Peer engagement in harm reduction strategies and services: a critical case study and evaluation framework from British Columbia, Canada

Harm reduction efforts in the Canadian province of British Columbia (BC) provide a case study of where community-based engagement with people who use drugs – peers – has gained momentum. Since 2003, the BC Centre for Disease Control (BCCDC) oversees and coordinates provincial distribution of harm reduction efforts including safer drug use and sex supplies [14]. As part of the BCCDC, the BC Harm Reduction Services and Strategies (BCHRSS) committee guide provincial harm reduction policies and convene quarterly, alternating between in-person and teleconference meetings. The committee includes representatives from the BC Ministry of Health, five regional Health Authorities, and First Nations Healthy Authority [15].

In 2007, an increase in peer engagement in BC coincided [6] with the release of “Nothing About Us Without Us,” a report published by the Canadian HIV/AIDS Legal Network which makes a compelling case for meaningful peer involvement from a public health, ethical, and human rights perspective [16]. From this report, the BCHRSS committee agreed: “people who use illegal drugs should be engaged in all aspects of harm reduction supply distribution program development, implementation, and evaluation” [6], and in 2008 increased support for peers by contributing to several peer-run events, including financial support for a conference organized by a peer-run group, Vancouver Area Network of Drug Users (VANDU) [17]. Thereafter, efforts to develop and expand meaningful peer engagement have increased and the BCHRSS committee has officially embraced peer engagement as an essential first step in decision-making.

Peer engagement has the potential to augment equity of harm reduction services by fostering communication, building trust, increasing knowledge, and reducing stigma and discrimination to remove barriers and increase utilization of harm reduction services; this, in turn, will have a direct impact on mental and physical health. Globally, public health research and practice has shown that involvement of people with lived experience results in improved health outcomes and reduced health disparities by improving the acceptability and utilization of health services and removing barriers to access [7]. However, despite the increasing international support for engaging various populations [7, 8], there is very little published evidence on the implementation, evaluation, or effectiveness of meaningful engagement with peers. This paper aims to describe and evaluate the peer engagement efforts undertaken by the BCHRSS committee from 2010 to 2014. We highlight key lessons learned and improvements needed to ensure meaningful peer engagement in the planning, delivery and evaluation of harm reduction efforts.

The evaluation team appraised the events, processes and products of peer engagement in the harm reduction program from January 2010 – December 2014 using a peer engagement evaluation framework developed specifically for this project (described below). The evaluation team included BCCDC staff as well as two peers. The peers involved in the evaluation had participated in BCHRSS meetings and other peer engagement activities with health authorities between 2010 and 2014. Evidence was obtained through a desk-based document review of BCHRSS materials. The document review was a retrospective review and synthesis of all relevant documents concerning the state of policies and provision of services and programs to identify social impacts and priorities for action [18]. One research assistant (SL) did the initial gathering of documents and literature; however, the findings were reviewed and discussed with all authors, including peers (CB & KL), and the drafting of this manuscript was in partnership with peers. The lack of more collaborative involvement of the gathering of information was mainly due to the geographic distance between team members.

Materials included formal documents, notes from relevant previously conducted focus groups and interviews, meeting agendas, minutes, and anonymous surveys, and the BC Harm Reduction website. For documents, we reviewed How to Involve People Who Use Drugs (2014) [19], the BC Harm Reduction Strategies and Services Committee Terms of Reference (2012) [15] and an internal document, Peer Consultants at HRSS Face-2-Face (2014). Summary notes were available from focus groups and telephone interviews that had been conducted to inform a research funding application on peer engagement in BC (Peter Wall Solutions). Researchers at the BCCDC consulted with seven representatives from all BCHRSS member organizations and interviewed three groups of peers from two health regions in 2014. Conversations with representatives and peers were not transcribed thus preventing detailed secondary data analysis for this evaluation. However, a document summarizing key themes to inform current and future peer engagement efforts was available, in addition to the grant application itself, and incorporated.

A review of the literature revealed a lack of evaluation frameworks based on the principles of health equity, as well as frameworks for engagement with people who use drugs. Public engagement evaluation tools were limited in that most focused on outcomes, such as cost-effectiveness, rather than considering the process of engagement itself. The Involve UK’s guidelines for public participation in central government most closely resembled our aims and equity-based evaluation principles [20]; thus, we adapted it, broadly using the language, themes, and structure as a general guide to developing an evaluation framework specific to peer engagement [see Table 1]. The four goals identified for evaluation were supportive environment, equitable participation, capacity building and empowerment, and improved programming and policy. Examples of constructs were derived from the evaluation of evidence itself and are by no means exhaustive or inclusive.

The evaluation framework allowed us to compare and contrast multiple sources of information and outcomes, increasing the validity of our findings through triangulation [21]. For example, we examined information about meetings involving peers by reviewing the agendas, minutes, attendee evaluation surveys, and post-meeting debriefing notes. Where sources provided similar data, we simplified and summarized the messages, and where sources provided different information, we presented the full breadth of perspectives. Our evaluation failed to present any contradictory information requiring resolution.

The University of British Columbia Research Ethics Board granted the ethics approval for the interview and focus group data used in this evaluation.

Peer engagement in BC was an iterative process that increased and improved over time as consequence of reflexive learning. When the committee began inviting peers to meetings, peers were not given clear expectations. Feedback revealed planning in advance, making travel arrangements, setting up support locally, and creating a welcoming environment were important factors for supporting and facilitating engagement. Organizing local methadone prescriptions or making arrangements for connecting to local peers for other supplies well in advance was essential for out-of-town peers to feel supported. It also contributed to their ability to be fully present at meetings. Sending an agenda and/or itinerary in advance developed peers expectations for the meeting. To establish rapport between attendees prior to the meeting, community-building activities were organized. Dinner at a restaurant was not comfortable, but in subsequent years sharing a meal in a more relaxed setting worked well. Developing a peer advisory group who could provide feedback on the meeting agenda and other activities was one way to improve on existing efforts. Figure 1 is one example of the equitability and environment of peer engagement in BC, offering a visual representation to highlight this reflexive and cyclical process.

In the beginning a single peer was invited to meetings. Activities offered to peers were separate from the rest of the committee. Feedback about the need for peer support led the committee to extend its invitation to two peers per region starting in 2011. Being in a new and/or different place can be destabilizing for some, leading to “triggering” or inducing behaviors peers would otherwise try to avoid. As such, offering supports around the meeting was imperative to equitable participation especially when working with a population with diverse needs and backgrounds. Due to the geographic structure of health authorities in BC, there was an unequal representation of peers from different regions at the meetings. Peer run organizations or groups, such as VANDU in Vancouver Coastal Health Authority, were asked to nominate participants as representatives from their regions. In areas where organized peer groups did not exist, such as the Northern Health Authority, harm reduction coordinators in were encouraged to invite peers who they had worked with during the year and to use the meeting as an opportunity to promote sustained involvement. Peers who had transportation, disability or mobility issues were accommodated. Nonetheless, peers from rural regions remained underrepresented, likely due to the geography and inconsistent staffing in these regions (i.e. Northern Health Authority, Interior Health Authority). Providers and peers from these regions were expected to travel great distances (sometimes more than 500 kilometres) to engage or reach services, greatly limiting engagement opportunities. “One-off” or one-time engagement opportunities outside of the BCHRSS were common but fragmented across events. Ongoing opportunities and strategies to keep peers engaged in the long run were needed. Peers also drew attention to power imbalances. Being attentive to the distribution of voices at the table so everyone was treated equally and respectfully was important. The need for strong but flexible facilitation, check-ins, and options to share ideas anonymously were identified as opportunities for improvement.

The BCHRSS committee supported the expansion of peer networks through research, networking, and funding opportunities. In 2010, the BCHRSS committee supported the BC-Yukon Association of Drug War Survivors to drive across BC as a team, meeting peers “where they’re at,” conducting harm reduction workshops and gathering information about peers’ health needs. This project, known as the “Caravan Project,” [22] highlighted the informal peer engagement efforts to date, and served as the impetus to examine and enhance peer engagement in BC. Peers from various regions were inspired by the bold leadership of representatives from peer-run organizations, such as the Society of Living Illicit Drug Users (SOLID) and VANDU, and some became more involved in peer activities in their own communities. Some efforts were financially supported by BCHRSS funds to form new entities, such as the Kelowna Area Network of Drug Users (KANDU). From this project, the Eastside Illicit Drinkers Group formed.

Even with limited financial supports, peer networks across BC were able to mobilize around important issues, such as social housing, anti-harm reduction by-laws, and methadone formulation changes. In 2013, the SOLID organized and hosted a national symposium of peers in Victoria that kick-started a conversation nationally with 14 peer-run organizations. These organizations documented their successes for other peer-run organizations and allies to learn from by creating a document called “Collective voices for Effective Change” [13]. We noted that the ability to distribute this information, form new peer networks, and build on already established capacity among groups of peers was limited due to financial and geographic challenges.

The BCCDC provided resources for the “Caravan Project,” [22] which identified the need for several policy and program initiatives through focus groups with peers across BC. Eight priority areas for promoting health equity were offered. In 2011, the BCCDC implemented two policy changes as a direct result of these findings: 1) regional representatives were asked to invite a local peer to the face-to-face meeting held in the spring of 2012, and 2) annual funds ($2000) were offered to support peer-led initiatives for harm reduction activities and matching funds ($5000) for community development activities in each health authority [15]. Peer engagement opportunities and feedback on policy and programming increased as a result, which had additional effects beyond the BCCDC. Harm reduction sites started providing safer inhalation supplies and the BC Take Home Naloxone program was launched. Also, an annual client survey at harm reduction supply distribution sites was introduced.