPs. © 1998 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Puerto Rico; HIV/AIDS prevention; Injection drug users; Syringe exchange program; Needle exchange program * Corresponding author. Tel.: +787 7854211; fax: +787 7854222; e-mail: ucccea@caribe.net 0168-8510/98/$ - see front matter © 1998 Elsevier Science Ireland Ltd. All rights reserved. PII S0168-8510(98)00046-3 210 R.R. Robles et al. / Health Policy 45 (1998) 209–220 1. Introduction Puerto Rico shares with various large metropolitan areas in the US mainland the epicenter of the acquired immunodeficiency virus (AIDS) epidemic (58.4 AIDS cases per 100000 population) [1]. Injection drug use is the most frequently reported risk for AIDS on the island [2]. Puerto Rican drug users, whether residents of Puerto Rico or residents of the United States, have been disproportionately affected by the AIDS epidemic. A study among Hispanics in the continental United States found that, among men born in Mexico or Central and South America, 65% of AIDS cases were attributable to male-male sex. Fewer than 10% of AIDS cases in this group were associated with injection drug use. In contrast, 61% of AIDS cases among Puerto Rican born men were attributable to injection drug use, and only 22% to male– male sex [3]. Moreover, in Puerto Rico as in the United States, transmission of human immunodeficiency virus (HIV) infection has had a cascading effect; infections have spread from injection drug users (IDUs) to their sexual and needlesharing partners and from HIV-infected mothers to their children. Since 1993, sexual transmission has accounted for the majority of AIDS cases among female Puerto Ricans [2]. A comparative study of drug users in Puerto Rico and the US mainland showed that Puerto Rican drug users are more likely to inject speedball (a mixture of cocaine and heroin) and to inject drugs in shooting galleries than their drug injecting peers in the US. Moreover, drug users residing on the island reported a significantly higher number of daily injections and use of previously used drug injection paraphernalia; 39% on the island reported any use in the previous 30 days compared with 22% in New York. Also significantly, more drug users residing on the island reported sharing used cookers, cotton or rinse water compared with their peers residing in New York (30% vs 22%) [4,5]. Although in Puerto Rico, up until 19971, there were no laws restricting the sale, distribution or possession of syringes, drug users have reported considerable impediments to obtaining sterile syringes. Some pharmacies require documentation that a client has a condition (e.g. diabetes) that justifies the purchase of a syringe. Other pharmacies sell syringes without documentation but limit purchases to large quantities (e.g. ten or more). The restrictive policies of some pharmacies present a barrier to drug injectors who prefer to buy one or two syringes at a time. Drug users’ access to sterile syringes has also been limited due to harassment by police who destroy the syringes drug users carry [6]. 1 In November 1997 law no. 4 of June 23, 1971 was amended with article 412 entitled — Paraphernalia Related to Controlled Substances; definitive, criteria, penalties. This new article of the law prohibits the production, distribution, transportation and possession of any article defined in the law as controlled substances paraphernalia. However this article excludes from the law the Department of Health and non profit Community Base Organizations authorized by the Department of Health which are permitted distribute syringes, equipment and educational materials to prevent the transmission of contagious diseases. R.R. Robles et al. / Health Policy 45 (1998) 209–220 211 Recent studies have shown the benefits of needle exchange programs (NEPs) in reducing syringe sharing and HIV transmission. These studies have also demonstrated the NEPs are not associated with an increase in the number of injectors or increased frequency of injecting [7–11]. On the basis of this evidence, many communities in the US have established NEPs [12]. In Puerto Rico, there were no data which could provide an understanding of the circumstances under which a NEP would be effective in reducing HIV needle risk behavior among drug users. This paper extends needle exchange prevention research by evaluating the effectiveness of the first NEP established in Puerto Rico, a different sociocultural and geographic site from those where previous programs were developed. 2. Methods The NEP was initiated in July of 1995 in 13 communities of the San Juan metropolitan area, in the municipalities of San Juan, Cataño, Bayamón and Trujillo Alto (Fig. 1). The data for this study were collected during the first eight months of the program from July, 1995 to March, 1996. Communities were selected for their high density of IDUs in relation to other communities in the San Juan metropolitan area, as determined by previous epidemiological studies [13], drug treatment program admissions data [14] and drug arrest data [15]. Outreach workers from two drug treatment community based organizations (CBOs) were responsible for the intervention. The design of the evaluation was developed by researchers at the Center for Addiction Studies in the School of Medicine of the Universidad Central del Caribe (UCC). Fig. 1. Municipalities in which the Puerto Rico NEP provided services. 212 R.R. Robles et al. / Health Policy 45 (1998) 209–220 Each respondent who exchanged at least one needle was interviewed using a short questionnaire (contact form) dealing with the characteristics of the participant (i.e. sex, age, employment status), number of syringes exchanged, years injecting, number of injections per day, and whether the participant was engaging in syringe sharing. Data to measure changes in sharing drug injection paraphernalia and length of participation in the program were obtained from a structured interview completed by a sample of 325 IDUs who were participants in a HIV prevention study (Cooperative Agreement for AIDS Community-Based Outreach/Intervention Research, Grant 5U01DA07287) funded by the National Institute on Drug Abuse (NIDA). These participants were assigned to two study groups. One group comprised 133 subjects who had their follow-up interview before the program was in operation, the second group comprised those subjects who were interviewed while the program was operating. The Risk Behavior Assessment (RBA) and Risk Behavior Follow-up Assessment (RBFA), structured interview protocols designed by NIDA and adapted to the island’s vernacular, were used to collect information related to drug use, injection and sex risk behaviors, health care, as well as drug treatment and incarceration history previous to the NEP and after the program had been established. The specific behavior change measures were reduction in sharing of syringes and cookers, and reduction in drug injection. The amount of time syringes were in circulation was measured by the following procedure: a sample of 1075 syringes was enumerated; a calendar was kept for each site indicating when the syringes were to be distributed as well as documenting the date when the distribution actually took place. The date was also documented in the contact form when the enumerated syringes were returned. The enumerated syringes were subsequently tested for HIV seropositivity in the laboratory of the School of Medicine, UCC, using the following methods: the traces of blood contained in the syringes were submitted to the ELISA test, using the commercial immunoassay Genetic Systems LAV EIA, which is manufactured using the virus propagated in the CEM cellular line and purified through centrifugation. It is worth mentioning that this test was developed and optimized by the manufacturer for the detection of HIV antibodies in serum/plasma, recommending a determined dilution of these antibodies to reach a sensitivity of 100% and a specificity of 99.8%. This control over the dilution of the sample is impossible with respect to the syringes, as the quantity of blood that might have adhered to the walls of the syringes is unknown. Understanding that for the purposes of this study, we had to focus on generating the highest sensitivity possible given the characteristics of the sample, we proceeded to dilute the contents of the syringes in the minimal volume that would permit its evaluation in duplicate. The remainder of the test was carried out, following strictly the recommendations of the manufacturer. We assumed that a reduction in needle-sharing would result in a decrease in related seropositivity; the lesser the number of individuals who use the same syringe, the lesser the probability that the syringe will contain antibodies. We understood that whatever limitation of the test with respect to its sensitivity would equally affect the study across the board, permitting the evaluation of tendencies through statistical methodology. R.R. Robles et al. / Health Policy 45 (1998) 209–220 213 3. The NEP The NEP comprised two modalities: a mobile team that visited assigned communities two to three times a week for a period of 45 min to 1 h, and a store-front office maintained by a community based drug treatment program that was open week-days from 08:00 to 17:00 h. Both modalities offered their services during the daytime on weekdays. The intervention team in each modality was comprised of three individuals: a male outreach worker, a male case manager and a female nurse. There was an official one-to-one exchange rule but both CBOs placed restrictions on the number of syringes participants were allowed to exchange. 4. Outcome Measures The effectiveness of the NEP was assessed with the following indicators: 1. the number of client contacts and syringes exchanged as recorded on the contact form; 2. the frequency of visits to the syringe exchange as reported by participants and recorded on the contact form; 3. the potential negative impact of the syringe exchange program was examined using the following indicators recorded on the contact form: 3.1. changes in the self-reported frequency of injection since the first time syringes were exchanged, 3.2. changes in the age distribution of participants, 3.3. proportion of respondents reporting first injection since the program started, 3.4. syringe sharing was examined by assessing the relationship between reported syringe exchange used during the first 32 weeks of the program and reported syringe sharing partners in the 30 days prior to the interview. We analyzed the self reports of syringe sharing and the HIV seropositivity among enumerated exchanged syringes. Our analysis shows that those syringes exchanged by participants who reported sharing syringes were more likely to be seropositive than those exchanged by participants reporting not sharing syringes. This analysis seems to indicate that self reports of syringe sharing seem valid. 5. Statistical analysis x 2 tests were used to determine differences in the proportion of male and female IDUs who shared syringes. To identify differences in the mean years of injecting and the reported frequency of daily injections, a t-test analysis was performed. A multiple regression analysis was used to determine the impact of the exchange program on syringe sharing and frequency of drug injection. All statistical analyses were performed using the Statistical Package for the Social Sciences (SPSS) version 7.5 for Windows. 214 R.R. Robles et al. / Health Policy 45 (1998) 209–220 Table 1 Number of new participants, exchange events and needles exchanged by NEP modality in the first 8 months of implementation NEP modality New participants Exchange events Needles exchanged On-site unit Mobile unit Total 743 1658 2401 8425 10 770 19 195 53 257 93 066 146 323 6. Results During the 31-week evaluation phase of the program, some 2401 IDUs were recruited, resulting in a total of 19195 exchange contacts and 146323 syringes exchanged. Table 1 shows the distribution of syringes by exchange modality: the mobile unit reported 10770 exchange contacts with 93066 syringes exchanged; the on-site modality reported 8425 exchange contacts and 53257 syringes exchanged. Fig. 2 shows the number of drug injectors recruited by month, indicating the high rate of recruitment in the first month and a continuing downward trend until the fifth month, when the number of subjects recruited stabilized. More women participated in the on-site modality (22.8%) than the mobile modality (16.3%) (P B0.01). There were no significant differences between the two modalities in years of injection (11.5 years in the mobile vs 12.1 years in the on-site modality; P B 0.27). However, participants in the on-site modality were more likely to inject more frequently than in the mobile modality (7.2 vs 5.9, PB 0.01) (Table 2). Fig. 2. Drug injectors recruited by the NEP by month. R.R. Robles et al. / Health Policy 45 (1998) 209–220 215 Table 2 Characteristics of participants recruited by the NEP by modality Modality Percentage of women Mean years of injection Mean number of daily injections Percentage informing shared use of syringes On-site Mobile P 22.8 12.1 7.2 35.4 16.3 11.5 5.9 39.8 B0.01 0.27 B0.01 0.29 Fig. 3. Percentage of enumerated syringes returned in a week or less by month of project. During the first 29 weeks of the program, some 1075 enumerated syringes were circulated. Of these, some 433 (40.3%) were returned to the program. A high percentage (91.1%) of those syringes were returned in the same community where the needles were originally exchanged. A significant increase in returned syringes was observed during the evaluation period. Some 12.4% of the syringes were returned during the first week, and 32.5% at 8 months (Fig. 3). Of the 433 enumerated returned syringes, 391 were tested for HIV seropositivity. Some 104 (26.6%) of the returned syringes with blood presence were seropositive and 241 (16.2%) without blood presence were HIV seropositive (Table 3). Table 3 Result of ELISA tests performed on enumerated syringes returned Visible traces of blood in syringe N Reactive ELISA (%) No Yes Total 241 150 391 16.2 43.3 26.6 216 R.R. Robles et al. / Health Policy 45 (1998) 209–220 Table 4 Multivariate logistic regression results Behavior Odds ratio 95% C.I. P Shared use of syringes Before NEP During NEP 1.00 0.50 0.25–0.97 0.04 Shared use of ‘cookers’ Before NEP During NEP 1.00 0.61 0.31–1.17 0.14 Drug injection on a daily basis Before NEP During NEP 1.00 0.83 0.49–1.43 0.51 All models include the behavior measurement collected during the previous measurement wave. The results of the multivariate analyses are shown in Table 4. Syringe sharing was significantly reduced during the period of program operation as compared to the period before the program started (OR = 0.50, P= 0.04). That is, subjects assessed while the program was in operation were half as likely to report syringe sharing than subjects assessed prior to the establishment of the program. No statistically significant differences were observed in the shared use of cookers (OR= 0.61, P = 0.14) or in the frequency of injection (OR= 0.83, P= 0.51). Fig. 4 shows the number of participants who entered drug treatment for each of the eight months of the evaluation period. A total of 9.4% entered treatment over the length of the evaluation period. As noted in Fig. 4, there was a tendency for an increasing number of participants to enter treatment. During the first month only 1% entered treatment. By the third month, this rate substantially increased (12%) and continued for the next two months. During the seventh month 28.9% of the participants entered treatment. However, this increase was a response to a number Fig. 4. Participants entering drug treatment programs as a fraction of new participants by month of recruitment. R.R. Robles et al. / Health Policy 45 (1998) 209–220 217 of strategies developed by outreach workers to encourage participants to enter treatment. During the last month of the evaluation period, the number of participants entering treatment was reduced to a level similar to the level established during the three months that preceded the special campaign to enroll participants in treatment. 7. Comments Our findings confirm that IDUs will participate in NEPs that can be easily accessed and negotiated. It seems that the Puerto Rico NEP was readily adopted by a group of drug injectors but was unable to recapture a large proportion of used and potentially infected enumerated syringes. It is likely that enumerated NEP syringes were sold, discarded after use, or given away by participants who also routinely obtained new syringes from other sources (i.e. pharmacies, private sellers) that do not collect used syringes. In addition, several NEP participants expressed the concern that their use of encoded syringes might result in the loss of anonymity, and this may have negatively affected retrieval of the encoded syringes. Police harassment of drug users also appears to have discouraged participants of the program from retaining the syringes and bringing them to the next exchange encounter, a process that could entail waiting for two days or over the week-end. Moreover, many of participants were homeless or lived with their nondrug-using parents, where they had little privacy. Families in Puerto Rico will generally offer shelter and food to members who use drugs or engage in other socially unacceptable behavior. However, keeping drug use paraphernalia at the parents’ home would be against a still very prevalent norm of the Hispanic culture, ‘respect for parents’. Thus, for the NEP to be able to recapture a larger number of used enumerated syringes it would need to have more frequent exchange encounters so that drug users did not need to keep and carry the syringes and expose themselves to police harassment and family disapproval. The on-site modality had a larger proportion of female participants than the mobile modality. The intervention teams of both modalities were similar in gender and occupational mix. The fact that women were more likely to exchange their syringes at the on-site modality might also be related to the traditional Hispanic cultural ideology still prevailing on the island. Participants in the on-site modality could exchange syringes any time during the day, whenever they felt most comfortable because they were not as likely to be observed by peers or neighbors. In the mobile modality all participants had to exchange syringes in a public setting which may have inhibited some female participants from exchanging syringes. The need for a more extensive and intensive exchange program also seems evident by the fact that our ethnographic data shows that the black market continued to be an important source of new syringes for IDUs [6]. It seems that the NEP in Puerto Rico was not able to replace the black market as in other sites in the US mainland [7]. Here again, a more intensive and extensive program is needed for a NEP to replace the syringe black market. 218 R.R. Robles et al. / Health Policy 45 (1998) 209–220 While the NEP was not as effective as expected in recapturing enumerated syringes and in replacing the syringe black market, the program was effective in decreasing the sharing of syringes and cookers, and in increasing the use of new syringes. These findings support studies in the US and other countries demonstrating that increased availability of sterile syringes can be an important factor in reducing needle sharing, a behavior highly related to HIV transmission [4,10,16– 19]. The high prevalence of HIV seropositivity in returned needles, with and without visible blood, suggests that after more than 16 years of the epidemic we need to continue aggressive prevention programs to arrest this epidemic among drug injectors. A more extensive and intensive NEP could be an effective strategy to enhance our preventive programs in arresting this catastrophic virus. Data related to availability of treatment suggest that NEPs need to consider community-based treatment and/or preventive programs as program sites. These organizations are already legitimized as health resources by the community and can offer other services needed by participants. NEPs could be another strategy to enhance the service program of these organizations. NEPs by themselves cannot address the many health, drug use and social problems of IDUs. Programs established outside service organizations need a concerted effort of organizational resources to address this complex disease. Undoubtedly, drug treatment programs need to play a central role in any serious endeavor to address the health consequences of drug use. There was no support in our study population for the view that NEPs promote drug use. Our data show a gradual but statistically significant decline in self-reported frequency of injection and a decreasing level of initiation of drug use over time. This study is limited in that it did not identify the circumstances under which syringe sharing was reduced. Moreover, we used self reports of respondents to collect most of the data. This information may be subject to socially desirable response problems of recall, intoxication and other sources of bias. However, high validity of self-reported drug use in a multi-site study using similar methods has been reported [7]. Despite these limitations, this study extends the useful information already collected in previous studies regarding NEPs. This study suggests that the NEP did help in reducing needle sharing in Puerto Rico, a different environment and cultural site from that of previous studies. Therefore, such programs should be initiated, continued and expanded to meet existing needs in areas where NEPs have not been implemented or are still very limited, as in Puerto Rico. However, factors related to the social environment, as well as cultural norms and traditions, need to be seriously considered when planning NEPs. Acknowledgements This study was supported in part by the Puerto Rico Department of Health and R.R. Robles et al. / Health Policy 45 (1998) 209–220 219 by a grant from the National Institute on Drug Abuse at the National Institutes of Health. The authors would like to thank Carmen Feliciano, MD, Secretary, Puerto Rico Department of Health, Commonwealth of Puerto Rico, for her continuous support and Eddie Rı́os, PhD, MPH, Department of Microbiology and Immunology, School of Medicine, Universidad Central del Caribe, for his helpful comments on earlier drafts of this manuscript. References [1] Centers for Disease Control and Prevention, US HIV and AIDS cases reported through December 1995, HIV/AIDS Surveillance Report 1995;7:1 – 39. [2] Puerto Rico Department of Health, AIDS in Puerto Rico, Puerto Rico AIDS Surveillance Program 1995;4:1–6. [3] Diaz T, Buehler JW, Castro KG, Ward JW. AIDS trends among Hispanics in the United States. American Journal of Public Health 1993;83:504 – 9. [4] Robles RR, Colón HM, Matos TD, Reyes JC, Marrero CA, López CM. Risk factors and HIV infection among three different cultural groups of intravenous drug users. In: Brown BS, Beschner GM, editors. Handbook on risk of AIDS: Injection drug users and sexual partners. Westport, CT: Greenwood Publishing, 1993:256–74. [5] Colón HM, Robles RR, Sahai H, Reyes JC, Matos TD. HIV seroprevalence among injection drug users in Puerto Rico: A comparative perspective. In: Brown BS, Beschner GM, editors. Handbook on risk of AIDS: Injection drug users and sexual partners. Westport, CT: Greenwood Publishing, 1993:72–87. [6] Finlinson HA, Colón HM, Robles RR, Deren S, Soto M, Muñoz A, Access to sterile syringes by injection drug users in Puerto Rico, Paper presented at the Annual Meeting of the Society for Applied Anthropology. San Juan, Puerto Rico, April 22 – 26, 1998. [7] Watters JK, Estilo MJ, Clark GL, Lorvick J. Syringe and needle exchange as HIV/AIDS prevention for injection drug users. Journal of the American Medical Association 1994;271:115 – 20. [8] Hart GJ, Carvell ALM, Woodward N, Johnson AM, Williams P, Parry JV. Evaluation of needle exchange in central London: Behavious change and anti – HIV status over one year. AIDS 1989;3:261–5. [9] Carvell AM, Hart GJ. Help–seeking and referrals in a needle exchange: A comprehensive service to injecting drug users. British Journal of Addiction 1990;85:235 – 40. [10] Hartgers C, Buning EC, van Santen GW, Verster AD, Coutinho RA. The impact of the needle and syringe–exchange programme in Amsterdam on injecting risk behaviour. AIDS 1989;3:571 – 6. [11] Groseclose SL, Weinstein B, Jones TS, Valleroy LA, Fehrs LJ, Kassler WJ. Impact of increased legal access to needles and syringes on practices of injecting-drug users and police officers-Connecticut, 1992–1993. Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology 1995;10:82–9. [12] Vlahov D. Deregulation of the sale and possession of syringes for HIV prevention among injection drug users (Editorial). Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology 1995;10:71–2. [13] Robles RR, Colón HM, Freeman DH. Copping areas as sampling and recruitment sites for out-of-treatment crack and injection drug users. Drugs and Society 1993;7:91 – 105. [14] Mental Health and Anti-Addiction Services Administration, Management Information Systems, Mental Health and Anti-Addiction Services Administration, Puerto Rico Department of Health. San Juan, PR, 1994. [15] Puerto Rico Police Department, Annual Report, Puerto Rico Police Department, Commonwealth of Puerto Rico. San Juan, Puerto Rico, 1995. 220 R.R. Robles et al. / Health Policy 45 (1998) 209–220 [16] Kaplan EH, Heimer R. HIV prevalence among intravenous drug users: Model-based estimates from New Haven’s legal needle exchange. Journal of Acquired Immune Deficiency Syndromes 1992;5:163–9. [17] Normand J, Vlahov D. Preventing HIV transmission: The role of sterile needles and bleach. Washington DC: National Academy Press, 1995. [18] Centers for Disease Control and Prevention, Syringe exchange programs — United States, 1994 – 1995, Mortality and Morbidity Weekly Report 1995;44:684 – 691, 759. [19] Koester SK, Hoffer L. ‘‘Indirect sharing’’: Additional HIV risks associated with drug injection. AIDS and Public Policy Journal 1994;9:100 – 5. . .
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Running head: NEEDLE EXCHANGE PROGRAMS

Cultural Tailoring of Evidence-Based Intervention
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NEEDLE EXCHANGE PROGRAMS

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Cultural Tailoring of Evidence-Based Intervention
Introduction
Injection Drug Users are the primary beneficiaries of programs that offer needle
exchanges. When people are using injection drugs, their primary tools are injection needles,
which they share, for lack of steady access to newer supplies (Bluthenthal et al., 2017).
According to Klevens et al. (2016), drug use seemed to be declining, as studies opined that IDUs
were aging people. However, subsequent studies posited that the use of injection drugs was
exponentially increasing. For areas such as downtown Los Angeles, the prevalence of Injection
drug users among the large population of drug users was 34% as of 2018 (Bluthenthal et al.,
2017). Such statistics present that with such high numbers of people using injection drugs, they
may be more pre-disposed to infections such as HIV than if they were not using injections as
drug pathways. As such, it became imperative that relevant interventions were put in place based
on the evidence of the extent of IDUs in the targeted areas.
The institution of needle exchange programs is one such evidence-based intervention,
which has been established in downtown Los Angeles, among other states. The homeless people
of downtown LA that use these drugs are the major beneficiaries of such exchange programs,
where they can get clean and sterilized needles after they deposit their used ones. So far, needle
exchange programs have been able to help reduce the prevalence of HIV infection among the
homeless of LA by 57%.
Evidence-Based Intervention: Needle Exchange Programs
The use of injection drugs is associated with health problem burdens, especially in states
where the prevalence of injection drug use is high. Some of the health problems that are closely

NEEDLE EXCHANGE PROGRAMS

3

linked to injection drug use include bloodborne diseases such as HIV and Hepatitis C. Facilities
that promote safe injection are now the most popular way of addressing the problem posed by the
use of injection drugs and the resultant disease transmissions (Tucker et al., 2016; Robles et al.,
1998). The g...


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