Capacity Building and Creating Supportive Environments for Inclusive Community-Based Participatory Research: A Case Study of the Overdose Prevention Peer Research Assistant (OPPRA) Project

Abstract

Community members, service users, and people with lived experience, sometimes referred to as “peers,” are increasingly engaged in public health research and practice. The involvement of peers can enhance the acceptability and efficacy of public health interventions, foster trust, and is particularly significant in public health contexts characterized by stigma and criminalization. The involvement of peers in research, such as through community-based participatory research (CBPR) approaches, presents important opportunities for meaningful community engagement. However, the complex challenges associated with research training, capacity building and creating supportive research environments remain underexplored in the literature, particularly for communities that experience social exclusion and marginalization. This study presents a case study of the Overdose Prevention Peer Research Assistant (OPPRA) Project, a CBPR initiative that meaningfully involved harm reduction workers and people who use drugs in research about overdose prevention sites. We describe how inclusion and shared decision-making were accomplished through tailored research training and capacity building with peers and the process of developing supportive research environments that integrate social supports and meet peer research assistants “where they are at.” Further, we outline innovative and collaborative methods for data gathering and analysis developed to involve peers at every step of the research process and share the results of this original research. Results demonstrate the potential for overdose prevention sites to serve as critical points of connection and promote human rights and wellbeing for peer workers, service users, and the broader community.

Introduction

Community engagement is increasingly understood as central to ethical and rigorous public health research and practice (Flicker & Nixon, 2015). Long valued for the potential to increase the acceptability, relevance, and benefit of public health research (Holzer et al., 2014), calls for “Nothing about us without us” also underscore the ethical imperative for community engagement in knowledge production and decision-making (Jürgens, 2008). “Community” refers broadly to the people affected by, or who would benefit from, public health policies, interventions, and research being considered or implemented. This may include service users, neighborhood residents, or groups with a collective experience of health inequity, health behavior, or identity (Israel et al., 1998).

Community engagement in knowledge production has been enriched through the development of community-based participatory research (CBPR). We understand CBPR to be a flexible approach to the co-production of knowledge, fundamentally committed to sharing power and decision-making through the active and meaningful involvement of community members and organizations throughout the research process (Israel et al., 1998). Additionally, CBPR generally aims to address social and structural inequities and create positive and transformative change through acting on issues of significance to the community (Collins et al., 2018).

As a flexible approach, CBPR practices have been adopted and taken up in different settings. For example, “patient-oriented research” has many shared principles with CBPR and has been widely promoted by health funding agencies in Canada, the United Kingdom, and the United States (Wyer, 2023). These investments have contributed to a growing awareness and interest in CBPR, particularly in approaches that directly involve “people with lived and living experience” in research, often as so-called “peers” (or “peer research assistants”).

The involvement of peers in public health research and practice has shown to be highly effective and acceptable (S. Greene, 2013; Simoni et al., 2011; Ti et al., 2012). Situated as an “insider” with the community, peers carry unique insights that can support meaning making and enhance the validity and reliability of research (Kelly et al., 2020). The involvement of peers may take on even greater significance with communities that experience stigma or criminalization, through creating connections, establish trust, and reducing barriers to participation (Marshall et al., 2015).

Drawing from a multi-year research collaboration between the British Columbia Centre on Substance Use (BCCSU) and the Overdose Prevention Society, we describe an inclusive model of CBPR with harm reduction workers and advocates for people who use drugs. We detail our approach to capacity building, outline novel and collaborative methods for data gathering and analysis, and share the results of this original research. We begin with a description of the public health context and study setting.

Harm Reduction & Overdose Prevention

Against a backdrop of the unrelenting toxic drug and overdose crisis (National Center for Health Statistics, 2024; Public Health Agency of Canada, 2024), and drug policy that continues to criminalize and stigmatize illicit substance use, a wide range of harm reduction initiatives have been implemented and expanded in different settings (Irvine et al., 2019). Grounded in human rights, harm reduction is focused on preventing the harms associated with substance use, drug policies, and drug laws (Mercer et al., 2021; National Harm Reduction Coalition, 2024). Principles of harm reduction are commonly understood to include respect and non-judgment, meeting people “where they are at” with substance use, and involving people who use drugs in programs and policies designed to serve them (National Harm Reduction Coalition, 2024; Mercer et al., 2021; Pauly, 2008). Harm reduction is a pragmatic public health approach that recognizes that the elimination of substance use is not necessarily attainable or desirable (Pauly, 2008).

Supervised consumption and overdose prevention sites have emerged as critical public health interventions to reduce the harms and risks of death associated with illicit substance use (Kennedy et al., 2017; Rammohan et al., 2024). These are designated service sites where people can consume pre-obtained illicit substances under the supervision of trained staff (Kennedy et al., 2017) and peers have been instrumental in the implementation and scale-up of these lifesaving services (Mercer et al., 2021; Olding et al., 2023). In some jurisdictions, including in the province of British Columbia (BC), Canada, a technical distinction exists between supervised consumption and overdose prevention sites (see: Kennedy et al., 2017). Broadly, these sites may differ in the types of services available and their staffing structures; overdose prevention sites are intended to be low threshold to access and may not have clinical capacity or medical staff.

Research with people who use drugs has widely benefited from adopting CBPR approaches and the involvement of peers (Damon et al., 2017; Souleymanov et al., 2016). The inclusion of peers in this context has been shown to increase the relevance and validity of the research, and support a more nuanced understanding of the complex experiences of people who use drugs and harm reduction practices (Brown et al., 2019; Greer et al., 2018). Furthermore, peers may gain confidence, develop skills, build social networks, and experience other benefits through their involvement with CBPR (Kelly et al., 2020). However, persistent stigma, social marginalization, and exclusion experienced by people who use substances require that practitioners of CBPR continuously examine and address power imbalances within the research partnership (Damon et al., 2017).

Research Setting

This research took place on the unceded and traditional territories of the Musqueam, Squamish, and Tsleil-Waututh First Nations, in the Downtown Eastside (DTES) of Vancouver, BC, Canada. The DTES is a neighborhood characterized by complex social and economic challenges, a large street-based drug scene, high concentration of social services, and deep-rooted inequities. It is considered the so-called “epicenter” of the toxic drug and overdose crisis in Canada (Lavalley et al., 2024). In response, the DTES is also the site of a high concentration of harm reduction services, and the long-documented involvement of people who use drugs in peer roles (Kerr et al., 2006).

The DTES neighborhood has a rich history of social activism, leadership in cutting-edge harm reduction initiatives, epidemiologic and addiction research, and treatment (Neufeld et al., 2019). These factors have contributed to the DTES being one of the most heavily researched communities in the world (Damon et al., 2017). The neighborhood is also the site of a variety of community-based research, and community-driven activism and initiatives related to research ethics and advocacy for greater meaningful involvement of community in research in the DTES (Boyd & NAOMI Patients Association, 2013; Neufeld et al., 2019). To meet community expectations and demand for community engagement, CBPR with harm reduction peer workers offers an important opportunity to bring new voices, lived experience, and perspectives into dialogue with public health researchers.

Overdose Prevention Peer Research Assistant (OPPRA) Model of CBPR

The Overdose Prevention Peer Research Assistant (OPPRA) Project was a research and capacity building partnership between the BCCSU, the Overdose Prevention Society, and the SpencerCreo Foundation. The BCCSU is an academic research center affiliated with the University of British Columbia focused on substance use and addiction medicine. The Overdose Prevention Society is a harm reduction service organization that operates overdose response services, including overdose prevention sites that employ peers in Vancouver’s DTES. The SpencerCreo Foundation is a private family foundation that provides transformational support for individuals, largely through reducing barriers to employment and education.

The research partnership was established between the BCCSU and the Overdose Prevention Society over meetings held in the fall of 2018, with the expressed intention of seeking funding to conduct CBPR that highlighted the work of the Overdose Prevention Society and the involvement of peers in overdose response. Funding for the OPPRA Project was received in the spring of 2019 and initial planning meetings and relationship building took place over the spring and summer of 2019. The OPPRA project ran until April 2023, although the OPPRA project team continued to meet on an as-needed basis, such as for developing and reviewing knowledge outputs.

The OPPRA model of CBPR was developed collaboratively with researchers and community partners, guided by shared values, and informed by principles of CBPR and harm reduction. In particular, central to the project was the meaningful involvement of peers at every step of the research process, shared decision-making and leadership, and commitment to inclusion and meeting peers “where they are at.” The term “peer” was used to align our project with terminology used widely in the DTES. As people who use drugs and access harm reduction and other social services, harm reduction peer workers often experience intersecting forms of structural violence, social exclusion, and vulnerability. Peers may also live with a variety of mental and physical conditions, abilities, and substance use patterns that may otherwise lead to exclusion from the workforce. Peer employment is intended to be low-barrier, and the inclusion and involvement of peers in research and decision-making raises two important dimensions of CBPR that remain underexplored in the literature and are highly relevant for the ethical engagement with people who use drugs and harm reduction service users: (1) The creation of supportive research teams that promote the inclusion of people who experience structural marginalization in the co-creation of knowledge; and (2) research training and capacity building among peers.

Supportive Research Environments

Inclusion and power sharing are core principles of CBPR and were ingrained in the OPPRA Project through our governance structure and peer engagement model. Co-leadership was established between academic and community partners. The academic and community co-leads made all decisions about the project together and funding was held by the community partner and overseen by a third-party bookkeeping service.

Towards greater inclusion, we engaged a large number of peers (up to 10 at any time) who worked a small number of hours each week (usually 2-3). One peer research assistant (PRA) was hired into a part-time “coordinator” role (approximately 20 hours/week). PRAs were recruited through information sessions at overdose prevention sites, referrals through a low-barrier non-profit employment organization in the DTES, and word of mouth, and were compensated in cash for their time with the project.

Working with a larger number of PRAs increased the diversity of voices and perspectives on the study team. The OPPRA project team members varied in age from people in their 20s to their 70s. Some actively used substances, while others were in recovery or were allies; PRAs had a variety of lived and living experiences with housing insecurity, among other factors. This organizational structure also contributed to power sharing and challenged traditional power dynamics between academic researchers and the community, as having more peers than academics in the room was almost always guaranteed. This approach contributed to a supportive environment in which PRAs did not feel tokenized, academic project team members could be challenged, and shared learning between all team members was optimized.

The staffing structure also reflected the reality that many peers required flexibility in their employment and income generation. For example, working only a few hours each week meant that peers could continue in other forms of harm reduction peer work. Compensation for the OPPRA Project did not exceed earning restrictions of some social assistance programs. Practically, this peer engagement model also mitigated potential disruptions from absences and group attrition. We expected that peers would not be able to attend every week or may leave the project over time; having a large team meant that work could progress even when some peers were absent.

Critically, the OPPRA Project also implemented so-called “wrap-around” social supports for peers, which recognized the unique structural inequities and social complexities experienced by people who use illicit substances while simultaneously working in the field. Wrap-around social supports, provided in-kind by the SpencerCreo Foundation Support Worker Program, helped PRAs access housing, social services, benefits, and addiction treatment when desired. These wrap-around supports enabled peers to show up and participate, when obstacles may have otherwise prevented their engagement. This support created a low-barrier environment and promoted inclusion and collaboration in our collective work.

Research Training and Capacity Building with Peers

Capacity building is key to inclusion and power sharing with non-academic study team members engaged in CBPR. Limited research experience can hinder meaningful involvement in the research process (Amico et al., 2011) and training and capacity building are needed to ensure peers are not disadvantaged in skills or understanding (Nind et al., 2016). Our engaged approach to research involved peers working in research roles, such as in recruitment and data gathering; lack of training could impact the integrity of the data and the safety of study participants (Anderson et al., 2012). As such, an ethical and practical need exists for some research training and capacity building. However, as Nind et al. (2016) argue, research capacity building is sometimes imagined as simply a way for marginalized people to “cross the line from researched to researcher,” and may undervalue the unique perspective peers bring. Therefore, our approach emphasized bi-directional knowledge exchange and attempted to enhance, rather than replace, peer voices in the research process.

To balance the need for research training and capacity building while valuing the unique perspective of peers, the OPPRA Project adopted a “learn-do” model, where peers participated in capacity building workshops on topics related to the research cycle and applied the learning to the research project (see Methods section). Academic members of the team developed and delivered a variety of tailored capacity building workshops. Outside of a few pre-determined core topics, such as research ethics and participant protections (Morgan et al., 2023), we used a “training-as-needed” approach, where training for specific skills occurred when it was determined to be necessary to progress with the project (e.g., qualitative data analysis). This approach and session timing were aligned with the research cycle (Nind et al., 2016; Strnadová et al., 2014).

Examples of the capacity building workshops included: Research for Action and Social Change; Developing a Research Question; Quantitative and Qualitative Study Designs; Group Facilitation and Qualitative Data Gathering; Qualitative Thematic Analysis; and Knowledge Translation. Peers were provided with copies of educational materials (e.g., PowerPoint slide decks) and were encouraged to leverage their research training for opportunities to work in other research projects and contexts. For example, peers who completed the Research Ethics training workshop (Morgan et al., 2023) received a certificate they could reference in their resumes or present to other research collaborators.

Methods

The bi-directional exchange of knowledge and capacity building activities occurred at weekly research meetings. From September 2019 to March 2020 and from September 2021 to April 2023, the OPPRA Project Team (i.e., academic and community co-leaders and PRAs) gathered in person every week for two to three hours at an accessible location in Vancouver’s DTES. Between March 2020 and September 2021, COVID-19 pandemic public health restrictions prevented in-person meetings, so meetings were paused. A few virtual meetings with the OPPRA Project Team took place, although these were determined to be largely unfeasible given the technological barriers experienced by peers (e.g., limited home internet or access to smart devices/computers). Over the COVID-19 period, communication was maintained with PRAs, who continued to receive wrap-around support facilitated by the community partner.

The following sections detail the collaborative methods for community engagement, data gathering, and analysis that we undertook with the OPPRA Project Team to meaningfully involve peers at every step of the research process. This process resulted in the design and implementation of a research project called “OPS Quest,” which was completed by the OPPRA Project Team by April 2023.

Research Question

To establish our research question, OPPRA Team members collectively brainstormed issues significant to harm reduction peer workers and people who use drugs, drawing from lived experience. All suggestions were recorded on sticky notes and mapped thematically on the wall. The x-axis represented the significance of the issue to community; the y-axis represented project feasibility based on expertise and resources available. Key issues included drug toxicity (e.g., adulterated drug supply, overdose crisis), harm reduction (e.g., gaps in services, barriers to access, distribution of naloxone), and issues related to peer employment (e.g., lack of engagement, importance of lived experience to these roles). Drawing from these suggestions, the OPPRA Project Team settled on the following:

Research question: How can overdose prevention sites promote the wellbeing of peers, clients, and the community?

Population

PRAs immediately identified peer workers as a participant population that was aligned with the selected research question and highly feasible to recruit, given existing connections to the community among the Project Team. Peer workers were also seen as holding relevant expertise as both service users and providers. The selected study inclusion criteria were self-identified peer workers with experience working at a supervised consumption or overdose prevention site. Reflecting a shared lived and professional experience as peers, most OPPRA Project PRAs would have met these inclusion criteria. As such, participants had “insider” knowledge (M. Greene, 2014) and access, which was leveraged to build trust with study participants and to reach prospective participants from a range of different service sites.

Study Design

The OPPRA PRAs engaged in two training and capacity-building workshops about study design. These workshops introduced the concepts of quantitative and qualitative data and described diverse data-gathering approaches (e.g., surveys, interviews, focus groups, arts-based methods, observation, etc.). Examples of local research about substance use and harm reduction were presented as illustrative examples. During the workshops, the OPPRA Project Team discussed potential benefits and challenges of different approaches, and academic co-leads were transparent about constraints related to budget and resources.

The OPPRA Project Team co-constructed a novel qualitative study design to answer the research question that leveraged the expertise and interests of its members. PRAs advocated strongly for interesting and interactive methods, challenging the expectation that research needed to be dry. Towards this end, PRAs proposed a focus group that could be facilitated or “played” like a board game, walking participants through a series of prompts and activities to elicit peer workers’ perspectives about the influences on wellbeing. We titled this research board game “OPS [Overdose Prevention Site] Quest.”

The purpose of OPS Quest was for focus group participants to collectively build their “ideal” overdose prevention site. While playing the game, participants were tasked with creating policies, defining staff roles, overcoming unexpected challenges, and designing the physical environment. These activities were prompted by discussion cards, which focus group participants read out loud to the group. To design the physical environment, participants had access to miniature furniture, people and supplies which facilitators labeled using sticky notes after participants placed them on the board, to represent different site features or amenities (See Figure 1). In doing so, we followed Woodward (2025) in recognizing the capacities of objects to provoke and inspire participants in ways that may not be expected. The focus groups, including gameplay, were audio recorded, and the discussion transcribed verbatim.

Figure 1.

Miniature Furniture, People and Supplies Used as Prompts in the OPS Quest Study

Recruitment

Efforts to recruit participants from a range of different overdose prevention sites were made to encourage diversity of experiences and operational contexts across focus groups. Peers and the community co-lead held information sessions at different overdose prevention sites and left posters and information sheets with study contact information. Participants were also recruited through word of mouth. Eligible participants were scheduled to attend one of four focus groups and received a $30 honorarium for their time, as well as lunch and refreshments.

Data Gathering

Between June and October 2022, the OPPRA Project Team hosted four 2-hour in-person OPS Quest focus groups at an accessible location in the DTES, with four, five, five, and six participants respectively (total n = 20). Participants also completed a sociodemographic questionnaire to allow us to describe the sample. To promote confidentiality, participants selected pseudonyms, which were used in the reporting of findings.

Focus groups were moderated by an academic study team member with experience facilitating focus groups, and a PRA who received training on group facilitation. PRAs who were not involved in facilitation took on additional roles, such as collecting consent forms and surveys, taking field notes, handing out or labelling OPS Quest items, making observations, audio recording, and supporting the creation of a safe and welcoming environment. Photos of OPS Quest gameplay were taken for visual analysis of participants’ “ideal” overdose prevention site.

Data Analysis

Following our adopted principles of CBPR, it was important that peers were meaningfully involved in the analysis of transcripts, photos, and fieldnotes (Flicker & Nixon, 2015). To accomplish this aim, we developed novel approaches to collective and participatory data analysis, inspired by the DEPICT model of participatory qualitative research (Flicker & Nixon, 2015), and grounded in thematic analysis, a method for identifying, analyzing, and interpreting patterns of meaning (Clarke & Braun, 2017). More specifically, we aligned ourselves with Braun and Clarke’s (2023) description of reflexive thematic analysis, a qualitative approach that values researcher subjectivity and strives for researchers to “own their perspectives.”

The first phase of data analysis involved individual dynamic reading (Flicker & Nixon, 2015). An academic study team member familiar with the transcripts prepared passages of transcripts and extracted quotes, which were printed and distributed to PRAs. Transcript passages and excerpts were selected because reviewing long transcripts can be onerous. Peers were provided with highlighters and pens and encouraged to take marginal notes and to highlight important quotes. To determine significance, team members were encouraged to draw from lived experience.

To develop an initial coding scheme, OPPRA project members identified categories and ideas in small groups that resonated with them while reading the transcripts and discussed initial themes and linked ideas. Categories and ideas were written onto index cards and placed onto a table. Illustrative quotes were cut and pasted onto the back of the index cards. Category and idea cards were moved around and grouped into loose themes through facilitated discussion (see Figure 2).

Figure 2.

Category Cards Used for the Development of Coding Schemes for Reflexive Thematic Analysis

Over several weeks, team meetings were dedicated to in-depth analysis of focus group transcripts, using the coding scheme as a starting point. An academic team member prepared thematic summaries, with illustrative quotes. Next, to move towards analytical discussions about the data, the academic study team members facilitated large and small group conversations. Peers were encouraged to consider the data against their own lived experience as peer workers and service users to construct and derive meaning. Notes from the conversation were documented on flipchart paper, with different colors representing data-driven versus experience-driven insights and reflections. Notes from the group conversation were digitized, archived, and incorporated into the analysis. From the process of group conversation and note-taking, potential themes were constructed with PRAs.

To analyze data derived from photographs and participants’ use of furniture and figurines to design their “ideal” overdose prevention site, photographs were printed, and sticky note labels were compiled (see Figure 3). Peers indexed all the identified environmental features and amenities. Indexed features and amenities were organized thematically by peers into constructed themes.

Figure 3.

Example of How OPS Quest Study Participants Used Labelled Miniature Furniture, People, and Supplies to Build an “Ideal Overdose Prevention Site”

To understand the relationships between themes constructed from data-driven conversations and from the indexed features and amenities, the academic co-lead amalgamated and organized the themes into a table and presented the findings back to the OPPRA Project Team for review. During this phase, the themes were organized together into higher-order themes and peers interpreted the significance of these higher-order themes in relation to the original research question. The themes were further refined through the drafting of this report and confirmed again with peers.

Results

Participant Characteristics

Table 1 provides a summary of OPS Quest focus group participant characteristics. Herein we use the term “participant” to refer to consented research participants of the OPS Quest focus groups, and PRA to refer to peer research assistants. Participants had experience working across seven unique overdose prevention and supervised consumption sites in Vancouver, bringing a wide range of expertise and exposure to different operational contexts and settings. Participants also had a range of lived and living experience: seven reported experiences of being unhoused in the past three years, and six reported being a client of the overdose prevention site before becoming staff.

Table 1.

Characteristics of Study Participants

Sample characteristics	Total (n = 20)
Gender
Male	9 (45%)
Female	5 (25%)
Agender	1 (5%)
Unknown	5 (25%)
Age
35-44	4 (20%)
45-54	5 (25%)
55-64	5 (25%)
Unknown	6 (30%)
Live in the downtown eastside
Yes	10 (50%)
Unknown	5 (25%)
Years’ experience working at a/n supervised consumption/overdose prevention site
Less than 1 year	4 (20%)
1-3 years	3 (15%)
3-5 years	4 (20%)
More than 5 years	3 (15%)
Unknown	6 (30%)

Study Findings: Under the Same Umbrella: Promoting Wellbeing for Peer Workers and Clients

Facilitated by the “OPS Quest” board game, focus group participants identified various ways that overdose prevention sites could promote wellbeing for peer workers and clients. Our analysis revealed how the wellbeing of peer workers was often intertwined with the wellbeing of clients, as many participants had lived experience in both roles. Recognizing the significance of overdose prevention sites in the lives of clients and peer workers, PRAs adopted the metaphor of being “under the same umbrella” in interpreting the research findings, highlighting factors that contributed to wellbeing for both groups (or keeping both clients and peers dry in a rainstorm). Through a process of participatory qualitative reflexive thematic analysis with peers, we constructed key themes related to the wellbeing of peers and clients, as described below.

Theme 1: “A Sense of Dignity”: Amenities and Services at Overdose Prevention Sites

Participants described how wellbeing was intimately shaped by the types of amenities and services offered at overdose prevention sites. Prompted by the game cards, and portrayed by miniature furniture, people, and other material objects, participants envisioned possibilities for services and environments that contributed to wellbeing.

Many of the identified amenities were related to sanitation; participants repeatedly stressed the need for bathroom amenities for peer workers and clients. PRAs emphasized that this finding should be understood against the backdrop of a lack of publicly accessible toilets in Vancouver’s DTES. Overdose prevention sites were often located in temporary, makeshift, or otherwise rundown spaces, and the availability of a functioning toilet – even for staff to use on shift – was not always guaranteed. A clean toilet for peer workers was viewed as an absolute necessity, although not one taken for granted by participants.

Some participants understood providing a bathroom for clients as an act of dignity.

Dildo: “I think bathrooms are super-duper important. Giving someone the self-respect of like ‘Hey, can I use the bathroom’ and nothing else... At [our overdose prevention site] we have issues where certain people say ‘No, you can’t use the bathroom!’ And I’m not very good at that because, well, people need to poop, so whatever... I’m never telling old ladies you can’t use the [the bathroom]. I don’t care. I’ll quit. I won’t do it so there it is. Bathrooms.”

For some participants, policies and norms that restricted clients from using bathrooms were unethical, and denying clients the use of bathrooms was morally distressing. However, participants described different bathroom policies across overdose prevention sites, and some participants had reservations about offering public bathrooms, which stemmed from previous negative experiences and challenges, such as poor bathroom maintenance and repair.

Stan: “I just have to say there’s a reason the one injection site does not offer the bathroom because, I don’t mean this as a broad statement, but people don’t know how to respect the bathroom. I know that they have spent almost a thousand dollars a week replacing our bathroom just to get it back up and running and it lasted days and then it’s gone again.”

Participants suggested separate bathrooms for clients and staff as an option, although as this finding illustrates, maintaining bathrooms and site sanitation requires continuous effort and should be resourced appropriately if offered.

In reflecting on this finding, PRAs suggested that a bathroom attendant model could be one solution to balance these competing needs and to recognize the labor involved. Bathroom attendants could support site sanitation and maintain clean bathrooms, as well as monitor the site for potential overdoses. The bathroom attendant role could also be an additional opportunity for peer employment.

Beyond a functioning toilet, participants also imagined expanded possibilities for bathroom amenities that could also support the wellbeing of clients and peers. For example, shower facilities would be appreciated by peer workers who were unhoused and would address an existing service gap in the neighborhood. For clients, showers were also seen as a way of promoting dignity, particularly in the context of incontinence that can occur after an overdose.

Tricky: “Access to showers, showers and perhaps, people a lot of times have accidents, so access to clean clothing.”

The Pope: “Actually, that’s quite important because we have had people when they’ve [overdosed], they’ve literally died and they soiled themselves... it makes the people feel so much better that they can go and get themselves cleaned up, because it’s embarrassing right?”

Tricky: “A sense of dignity back.”

Other bathroom amenities included publicly available sinks for handwashing to reduce the risk of skin and soft tissue infections or COVID-19 transmission. Foot soaking tubs were also named, which PRAs recognized might not be a practical suggestion, but they nevertheless highlighted the important ways that “street feet” (i.e., infections and wounds on feet commonly experienced by people experiencing homelessness) can detract from health and overall wellbeing.

While access to bathrooms and sanitation was particularly salient, participants also identified other amenities and services that could be offered to promote peer and client wellbeing. Calls for drinking water and food offerings, for example, demonstrated how participants viewed overdose prevention sites and harm reduction as a means of addressing a broader spectrum of social and human rights, beyond reversing overdoses.

Dildo: “We don’t have enough drinking water for people, the tap doesn’t work well, we don’t have cups, everyone wants drinking water. It’s a super basic thing but we don’t have it. It’s a huge problem.”

Tricky: “Things like fluids to keep people hydrated.”

As with bathroom facilities, participants recognized challenges in offering amenities and services like food, or with managing donations. Without thoughtful implementation, amenities could result in more stress for peer workers.

Pinono: “Make food.”

Facilitator: “Great. Yeah, we’ve said donations, clothes, a space for food, a pantry, somewhere people could get food, yeah. That’s great.”

Canine: “Then you get into hand sanitizing and all that. It’s got to be, you can't let people go in there, they can pick stuff up, open it, look at it, pick it up and put it back in the pile. If you do that... This goes back to Birdie’s point of maybe having someone there that can help sort of facilitate that, it’s a job someone could have, maybe.”

Birdie: “I think food is really important and I think that’s something that gets lost. Yea, everybody needs food.”

Canine: “Nutrition.”

Participants emphasized that offering and facilitating additional client services should be recognized as work, and through this lens, represented an opportunity for additional peer employment.

Taken together, participants highlighted the fundamental importance of access to bathrooms and sanitation and to other services that meet people’s basic needs, not only as a practical necessity of a functional workplace, but as a matter of maintaining dignity for peer workers and clients. Expanding facilities to include showers and sinks could further support efforts to promote dignity and wellbeing in moments of vulnerability and in ways that meet clients’ needs.

Theme 2: “A Whole Entire Meltdown”: Promoting Safe Environments

Safe environments were recognized as important contributors to the wellbeing of both clients and staff. Participants identified site policies, staff roles, and environmental features that promoted site safety. Safety was understood in different ways, although violence or tension, often between clients, carried significant weight and affected the wellbeing of peers, clients, and the broader community. PRAs emphasized that this finding should be contextualized against the reality that stress, hunger, sleep deprivation, economic marginalization, and criminalization experienced by many peer workers and clients can contribute to violence and tension, especially when people’s basic needs are not met.

Participants emphasized the importance of thoughtful site design, and highlighted opportunities to increase physical distance between clients, such as arranging “booths” (i.e., tables where clients can use substances) apart from one another and facing towards a wall or mirror, as opposed to positioning clients to look at each other. Placing barriers between booths could also increase privacy and discourage people from moving around the site.

Robert : “And then booths, with the mirror and the counter, right? Because that keeps them feeling like they're there by themselves, and they get to look at themselves.”

Bob: “Not [staring each other down] from across the room and starting fights.”

Participants also suggested policies, such as prohibiting clients from sharing a booth, to minimize potential drama and interpersonal conflict.

Bob: “The other day when I was working, some big-time guy was in there and he lost a big amount [of drugs] and some girl was like hanging out at his table, and then she got accused and it caused this whole entire meltdown that was just like a disaster. So, keeping people to their tables to avoid fighting and theft, and like dual overdoses, is important.”

As this participant identified, these policies and practices also have important implications for overdose response in the context of an unpredictable and toxic drug supply, because people using the same substance at the same time can lead to “dual overdoses” that are more difficult to manage concurrently. Staff roles identified by participants, such as “bouncers,” can help enforce site policies, and de-escalation training can help prevent violence from occurring.

Site safety was also understood in terms of managing overdose responses. Participants described the need for training, policies, and features that supported peer workers in identifying and responding to overdoses. For example, participants suggested providing regular training and periodic refreshers on overdose management and safety protocols.

Squid: “We need more refreshers on, like, going over the overdose protocol, how to pull somebody out of the chair and like if, like not picking somebody up that’s going to hurt you or the person.”

Another participant advocated for adaptive equipment that could help peer workers safely move clients out of chairs, for example, and effectively respond to overdoses. “It’s very hard and any of us girls, we cannot lift a guy” (Pinono).

These findings demonstrate the significant role peer workers have in maintaining a safe environment for clients, other peers, and even themselves, which may be underappreciated. Ultimately, participants emphasized that peer workers have a right to a safe workplace and that clients have a right to safe services.

Theme 3: “Looking up as Opposed to Looking Right Across”: the Significance of Peer Inclusion

Participants described how peer involvement in overdose prevention sites contributed to wellbeing for both peers and clients, and identified opportunities for peer workers to be better supported in doing this lifesaving work. From peer workers’ perspectives, the key benefits of peer involvement for clients related to creating low-barrier and welcoming environments where clients could access services without feeling judgment or stigma.

J-Dawg: “Whether I’m working or using, I feel I’m among equals. When I was a client or participant or patient at [an overdose prevention site without peers] I felt I was being cared for, or was in the custody of a superior professional so I felt like I should have been looking up at all times, as opposed to looking right across.”

Peer workers also had important forms of expertise and knowledge grounded in lived experience using drugs, which were transferable to their work as peers. As a result, participants described ways that peer workers were uniquely qualified for the work of overdose response, highly attuned to the needs of clients, and delivered more compassionate care.

Participants expressed how working alongside other peers contributed to wellbeing by fostering mutual support, shared understanding, and a sense of community.

Birdie: “I felt most supportive was when I was working with peers and coworkers that I had a relationship with. We worked shifts together and I know, like, if there’s an overdose, we kind of have a flow, so I can rely on them, and they can rely on me.”

As further contextualized by PRAs, frontline harm reduction work against the backdrop of an ongoing overdose epidemic can be distressing and emotionally draining. Having opportunities to debrief, grieve, and be in community with other people with shared lived experience was one way that peers remained resilient when confronted with loss and structural adversity. Ultimately, participants reflected on how peer employment translated to wellbeing in other dimensions of peer workers’ lives by creating opportunities for meaningful work and income generation.

Big City: “Going to work definitely brings stability to my life. And in relation to the overdose prevention site that I worked at, I really found that it was feeling ‘importance’. It was important for me to be part of that experience... I kind of fell in love with it in a way because it grew on me in a positive way and actually changed the way I lived my life in other areas.”

These reflections highlight how peer employment can contribute not only to more accessible and effective overdose response but also provide peer workers with a sense of community, purpose, and stability. By valuing the lived and living experiences of peers, these roles contribute to individual and community wellbeing.

Participants also identified a range of opportunities to improve working conditions and terms of employment that could contribute to peer worker wellbeing. Higher pay was raised as a contributor to wellbeing and financial security, although the timing (e.g., daily or bi-weekly) and method (e.g., cash, cheque, or direct deposit) of payment were also important.

Bob: “I think also we have to address the elephant in the room, which is financial stability, which a lot of these positions don’t provide. So, a stable and regular expected payment of money that is enough to live on.”

Many participants had experience working at overdose prevention sites as stipendiary volunteers, which was a model of peer employment that participants perceived as being low-barrier and offering greater flexibility in the timing of pay (e.g., daily, in cash), although stipends could be lower than what would constitute a living wage. Mixed support was expressed for unions, which were recognized as providing better wages and job security, although potentially at the expense of flexibility.

London: “I never wanted to be a union member. I wanted to stay a volunteer and be paid every day or once a week, so I consistently got money. Now [it’s] every two weeks... I just want to die every day because I can't afford... I need to use [drugs], but I can't. I have to borrow money and it's so humiliating.”

These reflections reveal the significance of different employment models in the lives of peer workers and the close relationship to wellbeing that may be overlooked by people without lived and living experience using illicit substances.

Beyond pay, participants emphasized mental health supports as another term of employment essential for peer worker wellbeing. Suggestions ranged from having flexibility to take paid mental health days off to accessing extended health benefits that covered therapy and counselling. Some participants benefited from embedded mental health supports, such as on-site mental health workers that peer workers could access in response to witnessing and responding to violence, crises, or trauma. On-site mental health support workers were also seen as a service that could benefit clients.

Rez: “Having that emotional support or having that one counsellor on shift or that we can call and say, ‘Hey, can we come and sit and chat for an hour or you know, how about Tuesday?’ or just having access to that mental health worker that we can, you know, make a call or make an appointment because we always don’t have that.”

These findings underscore the role of peer employment in peer worker wellbeing, expanding its focus beyond financial compensation to include flexibility, mental health supports, and fair employment. While peer involvement strengthens overdose response by drawing on lived experience to build trust and increase accessibility, sustaining this vital work requires policies that recognize the complexities of the lives of peer workers, and the challenges inherent in the role.

Discussion

Results from the OPS Quest study revealed how overdose prevention site characteristics – including how sites are operated, staffed, and the amenities and services they offer – play an important role in shaping the wellbeing of both peer workers and clients who operate and access these critical harm reduction services. Our analysis documented several ways that peer and client wellbeing were interconnected. True to the action-oriented objectives of CBPR, findings offered insight into how participants envisioned overdose prevention sites could meet a range of needs for peers, clients, and the community, beyond overdose response. While findings envisioned how these sites hold potential to offer points of connection and promote human rights, participants underscored that additional work should be recognized and resourced.

To accomplish this work, we developed novel approaches for inclusive community engagement and participatory data gathering and analysis that effectively integrated lived experience throughout the research cycle. In many ways, the process of carrying out our CBPR project was as impactful as the outcome. From the beginning, the OPPRA Project had a strong focus on research training capacity building and on creating opportunities for peer employment and growth. One intention of the OPPRA Project was to increase the pool of community members in Vancouver’s DTES who could partner in and drive research that addresses community priorities, responding to an identified need in the local research ecosystem. OPPRA PRAs were routinely consulted on other external research projects led by other researchers (e.g., review and provide input on study designs and data collection tools). As a “heavily researched community,” the OPPRA Project intended to build research capacity at the community level so that community members could feel empowered to question and critique research practices and to engage in research as informed participants. In observing the PRAs’ insightful input and contributions in each of these realms, we are confident that this goal has been achieved.

The OPPRA project balanced meaningful participation throughout the research process with meeting PRAs “where they are at” and respecting PRAs’ preferences and interests (Strnadová et al., 2014). As such, not all PRAs were involved in each activity; some joined after the pandemic break and were not involved in the pre-implementation phase of the research (e.g., defining a research question, study design). PRAs were not required to participate in all research activities (e.g., some PRAs were not interested in facilitating focus groups). Occasionally, we did have to motivate engagement in weekly meetings, recognizing that participation was not always possible (e.g., too tired, working at the overdose prevention site). Weekly meetings began with a check-in to gauge how PRAs were feeling and to tailor the meeting and facilitation approach. In practice, sometimes this meant being flexible with the meeting agenda and expectations. To reflect the realities of working with peers and people who experience structural vulnerability and trauma, sometimes engagement looked like providing a safe place for a nap, offering a snack, and having a conversation, or debriefing as a group after the loss of a community member to the toxic drug crisis. This was one way the principles of harm reduction were embedded within our CBPR approach.

To move the research forward, a lot of work needed to be done outside of weekly meetings. Often this meant that academic project team members acted on decisions made collaboratively by the team, followed by member checking with PRAs at subsequent meetings. Learning about and recognizing the type of work that was meaningful and of interest to PRAs, and what was not, was critical. For example, PRAs were interested in brainstorming interview questions and prompts but not in drafting and formatting the interview guide. We do not feel that tailoring involvement to align with PRA preferences made our project any less community-based or engaged; rather, this approach respected PRAs’ time and interests, while making progress towards our research objectives. PRAs were also involved in knowledge translation to varying degrees. In April 2023, PRAs and academic team members co-developed and co-presented a poster at an academic conference. All PRAs contributed to the design and implementation of the study, but not everyone chose to participate in delivering the poster presentation. Similarly, academic team members took the lead on writing the current manuscript based on the poster presentation. Co-authorship was discussed early in the project, with PRAs expressing strong interest. PRAs that could be reached reviewed the manuscript and had the opportunity to provide verbal or written feedback.

Limitations

The OPPRA Project had important limitations, and we took away many lessons learned for future CBPR with peer workers. The model of peer engagement we deployed was highly resource intensive. A significant proportion of the budget was dedicated to honoraria and wages for PRAs and research participants, which was aligned with the project objectives to create meaningful employment opportunities for peers. The project also took several years to complete, reflecting the time required for relationship building, intensive engagement, capacity building, and pandemic recovery. We believe these investments were warranted, and, in fact, critical to the research.

The project timeline and momentum were affected severely by the COVID-19 pandemic, which disrupted project operations for 17 months during public health restrictions and institutional guidance around in-person research. As in-person research was cancelled, the OPPRA Project co-leads experienced challenges engaging with PRAs remotely. Many PRAs did not have access to devices, data plans, or consistent internet, while technology skills varied among members. Consistent with broader community-wide service disruptions and the devastating impacts of dual public health emergencies (i.e., the COVID-19 pandemic and the overdose epidemic), some PRAs experienced forms of instability that complicated their engagement during this time.

Coming back together (gradually) in September of 2021 was both challenging and rewarding. The fact that many PRAs remained interested and engaged was a testament to the wrap-around social support provided over the pandemic period, and the meaningfulness of the work. Nevertheless, we experienced some attrition, for instance because of members’ geographic relocation. Tragically, two PRAs passed away over those 17 months. After regrouping and reestablishing trust, we recruited several new PRAs to join the Project Team and continued the work. Given the new members and significant time lapse, some additional capacity building was required.

Conclusion

We present a feasible model of CBPR for public health with people who use illicit substances and harm reduction workers. Our study highlighted operational contexts of overdose prevention sites that could contribute in different ways to wellbeing for peers, clients, and the broader community that extended beyond overdose response and included promoting dignity, human rights, safety, and fostering peer support. With an emphasis on creating supportive research environments and capacity building, the OPPRA model of CBPR can be adapted to other contexts and may be particularly effective with communities that experience forms of structural marginalization or exclusion. Through developing novel approaches for peer engagement, including methods for participatory data analysis, our research valued and embedded PRAs’ lived and living experience throughout the research process and empowered PRAs to “own their perspectives” (Braun & Clarke, 2023) to interpret and contextualize research findings. By implementing co-leadership with community partners and providing wrap-around supports for PRAs, we developed supportive and low-barrier research environments and engaged community members that may otherwise be excluded from participation in CBPR. Ultimately, this CBPR model fills a gap in the research ecosystem by expanding the diversity of perspectives and voices engaged in research and strengthens the implementation of CBPR with peers.