Abstract
A revised way of thinking is essential for promoting harm reduction strategies and reducing the negative implications of injection drug use (IDU). Despite the growth of harm reduction approaches in the United States, there is limited guidance for designing and implementing multi-sector efforts that address the external determinants that promote and facilitate IDU. Current frameworks fail to acknowledge the individual’s role and influence in multi-sector change. To address the multifaceted nature of IDU, we must address the complex relationship between people who inject drugs (PWID) and their external environment. As part of a community–academic partnership, a framework was developed to address the gaps in current theoretical models and community practice. Our Harm Reduction Collaboration Framework (HRCF) accepts PWID as key stakeholders and presents a practical framework in which PWID and community organizations partner in decision making to influence policy, systems, and environmental change. We provide examples of two organizations that have made substantive changes in implementing harm reduction strategies in their communities by utilizing the HRCF.
Introduction
Despite the widely acknowledged support for multilevel frameworks in public health initiatives, many programs and policies continue to direct their efforts toward individual behavior in response to addressing injection drug use (IDU). Public health initiatives continue to focus on individual behavior change and education instead of focusing on the external determinants such as unjust policy or dangerous environments which might influence unsafe drug use behaviors (Burris et al., 2004). This approach limits research and programs to focus on teaching the individual to cope with the external environment, rather than directing efforts toward changing the environment. As a result, many public health interventions in the United States targeting IDU fail to address the external factors that promote and facilitate substance use.
There is growing support from public health practitioners to initiate programs that focus on exploring the dynamic relationship between the individual, community, and policy, system, and environmental (PSE) determinants (Berman et al., 2018; Honeycutt et al., 2015; Rhodes, 2009). However, there are limitations with the current focus on PSE interventions. First, PSE interventions tend to focus primarily in areas of chronic disease management or wellness promotion. To our knowledge, there is a lack of guidance on how to implement PSE-targeted approaches associated with risk behavior and harm reduction. Second, these interventions are limited to health system structures and fail to explore how other traditional and nontraditional partnerships can influence health. A multitude of PSE barriers prevent the successful implementation of harm reduction strategies. Examples of PSE level barriers include harassment from law enforcement, community stigma, and inadequate social resources (Goldenberg et al., 2006; Hobden & Cunningham, 2006; Shirley-Beavan et al., 2020). Finally, while PSE constructs are discussed in public health interventions, there is no comprehensive conceptual framework that demonstrates the dynamic relationship between the PSE, the individual, and the community. Current PSE interventions fail to acknowledge or support the individual’s role in designing and implementing these interventions.
Research and community activism continue to call for people with lived experience to be involved in developing, implementing, and evaluating harm reduction efforts (Brown et al., 2019; Ti et al., 2012). Instead of reacting to the intervention, individuals with IDU need to be active stakeholders and part of the collaborative process for decision making when developing and implementing PSE change. There is currently no guidance for communities on how to authentically engage individuals in the decision-making process. With the growing support for harm reduction programs across the United States, it is imperative for these programs and policies to be authentic, person-centered approaches that adequately meet the needs of PWID and the community.
In this paper, we introduce the Harm Reduction Collaboration Framework (HRCF) that can guide public health practitioners and communities in the design and implementation of harm reduction strategies by authentically engaging individuals with community organizations. This framework was developed over 4 years through a community–academic partnership by incorporating lessons learned from a previous community-based participatory research (CBPR) study and gathering input from community partners. This paper outlines two exceptional examples of how community organizations can use this framework to create PSE partnerships and successfully initiate harm reduction strategies.
Harm Reduction and Community Engagement
The HRCF focuses on how to design and implement harm reduction strategies at PSE levels that are meaningful for PWID and the communities in which they live. Harm reduction is an international concept defined as a set of principles aimed at reducing the negative consequences of an associated behavior (Wodak & Cooney, 2006). Regarding substance use, the overall goal of harm reduction is to reduce the negative health, social, and economic harms associated with substance use behavior (Harm Reduction Coalition, n.d.). Despite its ubiquitous use in public health, harm reduction tends to lack support when associated with IDU due to the stigma related to PWID (Baker et al., 2019).
Due to the broader community’s stigma surrounding IDU, the United States has been slow to accept and utilize harm reduction strategies for the prevention and reduction of risks associated with substance use. Although certain communities are experiencing progress and the resistance to harm reduction is fading, the United States still lags behind much of Europe, Australia, and Canada regarding progressive illicit drug policy (Nadelmann & LaSalle, 2017). Literature deems the United States’ response to IDU as isolating and stigmatizing for PWID (Ahern et al., 2007; Tempalski & McQuie, 2009). The United States presents unique challenges, such as community stigma, toward supporting harm reduction practices and delegating power to the individual. Guidance is needed on how to create PSE partnerships for designing and implementing harm reduction strategies in our communities from the perspective and needs of PWID.
Impact Statement
The Harm Reduction Collaboration Framework seeks to provide a practical framework in which PWID and community organizations partner in decision making to influence policy, systems, and environmental change.
The societal stigma surrounding substance use behaviors commonly make it difficult for organizations, researchers, and policy makers to engage with PWID. Identifying and initiating a partnership with PWID is a challenging task, as there is often little incentive in “outing” oneself as a PWID. The limited efforts to outreach and engage PWID and instead implement a medical and criminal justice model of addiction continues to marginalize and control PWID in our communities (Lofaro & Miller, 2021). This marginalization further emphasizes the importance of including PWID as equal stakeholders in developing collaborative multi-sector partnerships.
Only recently have PWID been included in the design and implementation of research and community planning. Harm reduction views PWID as agents of change with a valuable voice to impact greater change (Boucher et al., 2017; Gilbert et al., 2018). Recent community-based studies have sought to understand how PWID define community and identify authentic engagement strategies for researchers and academic partners (Gilbert et al., 2018). Authentic engagement supports community members who actively participate with organizations to create health programs and policies that reflect the needs of the community. However, despite this call for communities to include PWID in meaningful participation, there is limited guidance on how communities can design and implement harm reduction strategies.
Methods: The Development of the Harm Reduction Collaboration Framework
There is a dearth of literature illustrating the multi-sector approach for addressing the health concerns of PWID in the United States. Although past social ecological models describe the influence that environments can have on an individual, such as Bronfenbrenner’s (1977) socioecological model or the McLeroy et al. (1988) ecological model for health promotion, these models do not sufficiently explain or examine the complex and dynamic relationship between the individual and PSE. Using previous ecological models, public health professionals and service providers can investigate how specific environmental factors influence individual behavior, but these frameworks fail to acknowledge the role of the individual and their dynamic relationship in PSE interventions. Due to the limitations of current frameworks, practitioners and researchers will struggle to identify the unique upward mobility individuals and organizations use to create change in the PSE.
The Harm Reduction Collaboration Framework.
There is an absence of the individual in the decision-making process. Friedman et al. (2007) describe how Americans view PWID as “incompetent and pathological, and thus objects of interventions rather than allies and participants in their own individual and collective health” (p. 13). Therefore, we present the development of the HRCF as a practical framework to understand and facilitate collaboration between the individual, organizations, and PSE. This integrative framework incorporates the individual as a key stakeholder and provides guidance for community organizations to support and incorporate the individual perspective when advocating for PSE change.
This framework was derived from a previous CBPR study that identified PWID as key stakeholders in determining community needs and strategies for authentic engagement (Gilbert et al., 2018). The results from the study provided the groundwork to develop the components of the HRCF. The conceptualization of the HRCF occurred as a collaborative effort between the public health department at a local university, the state government, and two community organizations. Community partners participated in the initial development of the HRCF, in the outline of the components, and in the manuscript review. The development of the HRCF was an iterative process to ensure that all feedback was incorporated from the community organizations. The outreach and engagement with the harm reduction organizations was supported by the main principles of harm reduction. Authors met with the organizations where they were located and during timeframes that fit their schedule. Community members identified the key gaps in current PSE and ecological models, and where harm reduction principles were often overlooked. For example, it was noted that current models focus primarily on behavior change and standards of healthy living, whereas the community partners stressed the need for a new framework to create space for harm reduction practices and clearly make harm reduction the foundational component. Two case examples were also identified to highlight how the HRCF can guide organizations toward the authentic community engagement of PWID and strategically work across PSE sectors to implement harm reduction strategies.
While ecological models are commonly applied to design health programs and to evaluate public health initiatives, these models fail to incorporate the individual’s role and upward influence. Many models explore the downstream impacts that different policies or environmental approaches have on individuals and communities. This approach ignores the individual and community potential for authentic engagement and change. Current ecological models do not provide guidance on how established community organizations can engage with individuals and partner together for PSE change.
Building off the socioecological models mentioned, the HRCF illustrates the dynamic and intrinsic nature between the framework components. The HRCF centers on the individual and uniquely supports bidirectional influence across the framework’s components. Each component within the HRCF can negatively or positively impact the individual. Given this inherent impact, it is crucial to represent the individual’s influence on the PSE and how community organizations can facilitate that influence. As organizations bring forth the resources and capacity to engage PSE sectors, they can act as a launching ground for incorporating individual level needs into large-scale policy and program changes.
A distinctive component of the HRCF is that the foundation is rooted in harm reduction. Whereas other frameworks might include harm reduction as a goal or an outcome, the HRCF asserts that the understanding and incorporation of harm reduction principles is necessary from the beginning of community engagement and collaboration. The harm reduction construct is positioned as the outer ring, or foundational layer, of the HRCF and encourages all components of the framework to incorporate harm reduction principles into all stages of the process.
Framework Components
Individual
The HRCF presents the individual as a key stakeholder and decision maker in collaborative efforts to create a safer community for all individuals through harm reduction. The individual is positioned at the center of the HRCF. In this position, the individual can provide an assessment and recommendations to the organization for harm reduction strategies such as enhanced access to care, advocacy for overdose prevention sites, or policy to decriminalize drug paraphernalia. The HRCF posits the inclusion of the individual to be in control of their health, be engaged with external factors, and to resist being only passively influenced. It is crucial to view the individual as a stakeholder and not the problem. This concept is important in terms of harm reduction as strategies should be “conceptualized by people who use drugs themselves to be most effective” (Boucher et al., 2017, p. 3). Opportunities for community engagement and active participation with PWID allows these populations to share and use their knowledge and experience to guide harm reduction strategies. Harm reduction strategies for PWID will not work if they are not practical or important to the users themselves (Hussey et al., 2019).
Organizational Collaboration
Organizational Collaboration, the second level within the framework, represents the collaboration that can occur between an individual and organizations. These organizations may, directly and indirectly, serve the individual’s community. The Organizational Collaboration component is intended to create authentic engagement while working with the individual to create PSE harm reduction strategies.
The dotted line between these two components emphasizes the fluidity and integrated nature of this partnership. Organizations can support the individual in ways beyond what would be capable if someone were working alone by providing supplemental support to the individual such as funding, resources, and education. Community organizations can also provide a trusted network and support system for people with lived experiences.
Policy, Systems, and the Environment
The HRCF supports the individual and organizations to engage traditional and nontraditional PSE sectors to improve individual and community health. These partnerships across sectors are important. For example, the criminalization and cultivated stigma of substance use create barriers to treatment, recovery, and safe use practices (Ahern et al., 2007; Tempalski & McQuie, 2009). PSE collaboration can be used to mitigate these legal, systemic, and environmental barriers for PWID.
Channels of Influence
The defining aspect of the HRCF is the representation of the Channels of Influence that illustrate the multidirectional mobility between components that is usually unaccounted for in other frameworks. During the design of the HRCF, PWID and community organizations advocated for a framework component to illustrate this relationship between individuals, organizations, and PSE levels. Harm reduction strategies require dynamic and nonlinear pathways for development and implementation, the Channels of Influence component mirrors this need. The HRCF encourages partnerships between individuals, organizations, and PSE. The flexibility of the engagement and influence within these components is a critical element that supports harm reduction strategies and practice. In real-world settings, community engagement and collaboration vary widely across different partnerships. The type of collaboration between sectors can vary depending on the partnership’s needs, capacity, and resources. The Channels of Influence assists in identifying how the individual, organization, and PSE interact. By identifying and outlining these relationships and gaps, areas of opportunity can be identified for further collaboration.
Examples of the Harm Reduction Collaboration Framework in Action
We present examples of the HRCF applied in two different organizations. These two organizations demonstrate authentic community engagement and support for PWID-centered design and implementation of harm reduction strategies. These organizations have incorporated the individual as a key stakeholder and aligned their organization’s agenda to meet the needs and priorities of PWID; in doing so, they successfully created PSE change in their communities. Our first example provides a traditional approach from a brick-and-mortar harm reduction center. The second example illustrates how a medical clinic can operate within this framework.
Established in 2002, the Harm Reduction Action Center (HRAC) began its work to reduce the harms associated with substance use by working closely with PWID, policy makers, health care providers, law enforcement, and the general community. The foundation of HRAC’s work is a commitment to a participant-centered approach to harm reduction and encouraging their participants to engage in all facets of direct service. Participants at the HRAC can advocate for harm reduction strategies and can influence PSE change.
HRAC is a community organization that uses its resources, knowledge, and rapport to connect with PWID and applies the Channels of Influence to generate PSE changes in Colorado. In this example, HRAC is the organization that engages with the individual through the Organizational Collaboration component of the HRCF. PWID are hired for positions within HRAC and can sit on the HRAC Board of Advisors to participate in decision making. HRAC participants are active in the daily operations and maintenance of the center which allows them to engage in development efforts of the organization to better meet the needs of the PWID community. Utilizing multiple Channels of Influence, the HRAC develops partnerships with local businesses, law enforcement, and policy makers. All partnerships stem from the individual and organization identifying their needs and priorities for harm reduction. Successes of the PSE partnerships include providing flexible commodities for PWID such as flexible hours of operation, locations of the facility, and social support services such as participants can use the organization’s address for mail. HRAC’s legislative advocacy has impacted changes in policies surrounding substance use, such as the decriminalization of the syringe, which allows HRAC to provide harm reduction services to the PWID of Denver, Colorado.
Recently, HRAC’s involvement in gathering support from the city of Denver to operate an overdose prevention site continues to illustrate the utilization of the HRCF. Although historically contested, overdose prevention sites not only provide a safe space for PWID, but also provide public health benefits and cost savings for the entire community (Finke & Chan, 2022; Khair et al., 2022). In Denver, PWID partner with HRAC to educate the public, gather business support, and work to advocate for policy changes to support overdose prevention sites. HRAC’s agenda for overdose prevention sites reflects the needs identified by PWID as heard through participant activism and storytelling of overdose deaths that could be avoided if safe spaces were available. According to the Executive Director of HRAC, “[PWID] are dying in public places and getting in trouble for publicly using. They have been asking for a safe space for years.” HRAC made strides in gathering support within PSE areas by using their community rapport and resources. Engaging with multiple PSE avenues allows HRAC to reach a broader audience to influence change and create support for harm reduction programs and policies.
In our second example, Front Range Clinic (FRC) provides a unique representation of the HRCF by incorporating harm reduction strategies into a medical clinic setting. Founded in 2014, FRC has 20 brick-and-mortar clinics, four mobile health units (MHUs), and a variety of embedded clinics, collectively offering services in over 60 locations. Through their network of medications for addiction treatment (MAT) clinics, the FRC prioritizes “low-barrier/high-access” addiction treatment. Low-barrier and high-access stems from a foundation of harm reduction and brings to life the concept of “meeting people where they are.” The clinics incorporate a person-centric approach to care that supports patients at their level of engagement and does not discharge patients for manifesting symptoms of a substance use disorder, including a return to use or relapse.
The MHUs offer a unique approach to MAT that works through a harm reduction lens. The goal of this program is to provide MAT services to underserved and rural communities in Colorado. Prior to implementation, a community assessment was used to determine the level of need and capacity to support treatment. Extensive outreach with traditional and nontraditional PSE partners was conducted to understand the community’s perception of need and the existing treatment landscape. The feedback offered invaluable guidance that determined parking, outreach, education, and referral partners. The community and PSE partnerships played a significant role in planning the MHU routes, availability, and places of service.
FRC’s partnership with various organizations highlights the value of Organizational Collaboration to influence PSE change. FRC has embedded services within over 15 Colorado agencies, such as shelters, syringe exchange programs, behavioral health facilities, residential treatment communities, and correctional facilities. Hosting organizations provide a private space and a bathroom for point-of-care urine drug screens. This model of care creates opportunities for individuals to initiate treatment in a safe and well-known environment where there is existing rapport.
A unique PSE partnership exists between the FRC and the justice system. Since the highest incidence of overdose often follows release from incarceration or residential treatment, partnerships within the justice system to create harm reduction strategies are imperative (Pizzicato et al., 2018). The FRC established partnerships with a variety of local programs to create a safety net for relapse and fatal overdose. An outcome of these types of partnerships is the implementation of treatment options while the individual is in the jail system, to include the induction and continuation of MAT services. Upward influence stems from incarcerated individuals pursuing legal action to change the laws around the continuation of MAT while incarcerated. Historically, if an individual becomes incarcerated while using MAT for substance use disorders, the medication would be discontinued, and the individual would be placed on a withdrawal protocol. With individual advocacy and legal action, legislation in Colorado now requires all county jails to continue MAT upon incarceration or risk being in violation of Americans with Disabilities Act. This type of approach provides an example of upward influence from the organization and individual to support policy change, allowing the justice systems to be more rehabilitative than punitive. The authors offer additional examples of PSE engagement in Table 1.
Examples of PSE Engagement Using the Harm Reduction Collaboration Framework.
Limitations
Although multi-sector collaboration provides immense benefits for the individual and community, the common challenges that can hinder this collaboration should be acknowledged. To begin, unique organizational funding and agendas can cause conflicting priorities among entities attempting to collaborate. Legality and the political climate also need to be recognized as potential barriers to successful multi-sector partnerships and interventions. Harm reduction practices are still illegal in many cities and counties. Substance use behaviors are typically addressed as legal issues rather than public health issues. If a proposed strategy requires the passing of policy, such as legalization or decriminalization, the political climate could prevent the policy from being implemented. Harm reduction must be framed as a community approach, as the specific health outcomes can directly and indirectly impact the community. Finally, stigma and unintended harm also need to be considered when using the HRCF to address complex issues among marginalized populations. Research supports interventions that target multiple sectors, ranging from individual, interpersonal, community, and policy, can reduce stigma and discrimination (Heijnders & Van Der Meij, 2006).
A final limitation of the HRCF is that the component of interpersonal support and influence was not identified during the framework’s development. Despite its absence in this framework, future research can explore how interpersonal relationships and collaboration could be included to support individual upward influence for PSE interventions.
Implications
Research continues to support the need for PSE interventions and collaboration. Organizations working toward harm reduction strategies can strengthen their community impact by incorporating the needs of the individual as identified by the individual. Organizations can use the HRCF to identify how to establish partnerships across diverse PSE avenues. Traditional and nontraditional partners spanning the PSE spectrum are essential in creating sustainable, person-centric harm reduction strategies. The HRCF provides a practical framework that can be used by organizations and communities to integrate individual voices and target PSE avenues for change.
Harm reduction is a public health matter that requires input, cooperation, resources, and support from all who are impacted both directly and indirectly. Our presented framework for incorporating the individual into decision making and facilitating an upward influence on PSE can assist those developing individual and community-based interventions. The foundation of harm reduction can be applied to various settings and community populations that engage in risk behavior. For harm reduction strategies to be implemented and effective, there is a need for PSE collaboration and individual input. Research is advocating for PSE institutions to adopt community engaged approaches toward harm reduction and require these efforts to be informed by people with lived experiences, especially those in racially marginalized communities (Hughes et al., 2022). The goal is to shift the focus from individual attributes related to substance use to understanding how to enhance PSE determinants to protect against substance use harm by adopting harm reduction strategies. Future research will work to determine how to support evaluation efforts to determine short- and long-term implications of the HRCF on individual and PSE level outcomes.
Footnotes
Acknowledgements
The authors acknowledge the contributions of Lisa Raville, Executive Director, and the staff and clients of the Harm Reduction Action Center located in Denver, Colorado, for illustrating the successful use of this model. Appreciation to Dr. Clark McCoy at the Front Range Clinic in Colorado for reviewing the Front Range Clinic content. Special thanks to Dr. Jill Bezyak of the Department of Human Services, Rehabilitative Counseling Sciences program at the University of Northern Colorado for thoughtful review of this manuscript. Appreciation to Leah Brunner, Master of Public Health student with the Colorado School of Public Health at the University of Northern Colorado, for formatting and review assistance.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
