What is the Program?
SisterSpace is a women-only overdose prevention site (OPS) in Vancouver’s Downtown Eastside (DTES). The OPS opened in May 2017 and allows women to use substances in the presence of workers trained in overdose response. Trans women, genderqueer women and non-binary people who are significantly femme-identified can use the services.
SisterSpace is run by Atira Women’s Resource Society (AWRS), with funding and/or staff support from Vancouver Coastal Health, the City of Vancouver, B.C. Housing, B.C. Women’s Hospital and the Provincial Health Services Authority. AWRS is a not-for-profit organization dedicated to ending violence against women. They provide women and children affected by violence with safe and supportive housing, as well as community support services, education and employment initiatives.
Why Was the Program Developed?
The SisterSpace OPS opened in response to British Columbia’s ongoing overdose crisis. Overdose prevention sites are one of the main strategies used to address the overdose crisis and prevent overdose deaths.
Many women in the DTES have multiple stigmatized and marginalized identities (e.g., sex work, homelessness). The need to provide a women-only OPS was identified through conversations with the women with whom AWRS worked, as well as stories from other community organizations that serve women in the DTES. Women noted that there were barriers in accessing harm reduction services (e.g., gender-based harassment and violence, stigma) and some women therefore make the decision not to use the services at all.
SisterSpace was developed in response to this need, as a safe space for women to access overdose prevention services. Knowledge that woman tend to be more relational helped to inform the initial development of the space, including its initial layout and feel. AWRS also looked for examples of other OPS models for women to help inform development of the service, but such information was limited.
The site was opened quickly in the midst of the overdose crisis. A developmental evaluation took place in the first three months of the program to inform the operation and policies associated with the site. On the basis of this evaluation, changes were made (e.g., hours of operation were extended and adjusted to better meet the needs of clients).
Development and implementation of the program are guided by a gender-responsive framework that acknowledges the influence of gender on the development of programs, as well as trauma-informed principles that consider how the accessibility of a program is informed by a service user’s experiences of trauma.
How Does the Program Work?
SisterSpace is attached to a women-only residence run by AWRS, although the OPS services can be accessed by the wider community. The site can accommodate up to 15 women at one time and is open 18 hours a day (6:00 p.m. to noon the following day), seven days a week. The site consists of a main room where women can use substances, a kitchen, a nurse’s office and an onsite bathroom.
SisterSpace provides a safe and supportive environment where women can use drugs (they can inject or inhale them or take them orally; smoking is only permitted outside) in the presence of peer support workers who are trained in overdose response. The program is promoted by word of mouth, although there have been efforts to distribute flyers and posters at other OPS and women-only programs (e.g., organizations that provide services to women involved in street-based sex work) in the DTES. An open house was held when the site first opened and was attended by community members, SisterSpace peer support workers and potential service users.
In addition to providing a space for women to use substances in the presence of workers trained in overdose response, SisterSpace provides a variety of other services, including the following:
- Referrals can be made to other programs and services, including emergency shelters and housing. Peer support workers can also refer clients to other related community supports and services (e.g., legal aid, take-home naloxone programs, counselling services)
- Referrals can be made to medical services such as dental care, as well as substance use treatment and detox programs; this includes making medical appointments for clients.
- Safer injection supplies (e.g., needles, sterile water, cookers, tourniquets, alcohol swabs and vitamin C packages), safer smoking supplies (e.g., pipes, mouthpieces, screens and push sticks) and condoms and lubricant are provided.
- An onsite nurse practitioner provides health care services three mornings per week (e.g., access to safe supply, including writing prescriptions; wound care; abscess care; annual Pap smears).
- Snacks (e.g., fruit, cookies), tea, coffee and water are provided (many women arrive at the site dehydrated).
- Clients can use a phone to make local phone calls.
- Attempts are made to follow up with women who stop accessing the program, and a missing persons report is filed if needed.
- Reports on bad dates (i.e., violent experiences that women have had while doing sex work) are shared. SisterSpace posts bad date reports on their wall, and through connections with other organizations that serve women in the DTES, support has been provided to help women complete bad date forms.
- Social support is provided by creating an environment that allows for both light-hearted social interaction and/or discussions on sensitive topics. Women may also receive support from other clients, as well as from peer support workers.
- A fentanyl testing machine is available at certain times.
The main room of the OPS has been furnished and decorated to create a “living room” atmosphere (with plants and murals) where women can feel comfortable and welcome. A main distinction between the SisterSpace OPS and other OPS is that the furniture can be moved around and women can use in groups if they wish. Individual chairs with privacy screens are also available for those who choose to use alone.
Initially the program did not have any specific guidelines for women’s behaviour, to ensure that the site was as accessible as possible for all women. The peer support workers later created guidelines for behaviour as a result of disruptive behaviours that were sometimes observed at the site. Guidelines are posted on the wall and women who use the OPS are now asked to:
- sign in when they arrive
- limit the amount time they spend at the OPS (30 minutes, if possible)
- smoke outside
- clean up when done and dispose of their works
- cap needles when they are walking around
- not unpack bags when visiting the site and not leave belongings behind, as SisterSpace does not have storage space
The guidelines are not strictly enforced and there are no consequences for not following them. They are meant to encourage clients to be considerate of others and the space (e.g., to limit the amount of time they are spending at the site, especially if it is busy).
Peer support workers staff SisterSpace 18 hours per day (because of adaptations to address the COVID-19 pandemic, one peer worker at a time staffs the site at present). There is also a full-time program manager, and a nurse practitioner is at the site three mornings per week.
Peer support workers
Peer support workers are paid staff. They are women who have a current or previous history of substance use. They often have shared experiences with SisterSpace clients, such as difficulties accessing the healthcare system, homelessness and experiences with substance use treatment. Shared experiences allow the peer support workers to form non-judgmental and trusting relationships with clients.
Peer support workers complete paid training before their employment at SisterSpace. Training includes topics such as how to respond to an overdose (e.g., administer naloxone and/or oxygen), non-violent crisis intervention and first-aid certification. Training is ongoing and can include topics such as anti-oppression and decolonization training, as resources are available or as the need arises.
Peer support workers work in shifts that are two to six hours long and attend weekly team meetings with the program manager. During these meetings, challenges are discussed, questions are answered and knowledge is shared between the peer support workers and the program manager. Semi-annual meetings are conducted by external facilitators, and one-to-one support is provided to peers as needed through programs such as AWRS’s Stopping the Violence counselling program. Staff members are given regular time to debrief with each other and space is provided for this debriefing, especially following a critical incident.
- Safe space with access to proper lighting and seating
- Harm reduction supplies, including injection supplies (e.g., needles, sterile water, cookers, tourniquets, alcohol swabs and vitamin C packages), condoms and lubricant and safer smoking kits (e.g., pipes, mouthpieces, screens and push sticks)
- Oxygen to respond to overdose
- Naloxone to respond to overdose
- Peer support workers
- Program manager
- Nurse practitioner
- Connections to community health and social service organizations for referrals
- The work of the peer support workers is demanding and occasionally women hired as peer support workers have quit or not shown up for shifts. Punctuality has also been an issue.
- It is difficult to reach women who are socially isolated and at increased risk of overdose deaths. Efforts to reach women in single-occupancy hotel rooms are one way to potentially address this issue.
A three-month developmental evaluation of the SisterSpace OPS was completed during its first three months of operation to inform the program’s implementation. The evaluation used both quantitative and qualitative data collection methods including surveys with program users, a focus group with peer support workers, observation of activities (e.g., staff meetings and trainings) and review of peer support worker logbooks.
During the first three months of the program, there were 1,073 visits to SisterSpace by 115 women. Among those who provided information on their age (89%), 69% were between 30 and 49 years old. During these visits, women accessed harm reduction supplies approximately 250 times.
The evaluation found that:
- SisterSpace was a safe and accessible program for women who are highly marginalized and underserved.
- The peer support worker model is essential to SisterSpace’s ability to provide a safe space.
- Integrated services are a way to increase the impact of the program.
Women mentioned that they felt safe at SisterSpace. Peer support workers believe that their work at SisterSpace is important and they value the contributions that they can make.
Results from a separate study on SisterSpace based on ethnographic fieldwork and in-depth interviews with 45 clients from May 2017 to June 2018 found that:
- SisterSpace provided a space free of some forms of stigma and discrimination, gendered and social violence, as well as drug-related harms, including overdose.
- SisterSpace made people feel safe.
- The initial hours of operation for the program were 6:00 a.m. to 12:00 p.m. and 6:00 p.m. to 12:00 a.m.; however, because of demand and the desires expressed by clients, the hours of operation were expanded to 18 hours a day, seven days per week, to ensure that services were always available.
- It is important to invest in the skills and well-being of peer support workers, as the program’s success relies on them. Dealing with issues such as burnout and stress in peer support workers is essential.
- SisterSpace Shared Using Rooms Women-Only Overdose Prevention Site: Three-Month Developmental Evaluation
Janice Abbott, CEO
Atira Women’s Resource Society
101 E Cordova St
Vancouver, BC V6A 1K7