Social Inclusion and Health –

Crossing the Borders

Sofia, September 27-29, 2007

Beyond HIV: The Peer

Driven Intervention and

Empowerment of

Vulnerable Populations

J-PC Grund & D. de Bruin

In fond memory of

Nico Adriaans

A personal timeline (i)

1970-1980 NL: Rising drug use, urban scenes, mild repression, abstinence-only, policy makers ignorant, prerogative of policy @ psychiatrists and social workers;

1980: Rotterdamse Junky Union (RJB), Nico Adriaans, Raising Hell, challenging politics, making voices heard (press strategy, Radio Junkiebond), Union Style self-organization;

1980s: Normalization policy, new generation policy makers, RJB guerilla methadone program, introduction of low-threshold methadone in Rotterdam, blooming chasing culture at house addresses; onset of decrease in injecting prevalence;

A personal timeline (ii)

1985-1988: HADON, community based outreach to IDUs, from methadone to needles, “sign of the times,” first needle exchange in Rotterdam;

1986: Client Zero, “collective exchange,” 1989: 60.000 (half of city’s) needles exchanged, natural organization in drug using networks;

1988-1993: Academia and back to the streets, observed “frontloading” and how hardening drug policy gave birth to crack, started to grasp the complexity of the streets, Drug use as a social ritual. Nico (CFW) was my eye opener, Charlie Kaplan made it all possible;

1993-1995: Go West, Group-Mediated-Social Control, the first peer driven intervention (PDI), Respondent Driven Sampling (RDS) in Ct, USA;

My experience with self-organization

Union Style self-organization, “fight (and negotiate) the power,” guerilla activism, immediate cause important (street user more prone to activism than methadonian), questions about sustainability, cooptation;

Service provider to clients;

Natural organization: IDU networks organized around critical commodities (drugs, needles, etc.), supplied by service provider (excl. drugs of choice)

A shot of mathematical sociology: how we all use our influence to serve our needs, economically, bio-socially, information-wise…

A personal timeline (iii)

1995-2003: Go East, main occupation harm

reduction policy stuff in CEE;

Part-time researcher:

1995: “A heroin epidemic in Macedonia,” HOPS, Skopje

1999- 2000: Roma, drugs & HIV (disenfranchised

community devoid of service provision);

1999- 2000: Needle exchange in CEE (Pskov, Yaroslavl);

All studies strengthened my conviction of the need

for empowerment and peer-led strategies;

Pskov, 1999: Opiates

Pskov, 1999: Stimulants

Pskov, 1999: Response

Both Pskov and also Yaroslavl (PDI) kept HIV under IDUS,

in contrast with most of the rest of Russia, under control.

RDS & PDI: Theory and Practice

Group Mediated Social Control;

From Theory to Practice

Respondent Driven Sampling;

Peer Driven Intervention

Group mediated social control

A theory about how people behave and influence (negotiate) each other in order to serve their needs, we have preferences regarding both our own and other people’s actions;

Two sources of social influence:

Individual sanction based control—primary incentives;

Group mediated social control—secondary incentives;

Example: The school class dilemma

Actor

Intra Group Control

Individual

Sanction

Agent

Actor’s Group

Group-Mediated

Social ControlIndividual Sanction-

based Control

Collective Sanction(e.g. spill-over from

individual Sanction)

Figure 1. The theory of Group-Mediated

Social Control (Heckathorn, 1997)

Sanctions can be both

positive and negative

From Theory to Practice (i)

Network approach applying positive incentives:

Primary Incentive for participation in intervention;

Secondary Incentive for engaging peers in

intervention;

Recognizes that peers know best about peers,

peers are better to convince peers than

professional workers

From Theory to Practice (ii)

Research: Respondent Driven Sampling

Peers are rewarded to convince their peers to join

the study;

Modified snowball sampling;

Mathematical model, based on GMSC, allows for

assessing and correcting bias: probability sample.

Coupon system for tracking and payment

Peer Y.1 Peer Y.2 Peer Y.Y

Seed 1

Seed 2

Seed X

Research unit

Peer 1

Peer 2

X = No. of seeds;

Y = 3-5

Peer 1.1

Peer 1.2

Peer 1.Y

Research

unit

Flow of

incentives

Community

Peer 1.1.1

Peer 1.1.2

Peer 1.1.Y

Figure 2. Respondent Flow in RDS

Research

unit

Peer Y Community

Flow of

incentives

Community

Research Worker

What’s good for science…

Sample composition stabilizes,

reaching equilibrium independent of

the choice of seeds. Recruitment by

race/ethnicity, NYC drug users

(Abdul-Quader et al., 2006)

Question: how long does it take

an outreach worker to get from… A

B

From Theory to Practice (iii)

Intervention: Peer Driven Intervention

Peers are rewarded to conduct the same tasks as

outreach workers;

Primary incentive for participation in a series of

health education sessions (accent on being taught);

Secondary incentive for engaging peers in

intervention and educating them in the community

(accent on teaching);

Figure 3. Schematics of Intervention

Exposure in a PDI and a TOI

Is “What’s good for science,” good

for the People?

Peer driven intervention superior to traditional outreach work intervention in HIV prevention among IDUs:

The PDI significantly outperformed the TOI in education performance, recruitment power, representation, and in reducing risk behaviours, while being about 30 times less costly.

Participants respond positively, rewarding contributes to self-esteem, stimulates networking and information flow, no noticeable effect on drug use.

Repeated studies have supported findings

A personal timeline (iv)

2004: Ukraine: respondent driven sampling

study of young IDUs and their non-injecting

friends about transition into injecting drug use

2006: CVO research line: New applications for

RDS and the PDI.

2007: The Hague Department of Public Health:

WEB-RDS

RDS : new directions

WEB-RDS of 1500 Nightlife

participants at The Hague

Department of Public Health

PDI: new directions (iii) Ukraine “transition into IDU” RDS study

Initiation into IDU is peer-based social process, different for boys

and girls, exposure to IDU events leads to curiosity, curiosity kills

the cat…

Follow up proposal: Peers Breaking the Cycle intervention (PDI),

aiming to reduce the incidence of injecting drug use;

Ukraine (Other countries?)

Two target groups: young/recent IDUs, non-IDU friends;

Two approaches:

Non-IDUs: social marketing PDI aiming to strengthen social norms

against injecting;

IDUs: PDI combining Break the Cycle & overdose prevention (Naloxone)

Targets two of the gravest health concerns associated with

(injecting) drug use: HIV & overdose

Conclusions (i)

Social theory supports community and peer based interventions;

Innovation in intervention development is important;

Group mediated social control is useful concept for community based interventions;

Applied in various vulnerable (IDUs, non-IDUs, CSW, MSM) and less vulnerable populations (recreational drug users, nightlife participants, Jazz musicians);

Participants respond positively to PDI & RDS;

Peer driven interventions enhance self-esteem, engagement and “solidarity groups” (Heckathorn & Rosenstein, 2002).

Conclusions (ii)

Need to study GMSC applications in different populations and towards different intervention goals; Netherlands: smokable cocaine users on the street;

Ukraine (and elsewhere?): prevention of initiation of drug injecting

Treatment PDI

Is model useful for community organizing approaches in vulnerable populations?

Positive action

Conveys useful ‘user knowledge’ & health information

Rewarding

Empowering

Possible recruitment pool for community activism and other forms of organizing around health, social and human rights issues?

Contact

Jean-Paul Grund

T: +31302381495

E: jpgrund@drugresearch.nl

W3: drugresearch.nl

Finally, Crossing the Borders…