Mid Sweden University

The aim of this thesis is to describe the users visiting the syringe exchange clinic in Malmö with respect to what characterises the group, how they utilize the services of the clinic and how their patterns of participation relate to risk behaviour, physical and mental health and social development. The heterogeneity of the group has been captured by the use of Stimsons dimensions “integration in majority society” and “involvement in sub-culture”, yielding four different groups of syringe exchangers: “stables”, “loners”, “two-worlders” and “junkies”. The study rests on two sources of data: a register from the clinic including all syringe exchangers that have visited the clinic between 1989 and 2003, altogether 3660 individuals, and an interview of visitors at the clinic during 1995, including 496 persons.

The results show that syringe exchangers, compared to other persons with severe addiction in Malmö, to a larger extent use amphetamine as their drug-of-choice, are older and inject more irregularly. The population visiting the clinic is heterogeneous with respect to integration in society and involvement in sub-cultures. The group classified as junkies do, as expected, display the highest inclination to share syringes and needles with other and hence have the most advanced risk behaviours. As to utilization of the programme, the results show that the longer the syringe exchangers stay in the programme, the more frequent they visit it. Also with respect to utilization-patterns, we find substantial variations within the studied group. Five categories are discernible: drop-in visitors with only one or two visits, sporadic visitors who in spite of contacts over a number of years never really establish a regular contact, intermittent visitors who have had contact over several years but display a very irregular visiting pattern, regular visitors who relatively fast establish a consistent contact with visits between uniform time intervals and frequent visitors who tend to stay longer than others and visit the clinic more often. Another aspect of utilization is to what extent the distribution of needles and syringes cover the needs of the visitors. With a strict definition of need, only a minority manages to cover their needs, but if we accept a more extensive individual re-use, around 90 percent of the average need is covered. Data also reveals that a very high proportion of the users on at least one occasion have visited the programme without syringe exchange taking place or any complementary service delivered. Basically these visits seem to be of a more social nature, reinforcing the contacts between the staff and the visitors.

Data do not give any clear support for the basic assumption that syringe exchange reduce the incidence of HIV or hepatitis. Recent sharing of utensils or low coverage of syringe need through the programme do not predict a higher infection risk. Instead we find that the social contacts with the staff (without syringe exchange) function as a predictor of lower incidence. This indicates that the mechanisms may be more complex than just related to the provision of clean needles and syringes. The result shows that integration increase over time while sub-cultural involvement decreases. However, the patterns for different groups are very diverse and we find no evidence that more frequent contacts as such are related to increased integration. There is however, some evidence that social visits are positively related to increased integration. No support could be found for the assumption that the programme increases the number of severe addicts.

Background: This study monitors a syringe exchange program (Malmö, Sweden), in which all visits and exchanges are registered anonymously, although some services e.g. HIV-tests and vaccinations need identification. Methods: Two datasets are used. a) About 500 visitors were interviewed on childhood as well as present social situation, health, drug use, risk behaviors, social network and treatment experiences. Their visits as well as amount and types of services used were monitored during 40 months. b) All visits between 1989 - 2003 (177699 visits, 3660 users) were continuously registered, including services used. Results: The visitors (mean age 35.5 ys, 71 % men) had used drugs 23 years and injected 16 years. Prevalence of HIV was low (2.3 %) but frequent on hepatitis B and C (61 and 86 %, respectively). The number of users who shared needles �last year� was 37 % and �last month� 19 %. Number of visits varied from 1 to 616, and the average visitor came once in two months. They collected 63 syringes per year (mean) and gave 44 (70 %) in return. Most visitors (86 %) used additional services, and in more than 40 % of the visits. Nearly all (98.5 %) tested for HIV; 36 % had physical examination, and 22 % other health care, 20 % met the counsellor and 27 % vaccinated against Hepatitis B. This had a dramatic effect in reducing the relative risk for such infection (odds ratio 0,004). The second dataset is currently being analyzed. The presentation will include various patterns of program utilization over time. Conclusions: Utilization of the services varies to a great extent. Few visitors make the majority of visits. Most users do not visit frequently enough to supply their need of clean needles. Hence, there is still a high incidence of hepatitis. But the large majority seems to use the additional services. The development over time for diverse groups of visitors will be further explored in the paper.

The need for knowledge-based social work is being widely discussed internationally. The Department of Social Work at Stockholm University has taken part in a pilot project in Lithuania, the aim of which is to develop community-based and knowledge-based social work. An educational and training programme has been adopted for this purpose. An important part of this effort is the implementation of a computerised case management system backed by advisory supervision at 14 social service centres throughout Lithuania. The objective of the computerised case management system is to enable social service centres to simply and effectively gather key information about clients, treatment procedures and outcome. The objective of the advisory supervision programme is to implement new methods, including a psychosocial approach vis-à-vis clients. The purpose of both programmes is to strengthen the development of the social service centres. The strategy is to analyse the empirical material generated by the computerised case management system. This analysis makes it possible to evaluate and monitor the client population, as well as the procedures employed and the results achieved by the treatment centres. Thus, the computerised case management system enables the staffs of the social service centres to be more aware of what their work entails. This heightened awareness then forms the basis for advisory supervision. The integration of the computerised case management system with advisory supervision is a powerful tool for broadening the interface between research and practice in social work, thereby making social work more securely knowledge-based.