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

People who use illicit drugs are more likely to contract HIV and hepatitis C virus
1], experience mental and physical illness 2], and die prematurely 3]. The consequences of drug use negatively impact individuals, families, communities
and society as a whole 3], 4]. Harm reduction is internationally recognized as best practice to prevent the transmission
of blood-borne infections, promote safer drug use and safer sexual behaviours, increase
access to social services and supports, and prevent and reverse overdoses 5]. However, simply making no-cost supplies and services available is not sufficient
for providing comprehensive harm reduction interventions; services must also be accessible,
accommodating, affordable, and acceptable (i.e. equitable regardless of drug used,
route of administration, or where reside) 6].

Engaging people who use or have used drugs, herein referred to as ‘peers’, to participate in policy making, research, programming, and practice is fundamental
to harm reduction globally 7]. The definition of ‘peers’ varies across the literature, but can be defined as “any
persons with equal standing within a particular community who share a common lived
experience” 7]. ‘Peers’ in the context of harm reduction are “people with lived experience of drug
use work both behind the scenes and at the forefront of needle distribution services,
harm reduction education, peer support, and community-based research initiatives”
8], providing valuable insights about the barriers and facilitators to accessing harm
reduction services in their communities. Peer roles can be considered across multiple
dimensions, including political advocacy, research assistance, program governance,
peer support, and harm reduction messaging 8].

Peer engagement has been defined as a community-based approach to decision making
by “consulting and collaborating with decision makers using a bottom-up approach in
order to better address the needs of the community” 7]. Methods applied to engaging peers can vary considerably. Several frameworks for
engagement and participation have been developed for examining citizen participation,
although none of these models pertain specifically to peers. Arnstein’s ‘ladder of
citizen participation’ was first published over forty years ago 9]; since, adapted versions have emerged including Hart’s ladder of youth participation
10] and Pretty’s participatory learning model for sustainability 11]. In all models, a policy, program or project can elicit equitable participation in
resources, recognition, results, and knowledge by sharing power in partnerships 12]. Many peer engagement efforts are limited to exchanging information without sharing
any decision-making authority; thus, efforts are merely “tokenism”9]. Peers are increasingly involved in varying roles, but still underutilized, in the
prevention of substance use related harms 8]. In 2013, a national symposium of fourteen peer-run organizations across Canada concluded
that “tokenism and lack of representation are still common” obstacles to meaningful
participation 13]. Stigma and discrimination also make it more difficult for peers becoming engaged
in decision making processes 7].

Peer engagement in British Columbia

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.