Harm Reduction Peer Backpack and Vending Machine Project

What is the Program?

The Harm Reduction Peer Backpack and Vending Machine Project aims to increase the distribution of harm reduction supplies (e.g., needles, pipes) in the rural Saskatchewan communities of North Battleford, Cut Knife, Lloydminster, Meadow Lake and Green Lake to decrease the transmission of hepatitis C and HIV.  The program distributes harm reduction supplies through the use of peer backpackers (current or former injection drug users) who distribute supplies on foot from backpacks and through a mobile outreach van and a fixed-site harm reduction room and who maintain harm reduction vending machines located in rural towns. People with the lived experience of drug use guided the development of the program.

The program’s strength is its strong peer component. At the core of the program is its ability to empower people who currently or previously injected drugs to strengthen their skills and to help other people who inject drugs. 

The program was funded in February 2019 by the Public Health Agency of Canada through the Harm Reduction Fund.

Why Was the Program Developed?

HIV and hepatitis C rates continue to rise in Saskatchewan, especially among people who inject drugs. Rural and remote communities often lack after-hours access to harm reduction supplies, which are known to reduce transmission of both HIV and hepatitis C. The program aims to increase access by facilitating secondary distribution of harm reduction supplies, or the distribution of supplies through peers, as well as offering after-hours distribution services.

The program was developed not only to improve access to harm reduction supplies and reduce risk-taking behaviour (e.g., sharing drug use equipment), but also to improve relationships with clients to encourage engagement in health and wellness services. The program also seeks to strengthen the skills, competencies and abilities of peers through employment in the program.

How Does the Program Work?

The Harm Reduction Peer Backpack and Vending Machine Project is a peer-led program that involves the distribution of harm reduction supplies (e.g., needles, pipes) in several rural Saskatchewan communities. The program accomplishes this in the following ways:

• Peer backpackers (i.e., “peers”) walk all five communities and distribute supplies from backpacks.
• Peers distribute supplies from a mobile outreach van and a fixed-site harm reduction room alongside public health staff (e.g., nurse, outreach workers) in North Battleford.
• Clients can access supplies after hours from harm reduction vending machines in North Battleford, Lloydminster and Meadow Lake. The vending machines are stocked and maintained by peers.

Hiring, training and supervising peers

Peers are recruited at the recommendation of the staff at local harm reduction sites/ public health offices, both of which are run by the Saskatchewan Health Authority (SHA). Peers sign a work and confidentiality agreement and are engaged as contract workers for the SHA.

A public health nurse employed by the SHA coordinates the program centrally. Staff at local public health offices (e.g., nurses, outreach workers) act as a point of contact and support for peers, in each community. A peer advisor, who is a contract worker of the SHA, supports peers one to one. The peer advisor connects with peers by telephone and text and is allotted 9.5 hours per week for their work. Much of the peer advisor’s work is to ensure that the peers stay engaged and that they are distributing supplies out in the community rather than just having people stop by their home. The peer advisor and local office staff are responsible for collecting paperwork, holding a monthly meeting with all program staff, ensuring that tracking forms are completed and returned, helping peers access supplies from local public health offices and supporting peeers in attending fixed-site harm reduction rooms to pick up supplies.

Peers receive orientation training when they start in the program as well as ongoing trainings. Trainings can happen in person or via telephone and provide an opportunity to bring peers together. Training topics include:

• how to administer naloxone in the event of an overdose
• safer drug-use principles including not sharing drug use equipment and the “cook your wash” concept
• how to track the supplies that are given out and to whom they are given
• HIV and hepatitis C education (e.g., disease progression, testing, treatment)
• how to make referrals for testing, infectious disease treatment, addiction counselling or detox/treatment and referrals to an outreach van or walk-in clinic for wound care (e.g., abscesses)
• confidentiality
• boundary setting, safety and professionalism
• injection safety (e.g., learn to inject yourself, changing injection sites)
• safe disposal of needles (e.g., how to handle discarded needles, use of containers, where to return used needles)
• post-exposure prophylaxis and its relevance following an accidental needle stick injury
• prevention of HIV and hepatitis C, including pre-exposure prophylaxis, condoms, the importance of not sharing personal grooming equipment (e.g., razors, clippers)

The peers are paid $80–$120 per week for approximately 4–6 hours of work. Their work includes building connections, providing education and referrals, distributing supplies, packing supplies and stocking the harm reduction vending machines.

Peer backpackers

The program currently has eight peers who are distributing supplies from backpacks in North Battleford, Cut Knife, Lloydminster, Meadow Lake and Green Lake. In addition to walking communities to hand out supplies, peers work to improve connections between people who use drugs and community supports and to provide education and referrals. When distributing supplies from backpacks, peers track the age and gender of the clients to whom they provide supplies, the number of supplies (e.g., pipes, needles) they give out, whether they engage in educational activities with clients and how many referrals they make.

It is important to recognize that many community members informally distribute supplies to their networks outside of the formal peer backpacker program. The program is developing a video-based training module that peers employed by the program can distribute to community members.The videos will reinforce the educational messages shared by the program’s peers and will be used to train and provide support to informal secondary distributors. The program is looking into providing compensation to community members who complete training on secondary supply distribution.

Harm reduction vending machines

Harm reduction vending machines are used to distribute supplies 24 hours a day and are housed at SHA sites (two hospitals, one public health site). There are currently vending machines in North Battleford, Lloydminster and Meadow Lake. The supplies in the vending machines are accessible by tokens. Tokens are available from a variety of local community organizations (e.g., Battleford Sexual Health Clinic, Lloydminster Men’s Shelter, SHA fixed-site harm reduction rooms) and each client can take up to five tokens at a time. Most clients access the vending machines between 4:00 p.m. and 10:00 p.m.

The vending machines are secured to a cement pad and sheltered to block heavy rain. The vending machines have a Plexiglas front reinforced with metal cages. Sharps disposal bins are placed near the vending machines and secured to the ground. Peers are responsible for monitoring, restocking and maintaining the vending machines. A tracking system is used to identify any issues in relation to the vending machines. Peers check the vending machine sites one or two times per day, seven days per week.

The packaging and types of supplies available in the vending are designed to meet the needs of the community in which they are located. Supplies can include:

• needles
• swabs
• cookers or spoons
• water
• filters
• vitamin C
• condoms
• tourniquets
• sharps containers
• Fitpacks that include a small yellow sharps container and are filled with two needles, two swabs, two filters, two cookers, one tourniquet and two small containers of water
• safer inhalation kits that include pipes for crystal meth and crack pipes

Mobile outreach van and fixed-site harm reduction room

The program has evolved to have peers accompany outreach staff (e.g., nurses, social workers, outreach workers) in a mobile outreach van to distribute supplies to locations where they are needed. In North Battleford, three peers work alongside staff in the van. The van is the preferred model of supply distribution, as it helps to set working hours for peers. Peers identify locations where outreach is needed and help staff to build relationships with community members to facilitate supply distribution, testing and referrals. Peers also promote the van to community members and bring people to the van for services. Peers often talk to potential clients outside of the operating hours for the van; they educate them on the importance of testing and work to connect the outreach nurse and clients through the van if clients are ready to engage. The mobile van operates one day per week (11:00 a.m. to 2:00 p.m.) and one evening per week (4:00 to 7:00 p.m.). 

Testing for sexually transmitted and blood-borne infections (STBBI) such as HIV, hepatitis C, syphilis, gonorrhea and chlamydia is completed at the van. Referrals to community-based organizations and services (e.g., friendship centres, support groups, mental health supports, opioid recovery programs, physicians) are also made from the van. In addition, staff can help clients to navigate different systems (e.g., obtaining income assistance or a health card) and offer simple supports such as letting clients use a phone and providing food.

Peers also work out of a fixed-site harm reduction room at the Battleford Sexual Health Clinic. This has brought new clients into the sexual health clinic. The harm reduction room is open during the clinic’s hours on Monday to Friday, and clients can attend to pick up needed supplies and receive education from harm reduction staff (e.g., peers, outreach workers). The harm reduction room also provides an opportunity to connect clients to STBBI testing at the sexual health clinic and other community services.

Required Resources

• Peer backpackers
• Peer mentor/advisor
• Project coordinator (the current program coordinator is a public health nurse)
• Public health nurse, harm reduction outreach workers, outreach and social worker for local peer supervision and support, and to staff the mobile van and fixed-site locations
• Harm reduction supplies and backpacks
• Harm reduction vending machines
• Mobile outreach van

Challenges

• There was no local supplier of vending machines and it was difficult to hire someone to maintain and service the vending machines locally.
• It can be difficult for the program coordinator or peer advisor to contact the peers, as peers do not always have a working phone (even if the program has supplied them with one). It was decided that keeping an active phone was a requirement to work in the program. If peers had not already received a phone from the program they were required to obtain one on their own and the cost of their minutes would be covered by the program.
• There have been inconsistencies with vending machine stocking and peers’ shift attendance.
• Turnover of peers has been common because of competing or changing life priorities.
• Issues with inconsistent completion of data collection work sheets.
• The vending machines do not always work when it rains.
• There has been vandalism of the vending machines (e.g., clients have kicked the machine if an item is stuck).
• Some peers have slowly reverted to providing supplies from their home rather than walking around to various locations, which can lead to boundary issues (e.g., community members requesting supplies outside of a peer’s working hours).
• There was hesitancy from nearby residents regarding the placement of the vending machines, which caused delays and required a lot of education and compromise to get the program running.

Evaluation

Data on the program are being collected through client surveys and focus groups. Program implementation is being assessed, as well as the program’s effectiveness in decreasing hepatitis C and HIV infections. The program aims to decrease the sharing of needle equipment by 30% and to increase the capacity, through education (e.g., videos), of informal secondary distributors by 25% in three rural communities.

From March to June 2020 the following supplies were distributed:

In North Battleford:

• 18,320 needles
• 1,177 crack pipes
• 1,917 meth pipes

In Meadow Lake:

• 5,013 needles
• 397 crack pipes
• 268 meth pipes

In October 2019, there was an average of 3–16 visits to the vending machine per day.

Lessons Learned

• Adjustments to the vending machines had to be made to ensure that slots were the necessary sizes to prevent jamming. Supply packages were adjusted to ensure that the vending machine’s capacity was maximized.
• It was found that it was necessary to check and stock the vending machines daily. If the machine is in good working order and stocked, it helps to prevent vandalism.
• The need to give the program a brand identity was noted. For example, a logo was created for peers to wear on bunnyhugs (i.e., hoodies), toques and backpacks. This improved the program’s credibility with peers but also with community members such as the police and staff at community-based organizations. It provided a sense of identity and cohesion.
• The program purchased the vending machines from a supplier in Ontario. Leasing vending machines locally may be a better option as it would allow for on-site maintenance support, rather than remote support, which is limited.
• Consistency in expectations with peers is essential to ensure that shifts are covered and that the team is not left with inadequate staffing.
• Tokens seem to disappear. If a program decides to pursue the token approach, it may wish to buy the tokens in bulk. Alternatively, a passcode system could be used to access the vending machines.
• Informal secondary distribution was already happening in the community. It made sense to pay peers employed by the program to complete training on how to do secondary distribution so that they could then train and support community members providing this service.
• Some peers do not want to set specific working hours and would rather distribute supplies throughout the week, so there needs to be flexibility in how peers distribute supplies and how they are compensated (e.g., compensated for tasks completed rather than the amount of time that their work took).
• It is difficult to track hours worked and supplies distributed. Having peers work alongside public health staff at a fixed-site location or in a mobile outreach van allows for clearer working hours and tracking of hours worked.

Program Materials

• Surveys
• Peer agreements (revised from Regina peer mentor program)
• Tracking forms (vending machines)
• Tracking forms (peer backpacker)

Contact Information

Danielle Radchenko, Registered Nurse and Program Coordinator
Saskatchewan Health Authority
11427 Railway Avenue
North Battleford, SK
S9A 3G8
Danielle.Radchenko@saskhealthauthority.ca