Learning from Each Other: Enhancing Community-Based Harm Reduction Programs and Practices in Canada

"The harm reduction approach is as much a means of relationship building, getting people connected with programs and services, assisting them in taking better care of themselves and discovering new options and opportunities, and making positive changes to improve their quality of life and well-being as it is about safer drug use."

Prepared by the Canadian Harm Reduction Network (CHRN) and the Canadian AIDS Society (CAS), this report is the culmination of a 17-month-long research study which included a harm reduction symposium and a series of focus groups, site visits, photo shoots, and community walkabouts in 9 medium-sized cities across Canada. The study was funded by the federal government's Drug Strategy Community Initiatives Fund.

"Learning from Each Other" highlights how programmes in nine small-to-medium-sized cities were developed and implemented, gleaning the challenges encountered and the lessons learned along the way. It also provides in-depth testimony from people with drug-use experience about what works well, what does not, the impact that harm reduction programmes and services have on their lives, and what can be done to improve these programmes. The report is enhanced with numerous on-site photographs.

"Learning from Each Other" shows how community and healthcare organisations are preventing harm related to drug use, primarily the transmission of HIV and hepatitis C. It also portrays the holistic underpinnings of the programmes, which cater to both the basic health and the emotional well-being of people who use drugs. The report also shows the human side of harm reduction by including the perspectives of some of the people harm reduction programmes serve, in their own words. It provides a glance at societal challenges, including poverty, homelessness, and the gentrification of urban centres.

A selected list of communication-related challenges for harm reduction programmes and practices:

• Marginalisation and discrimination afflict people who use drugs and pose challenges to providing services for them. Racism exists and is not being adequately addressed.
• Peer involvement is hindered by agency reluctance to engage drug users to provide services and by challenges and barriers to user group organising.
• Rural and remote areas face challenges in maintaining privacy and confidentiality, and in providing services to cover vast territories.
• The sustainability of programmes and services is often compromised by a lack of sustained funding and a tendency towards project-based funding.
  
• Harm reduction programmes face threats and challenges which can affect community buy-in. For example, "not in my back yard" actions by neighbourhood groups make it difficult for programmes and services. "Harm reduction messages have to be constantly repeated, in order to get through to those opposing them."
• Some policies are an infringement of human rights, drive clients underground and out of reach, and are antithetical to harm reduction.
  
• It is often difficult to find people willing to go public about their drug use and be spokespeople, due to stigma and the illegality of drugs.
  
• "Programs should not discriminate based on age. That said, providing harm reduction service and supplies to minors is considered controversial, even though they may legitimately require it."
• Police opposition to programmes is not being addressed by people with authority.
• Policy conflicts among collaborating agencies can limit service. (e.g., in one community, Red Cross would not allow needles to be distributed from their van, which is used in a collaborative outreach programme).

A selected list of lessons learned:

• Community buy-in strategies are important, and can include: establishing a broad coalition of community members, service organisations, researchers and potential partner organisations; ensuring that logistics are well worked out before launching a programme; courting the media and educating them about what is being planned before a programme is launched; establishing good working relationships with key police staff and politicians; anticipating community concerns and addressing them in advance; holding community consultations prior to moving into a neighbourhood; performing periodical community clean-ups and public information forums; celebrating agency and community champions; and organising community-building events.
• Capitalise on the experience of community members with drug-use experience, who "have a right to be involved in making decisions that affect their lives....Include them in program planning, delivery and evaluation. They can be advocates within their own community, and, as spokespersons to the broader community, they can help counter the misinformation about drugs and the people who use them..."
  
• Adopting a harm reduction approach means that everyone is treated as equals, in a person-centred respectful and non-judgmental manner. The approach is based on the observation that dignity and respect are basic needs, along with food, shelter, and the other social determinants of health.
• Patience and perseverance are required when developing and implementing harm reduction programmes and practices. Often a community's fears are worse than the reality and, after services have been open for a while, the fears subside. Identify allies and support them. Be strategic and creative.
• "Enhanced human resources can be attained through the use of volunteers and peers. This can increase the scope of programs and develop a cadre of supporters and spokespeople. Seek out and hire staff with experiential knowledge. Pair seasoned workers and volunteers with new ones, to ensure support, continuity and appropriate work performance. Provide practice guidelines for outreach workers and hold monthly information and support meetings for them. Employ a multidisciplinary approach and ensure that all collaborating disciplines buy into harm reduction. Celebrate and support dedicated staff and volunteers."
• Enhanced harm reduction programmes and services can be achieved by providing a welcoming, non-judgmental space and staff and making services as accessible as possible; offering services such as food, clothing, medical care, personal and social support, activities, and referrals; delivering services close to where prospective clients are; collaborating with other agencies to ensure continuity of service; accommodating the needs of active drug users; and employing mobile outreach vans and secondary distribution to reach rural and remote areas.
• Involvement in community-based research can contribute to the body of evidence on the efficacy of harm reduction programmes and practices.
• Learning from other cities' experiences in the development and implementation of programmes can be very beneficial to avoiding the same challenges and reinventing the wheel.
  

The report features detailed discussion of specific focus group findings in the categories of: treatment and counselling, methadone maintenance programmes, drug substitution, safe injection sites, needle and injection equipment distribution (e.g., peer involvement is a necessary component), drop-in centres and shelters, and harm reduction and drug policy.

Highlights from some of the more communication-centred findings are as follows:

Peer Involvement:

• It is essential that people who use drugs be included in programme development, implementation, delivery, and evaluation.
• People who use drugs recognise the importance of educating others, especially youth, on the realities of drug use and want to be a part of such programmes. Their expertise and commitment should be utilised.
• People who use or have used drugs should be offered training and mentoring for specific tasks, such as public speaking and writing proposals for funding, and provided with support at the same level as other staff.
  
• Barriers to involvement and participation exist, such as systemic barriers within organisations (e.g., policies) and exclusion (e.g., not being allowed to make presentations at schools), and must be addressed.
• For some, getting involved in service provision can be a trigger for relapse. Supervision and support are essential.

Education, Awareness, and Information Dissemination: Focus group participants express interest in public speaking to raise awareness and educate people - especially youth - about the realities of substance use. The dissemination of information about harm reduction, HIV, hepatitis C, and other consequences of substance use must be increased. Police need to be educated about harm reduction and the realities of the lives of people who use street drugs. Referrals are an effective means of disseminating information about services.

Outreach: Focus group participants express great appreciation for outreach services. Outreach delivers materials, information, and services to them and reaches people who do not access agencies. "Agencies must recognize and unconditionally support outreach workers for their unique role as the sole service providers of many people who use street drugs, as surrogate family, and as trustworthy partners who are able to develop relationships with a highly cautious client group. They are called upon to be everywhere to provide services, which is a significant challenge." Peer outreach is described as especially effective and desirable. Outreach teams must provide a broader range of information about available services, and outreach to people in prisons and hospitals is essential.

One specific community buy-in strategy discussed in the report that is communication-centric involves establishing a coalition of community members, service organisations, and potential partner organisations. In doing so, creative strategies in reaching out are recommended. Providing media kits/information prior to programme launch is important, as is getting politicians on board. Proactively anticipating community/neighbourhood concerns and being prepared to address them can be accomplished in part by holding community consultations, identifying champions from the community, setting up a process where community concerns can be heard and respected, and developing strategies for how best to address these concerns. Celebrations and ceremonies, including memorials, are valuable for community building and healing. "When involved in awareness raising endeavours, remember that though it is easiest to preach to the converted, this is not usually what you need to do. Identify and 'preach to' those in the mushy middle, who are more likely to change than are those on either end of the spectrum."

Specific advocacy tips are also offered, with Ontario's methadone case management approach presented as a model. It is set up to work with the client and ensure that she/he cannot fail the programme. It also provides advocacy, mediation, support, and flexibility. In order to destigmatise harm reduction, organisers recommend (among other ideas) addressing the political climate and ideological opposition by calling on the Charter of Rights and Freedoms, or other international human rights treaties, to force implementation of harm reduction programmes. They also suggest participating on community advisory committees/boards to get your message out.

For more information and to request a copy of a CD-ROM of the report in English and French, please see contact details, below.