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Peer engagement in harm reduction strategies and services : a critical case study and evaluation framework… Greer, Alissa M.; Amlani, Ashraf; Luchenski, Serena A.; Lacroix, Katie; Burmeister, Charlene; Buxton, Jane May 27, 2016

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RESEARCH ARTICLE Open AccessPeer engagement in harm reductionstrategies and services: a critical case studyand evaluation framework from BritishColumbia, CanadaAlissa M. Greer1,2*, Serena A. Luchenski3, Ashraf A. Amlani1, Katie Lacroix1,4, Charlene Burmeister1and Jane A. Buxton1,2AbstractBackground: Engaging people with drug use experience, or ‘peers,’ in decision-making helps to ensure harm reductionservices reflect current need. There is little published on the implementation, evaluation, and effectiveness of meaningfulpeer engagement. This paper aims to describe and evaluate peer engagement in British Columbia from 2010–2014.Methods: A process evaluation framework specific to peer engagement was developed and used to assess progressmade, lessons learned, and future opportunities under four domains: supportive environment, equitable participation,capacity building and empowerment, and improved programming and policy. The evaluation was conducted byreviewing primary and secondary qualitative data including focus groups, formal documents, and meeting minutes.Results: Peer engagement was an iterative process that increased and improved over time as a consequence of reflexivelearning. Practical ways to develop trust, redress power imbalances, and improve relationships were crosscutting themes.Lack of support, coordination, and building on existing capacity were factors that could undermine peer engagement.Peers involved across the province reviewed and provided feedback on these results.Conclusion: Recommendations from this evaluation can be applied to other peer engagement initiatives indecision-making settings to improve relationships between peers and professionals and to ensure programs andpolicies are relevant and equitable.Keywords: Peer engagement, Community engagement, Public participation, Substance use, Harm reduction, Healthequity, Process evaluationBackgroundPeople who use illicit drugs are more likely to contractHIV and hepatitis C virus [1], experience mental andphysical illness [2], and die prematurely [3]. The conse-quences of drug use negatively impact individuals, fam-ilies, communities and society as a whole [3, 4]. Harmreduction is internationally recognized as best practiceto prevent the transmission of blood-borne infections,promote safer drug use and safer sexual behaviours,increase access to social services and supports, and pre-vent and reverse overdoses [5]. However, simply makingno-cost supplies and services available is not sufficientfor providing comprehensive harm reduction interven-tions; services must also be accessible, accommodating,affordable, and acceptable (i.e. equitable regardless ofdrug used, route of administration, or where reside) [6].Engaging people who use or have used drugs, hereinreferred to as ‘peers’, to participate in policy making,research, programming, and practice is fundamental toharm reduction globally [7]. The definition of ‘peers’varies across the literature, but can be defined as “anypersons with equal standing within a particular commu-nity who share a common lived experience” [7]. ‘Peers’* Correspondence: a.greer@utoronto.ca1BC Centre for Disease Control, 655 West 12th Avenue, Vancouver, BritishColumbia V5Z 4R4, Canada2School of Population and Public Health, University of British Columbia, 2206East Mall, Vancouver, BC V6T 1Z3, CanadaFull list of author information is available at the end of the article© 2016 Greer et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Greer et al. BMC Public Health  (2016) 16:452 DOI 10.1186/s12889-016-3136-4in the context of harm reduction are “people with livedexperience of drug use work both behind the scenes andat the forefront of needle distribution services, harmreduction education, peer support, and community-based research initiatives” [8], providing valuable insightsabout the barriers and facilitators to accessing harm re-duction services in their communities. Peer roles can beconsidered across multiple dimensions, including polit-ical 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 andcollaborating with decision makers using a bottom-upapproach in order to better address the needs of thecommunity” [7]. Methods applied to engaging peers canvary considerably. Several frameworks for engagementand participation have been developed for examiningcitizen participation, although none of these modelspertain specifically to peers. Arnstein’s ‘ladder of citizenparticipation’ was first published over forty years ago [9];since, adapted versions have emerged including Hart’sladder of youth participation [10] and Pretty’s participa-tory learning model for sustainability [11]. In all models,a policy, program or project can elicit equitable partici-pation in resources, recognition, results, and knowledgeby sharing power in partnerships [12]. Many peer en-gagement efforts are limited to exchanging informationwithout sharing any decision-making authority; thus,efforts are merely “tokenism” [9]. Peers are increasinglyinvolved in varying roles, but still underutilized, in theprevention of substance use related harms [8]. In 2013, anational symposium of fourteen peer-run organizationsacross Canada concluded that “tokenism and lack of rep-resentation are still common” obstacles to meaningfulparticipation [13]. Stigma and discrimination also makeit more difficult for peers becoming engaged in decisionmaking processes [7].Peer engagement in British ColumbiaHarm reduction efforts in the Canadian province ofBritish Columbia (BC) provide a case study of wherecommunity-based engagement with people who usedrugs – peers – has gained momentum. Since 2003,the BC Centre for Disease Control (BCCDC) overseesand coordinates provincial distribution of harm reduc-tion efforts including safer drug use and sex supplies[14]. As part of the BCCDC, the BC Harm ReductionServices and Strategies (BCHRSS) committee guide pro-vincial harm reduction policies and convene quarterly,alternating between in-person and teleconference meet-ings. The committee includes representatives from the BCMinistry of Health, five regional Health Authorities, andFirst Nations Healthy Authority [15].In 2007, an increase in peer engagement in BC coin-cided [6] with the release of “Nothing About Us WithoutUs,” a report published by the Canadian HIV/AIDSLegal Network which makes a compelling case formeaningful peer involvement from a public health, eth-ical, and human rights perspective [16]. From thisreport, the BCHRSS committee agreed: “people who useillegal drugs should be engaged in all aspects of harmreduction supply distribution program development, im-plementation, and evaluation” [6], and in 2008 increasedsupport for peers by contributing to several peer-runevents, including financial support for a conferenceorganized by a peer-run group, Vancouver Area Networkof Drug Users (VANDU) [17]. Thereafter, efforts todevelop and expand meaningful peer engagement haveincreased and the BCHRSS committee has officiallyembraced peer engagement as an essential first step indecision-making.Peer engagement has the potential to augment equityof harm reduction services by fostering communication,building trust, increasing knowledge, and reducingstigma and discrimination to remove barriers and in-crease utilization of harm reduction services; this, inturn, will have a direct impact on mental and physicalhealth. Globally, public health research and practice hasshown that involvement of people with lived experienceresults in improved health outcomes and reduced healthdisparities by improving the acceptability and utilizationof health services and removing barriers to access [7].However, despite the increasing international supportfor engaging various populations [7, 8], there is very lit-tle published evidence on the implementation, evalu-ation, or effectiveness of meaningful engagement withpeers. This paper aims to describe and evaluate the peerengagement efforts undertaken by the BCHRSS commit-tee from 2010 to 2014. We highlight key lessons learnedand improvements needed to ensure meaningful peerengagement in the planning, delivery and evaluation ofharm reduction efforts.MethodsEvaluation resources and appraisalThe evaluation team appraised the events, processes andproducts of peer engagement in the harm reduction pro-gram from January 2010 – December 2014 using a peerengagement evaluation framework developed specificallyfor this project (described below). The evaluation teamincluded BCCDC staff as well as two peers. The peersinvolved in the evaluation had participated in BCHRSSmeetings and other peer engagement activities withhealth authorities between 2010 and 2014. Evidence wasobtained through a desk-based document review ofBCHRSS materials. The document review was a retro-spective review and synthesis of all relevant documentsGreer et al. BMC Public Health  (2016) 16:452 Page 2 of 9concerning the state of policies and provision of servicesand programs to identify social impacts and prioritiesfor action [18]. One research assistant (SL) did the initialgathering of documents and literature; however, thefindings were reviewed and discussed with all authors,including peers (CB & KL), and the drafting of thismanuscript was in partnership with peers. The lack ofmore collaborative involvement of the gathering of infor-mation was mainly due to the geographic distancebetween team members.Materials included formal documents, notes from rele-vant previously conducted focus groups and interviews,meeting agendas, minutes, and anonymous surveys, andthe BC Harm Reduction website. For documents, wereviewed How to Involve People Who Use Drugs (2014)[19], the BC Harm Reduction Strategies and ServicesCommittee Terms of Reference (2012) [15] and an in-ternal document, Peer Consultants at HRSS Face-2-Face(2014). Summary notes were available from focus groupsand telephone interviews that had been conducted to in-form a research funding application on peer engagementin BC (Peter Wall Solutions). Researchers at the BCCDCconsulted with seven representatives from all BCHRSSmember organizations and interviewed three groups ofpeers from two health regions in 2014. Conversationswith representatives and peers were not transcribed thuspreventing detailed secondary data analysis for thisevaluation. However, a document summarizing keythemes to inform current and future peer engagementefforts was available, in addition to the grant applicationitself, and incorporated.A review of the literature revealed a lack of evaluationframeworks based on the principles of health equity, aswell as frameworks for engagement with people who usedrugs. Public engagement evaluation tools were limitedin that most focused on outcomes, such as cost-effectiveness, rather than considering the process of en-gagement itself. The Involve UK’s guidelines for publicparticipation in central government most closely resem-bled our aims and equity-based evaluation principles[20]; thus, we adapted it, broadly using the language,themes, and structure as a general guide to developingan evaluation framework specific to peer engagement[see Table 1]. The four goals identified for evaluationwere supportive environment, equitable participation,capacity building and empowerment, and improvedprogramming and policy. Examples of constructs werederived from the evaluation of evidence itself and are byno means exhaustive or inclusive.The evaluation framework allowed us to compare andcontrast multiple sources of information and outcomes, in-creasing the validity of our findings through triangulationTable 1 Peer engagement process evaluation frameworkGoal Assessment Description Examples of constructsSupportiveEnvironmentHow were barriers and facilitatorsto engaging addressed?Assess and address barriers and facilitatorsof engagement; ‘environment’ encompassesmicro (i.e. power dynamics between individuals),meso (ie. organizing transportation to/from),and macro levels (i.e. meeting location).• Easy access/low threshold meetings(immediate compensation, supportivearrangements for people travelling fromout of town by paying transportationcosts in advance)• Community building activities• Building, location chosen• Planning in advance• Flexible scheduleEquitableparticipationHow were experiencesrepresented and respected?Ensure all experiences respected and representedat the table to address the diverse and uniquehealth needs of each community.• Democratic participation• Power dynamics• Flexible facilitation• Distribution of voices• Representativeness at the table• Awareness of peer issues andstrengths within the communityCapacitybuilding &empowermentHow did capacity increaseover time and how werebenefits derived?Develop the abilities of individuals and groupsdefined in terms of access, ability, mobilization,interest, networks, opportunity, and literacy.• Skills and ability• Confidence• Ongoing engagement or attrition• Social capital• Community building• Enhanced peer networks• CohesionImprovedprogramming& policyHow engagement impactsprogramming and policy?The explicit and implicit evolution of programmingand/or policy in relation to the purpose identified;ability to understand local risk environment,synthesize information, and design relevant solutions.• Programming and/or policy• Competency• Activities• Outputs• Feedback from within and/or outsidethe inner and/or broader communityGreer et al. BMC Public Health  (2016) 16:452 Page 3 of 9[21]. For example, we examined information about meet-ings involving peers by reviewing the agendas, minutes, at-tendee evaluation surveys, and post-meeting debriefingnotes. Where sources provided similar data, we simplifiedand summarized the messages, and where sources provideddifferent information, we presented the full breadth of per-spectives. Our evaluation failed to present any contradict-ory information requiring resolution.The University of British Columbia Research EthicsBoard granted the ethics approval for the interview andfocus group data used in this evaluation.ResultsThe evaluation results in Table 2 outlines our assessmentof peer engagement processes in BC from 2010–2014.These results focus mainly on events surrounding peer en-gagement with the BCHRSS, but also involve several otherharm reduction initiatives in BC at that time.Supportive environmentPeer engagement in BC was an iterative process thatincreased and improved over time as consequence of re-flexive learning. When the committee began invitingpeers to meetings, peers were not given clear expecta-tions. Feedback revealed planning in advance, makingtravel arrangements, setting up support locally, and cre-ating a welcoming environment were important factorsfor supporting and facilitating engagement. Organizinglocal methadone prescriptions or making arrangementsfor connecting to local peers for other supplies well inadvance was essential for out-of-town peers to feel sup-ported. It also contributed to their ability to be fullypresent at meetings. Sending an agenda and/or itineraryin advance developed peers expectations for the meeting.To establish rapport between attendees prior to themeeting, community-building activities were organized.Dinner at a restaurant was not comfortable, but in sub-sequent years sharing a meal in a more relaxed settingworked well. Developing a peer advisory group whocould provide feedback on the meeting agenda and otheractivities was one way to improve on existing efforts.Figure 1 is one example of the equitability and environ-ment of peer engagement in BC, offering a visual repre-sentation to highlight this reflexive and cyclical process.Equitable participationIn the beginning a single peer was invited to meetings.Activities offered to peers were separate from the rest ofthe committee. Feedback about the need for peer sup-port led the committee to extend its invitation to twopeers per region starting in 2011. Being in a new and/ordifferent place can be destabilizing for some, leading to“triggering” or inducing behaviors peers would otherwisetry to avoid. As such, offering supports around themeeting was imperative to equitable participation espe-cially when working with a population with diverseneeds and backgrounds. Due to the geographic structureof health authorities in BC, there was an unequal repre-sentation of peers from different regions at the meetings.Peer run organizations or groups, such as VANDU inVancouver Coastal Health Authority, were asked tonominate participants as representatives from theirregions. In areas where organized peer groups did notexist, such as the Northern Health Authority, harm re-duction coordinators in were encouraged to invite peerswho they had worked with during the year and to usethe meeting as an opportunity to promote sustainedinvolvement. Peers who had transportation, disability ormobility issues were accommodated. Nonetheless, peersfrom rural regions remained underrepresented, likelydue to the geography and inconsistent staffing in theseregions (i.e. Northern Health Authority, Interior HealthAuthority). Providers and peers from these regions wereexpected to travel great distances (sometimes more than500 kilometres) to engage or reach services, greatly lim-iting engagement opportunities. “One-off” or one-timeengagement opportunities outside of the BCHRSS werecommon but fragmented across events. Ongoing oppor-tunities and strategies to keep peers engaged in the longrun were needed. Peers also drew attention to power im-balances. Being attentive to the distribution of voices atthe table so everyone was treated equally and respectfullywas important. The need for strong but flexiblefacilitation, check-ins, and options to share ideas anonym-ously were identified as opportunities for improvement.Capacity building and empowermentThe BCHRSS committee supported the expansion ofpeer networks through research, networking, and fund-ing opportunities. In 2010, the BCHRSS committeesupported the BC-Yukon Association of Drug WarSurvivors to drive across BC as a team, meeting peers“where they’re at,” conducting harm reduction work-shops and gathering information about peers’ healthneeds. This project, known as the “Caravan Project,”[22] highlighted the informal peer engagement efforts todate, and served as the impetus to examine and enhancepeer engagement in BC. Peers from various regions wereinspired by the bold leadership of representatives frompeer-run organizations, such as the Society of LivingIllicit Drug Users (SOLID) and VANDU, and somebecame more involved in peer activities in their owncommunities. Some efforts were financially supported byBCHRSS funds to form new entities, such as theKelowna Area Network of Drug Users (KANDU). Fromthis project, the Eastside Illicit Drinkers Group formed.Even with limited financial supports, peer networksacross BC were able to mobilize around importantGreer et al. BMC Public Health  (2016) 16:452 Page 4 of 9Table 2 Evaluation Results from the British Columbia Harm Reduction Programme: lessons learnt, evidence of progress andopportunities for improvement, 2011–2014Construct Lessons Learnt Evidence of progress Opportunities for improvementGOAL: Supportive environment (How were barriers and facilitators to engaging addressed?CommunityBuilding activities• Reported feelings of exclusionamong peers• Lack of trust or legitimacy builtearly on members and otherpeers• Introduced various team-buildingactivities and ice breakers to buildtrust & openness• Included Aboriginal opening andclosing ceremonies, and pre-meetingdinner socialForm peer advisory group that isengaged with HRSS committeethroughout the yearPlanning inadvance• Peers unaware of role andexpectations; some informed ofmeeting with too short ofnotice• Invited multiple peers at least sixweeks in advance• Arrangements provided for transportation,accommodation, local support (i.e. methadone)Develop list/map of commonlyaccessed resources in hostcommunityStructure ofSchedule• Lack of opportunity to developrapport and trust withcommittee• Inconsistency of information• Agenda modified based on feedback provided bypeers before, during and after meeting• Meeting agenda more flexible with less contentDevelop agenda together (i.e.with peers and committee)GOAL: Equitable participation (How were experiences represented and respected?)Representativenessat the table• Unequal representation fromhealth authorities due tostaffing issues or lack ofcommitment from region• Shifted to inviting two peers per health region• Caravan project traveled to rural regions tomeet peers “where they’re at”Form peer advisory group engagedwith BCHRSS throughout the yearPower Dynamics;Distribution ofvoices• Inequitable distribution ofpower among peer groups andacross• Provided peers with cash stipend based on wage• Extra attention paid to distribution of power,people at the table, voices being heard• Discussions captured on flipchart so peers couldsee their voices being heard and respected• Shorter duration of roundtable updates allowedtime and space for peers to voice their concernsConsider options for peers tocommunicate their thoughts innon-verbal ways or in smallergroups; routine check-ins withpeers during breaksFlexible Facilitation • Heterogeneous representationof peers at the table• Rural/remote regions needattention• Attention paid to the attitudes during activities;able to adapt based on energy/positivity in room• Kept discussion positive and solutions-basedOngoing need for strong butflexible facilitatorGOAL: Capacity building &empowerment(How did capacity increase over time and how was it built on?)CommunityBuilding• Lack of opportunities initiatedoutside the BCHRSS meetings• Staffing issues remain aproblem• Peer engagement activities supported financiallythrough funds offered in each health authority• Beginning of peer-based harm reduction supplydistribution & educationDevelop sustained, ongoing fundingmechanism e.g. for work contractedto peer organizationsSocial Capital; skills&ability; confidence• Inability to build on existingcapacity within communities• Peers create EIDGE group with illicit alcohol users• Peer groups organize around key issues: socialhousing, anti-harm reduction by-laws, methadoneformulation changeSocial capital is strongest in urbanpeer groups; knowledge transferneeded with rural peer groupsEnhanced Peernetworks• Efforts fragmented acrossprovince• Some drug user organizationsdissolved due to lack of support• Peer network in BC grows via BCHRSS meetings,HR activities; opportunities for growing peer-run orgsBuild organizational capacity toincrease autonomy from anygroup of peersGOAL: Improved policy & programming (How engagement impact programming and policy?)Improved harmreductionprogramming• Identified inconsistent access toharm reduction supplies• Lack of capacity building andtraining for peer workers,service providers and decisionmakers• The Caravan Project• Expanded range of supplies to include saferinhalation supplies• Introduced BC Take Home Naloxone program• Developed specialized harm reduction trainings;posted training manual online• Introduced annual harm reduction client surveyBudget and other organizationalconstraints limit the expansion ofcomprehensive harm reductionservices – (frustrating for peers)Improved policies • Lack of peer engagement atother tables outside BCHRSS• Lack of best practices on bestways to engage peers• Developed one-page guidelinesfor providers on inviting peers to meetings• Peer engagement literature review(Ti et al., 2012 [7])• Improved documentation and disseminationof HRSS policies and research for lay audiencesDevelop best practice guidelinesfor services to meaningfullyengage peersGreer et al. BMC Public Health  (2016) 16:452 Page 5 of 9issues, such as social housing, anti-harm reduction by-laws, and methadone formulation changes. In 2013, theSOLID organized and hosted a national symposium ofpeers in Victoria that kick-started a conversation nation-ally with 14 peer-run organizations. These organizationsdocumented their successes for other peer-run organiza-tions and allies to learn from by creating a documentcalled “Collective voices for Effective Change” [13]. Wenoted that the ability to distribute this information, formnew peer networks, and build on already establishedcapacity among groups of peers was limited due tofinancial and geographic challenges.Policy and programmingThe BCCDC provided resources for the “Caravan Pro-ject,” [22] which identified the need for several policyand program initiatives through focus groups with peersacross BC. Eight priority areas for promoting healthequity were offered. In 2011, the BCCDC implementedtwo policy changes as a direct result of these findings: 1)regional representatives were asked to invite a local peerto the face-to-face meeting held in the spring of 2012,and 2) annual funds ($2000) were offered to supportpeer-led initiatives for harm reduction activities andmatching funds ($5000) for community development ac-tivities in each health authority [15]. Peer engagementopportunities and feedback on policy and programmingincreased as a result, which had additional effectsbeyond the BCCDC. Harm reduction sites started pro-viding safer inhalation supplies and the BC Take HomeNaloxone program was launched. Also, an annual clientsurvey at harm reduction supply distribution sites wasintroduced.Despite increased support for peer engagement by theBCHRSS, the lack of a formal peer engagement processesor guide as to how stakeholders reach out to engage peers,including how to invite, involve, and encourage participa-tion, led to inconsistent efforts. The committee struggledthrough staffing changes and turnover, leading todisjointed peer engagement efforts. These internal gapscontributed to the disbanding of some independent peernetworks (i.e. KANDU) and inconsistent support for newnetworks.DiscussionThis manuscript shares the lessons learned by theBCHRSS committee in adopting peer engagementTable 2 Evaluation Results from the British Columbia Harm Reduction Programme: lessons learnt, evidence of progress andopportunities for improvement, 2011–2014 (Continued)Activities • No formal process or evaluationof peer engagement in BC• Inconsistent effort toimplement processes, sustaininitiatives• Obtained financial support for peer engagementresearch in BC• Presented results and reports on peer engagementto stakeholders across the provinceEvaluate best practice guidelinesto ensure acceptability indifferent contexts (regions,populations)Fig. 1 Evolution of the equitable and enabling environment of peer engagement 2011–2014Greer et al. BMC Public Health  (2016) 16:452 Page 6 of 9practices in harm reduction initiatives in BC from 2010–2014. Increasing capacity and equity of peer engagement,as well as positive program and policy changes were evi-dent throughout. We found providing clear expectationsof the roles of peers and committee members at meetingsand purposeful engagement opportunities influenced thequality and overall success of events. However,organizational constraints, including staff and peer turn-over, were ongoing issues in terms of achieving opportun-ities for equitable peer engagement. Where there wasturnover, it was imperative new staff and peers are in-formed of previous practices, discussions, and culturalcontext. We also found that geography was a persistentchallenge for peer engagement in BC. For instance, North-ern Health Authority spans over half the province geo-graphically, yet has the smallest population. The healthneeds in rural areas have been found to differ from thosein urban areas, therefore requiring “rurally sensitive” ini-tiatives [23].This evaluation provides a case study of the cyclicaland iterative nature of peer engagement. Public partici-pation literature highlights the interrelated, iterativesteps in the engagement process, as a cycle of 1)designing for context; 2) enlisting and managing re-sources; and 3) evaluating and redesigning continuously[24]. Given that peer engagement is relatively new bothlocally and internationally, learning from past successesand failures is key to developing effective initiatives[24]. To ensure the integrity of this cycle, we learnedand stress the importance of unwavering commitmentto this work, both in terms of financial and staff re-sources, tailored to the context and individual experi-ences that vary among peers.A large body of evidence exists that supports citizenengagement in policy and program decisions to more ef-fectively address the needs of the public. Some argueparticipation may be ineffective and costly [25], whileothers see the public as the “most important stakeholderin the health care system” [26]. In a review of the litera-ture, Marshall et al. suggests systemic, organizational,and individual obstacles to peer roles exist in harm re-duction initiatives, including stigmatization, inadequatetraining, and lack of availability of peer roles [7]. It maybe that the effectiveness of engaging and involving peersdepends on methods adapted to population and context[27]. Literature stresses that both the form of engage-ment as well as the interactions that build trust andlegitimacy promotes meaningful and sustainable rela-tionships between stakeholders [8, 24]. Establishing legit-imacy may be particularly important for marginalizedgroups. Therefore, practical ways to develop trust, re-dress power imbalances, and improve relationships mustbe continually assessed and addressed [26]. Marginalizedgroups face unique interpersonal and structuralobstacles that may restrict their involvement in decision-making [7, 8, 16]. Similarly, by excluding some of themost marginalized members of society, we risk exacer-bating disparities among these groups [26].Support for engaging peers at the decision-makingtable has been expanding both locally and internationally[26]. Within Canada, peer input has influenced decisionsaround harm reduction best practices [6], [28] and mes-saging for overdose prevention [29]. Examples such asthese are evidence that peer engagement has the poten-tial to advance social justice by improving equity in thedistribution of services or by increasing marginalizedgroups’ influence over decisions [24, 30]. Although therehas been increasing evidence of positive outcomes frompeer-run programs, attention paid to upstream policyand program development is still lacking [7], [8]. Duringthis process evaluation, a time of increasing efforts to in-tegrate peer engagement in harm reduction services andstrategies in BC, peer groups across Canada noted thelack of initiatives for meaningful peer involvement inpolicies and programs across the country [13].Although we developed our own peer engagementprocess evaluation framework, efforts remain difficult tomeasure and evaluate. There is no single set of metricsin any evaluation of public engagement, but rather asubset of criteria based on most desirable implementa-tion outcomes [24]. Our evaluation framework focusedon four engagement goals that are not mutually exclu-sive and non-exhaustive; other aspects to peer engage-ment may need additional evaluation. The public healthoutcomes of peer engagement in harm reduction werenot examined as they were outside of the scope of thisresearch. As well, interactions between service providersand peers were not examined but likely played a key rolein the success of engagement efforts. The communityand relationships built through peer engagement are alsobeneficial products of this process. However, for thepurposes of this evaluation, these factors were not ex-amined. Future research should examine interpersonalfactors that are at play in peer engagement in harmreduction and the potential impact peer engagementcan have on overall public health. Any unintendedconsequences from any peer engagement approach,such as tokenistic engagement opportunities, “trigger-ing” or destabilizing situations, or exploitation of peers,should also be explored and documented in greater detail.Procedures offered in this evaluation may be used as strat-egies to avoid some negative consequences of peerengagement.Furthermore, peer engagement is an evolving process,influenced by many external ecological factors over time.It may not be possible to measure latent impacts of pol-icy choices or peer engagement within the timeframe ofthe evaluation itself [24]. It is difficult to attributeGreer et al. BMC Public Health  (2016) 16:452 Page 7 of 9findings to one decision or time as engagement evolveswithin an ever-changing context. Most data was qualita-tive, requiring a subjective, retrospective assessment ofquality, rather than a quantitative indicator of success orfailure. There are likely several other aspects to peer en-gagement that were not evident, such as improvinghealth and social networks. Given that consultationswith peers and harm reduction representatives wereintended to identify and inform the application of peerengagement processes, we did not record and transcribethese conversations. The retroactive assessment of peerengagement and lack of primary data from peers in amajor methodological limitation of this evaluation. Thevoices and experiences of peers and harm reduction rep-resentatives are crucial to improving future peer engage-ment initiatives. It is our hope that future research willconsider more in-depth experiences of peer engagementto provide a richer understanding of peer engagementprocesses and practices in the field.ConclusionsOverall, this evaluation emphasized the ongoing import-ance to engage peers in the planning, delivery, and evalu-ation of harm reduction initiatives. It provided a foundationfor establishing new or promoting existing peer engage-ment. Broadly, this evaluation offers some of the first evi-dence showing peer engagement as a tool for policychange, capacity building, and equity by facilitating inclu-sion regardless of social position or other circumstance.Findings included important lessons learned and strategiesfor improving the implementation, delivery, and sustain-ability of peer engagement. Several practice recommenda-tions based on crosscutting themes were highlighted in ourevaluation, derived for designing future peer engagementinitiatives [see Table 3]. Finally, we offer opportunity tofuture research to further develop our evaluation frame-work for peer engagement in other health equity contexts.AbbreviationsBC, British Columbia; BCCDC, British Columbia Centre for Disease Control;BCHRSS, British Columbia Harm Reduction Services and Strategies; KANDU,Kelowna Area Network of Drug Users; SOLID, Society of Living Illicit DrugUsers; VANDU, Vancouver Area Network of Drug UsersAcknowledgmentsWe would like to thank Hugh L. from the Vancouver Area Network of DrugUsers and the Society of Living Illicit Drug Users for their support andcommitment to this work.Availability of data and materialsThe data from this project consists primarily of internal documents and focusgroups. Due to the confidentiality of this information, the data will not be shared.Authors’ contributionsAG developed the evaluation framework, conducted the evaluation, anddrafted the manuscript. SL and AA did the document review and participatedin drafting the manuscript. KL and CB were involved in peer engagementactivities and conducted member checking on the findings and interpretation.AG, SL, AA and JB participated in the design and coordination of the study.All authors read and approved the final manuscript.Competing interestsThe authors wish to declare that they have no competing interests.Ethics, consent and permissionsEthics for the interviews and focus groups reviewed in this study wasprovided by the University of British Columbia Research Ethics Board.Participants in interviews and focus groups consented to participate and topublish findings from this study.Author details1BC Centre for Disease Control, 655 West 12th Avenue, Vancouver, BritishColumbia V5Z 4R4, Canada. 2School of Population and Public Health,University of British Columbia, 2206 East Mall, Vancouver, BC V6T 1Z3,Canada. 3The Farr Institute of Health Informatics Research, University CollegeLondon, 222 Euston Road, London NW1 2DA, United Kingdom. 4Society ofLiving Illicit Drug Users, 857 Caledonia Street, Victoria, British Columbia V8T1E6, Canada.Received: 21 January 2016 Accepted: 14 May 2016References1. 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HIV prevention, treatment, and care services for peoplewho inject drugs: a systematic review of global, regional, and nationalcoverage. The Lancet. 2010;375(9719):1014–28.6. Best Practices for British Columbia’s Harm Reduction Supply Distribution Program.Vancouver: BC Center for Disease Control 2008. http://www.bccdc.ca/resource-gallery/Documents/Guidelines%20and%20Forms/Guidelines%20and%20Manuals/Epid/Other/BestPractices.pdf. Accessed 23 May 2016.Table 3 Recommendations for peer engagement in harmreduction initiatives• Create a low barrier, low threshold environment adapted to thecontext of the peers involved• Use reflexivity, reflecting and learning from the process• Define roles and expectations for all stakeholders• Be conscientious of who is at the table and prioritise traditionallyunder-represented peer groups (e.g. those from rural and remotecommunities)• Develop formal best practice peer engagement guidelines• Ensure consistency across regions and stakeholders• Provide support for building and connecting new and existing peernetworks• Make the most of and expand on capacity that has already been built• Promote ongoing commitment to the process from all stakeholdersGreer et al. BMC Public Health  (2016) 16:452 Page 8 of 97. Ti L, Tzemis D, Buxton JA. Engaging people who use drugs in policy andprogram development: A review of the literature. Subst Abuse Treat PrevPolicy. 2012;7(1):47.8. Marshall Z, Dechman MK, Minichiello A, Alcock L, Harris GE. Peering into theliterature: A systematic review of the roles of people who inject drugs in harmreduction initiatives. Drug Alcohol Depend. 2015;151:1–14.9. Arnstein SR. A Ladder Of Citizen Participation. J Am Inst Plann. 1969;35(4):216–24.10. R. A. Hart. Children’s Participation in Planning and Design. In: C. S. Weinsteinand T. G. David, Editors. Spaces for Children. United States: Springer; 1987,p. 217–239.11. Pretty JN. Participatory learning for sustainable agriculture. World Dev.1995;23(8):1247–63.12. Cornwall A. Unpacking ‘Participation’: models, meanings and practices.Community Dev J. 2008;43(3):269–83.13. Collective voices effective change: A final report of National meeting ofpeer-run organizations of people who use drugs. Canadian Association ofPeople Who Use Drugs. Victoria: Centre for Addictions Research of BC; 2014.https://static1.squarespace.com/static/53015f40e4b0c6ad9e406a13/t/53972833e4b0240065925810/1402415155682/CollectiveVoices+Report+FINAL+30May14.pdf. Accessed 23 May 2016.14. British Columbia Harm Reduction Program: Toward the Heart. http://towardtheheart.com/. Accessed 23 May 2016.15. BC Harm Reduction Strategies and Services Committee Terms of Reference.Vancouver: BC Center for Disease Control; 2012. http://www.bccdc.ca/resource-gallery/Documents/Guidelines%20and%20Forms/Guidelines%20and%20Manuals/Epid/Other/TORSept2012_final.pdf. Accessed 23 May 2016.16. "Nothing About Us Without Us" Greater, Meaningful Involvement of PeopleWho Use Illegal Drugs: A Public Health, Ethical, and Human RightsImperative. Canadian HIV/AIDS Legal Network. 2006. http://www.aidslaw.ca/site/wp-content/uploads/2013/04/Greater+Involvement+-+Bklt+-+Drug+Policy+-+ENG.pdf. Accessed 23 May 2016.17. The history of harm reduction in BC. BC Center for Disease Control. 2012.http://www.bccdc.ca/resource-gallery/Documents/Educational%20Materials/Epid/Other/UpdatedBCHarmReductionDocumentAug2012JAB_final.pdf.Retrieved May 23, 2016.18. Smith M. Evaluability assessment: a practical approach. Boston: KluwerAcademics; 1989.19. How to involve people who use drugs. BC Center for Disease Control; 2014.http://towardtheheart.com/assets/uploads/files/How_to_Involve_People_Who_USe_Drugs.pdf. Accessed 23 May 2016.20. Making a difference: a guide to evaluating public participation in centralgovernment, Involve, London, UK, 2007.21. Y. S. Lincoln and E. G. Guba, Naturalistic Inquiry. Newbury Park, CA: SAGE,1985.22. Crabtree A. It’s powerful to gather: a community-driven study of drug users’and illicit drinkers’ priorities for harm reduction and health promotion inBritish Columbia, Canada. Vancouver: Doctor of Philosophy, University ofBritish Columbia; 2015.23. Hay D, Varga-Toth J, Hines E. Frontline health care in Canada: Innovations indelivering services to vulnerable populations. Canadian Policy ResearchNetworks: Ottawa, ON, Research Report F 63, 2006.24. Bryson JM, Quick KS, Slotterback CS, Crosby BC. Designing PublicParticipation Processes. Public Adm Rev. 2013;73(1):23–34.25. Irvin RA, Stansbury J. Citizen Participation in Decision Making: Is It Worth theEffort? Public Adm Rev. 2004;64(1):55–65.26. Bruni RA, Laupacis A, Martin DK, the U. of T. P. S. in H. C. R. Group. Publicengagement in setting priorities in health care. Can Med Assoc J. 2008;179(1):15–8.27. Crawford MJ, Rutter D, Manley C, Weaver T, Bhui K, Fulop N, Tyrer P .Systematic review of involving patients in the planning and developmentof health care. BMJ. 2002;325(7375):1263.28. New best practice guidelines for harm reduction programs promote needledistribution | CATIE - Canada’s source for HIV and hepatitis C information.http://www.catie.ca/en/pif/spring-2014/new-best-practice-guidelines-harm-reduction-programs-promote-needle-distribution. Accessed 23 May 2016.29. Y. Soukup-Baljak, A. M. Greer, A. Amlani, O. Sampson, and J. A. Buxton. Drugquality assessment practices and communication of drug alerts amongpeople who use drugs. Int. J. Drug Policy. 2015;26(12):1251–1257.30. M. Feldman, K. Quick, and N. Guillermo. The emergence of co-production:learning from history. presented at the 11th Public Management ResearchConference, Madison, Wisconsin, 2013.•  We accept pre-submission inquiries •  Our selector tool helps you to find the most relevant journal•  We provide round the clock customer support •  Convenient online submission•  Thorough peer review•  Inclusion in PubMed and all major indexing services •  Maximum visibility for your researchSubmit your manuscript atwww.biomedcentral.com/submitSubmit your next manuscript to BioMed Central and we will help you at every step:Greer et al. BMC Public Health  (2016) 16:452 Page 9 of 9

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