Product Details

Author Information

Corresponding Author
Julie Gleason-Comstock
Wayne State University
Center for Urban Studies
5700 Cass Avenue
Detroit, MI 48202
United States
p: (313) 577-9143
f: (313) 577-1274
jgleason@med.wayne.edu

Authors (listed in order of authorship):
Julie Gleason-Comstock
Wayne State University

Alicia Streater
Wayne State University

Cindy Bolden Calhoun
Community Health Awareness Group

Luke Bergmann
New York City Dept Health & Mental Hygiene

Product Description and Application Narrative Submitted by Corresponding Author

What general topics does your product address?

Public Health, Social & Behavioral Sciences

What specific topics does your product address?

Health behavior, Health education , Interdisciplinary collaboration, Prevention, Substance use, Urban health, Program evaluation, Community-based participatory research

Does your product focus on a specific population(s)?

Urban

What methodological approaches were used in the development of your product, or are discussed in your product?

Community-academic partnership, Community-based participatory research , Focus group , Qualitative research, Quantitative research, Survey

What resource type(s) best describe(s) your product?

Best practice , Evaluation tool, Evidence-based practice

Application Narrative

1. Please provide a 1600 character abstract describing your product, its intended use and the audiences for which it would be appropriate.*

A community based participatory research (CBPR) collaborative was formed to adapt an opiate overdose reversal training and distribution program model to the local community. The program can prevent unnecessary death by allowing trained injecting drug users to administer naloxone immediately, increasing chances of successful revival. The CBPR was built on an existing CBPR relationship on HIV testing technology and risk reduction (1). CBPR partners were Community Health Awareness Group, Inc. (CHAG) a community-based organization with a mobile harm reduction/syringe exchange program, the City of Detroit Department of Health & Wellness Promotion (DHWP), and public health researchers from Wayne State University (WSU). Evaluation provided an important feedback loop for program development, improvement and determining impact in reducing deaths and changes in substance use. Results of pre-implementation focus groups with injecting drug users (IDU) provided input into subsequent training and recruitment procedures and evaluation protocols and tools. Products developed included the Naloxone and Substance Use History, Naloxone Focus Group Questions, CHAG Overdose Reversal Program (Naloxone Project) Pre- and Post-Training Survey and a Follow-Up Interview/Survey.

2. What are the goals of the product?

The products developed were designed to meet three objectives: (1) to elicit input and feedback from the program's target population, (2) to reduce staff and client burden in completing evaluation instruments and (3) to evaluate the achievement of program process and outcome objectives. The first objective was met by creating a focus group script designed to elicit input from potential program participants, including homeless IDU, on the best methods for recruiting, training, and engaging injecting drug users in the opiate reversal program. Customized program registration materials were subsequently developed. The second objective was met by blending required program elements with data collection needed for research evaluation. Surveys were formulated in conjunction with harm reduction staff to meet the time and space constraints inherent in mobile outreach environments. To met the third objective, evaluation tools and protocols for administering them were created to (a) establish consumer health behavior and substance use baseline data from participants in a harm reduction/syringe exchange, (b) assess training outcomes through pre and post-training surveys, and (c) identify achievement of short and long term objectives through six-month follow-up surveys.

3. Who are the intended audiences or expected users of the product?

The intended audiences are a) researchers and evaluators in substance abuse prevention and drug overdose reversal, b) community-based organizations conducting prevention and harm reduction programs, and c) public health practitioners seeking to improve health outcomes.

4. Please provide any special instructions for successful use of the product, if necessary. If your product has been previously published, please provide the appropriate citation below.

Although the tools do not require any special instructions, they were developed to meet the specific interests of the collaborative. Some adjustments may be needed to ensure that they meet local or regional needs. Successful use of the product should include IRB review and/or standard consent for public health evaluation and research.

Preliminary results from the focus group questions were presented at the Michigan Public Health Conference (2).

Gleason-Comstock J, Streater A, Sorbo M, Bolden Calhoun C, Jones B, Milller C, Bergmann L. CBPR with an IDU focus group on overdose prevention and reversal. Michigan's Premier Public Health Conference, 2009. Poster presentation. Available from http://www.mipha. Accessed November 13, 2009.

5. Please describe how your product or the project that resulted in the product builds on a relevant field, discipline or prior work. You may cite the literature and provide a bibliography in the next question if appropriate.

Opiate overdose is a leading cause of death IDU internationally as well as the single greatest cause of mortality among IDUs in the United States (3, 4). High rates of opitate overdose, often related to emergency department visits and fatalities, have resulted in opiate overdose prevention and reversal programs being implemented in Chicago (5), San Francisco (6), Baltimore (7) and New York (8,9,10). The Detroit project built upon the Chicago Recovery Alliance (CRA) training model (11) as well as literature review and lessons learned from other urban areas (12, 13). Training IDUs to use naxolone to promote overdose reversal in community settings for intravenous drug users could be considered an emerging public health strategy.

6. Please provide a bibliography for work cited above or in other parts of this application. Provide full references, in the order sited in the text (i.e. according to number order). .

(1) Gleason-Comstock J, Streater A, Bolden Calhoun C, Simpson H, Rolack R, Norman S.. Development of community-based participatory research to evaluate conventional HIV testing and HIV rapid testing. J of HIV and Social Services 2006 5 (3/4): 201-219. http://www.haworthpress.com/store/ArticleAbstract.aspID=94873

(2) Gleason-Comstock J, Streater A, Sorbo M, Bolden Calhoun C, Jones B, Milller C, Bergmann L. CBPR with an IDU focus group on overdose prevention and reversal. Michigan's Premier Public Health Conference, 2009. Poster presentation. Available from http://www.mipha. Accesed November 13, 2009.

(3) Wright N, Oldham N, FrancisK, Jones L. Homeless drug users’ awareness and risk perception of peer “Take Home Naloxone “ use – a qualitative study. Substance Abuse Treatment, Prevention and Policy 2006 1:28 doi.10.1186/1747-597X-1

(4) US. DHHS. SAMHSA. Drug Abuse Warning Network, 2006: National Estimates of Drug-Related Emergency Department Visits. http://DAWNinfo.samhsa.gov. Accessed October 15, 2009.

(5) Sherman S, Gann D, Scott G, Carlberg S, Bigg D, Heimer R. A qualitative study of overdose responses among Chicago IDU. Harm Reduction J 2008 5:2 doi.10.1186/1477-7517-5-2.

(6) Seal K, Thawley R, Gee L, Bamberger J, Kral A, Ciccarone D, Downing M, Edlin B. Naloxone distribution and cardiopulmonary resuscitation training for injection drug users to prevent heroin overdose death: a pilot intervention study. J of Urban Health 2005 82:2: 303- 311. Doi.10.1093/jurban/jti053

(7) Tobin K, Sherman S, Beilenseon P, Welsh C, Latkin. Evaluation of the Staying Alive program: training injection drug users to properly administer naloxone and save lives. International J of Drug Policy 2009 20 131-136.

(8) Worthington N, Piper T, Galea S, Rosenthal D. Opiate users’ knowledge about overdose prevention and naloxone in New York City: a focus group study. Harm Reduction J 2006 3:19 doi.10.1186/1477-7517-3-19

(9) Piper TM, Rudenstein S, Stancliff S, Sherman S, Nandi V, Clear A, Galea S. Overdose prevention for injection drug users: lessons learned from naloxone training and distribution programs in New York City. Harm Reduction Journal 2007 4:3. Doi: 10.1186/1477-7517-4-3.

(10) Piper Markham, TM, Stancliff, S, Rudenstine S, Sherman S, Nanci V, Clear, A, Galea, S. Evaluation of a naloxone distribution and administration program in New York City. Substance Use & Misuse 2008 43:7, 858-870.

(11) Chicago Recovery Alliance. www.anypositivechange.org Accessed October 15, 2009.

(12) Gaston RL, Best D, Manning V, Day E.. Can we prevent drug related deaths by training Opioid users to recognise and manage overdoses? Harm Reduction J 2009 6:26. Doi:10.1186/1477-7517-6-26.

(13) Stang J, Manning V, Mayet S, Best D, Titherington E, Santana L, Ofor E, Semmler C. Overdose training and take-home naxolone for opiate users: prospective cohort study of impact on knowledge and attitudes and subsequent management of overdoses. Addiction 2008 103:1648-1657.

7. Please describe the project or body of work from which the submitted product developed. Describe the ways that community and academic/institutional expertise contributed to the project. Pay particular attention to demonstrating the quality or rigor of the work:

• For research-related work, describe (if relevant) study aims, design, sample, measurement instruments, and analysis and interpretation. Discuss how you verified the accuracy of your data.
• For education-related work, describe (if relevant) any needs assessment conducted, learning objectives, educational strategies incorporated, and evaluation of learning.
• For other types of work, discuss how the project was developed and reasons for the methodological choices made.

The CHAG opiate reversal project was based on the Harm Reduction Theory. The project was developed to increase the chance that someone will recover from an opiate overdose by allowing immediate intervention by bystanders who are often reluctant to call 911 emergency. The project and products grew from the active involvement of all three institutions represented in the CBPR. The CBO provided extensive knowledge and experience with harm reduction, the city health department provided guidance and sponsorship, and the university provided expertise in research methodology and community engagement.

CHAG began meeting with the DHWP in spring of 2009 to develop a Naloxone overdose reversal program. CHAG and DHWP received training on the CRA model. Literature review included lessons learned from other urban areas such as New York and Baltimore. This process allowed the group to familiarize themselves about issues to consider in developing the project. WSU joined the group to help develop the focus group procedures and program evaluation methods. Focus groups provided input from the IDU community on appropriate recruitment, training, and evaluation strategies. Representatives from all three institutions observed the groups and reviewed findings to develop an implementation plan.

Participation is open not only to IDU enrolled in CHAG’s needle exchange program but also to family and friends of IDUs. Project protocols require that all participants must register with the program and receive training before receiving a single dose supply of naloxone. Recruitment and training are done primarily in street outreach settings. After training, participants complete the “CHAG Naloxone and Substance Use History” form, which doubles as a registration form and evaluation tool. Because of focus group suggestions, participants receive a fanny pack to store the naloxone, pocket-sized instructions for reference, and a training DVD to educate others in their injecting network about the naloxone in case the trainee has an overdose. Fanny packs are not only for convenience but also allow homeless participants a dark place to store nalaxone as it is sensitive to light. Participants are instructed to return for another supply when the vial expires or if they need to replace the naloxone.

8. Please describe the process of developing the product, including the ways that community and academic/institutional expertise were integrated in the development of this product.

The products developed for the project are the result of the ten year evaluation and research collaboration between CHAG and WSU. WSU began evaluation of the harm reduction/ syringe exchange program in 2000 and has continued to provide protocol and instrument development and training to CHAG program and administrative staff. WSU also provides quarterly process and semi-annual outcome harm reduction program reports.

Representatives from all three institutions discussed what program and evaluation tools would be needed. Based on group discussion and literature review, the WSU team created draft versions of focus group questions, substance use history, pre and post-training surveys, a follow-up survey, and informed consent. The drafts were circulated to the planning group for review and modification. The entire CBPR team then met to review the tools for ease of use and integration with project protocols. The final set of tools was submitted to the WSU Human Investigative Committee and received IRB approval.

Program registration and training was designed to be brief (e.g., 15 minutes) and conducted in the outreach environment. Therefore, the evaluation tools needed to be brief and staff and client friendly. As a result, all evaluation tools were designed to be completed quickly, with few open-ended items and serve overlapping needs (e.g., program and evaluation) to the extent possible. The pretest form assessed baseline knowledge and behaviors related to opiate overdoses. Staff could use the responses to identify and address misconceptions. The Naloxone and Substance Use History form served double duty for registration and baseline assessment. The post-test was focused solely on evaluating the training, rather than training outcome (e.g., knowledge change); however, an open-ended item was included to prompt participants for any questions they want the staff to address. Only the follow-up tool is more evaluation than program driven.

Initially the team debated whether a 3 or 6 month follow-up was more advantageous. Ultimately, a six month follow-up was chosen to coincide with the follow-up survey for CHAG's syringe exchange program because many of the participants were also in that program. This procedure was expected to reduce staff and participant burden. Alternatively, the follow-up could be administered when someone returns for a naloxone refill.

9. Please discuss the significance and impact of your product. In your response, discuss ways your product has added to existing knowledge and benefited the community; ways others may have utilized your product; and any relevant evaluation data about impact, if available. If the impact of the product is not yet known, discuss its potential significance.

Drug overdose is the most common reason for intravenous drug users death. Nalaxone has a history of administration by emergency medical technicians and paramedics in ambulatory emergencies, and by hospital emergency department staff. For community implementation, it was important to have appropriate evaluation tools to collect data (e.g., focus group feedback to adapt to target poulations, a post-test to evaluate training, pre-tests and follow-up surveys to assess impact on participants) as well as potential decrease in OD deaths. The data collected through these tools provide valuable feedback on project successes and potential weaknesses. Besides program improvement, outcome data strengthens the potential for future funding and/or project expansion.

The Detroit project may be unique in that the sequence of products evolved from a decade-long research relationship in needle exchange. The trust built through this relationship facilitated candid CBPR team discussions. Community members provided input into defining the local issues to be addressed, not only through their experiences with the needle exchange program but also how well the program would serve their needs.

A significant aspect of the product could be the relative ease of instrument adaptation to other communities attempting to start an opiate reversal program. Agencies and researchers who are new to needle exchange and harm reduction models may find the focus group tool useful for obtaining insight into issues to resolve in developing their own opiate reversal program.

10. Please describe why you chose the presentation format you did.

The goal of the product utilization is to share instruments which can be adapted for public health population-based interventions. Presentation of preliminary focus group results are featured in poster format. Instruments are available in pdf, including focus group questions, baseline substance use history, training pre & post-tests, and follow-up surveys. The poster and instruments can be accessed on the Wayne State University Center for Urban Studies website (http://www.cus.wayne.edu/uchr/cbprpresent.asp).

11. Please reflect on the strengths and limitations of your product. In what ways did community and academic/institutional collaborators provide feedback and how was such feedback used? Include relevant evaluation data about strengths and limitations if available.

The key factor in the development of this CBPR program and its resulting products was the continuous feedback loop between the three institutional partners. Feedback was solicited and provided for each step in the development process, including inviting the injecting community to offer suggestions in program planning. This step helped to ensure culturally competent tools and procedures as well as promote program recruitment. Because of the inclusion of researchers throughout the collaboration, more effort was made to develop tools that could fit a broader scope than the immediate needs of the program. This CBPR approach comes from discussion between several different perspectives - the CBO who looks out for client and staff needs, the health sponsor who looks at funding viability, and evaluation researchers who look at program improvement and documentation for planning sustainability.

The needle exchange program facilited by the community organization was key to participant recruitment. However, there are nuances even within the coordination of evaluation within an exchange program. Specific to naloxone distribution, it may be more desirable to conduct follow-up when participants return to get more Naloxone because it expired, or they lost or used it, rather than combining the follow-up with the CBO's standard six-month syringe exchange participant follow-up.

If the products were to be used without the benefit of an imbedded syringe exchange program, a research partnership with local substance abuse treatment organizations that provide services to opiate users could be desirable to assure access to IDU populations.

12. Please describe ways that the project resulting in the product involved collaboration that embodied principles of mutual respect, shared work and shared credit. If different, describe ways that the product itself involved collaboration that embodied principles of mutual respect, shared work and shared credit. Have all collaborators on the product been notified of and approved submission of the product to CES4Health.info? If not, why not? Please indicate whether the project resulting in the product was approved by an Institutional Review Board (IRB) and/or community-based review mechanism, if applicable, and provide the name(s) of the IRB/mechanism.

Given the long standing relationship between the partners, mutual trust and respect had been previously established. All research partners were involved in the development of the project and products. Although meetings were hosted and led by the community organization, all members had equal say in shaping the program. The three institutional partner authors are credited in the dissemination of program findings and have been informed of the submission to CES4 Health.info. Protocol and instruments were approved through the Wayne State University IRB.