ABSTRACT: On 16 April 2022, the province of British Columbia will enter its 7th year of the public health overdose emergency. An increasingly toxic drug supply coupled with stigma toward people who use drugs continues to contribute to unprecedented increases in overdoses and overdose deaths. The Interior Health Authority, which serves medium and small communities in British Columbia, initiated a project to address stigma in the midst of both the overdose and COVID-19 public health emergencies. Through consultation and collaboration with people with lived experience of substance use, a number of tools were developed to create awareness of stigma and its impacts. The highlight of the collaboration was a series of dialogue sessions where health care staff and physicians heard directly from people with lived experience about their experience of stigma in health care and had the opportunity to ask questions. Participants in the session reported their understanding of stigma and its impacts increased significantly after participating in the session, that hearing directly from people with lived experience was valuable, and many indicated they were able to identify steps they could take to reduce stigma. Collaboration with people with lived experience when developing antistigma resources, and the opportunity for meaningful dialogue with health care providers, helps raise awareness of the impacts of stigma and may increase motivation to change stigmatizing behaviors and practices. Future directions for this work include measuring short- and long-term impacts on behavior change as well as expansion of the model to other sectors.
This blog post describes a pilot project aimed at reducing stigma among health care workers by facilitating a dialogue between health care workers and people with lived experience of stigma related to substance use.
Background
Harms related to substance use remain a top public health issue in virtually every jurisdiction across Canada. In British Columbia, 7808 people have died since a public health emergency was declared in the province in 2016, with 49% of deaths occurring during the pandemic.1 In fact, the COVID-19 pandemic has negatively influenced this trend in the province, where a record number of deaths (2224) occurred in 2021.[1]
The root causes of overdose deaths are complex and call for multiple approaches to mitigate substance use harms. Stigma toward people who use substances is an important factor that negatively contributes to substance use morbidity.
Stigma consists of “negative attitudes, beliefs or behaviours about or towards a group of people because of their situation in life. It includes discrimination, prejudice, judgment and stereotypes, which can isolate people who use drugs.”2 Stigma is negatively perceived by individuals who use illicit substances, which poses a barrier to accessing services and supports. In the health care setting, individuals will often withhold information about substance use for fear of being stigmatized.[2] Furthermore, individuals who feel stigmatized mistrust and avoid health care services, undermining the quality of care, resulting in increased morbidity and mortality, and ultimately raising health care and societal costs.[3]
It is not uncommon for health care professionals to hold stigmatizing and negative beliefs toward people who use substances. Such beliefs are often rooted in their perception of danger or manipulation, and the emotional stress that can be triggered by people who use substances.[4] Stigma among health care providers can lead to a reluctance to provide care for people who use substances and the belief that substance use is a moral failing instead of a health condition.[5]
Stigmatizing beliefs and attitudes have been correlated to a lack of formal education and exposure to people who use substances.[6,7] Health care providers in addiction services, and other providers who have experience with substance use, tend to have less stigmatizing views of people who use substances than their colleagues who have not had this exposure.[8]
Formal education, exposure to individuals who use substances in the clinical setting, and reflective exercises could be effective in reducing stigmatizing beliefs, leading to meaningful engagement and improving the quality of services clients receive.[4-6]
The case for tackling stigma in the health care setting
In April 2018 the Interior Health Authority launched the Use Safe Campaign to understand barriers to accessing health care services among people who use substances. The campaign consisted of surveys, interviews, and focus groups with people at risk of overdose, their family and friends, and health care providers in Kelowna, British Columbia. Approximately 125 people participated in the campaign.
Stigma was identified as one the top barriers that prevents people who use substances from accessing health and social supports. The shame of coming forward and seeking help is so stigmatizing that they would rather hide. Stigmatizing attitudes when seeking health care was a recurring theme; participants identified a need to educate health care staff so they could in turn support clients with mental health and substance use disorders in a compassionate and respectful way.
The intervention
The Interior Health Addressing Stigma project began shortly before the COVID-19 pandemic was declared. The initiative involved a collaborative approach among teams from population health, mental health and substance use, and communications. The goal of the project was to increase awareness among health care providers about the impact of stigma and invite providers to reflect on attitudes and behaviors toward people who use substances.
Consultation and collaboration with people with lived experience of substance use was a key component from conception to implementation of this project. The involvement of people with lived and living experience in this health care initiative was facilitated through Interior Health’s formal structure and framework for the inclusion and engagement of people with lived experience of substance use.[9]
Deliverables of the Addressing Stigma project included a social marketing campaign with videos portraying stories from people who experienced stigma, a toolkit to educate and support staff in their interactions with people who use substances, and a series of dialogue sessions between Interior Health staff and physicians and people with lived experience.
Dialogue sessions
A series of dialogue sessions were delivered to provide education about the impact of stigma on individuals who use substances and to give participants an opportunity to connect with people with lived experience. During the sessions, a lived-experience educator spoke about their experience of stigma as well as positive health care interactions and responded to questions from participants. This was followed by an overview of the toolkit, and an invitation for attendees to reflect on their beliefs and attitudes toward people who use substances.
The sessions were initially planned to be held in person; however, due to pandemic restrictions, a shift to Zoom and a virtual dialogue platform was necessary. Registration was limited to a maximum of 25 participants per session in order to create a space that encouraged dialogue and a sense of connection. Sessions were promoted to staff and physicians via posters, emails, and a weekly staff newsletter.
Six dialogue sessions were provided for 85 attendees (7 physicians and 78 health care staff). Four lived-experience educators were recruited and a minimum of two per session were invited. Honorariums were provided to lived-experience educators at a rate of $50 per hour for their time presenting.
Participants were asked to complete a postdialogue session evaluation via Survey Monkey (see the Box for a sample question and responses). A total of 36 participants (42%) responded to the survey. Of those, 38% of respondents felt knowledgeable or very knowledgeable about substance-use-related stigma before the session and after the session 90% of respondents felt knowledgeable or very knowledgeable about the topic. A total of 28 participants (78%) felt hearing directly from people with lived experience was the most valuable part of the session, and 34 (95%) agreed or strongly agreed that all learning objectives of the dialogue sessions were met.
Including people with lived experience as educators rather than patients to address stigma beliefs and practices9 was mutually beneficial to participants and lived-experience educators. Being able to share stories in a safe and supported way allows people who use substances to reduce self stigma they may be experiencing in their own recovery from substance use.[8] Lived-experience educators’ feedback indicated the sessions were beneficial for them. Staff and physician participants were engaged in the sessions and provided acknowledgement of courage and bravery to the lived-experience educators for being vulnerable in sharing their stories. Participants asked questions of the lived-experience educators and many expressed ways in which they would make improvements in the language they use toward, and about, people who use substances.
Toolkit
Gao and colleagues8 noted that developing educational toolkits focused on stigma can support staff in understanding the different types of stigma and increase comfort in having health-related discussions with patients. The purpose of the Interior Health Addressing Stigma toolkit was to create a repository of resources for staff and physicians. The toolkit includes definitions on organizational, public, and self stigma; reports on the impact of stigma; highlights of the marketing campaign; stigma self-assessment tools; stories from people with lived experience; and online education and resources. This toolkit is an evergreen resource for staff and physicians and is regularly updated to include newly developed local, provincial, and national resources aimed at reducing stigma toward people who use substances [Figure 1].
Marketing campaign
The goal of the media campaign was to humanize the ongoing toxic drug crisis and shift public perception about people who use substances. Four videos were produced to share first-person experiences of substance use and stigma. A storytelling approach was used to connect with people on an emotional level.
The key messages of the Addressing Stigma marketing campaign were:
- People with substance use disorders are highly stigmatized due to the misinformed notion that addiction is a form of moral failing.
- Stigma is a major barrier that prevents people from getting well.
- Stigmatizing language perpetuates further disengagement, and many people with substance use challenges have also experienced trauma and violence.
- People internalize the negative messages they hear around them (self-stigma).
The videos were highlighted in staff newsletters, shared with the general public on social media, and played in health care site waiting rooms. Social media posts had 154 170 engagements. YouTube video views totalled 5551. Organic posts garnered 891 engagements and 206 link clicks. The videos were made available to stakeholders to use in their own stigma education efforts. To date, they have been used in one municipal government workshop, one public board meeting, and are included as education resources in the online staff/physician stigma toolkit [Figure 2].
Conclusions
Survey data collected by the health authority during this public health emergency identified stigma as a barrier to accessing quality health services for people who use substances. Evidence suggests education and face-to-face exposure to individuals’ lived-experience stories allows for understanding and reflection, which could subsequently lead to a change in attitude and behavior in interactions with people who use substances.8 The project team sought advice from people with lived experience to develop dialogue sessions, a social marketing campaign, and a toolkit to create awareness about stigma. Overall, engagement with the project deliverables was high and feedback was very positive. The dialogue session approach in particular was an innovative tool in addressing this issue.
Strengths of this project include the ability to rapidly adapt to online delivery of the dialogue sessions and overcome logistical challenges of ensuring presenters had access to the technology. Despite the virtual platform, engagement was high and based on survey results and anecdotal feedback, the planning group felt the sessions fully achieved their intended goal. Feedback from dialogue participants and peer educators was positive, and engagement with videos and the toolkit was high. The planning and implementation incorporated input from peers—a truly collaborative infrastructure to support this work was critical.
Future directions include measuring the impact in terms of behavior change. Specific stigma indicators and metrics would help monitor progress. In addition, given the positive experience of this pilot we advocate for sustaining this effort in the health sector and expanding to other sectors that interact with people who use substances, such as local governments.
—Amanda Lavigne, BScPN
Substance Use Clinical Nurse Specialist, Interior Health
—Silvina Mema, MD
Medical Health Officer, Interior Health
—Lesley Coates
Harm Reduction Coordinator, Interior Health
—Erin Toews
Communications Consultant, Interior Health
References
1. BC Coroners Service. Illicit drug toxicity deaths in BC: January 1, 2012 - January 31, 2022. Accessed 7 April 2022. www2.gov.bc.ca/assets/gov/birth-adoption-death-marriage-and-divorce/deaths/coroners-service/statistical/illicit-drug.pdf.
2. Government of Canada. Stigma around drug use. 2021. Accessed 20 December 2022. www.canada.ca/en/health-canada/services/opioids/stigma.
3. Government of Canada. The Chief Public Health Officer’s report on the state of public health in Canada 2019. Accessed 15 November 2021. www.canada.ca/en/public-health/corporate/publications/chief-public-healt...
4. Elliott KM, Chin E, Gramling KL, Sethares KA. Changing nurse practitioner students’ attitudes and beliefs about caring for those with opioid use disorders. J Addict Nurs 2021;32:115-120.
5. Ford R. Interpersonal challenges as a constraint on care: The experience of nurses’ care of patients who use illicit drugs. Contemp Nurse 2011;37:241-252.
6. Abram MD. The role of the registered nurse working in substance use disorder treatment: A hermeneutic study. Issues Ment Health Nurs 2018;39:490-498.
7. Finnell DS, Tierney M, Mitchell AM. Nursing: Addressing substance use in the 21st century. Subst Abus 2019;40:412-420.
8. Gao C, Voorheis P, Filbey L, Wilson MG. Rapid synthesis: Identifying impacts of approaches to address stigma associated with substance use. Hamilton: McMaster Health Forum, 20 March 2020. www.mcmasterforum.org/docs/default-source/product-documents/rapid-respon....
9. Interior Health. Peer engagement and inclusion framework: Peer engagement and employment in Interior Health Substance Use Services. Developed 5 May 2020 [internal document].
Figure 1. Screenshot of the Addressing Stigma toolkit.
Note: The toolkit is only available to Interior Health, but the PDF at the following link (available to the public) is a summary of the majority of the online resources included in the toolkit: www.interiorhealth.ca/sites/default/files/PDFS/addressing-stigma.pdf.
| End the stigma: Jill’s story www.interiorhealth.ca/stories/stop-the-harm-jills-story |
End the stigma: Shane’s story www.interiorhealth.ca/stories/end-the-stigma-shanes-story |
 |
 |
| End the stigma: Brian’s story www.interiorhealth.ca/stories/end-the-stigma-brians-story |
End the stigma: Rachel’s story www.interiorhealth.ca/stories/end-the-stigma-rachels-story |
 |
 |
Figure 2. End the Stigma marketing campaign. People with lived experience and their stories.
Box. Interior Health staff participant responses from the Addressing Stigma Dialogue Session evaluation
When asked “What is one thing you (participants) will take from today to incorporate into your work?”
“How subtly stigma can be communicated and how important it is to be aware of one’ own biases”
“It meant a lot to hear from people with lived experience directly and find out how our words and actions affect them”
“Always be conscious of my language remembering to meet people where that are at and letting them guide our work together”
“A better understanding of the different types of stigma and what people face everyday and how it makes them feel and how I can support them”
“I will understand that people who use substances may have experienced stigma during previous health care experiences, and I will remember that their emotions may reflect this, such as fear and anger.”
This post has been peer reviewed by the BCMJ Editorial Board.
 |
| This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License. |