RESEARCH AND PRACTICE Community Mobilization to Reduce Drug Use, Quang Ninh, Vietnam Hien Tran Nguyen, MD, PhD, Anh Viet Tran, MSc, Nguyen Binh Nguyen, MD, PhD, Son Hong Nguyen, MD, PhD, Diep Bich Vu, MD, PhD, Nhu To Nguyen, MD, PhD, Ronald S Brookmeyer, PhD, and Roger Detels, MD An epidemic of injection drug use began in Vietnam in the mid-1990s, concurrent with an increase in injection drug use in Guangxi, China.1 Drug abuse has risen threefold in the last 10 years in Vietnam, involving younger males, and more recently, females.2 Concurrently, heroin has replaced opium as the preferred drug.3 The provinces of Vietnam along the border of China now have among the highest rates of injection drug use and HIV among drug users in Vietnam.4 According to national sentinel surveillance data, HIV prevalence among injection drug users (IDUs) increased from 10% in 1996 to a peak of 30% in 2001 to 2002, and then gradually decreased to 20% in 2008.5 At the time we conducted our study in Quang Ninh, the prevalence of HIV among IDUs was 46.7% in Quang Ninh, compared with 35.7% in Haiphong and 51.3% in Ho Chi Minh City.6 A variety of strategies have been tried to prevent drug use in various countries worldwide, with limited success.7,8 One approach to prevention of drug use has been to mobilize the affected communities to take supportive action.9 Drug users in Asia, unlike the United States and Europe, tend to remain a part of their families and their communities.10 This characteristic provides an opportunity to use the family and the community as an interventional tool to prevent initiation of drug use.11 Following a study to identify the characteristics of drug users in southern Yunnan, China, Wu et al.12 met with official and unofficial leaders in 19 villages in Dehong County, Yunnan, China, to discuss the drug problem they were experiencing in young men, and to encourage them to mobilize a community intervention to reduce initiation of drug use The meeting was successful in persuading the village leaders that they had to take the initiative in preventing drug use in their community Subsequently, the villagers mounted a broad intervention program that resulted in a 66% Objectives We implemented an intervention to reduce drug use in an urban commune in northern Vietnam Methods We encouraged the intervention commune to accept responsibility for developing their own intervention strategies based on a community mobilization model used in southern, rural China We selected a comparison commune, which had demographic characteristics and a drug history similar to the intervention commune The 2-year incidence of new drug users was estimated retrospectively in the intervention and comparison communes between baseline (2003) and follow-up (2009) Results Increased incidence of new (noninjecting) drug users between 2003 and 2009 in the intervention commune was lower than that in the comparison commune, and these participants expressed more positive attitudes toward local authority and people with drug use and HIV/AIDS Increased condom use during last intercourse with female sex workers and with female casual partners was observed in the intervention commune HIV prevalence and positive opioid tests decreased more in the intervention commune Conclusions Our results suggested that the community mobilization had a positive influence in the intervention commune (Am J Public Health 2015;105: 189–195 doi:10.2105/AJPH.2014.302101) decrease in new drug users compared with matched villages in the same area The intervention was most effective among those groups at highest risk of initiating drug use.13 Intervention strategies implemented by the government and nongovernment organizations have not halted the epidemic of drug use in Vietnam Upon learning the results of the Yunnan community intervention program, public health leaders in Vietnam requested that the Hanoi Medical University (HMU) implement and evaluate a similar community mobilization strategy to reduce drug use in Quang Ninh, Vietnam, which was one of the provinces most affected by the drug epidemic, with the assistance of researchers from the University of California, Los Angeles School of Public Health In response to the request, we met with formal and informal leaders of a commune (Ha Tu) in Ha Long City to discuss the possibility of their mounting a community-based intervention to prevent the initiation of drug use by young men and to prevent injection use by young men already January 2015, Vol 105, No | American Journal of Public Health using drugs in their commune We report the results of that intervention as compared with a similar commune in the same area METHODS Two communes with similar estimated numbers of drug users, population size, geography, community political organizations, estimated prevalence of IDUs and HIV, and national drug prevention and HIV prevention programs were selected in Ha Long City (Ha Tu) and Cam Pha City (Cam Thinh) in northern Vietnam in 2003 By coin toss, Ha Tu was designated as the intervention site and Cam Thinh was the comparison (control) site At that time, no other nationwide interventions had been implemented in Ha Tu Family Health International (FHI) subsequently initiated an intervention in Cam Pha City, which includes Cam Thinh; the comparison area was one of the communes in that city The ECHO intervention model was based on a model Nguyen et al | Peer Reviewed | Research and Practice | 189 RESEARCH AND PRACTICE developed by sociologists at the University of Connecticut, and subsequently, the peer outreach model was implemented The Interventions The national intervention program operating in both communes during the study included media announcements, clean needle distribution programs, AIDS care and support, and drop-in centers for IDUs The theoretical framework used for the intervention in Ha Tu was based on strategies used in our previous study to reduce the incidence of new drug users in southern Yunnan, China That study used a community intervention model directed at both at-risk youths and current drug users, in which community leadership and local residents were mobilized for social action.13,14 The intervention was based on the behavior change and self-efficacy model of Bandura’s social learning theory.15 New behaviors were promoted through social reinforcement from the community Persuasive influences included community norms, village leadership, family, and peers, and supportive attitudes and programs involving youth, schools, and drug users Figure presents the conceptual model for the intervention program The model incorporated factors demonstrated to be associated with uptake of drug and injection use, and both personal and community factors associated with self-efficacy Community involvement was key in influencing community norms Traditional moral principles accepted by the communes were used to encourage youths to avoid drugs and to contribute to the wellbeing of the community.16 Social marketing principles were used to guide the design of the educational messages.17,18 Initially, a meeting was held in Ha Tu with key groups, including both commune officials and semiofficial groups, such as the women’s and youth associations, to discuss the issue of drug use by the youths in the commune Through these discussions, the participants recognized their problem and accepted the idea that they would need to take the primary responsibility to develop and implement an intervention program to reduce the incidence of new drug users and the transition from noninjecting drug use to injecting drug use We then assisted the commune leaders in developing intervention activities that were appropriate for the commune, including monthly meetings at which the commune subunit leaders reported on the progress of the intervention in their districts These interventions included development of a didactic school curriculum on drug prevention, school assemblies, informal skits put on by youths, development of videos and games, parades to promote nondrug use, dissemination of drug prevention messages, Community involvement Community norms Education Family norms Peer pressure Smoking Parental pressure Drop-in centers Age Drug use Self-efficacy Youth groups Youth community service productivity FIGURE 1—Conceptual model for factors influencing initiation of drug use: Community Mobilization to Reduce Drug Use; Quang Ninh, Vietnam; 2003–2009 190 | Research and Practice | Peer Reviewed | Nguyen et al loudspeaker announcements in the residential blocks, bulletins, establishing and staffing of an intervention center, posters, banners, and media announcements (including television, radio, and newspapers), visits by youth to detoxification centers, and messages from current and former drug users CDs and cassette tapes that provided education about HIV/AIDS and promoted reduction of stigmatization and discrimination against drug users and persons living with HIV/AIDS were also distributed to the blocks within the commune The intervention program was received with enthusiasm (as observed by the investigators) by the commune members who, because they played a key role in developing the intervention, felt they had ownership of it During the study, FHI also implemented an enhanced drug intervention in Cam Thinh, the comparison commune, in 2004 to 2005, which included the founding of a drop-in center for persons at high risk for HIV/AIDS, a peer education outreach model, group events, and media messages emphasizing destigmatization and antidiscrimination A team of 12 IDUs or former drug users was also recruited to play the roles of outreach workers and HIV/AIDS educators Assessment In December 2003 and March 2009, all males aged 15 to 24 years were invited to participate in anonymous cross-sectional surveys on drug use and sexual behaviors in both Ha Tu and Cam Thinh A meeting was held in each commune to emphasize to the young men of the commune the importance of participating in the survey Before administration of the interview, verbal informed consent was obtained The youths were invited to be interviewed at the village public house or a school Youths who did not come for an interview were followed up by village leaders and encouraged to participate Information about demographic characteristics, HIV/AIDS-related knowledge, attitudes, sexual behaviors, and substance-use behaviors were solicited in both surveys The interview questions were asked by use of a CD player.11 The participants marked their answers on blank sheets of paper that contained only a study identification number and the question numbers, but not the text of the questions The American Journal of Public Health | January 2015, Vol 105, No RESEARCH AND PRACTICE participants then marked their answers in the appropriate spaces None of the participants were illiterate The answers usually involved numbers or words that would not reveal the nature of the question At the completion of the interviews, the answer sheets, which contained no identifying information, were placed in a large box to assure respondents that their answers could not be attributed to them Each participant was then requested to provide a urine specimen that was later tested for opioids using Quick-Check (ACON Labs, San Diego, CA) Blood samples were also collected from all participants and tested for HIV at the nationally certified HIV laboratory of Viet Duc Hospital (Hanoi, Vietnam), using HIV testing strategy III stipulated by the Vietnam Ministry of Health (for diagnosing individual HIV cases) According to this strategy, a sample was considered positive for HIV only if it was positive with different techniques or different methods of antigen preparation In our study, each blood sample was tested for HIV using the enzyme-linked immunosorbent assay technique from different test kits (i.e., different methods of antigen preparation) Data Analysis We conducted surveys of young men in the intervention and comparison communes: a baseline survey in 2003 and a follow-up survey in 2009 Data were entered using EPI INFO version 6.04d (Centers for Disease Control and Prevention, Atlanta, GA), and then processed and analyzed using SAS 9.2 (SAS Institute, Cary, NC) Data processing included cleaning (range and logic checking), scoring, grouping of variables, and categorization Because the distribution of demographic characteristics in the communities at the points in time were not significantly different, and because the proportions of the mobile population were low and quite similar, we assumed that the communes were stable We were thus able to retrospectively reconstruct the 2-year incidence of new drug use by counting those who reported initiation of any drug use in the previous years in both the 2003 and 2009 surveys We calculated descriptive statistics to describe the changes in demographic characteristics, drug- and HIV/AIDS-related knowledge, and attitudes and behaviors in the period between the surveys in the communes For comparing the changes in incidence of drug use initiation over the time period in the communes, we calculated the ratio of relative risk (assessment vs baseline) in the intervention commune to that in the comparison commune, using the following formula: ratio of relative risks = r = RR09/RR03 = (IINT09/ICTR09)/(IINT03/ICTR03) An r < indicated that the proportionate increase in incidence over time in the intervention commune was smaller than that in the comparison commune The Wald 95% confidence interval (CI) was calculated for log r, and then antilogs were taken to obtain CI for r The z-test (where Z = log r/SE [log r]) was used for determining the P value for testing the hypothesis that r = For prevalence measures (regarding knowledge, attitudes, behavior, urine test positivity, and HIV prevalence), we used a formula analogous to the preceding one to calculate ratios of relative prevalence changes, that is: ratio of prevalence ratios = (PINT09/PCTR09)/(PINT03 /PCTR03 ) RESULTS The response rates for the survey of young men in Ha Tu were 614 of 683 men (89.9%) in 2003 and 565 of 621 men (91.0%) in 2009 The comparable response rates in Cam Thinh were 583 of 667 men (87.4%) in 2003 and 574 of 631 men (91.0%) in 2009 The proportion of married interviewees was low (approximately 2%) in both communes The percent unemployed was higher in Cam Thinh (16.0% vs 10.6%; Table 1) Levels of education overall were lower in TABLE 1—Demographic Characteristics of Participants at Baseline (December 2003) in Intervention and Control Areas: Community Mobilization to Reduce Drug Use; Quang Ninh Province, Vietnam; 2003–2009 Variable Intervention Commune, No (%) Comparison Commune, No (%) 370 (60.3) 244 (39.7) 358 (61.4) 225 (38.6) 600 (97.7) 518 (88.9) 14 (2.3) 65 (11.1) Single 601 (97.9) 572 (98.1) Married 12 (2.0) 11 (1.9) (0.2) (0.0) Age, y 15–19 20–24 Ethnic group Kinh Others Marital status Divorced Education £ grade 141 (23.1) 100 (17.2) Grades 10–12 337 (55.2) 343 (59.1) ‡ some college 133 (21.8) 137 (23.6) Student 347 (56.7) 348 (59.8) Employed 200 (32.7) 141 (24.2) Unemployed Local residency 65 (10.6) 93 (16.0) Employment status Yes 455 (74.1) 477 (81.8) No 159 (25.9) 106 (18.2) Living alone Yes 43 (7.0) 17 (2.9) No 571 (93.0) 566 (97.1) 614 (100.0) 583 (100.0) Total Note Percentages may not add to 100 because of rounding January 2015, Vol 105, No | American Journal of Public Health Nguyen et al | Peer Reviewed | Research and Practice | 191 RESEARCH AND PRACTICE Ha Tu (77.0% had more than secondary school in Ha Tu vs 82.7% in Cam Thinh) Fewer were local residents in Ha Tu (74.1%) than Cam Thinh (81.8%) at baseline, and more respondents lived alone in Ha Tu (7.0%) than in Cam Thinh (2.9%) Between 2003 and 2009, the incidence of new drug users increased more in the comparison group (from 1.4% to 7.1%) than in the intervention group (from 2.6% to 7.1%) The ratio of relative risk (assessment vs baseline) in the intervention commune to that in the comparison commune was r = 0.6 (95% CI = 0.2, 1.4; Table 2) The impact of the intervention on the incidence of new drug users differed by ethnic group and education level, but not by age The value of r was not available for comparison across categories of marital status and ethnic group because there were too few participants in the married and divorced marital status groups and in others for ethnic groups (Table 2), resulting in zero values, precluding calculation of risk ratios The increases in the incidence of new drug users (among participants who had never used drugs) were caused by increases in noninjecting use only (mainly use of marijuana and amphetaminetype stimulants) Only 10 participants in Ha Tu and in Cam Thinh reported first injecting drug use during the 2-year period before the baseline survey (December 2003); no one reported first injecting drug use in either commune during the 2-year period before the assessment survey (March 2009) Drug- and HIV/AIDS-related knowledge, attitudes and behavior, urine test positivity, and HIV prevalence among participants in the study sites at the baseline and assessment surveys (in 2003 and 2009, respectively) are presented in Table Knowledge regarding routes of HIV transmission and prevention methods remained at approximately 80% at baseline and assessment in both communes However, there were increases in the percentages of participants who knew that an HIV-infected person might have a healthy appearance, from 65.6% to 72.9% in Ha Tu and from 62.6% to 72.9% in Cam Thinh In the intervention commune, participants reported greater reductions in negative attitudes of local authority and people regarding drug use and HIV/AIDS, compared with the comparison commune In the intervention commune, the percentage of participants who agreed with the statement “local authority and people currently see drug users as criminals who need to be controlled harshly” decreased by 15.7 percentage points (from 31.5% to 15.9%) In the comparison commune, the percentage decreased by 9.7 percentage points (from 31.1% to 21.4%) The percentage of participants who agreed with the statement “distributing clean needles and syringes to injecting drug users is acceptable to the local authority and people” increased by 12.7 percentage points (from 50.6% to TABLE 2—Change in Incidence of New Male Drug Users Before and After Intervention Program in Intervention and Control Areas: Community Mobilization to Reduce Drug Use; Quang Ninh Province, Vietnam; 2003–2009 Intervention Commune Incidence Change, % Points Assessment Period 3/07–3/09, % (No.) Incidence Change, % Points Attributable Incidence Changea Ratio of Relative Risksb (95% CI) P 7.1 (39/551) +4.5 1.4 (8/561) 7.1 (39/547) +5.7 –1.2 0.6 (0.2, 1.4) 22 2.5 (9/362) 8.0 (24/301) +5.5 0.9 (3/354) 6.8 (18/265) +5.9 –0.4 0.4 (0.1, 1.7) 21 2.7 (6/224) 6.0 (15/250) +3.3 2.4 (5/207) 7.4 (21/282) +5.0 –1.7 0.7 (0.2, 2.8) 68 Assessment Period 3/07–3/09, % (No.) 2.6 (15/586) 15–19 20–24 Stratifying Variable Total Comparison Commune Baseline Period 12/01–12/03, % (No.) Baseline Period 12/01–12/03, % (No.) Age, y Ethnic group Kinh 2.6 (15/574) Others (0/12) Marital status Single 2.6 (15/575) Married (0/10) Divorced (0/1) 7.0 (38/543) +4.4 1.6 (8/497) +12.5 (0/64) 7.2 (38/528) +4.6 1.4 (8/551) (0/17) 0.0 (0/10) NA 12.5 (1/8) 25 (1/4) +25 7.7 (37/478) +6.1 –1.7 0.6 (0.2, 1.4) 07 3.4 (2/58) +3.4 +9.1 NA NA 7.4 (38/512) +6.0 –1.4 0.5 (0.2, 1.4) 3.0 (1/33) +3.0 –3.0 NA NA (0/1) NA NA NA NA Education level £ grade 3.7 (5/134) 7.9 (5/63) +4.2 2.1 (2/96) 5.6 (4/72) +3.5 –0.6 0.8 (0.1, 6.2) 83 Grades 10–12 2.8 (9/321) 6.5 (21/321) +3.7 1.2 (4/333) 7.0 (18/258) +5.8 –1.8 0.4 (0.1, 1.5) 17 ‡ some college 0.8 (1/129) 7.3 (12/164) +6.5 1.6 (2/129) 7.9 (17/215) +6.3 +0.2 1.9 (0.2, 22.4) 37 Note CI = confidence interval; NA = not available a Attributable incidence change is the incidence change in the intervention group minus incidence change in the control group Minus signs indicate that the incidence increase in the intervention group was lower than the incidence increase in the control group (i.e., the intervention helped reduce the risk of starting drug use), and vice versa b A ratio of < indicates that the relative risk (assessment vs baseline) for the intervention group is lower than that for the control group, and vice versa Some ratios and the corresponding CIs and P values are left blank because they cannot be calculated when there is at least zero incidence in the same data line 192 | Research and Practice | Peer Reviewed | Nguyen et al American Journal of Public Health | January 2015, Vol 105, No RESEARCH AND PRACTICE TABLE 3—Changes in Knowledge, Attitudes, Behavior, Urine Opioid Test Results, and HIV Prevalence in Intervention and Control Areas: Community Mobilization to Reduce Drug Use; Quang Ninh Province, Vietnam; 2003–2009 Intervention Commune Variable Comparison Commune Baseline Survey Assessment Survey Prevalence Baseline Survey Assessment Survey Prevalence Ratio of 12/03 (n = 614), 3/09 (n = 565), Change, 12/03 (n = 583), 3/09 (n = 574), Change, Prevalence % (No.) % (No.) % Points % (No.) % (No.) % Points Ratiosa (95% CI) P 65.6 (386/588) 72.9 (409/561) 7.3 62.6 (356/569) 72.9 (417/572) 10.3 1.0 (0.9, 1.1) 80.9 (473/585) 83.1 (466/561) 2.2 81.5 (463/568) 78.3 (448/572) –3.2 1.1 (1.0, 1.2) 80.2 (457/570) 80.8 (442/547) 0.6 78.1 (438/561) 78.0 (428/549) –0.1 1.0 (0.9, 1.1) 83 31.5 (185/587) 15.9 (89/561) –15.7 31.1 (177/570) 21.4 (122/571) –9.7 0.7 (0.5, 1.0) 04 35.1 (206/587) 15.1 (85/561) –19.9 27.4 (156/570) 10.7 (61/571) –16.7 1.1 (0.8, 1.6) 58 50.6 (297/587) 63.3 (354/559) 12.7 46.3 (263/568) 37.0 (211/571) –9.4 1.6 (1.3, 1.9) < 001 59.3 (54/91) 66.1 (80/121) 6.8 58.0 (40/69) 64.0 (87/136) 6.0 1.0 (0.7, 1.4) 95 100.0 (24/24) 11.5 93.8 (15/16) 92.9 (13/14) –0.9 1.1 (0.9, 1.4) 28 74.2 (23/31) 31.3 70.0 (14/20) 76.9 (20/26) 6.9 1.6 (0.8, 3.0) 16 Knowledge Knew that an HIV-infected person can have a healthy appearance Correctly identified all listed possible routes of HIV transmission Correctly identified main measures for prevention of HIV transmission Perceived attitude of the local government and people Drug users are currently seen as criminals who need to be controlled harshly HIV-infected people are not allowed to work in public places Distributing clean needles and syringes to injecting drug users is acceptable Behavior Used condom in last sexual intercourse with any female partner in past 12 mo Used condom in last intercourse with a female sex 88.5 (23/26) worker in past 12 mo Used condom in last intercourse with a casual female 42.9 (9/21) sex partner in past 12 mo Reported current use of any drug 1.0 (6/614) 1.2 (7/565) 0.3 1.2 (7/583) 1.2 (7/574) 1.2 (0.3, 5.6) 77 Reported current heroin use Reported current injecting use 0.7 (4/614) 0.7 (4/614) (0/565) 0.4 (2/565) –0.7 –0.3 1.2 (7/583) 1.0 (6/582) 0.2 (1/574) (0/574) –1.0 –1.0 NA NA NA NA Injected drugs at least once in past month 1.1 (7/614) (0/565) –1.1 0.9 (5/583) (0/574) –0.9 NA NA –1.4 2.9 (17/583) 1.9 (11/574) –1.0 0.7 (0.2, 2.2) –2.3 2.2 (13/583) 0.3 (2/574) –1.9 NA NA Urine test opioid-positive 2.4 (15/614) HIV-positive 2.3 (14/614) 1.1 (6/564) (0/564) Note CI = confidence interval; NA = not available a A ratio of < indicates that the prevalence ratio (assessment vs baseline) for the intervention group is lower than that for the control group, and vice versa Some ratios and the corresponding CIs and P values are left blank because they cannot be calculated when there is at least zero prevalence in the same data line 63.3%) in the intervention commune, but decreased by 9.4 percentage points (from 46.3% to 37.0%) in the comparison commune These relative changes over time were statistically different between the intervention and comparison communes, and reflected a more positive attitude among young men in Ha Tu following the intervention Although measures did not reach statistical significance individually, most measures of knowledge, attitudes, and behavior showed more improvement in Ha Tu Regarding HIV-related behaviors, the level of condom use during last sexual intercourse with a female sex worker increased from 88.5% to 100% in the intervention commune, but slightly decreased (from 93% to 92.9%) in the comparison commune The level of condom use during last sexual intercourse with a female casual partner increased from 42.9% to 74.2% in the intervention commune, and from 70.0% to 76.9% in the comparison commune Prevalence of reported injecting drug use at least once in the past month was low in both communes at baseline (only of January 2015, Vol 105, No | American Journal of Public Health 614 participants reported using an injection drug in the past month in Ha Tu, compared with of 583 participants in Cam Thinh), and reduced to zero in both communes in 2009 In Ha Tu, urine opioid positivity among participants decreased from 2.4% to 1.0% (–1.4 percentage points), whereas in Cam Thinh, it decreased from 2.9% to 1.9% (–1.0 percentage points) Analogously, HIV prevalence (determined by laboratory serum testing) decreased from 2.3% to 0% in Ha Tu, whereas it decreased from 2.2% to 0.3% (–1.9 percentage points) in Cam Thinh Nguyen et al | Peer Reviewed | Research and Practice | 193 RESEARCH AND PRACTICE DISCUSSION Studies of community and outreach-based interventions have reported differing results Singh reported that a community-based outreach program that used a multipronged approach directed at IDUs in Manipur, India, was successful, although there was no comparison group, and the outcome variables were primarily process variables (number of interventions implemented, condoms distributed, and education workshops held).19 Coyle et al., in a review of published papers on outreach programs in the United States, concluded that outreach-based interventions have been effective in reaching out-of-treatment IDUs, providing the means for behavioral changes and inducing behavior change in the desired direction.20(p20) By contrast, Giesbert and Haydon, who reviewed community-based interventions at the local level, concluded that “many but not all interventions have modest or equivocal impact.”9(p633) It should be noted that our study, which was originally meant to be an evaluation of a community intervention in comparison with a community with no intervention, was a comparison of different interventions in communes In Ha Tu, a “bottom-up” approach was implemented, which focused on at-risk youths and current drug users The key factor in the intervention was, in our opinion, assisting the community to recognize that they had a problem with their young people becoming drug users and, secondly, assisting the community to recognize that they needed to take the initiative in designing and implementing the intervention program Thus, the key elements of the intervention strategy in Ha Tu were designed by the commune, giving them “ownership” of the program After this study began, FHI implemented some drug and HIV/AIDS intervention activities in the comparison commune (Cam Thinh, as part of Cam Pha City) The activities were mainly directed at current drug users, but some activities (such as media messages emphasizing destigmatization and antidiscrimination and recruitment of 12 drug users or former drug users to play the role of outreach workers and HIV/AIDS educators) might have had the effect of improving the knowledge and attitudes and reducing high-risk behaviors and HIV transmission among people in the comparison commune as a whole Low response rate is a common problem for many studies of sensitive topics However, the response rates in our study were relatively high—88.9% in Cam Thinh and 87.4% in Ha Tu for the baseline survey, and 91% in both for the assessment survey Because drug use is a stigmatized behavior, nonresponders were probably more likely to be drug users and HIV-infected persons Significantly greater improvement in perceived attitudes of local authority and people toward drug users and persons living with HIV/AIDS were observed in Ha Tu, the intervention commune, than in Cam Thinh Because stigma is a major barrier to testing, this result suggested that the intervention strategy used in Ha Tu helped get people tested for HIV, an essential element of any HIV intervention program, by improving acceptability and willingness of drug users to accept testing and seek assistance 21 -22 We did not objectively verify reported injecting status Because of the strong repeated messages against drug injecting during the study in both communes, it was likely that the zero incidence of injecting during the assessment period (2007 -2009) reflected bias The greater decline in HIV prevalence in Ha Tu, however, suggested that there was greater decline in injecting in the Ha Tu than in the comparison area Our results indicated that positive results from both urine testing for opioids and blood testing for HIV declined, somewhat more in the intervention area The reported incidence of any drug use increased in both areas, although the rate of incidence increase was lower in the intervention area The reported prevalence of injecting drugs at least once in the past month was lower in both areas at the second survey, but the rate of decline was greater in the comparison area The greater decline in the prevalence of positive urine testing results and prevalence of positive HIV results in Ha Tu suggested a greater impact of the intervention in Ha Tu, despite the lack of statistical significance 194 | Research and Practice | Peer Reviewed | Nguyen et al for each element alone The data also suggested that new drug users were more likely to not inject at the time of the second survey than at the baseline survey The results of this community intervention study paralleled those observed by Wu et al in rural China.10 The common factor was the design of the intervention by the community, and thus, their ownership of the intervention The details of the intervention, however, differed, reflecting the differences in the cultures of the countries and the urban (Vietnam) versus rural (China) settings of the intervention Therefore, it was not the details of the intervention strategy that were important in our opinion, but the local ownership of the intervention It was this strategy of mobilizing the community to recognize and take responsibility for designing and implementing the intervention that should be adopted by other localities with significant problems with drug use among their youths Health officials are, therefore, likely to achieve better success at preventing drug use by working with affected communities to develop interventions appropriate for those communities and involving the commune leaders in designing the intervention j About the Authors Roger Detels and Ronald S Brookmeyer are with the Fielding School of Public Health, University of CaliforniaLos Angeles Hien Tran Nguyen, Nguyen Binh Nguyen, and Diep Bich Vu are with the National Institute of Hygiene and Epidemiology, Hanoi, Vietnam Anh Viet Tran and Son Hong Nguyen are with the Hanoi Medical University, Hanoi Nhu To Nguyen is with the Family Health International 360, Hanoi Correspondence should be sent to Roger Detels, Department of Epidemiology, UCLA Fielding School of Public Health, 71-269 CHS, Box 951772, Los Angeles, CA 90095-1772 (e-mail: detels@ucla.edu) Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link This article was accepted May 13, 2014 Contributors H T Nguyen implemented the study and participated in analysis and writing the article A V Tran assisted with study implementation and data management N B Nguyen performed data analysis and took part in writing the article S H Nguyen assisted with study implementation D B Vu took part in data management and analysis N T Nguyen took part in data management and analysis R S Brookmeyer provided the statistical design and contributed to writing the article R Detels took part in study design, implementation, analysis, and writing the article Acknowledgments This study was funded by National Institutes of Health/ Fogarty International Center grant D43 TW005795 American Journal of Public Health | January 2015, Vol 105, No RESEARCH AND PRACTICE Human Participant Protection The study was approved by the ethical institutional review boards of both Hanoi Medical University and the University of California, Los Angeles References Des Jarlais DC, Kling R, Hammett TM, et al Reducing HIV infection among new injecting drug users in the China-Vietnam Cross Border Project AIDS 2007;21(suppl 8):S109 -S114 Tran TN, Detels R, Long HT, Phung LV, Lan HP HIV infection and risk characteristics among female sex workers in Hanoi, Vietnam J Acquir Immune Defic Syndr 2005;39(5):581 -586 Nguyen VT, Scannapieco M Drug abuse in Vietnam: a critical review of the literature and implications for future research Addiction 2008;103(4):535 -543 18 Kotler P, ed Marketing for Nonprofit Organizations 2nd ed Englewood Cliffs, NJ: Prentice Hall; 1975 19 Singh N AIDS outreach program targeting injecting drug user community intervention program Int Conf AIDS 1996;11:503 (abstract 1419) 20 Coyle SL, Needle RH, Normand J Outreach-based HIV prevention for injecting drug users: a review of published outcome data Public Health Rep 1998;113 (suppl 1):19 -30 21 Kalichman SC, Simbayi LC HIV testing attitudes, AIDS stigma, and voluntary HIV counselling and testing in a black township in Cape Town, South Africa Sex Transm Infect 2003;79(6):442 -447 22 Sullivan SG, Xu J, Feng Y, et al Stigmatizing attitudes and behaviors toward PLHA in rural China AIDS Care 2010;22(1):104 -111 UNAIDS, World Health Organization AIDS Epidemic Update Geneva, Switzerland: World Health Organization; 2007 Ministry of Health Vietnam National Report on the HIV/AIDS Situation, Prevention and Control Activities in 2011: Direction and Major Tasks in 2012 Hanoi, Vietnam: Ministry of Health; 2012 Ministry of Health Vietnam: HIV/AIDS Control Review Hanoi, Vietnam: Ministry of Health; 2008 Mathers BM, Degenhardt L, Phillips B, et al Global epidemiology of injecting drug use and HIV among people who inject drugs: a systematic review Lancet 2008;372(9651):1733 -1745 Panda S, Sharma M Needle syringe acquisition and HIV prevention among injecting drug users: a treatise on the “good” and “not so good” public health practices in South Asia Subst Use Misuse 2006;41(6-7):953 -977 Giesbrecht N, Haydon E Community-based interventions and alcohol, tobacco and other drugs: foci, outcomes and implications Drug Alcohol Rev 2006; 25(6):633 -646 10 Wu Z, Detels R, Zhang J, et al Risk factors for intravenous drug use and sharing equipment among young male drug users in Longchuan County, southwest China AIDS 1996;10(9):1017 -1024 11 Detels R HIV/AIDS in Asia: introduction AIDS Educ Prev 2004;16(suppl A):1 -6 12 Wu Z, Zhang J, Detels R, et al Characteristics of risk-taking behaviors, HIV/AIDS knowledge and risk perception among young males in southwest China AIDS Educ Prev 1997;9(2):147 -160 13 Wu Z, Detels R, Zhang J, Li V, Li J Communitybased trial to prevent drug use in Yunnan, China Am J Public Health 2002;92(12):1952 -1957 14 Rothman J Three Models of Community Organization Practice, Their Mixing and Phasing Strategies in Community Organization 3rd ed Itasca, IL: F F Peacock Publishers Inc.; 1979:86 -102 15 Bandura A Social Learning Theory Englewood Cliffs, NJ: Prentice Hall; 1977 16 Gossop M, Grant M Preventing and Controlling Drug Abuse Geneva, Switzerland: World Health Organization; 1990 17 Kotler P, Zaltman G Social marketing: an approach to planned social change J Mark 1971;35(3):3 -12 January 2015, Vol 105, No | American Journal of Public Health Nguyen et al | Peer Reviewed | Research and Practice | 195 ... productivity FIGURE 1—Conceptual model for factors influencing initiation of drug use: Community Mobilization to Reduce Drug Use; Quang Ninh, Vietnam; 2003–2009 190 | Research and Practice | Peer... primary responsibility to develop and implement an intervention program to reduce the incidence of new drug users and the transition from noninjecting drug use to injecting drug use We then assisted... accepted by the communes were used to encourage youths to avoid drugs and to contribute to the wellbeing of the community. 16 Social marketing principles were used to guide the design of the educational