Policy and public health: an evaluation of the Sydney medically supervised injecting centre

While supervised injecting facilities (SIF) can be found world-wide they remain politically sensitive and controversial public health policy initiative and several important questions pertaining to SIFs remain unanswered. What type of evidence is necessary to validate controversial public health policy initiatives such as SIFs? How much evidence is enough to support public health policy initiatives to address the health of marginalised groups in our society such as injecting drug users? This thesis presents the results of a number of studies designed to evaluate the success of the Sydney Medically Supervised Injecting Centre (MSIC) against its stated objectives.Firstly, a background to Supervised Injecting Facilities (SIFs) generally and the Sydney MSIC specifically is provided, as well as a summary of evidence of their effectiveness to date. Secondly, a descriptive study is presented which is designed to assess the success of the MSIC in attracting a target population of high-risk IDUs and its success in providing a gateway to treatment. Thirdly, evidence of community support for the MSIC is presented, as are perceptions of drug-related public amenity prior to and following Sydney MSIC establishment, based on repeat cross-sectional random surveys. Presented next are the findings of an ecological study investigating the success of the MSIC against its stated objective of decreasing overdose deaths using three different indicators. The final empirical chapter presents a prospective observational study which investigates the potential impact of MSIC utilisation on levels of public injecting drug use among a client cohort. The findings of these studies are then integrated with existing evidence relating to the effectiveness of SIFs and critically reviewed according to the hierarchy of evidence framework.Finally, a way forward in assessing the effectiveness of SIFs, and other controversial public health initiatives, is presented in the form of an alternative public health-focussed framework