What is the Program?
The Mail Out Distribution Program is a service offered through the Safe Works Access Program (SWAP), based at the AIDS Committee of Newfoundland and Labrador (ACNL). The Mail Out Distribution Program is a needle and syringe distribution program designed to provide harm reduction materials and education to people in rural and remote areas of Newfoundland by sending the material and information through the mail. The program also facilitates referrals to local services for clients in rural and remote areas. SWAP, including the Mail Out Distribution Program, has three primary goals:
- to reduce the incidence of drug related health harms, including HIV and hepatitis C transmission
- to promote and facilitate referral to primary healthcare and addiction/mental health services
- to increase public awareness of harm reduction principles, policies, and programs
In addition to its support and education for clients, ACNL staff from the St. John’s and Corner Brook sites have also begun to provide harm reduction trainings and education to service providers in rural and remote areas to enable stronger partnerships with local service providers and better referral opportunities for people who use drugs.
Why Was the Program Developed?
The Mail Out Distribution Program emerged out of a strong need for harm reduction services in rural and remote communities. The program was developed after SWAP began receiving calls from across the province for harm reduction materials, even though ACNL was only distributing materials in urban centres such as St. John’s and Corner Brook. Based on the need for harm reduction services in rural and remote areas of Newfoundland, and government-funded task forces which outlined the high incidence of drug use across the province, the Mail Out Distribution Program was established.
How Does the Program Work?
The Mail Out Distribution Program uses mail, phone, and occasional land travel to make harm reduction services available and accessible in rural and remote areas of Newfoundland. Individuals call either of ACNL’s sites in St. John’s or Corner Brook to order new drug use equipment that is then sent to them by mail. Clients are asked about their drug use equipment needs and are also invited to share a bit more about their lifestyle and health to provide harm reduction workers some context for their orders.
If the inventory allows it, harm reduction materials are sent in the amounts requested – there are no limits. When available, dietary supplements, such as Ensure are also sent. Aside from new drug use equipment, clients are mailed condoms, information about safer drug use, and information about health services in their area.
There are not always agencies in rural areas that accept or collect used needles. Most health authorities, pharmacies, nurses, and other potential partners outside large centres in the province do not yet work from a harm reduction framework. The program does not send out sharps containers. Each order includes a flyer that describes how to safely dispose of needles in the garbage and what kinds of containers can be used to make sharps containers.
There are some elements of the mail-based program that differ from ACNL’s onsite harm reduction services. Clients seeking harm reduction supplies onsite do not need to identify themselves. Instead, they are given a code which is used for evaluation purposes. Individuals who call in from rural and remote areas are asked to provide a name, address, and postal code where the equipment and information can be sent for pick-up. Clients do not need to provide their real name or personal address.
The Mail Out Distribution Program staff uses a number of strategies to protect the confidentiality of its mail-based clients. First, equipment and information are mailed in black garbage bags wrapped in brown packaging that is not identifiable. Second, a return address to ACNL is not typically included on postal packages. Third, for clients who may know somebody who works at the post office or who are concerned about the package identifying them as someone who uses drugs, packages can also be sent to a neighbouring town for pick-up.
The role of Natural Helpers
The Mail Out Distribution Program supports volunteers, known in Newfoundland as Natural Helpers, in rural communities to further distribute information and equipment in their communities. Natural Helpers may be people who use drugs, parents of people who use drugs, or social workers and healthcare providers whose clients use drugs. Working with Natural Helpers is one way that Mail Order Distribution Program extends harm reduction support beyond those individuals that are comfortable and able to call in and place an order.
Natural Helpers also volunteer in the onsite programs in St. John’s and Corner Brook. ACNL typically issues identification cards to Natural Helpers who work in the onsite programs. This identifies them as harm reduction volunteers to police and other authorities. It can be difficult to get cards signed and laminated for Natural Helpers in rural areas.
Referrals to other services
The Mail Out Distribution Program has developed contacts with service providers across a range of sectors to promote and facilitate referrals to primary healthcare, mental health and addictions services, and other support services. The program is able to offer referrals in some rural areas and is continuing to expand its network of contacts around the province.
The program is also beginning to engage nurses, pharmacists, and others in rural and remote areas in harm reduction training. The goal is to expand the network of supports, partners, and referrals available for people who use drugs in rural and remote communities.
Advocacy support
The Mail Out Distribution Program does a significant amount of advocacy with clients and awareness-raising broadly with healthcare and social service providers about the need for services for people who use drugs. They do this because the network of healthcare providers and social service providers in rural and remote areas of Newfoundland who use a harm reduction framework is limited.
Many of the clients from rural and remote areas face a great deal of discrimination and stigma from service providers in their region when seeking care. Staff support individuals to advocate for themselves. They also advocate directly for clients when necessary.
In addition, staff advocate for more mental health/addictions and support services for people who use drugs in rural and remote areas. Wait lists are long and services are far away from people’s place of residence. Staff have engaged media and developed a documentary in an effort to reduce drug use-related stigma and to raise awareness of harm reduction principles across Newfoundland. These advocacy efforts aim to promote the development of harm reduction services in rural and remote areas, so that individuals from rural areas do not need to rely on mail and phone-based services from St. John’s and Corner Brook.
Required Resources
- Harm reduction coordinator. To receive, process and mail-out orders to clients in rural and remote areas, and advocate for better services for people who use drugs.
- New drug use equipment (needles, syringes, cookers, screens, etc.)
- Resource with information about safe needle disposal
- Resources on safer drug use
- Information about primary care and mental health/addictions services in rural and remote areas
- Contact information of, and partnership with, health and social service providers in rural and remote areas
Challenges
- Stigma and discrimination by healthcare professionals. Many of the individuals using the Mail Out Distribution Program, and people who use drugs in general, face stigma and discrimination when accessing healthcare services in their region. This deters individuals from seeking care and makes it challenging to facilitate referrals.
- Limited organizations/institutions that work from harm reduction model. There are few healthcare providers, healthcare organizations, pharmacists, and social service providers outside large centres who work from a harm reduction framework. This makes it difficult for the Mail Out Distribution Program workers to form partnerships and work collaboratively with other service providers.
- Gaps in addictions/mental health resources and services. Despite investment in mental health and addictions services in the province, there are still considerable gaps in the resources and services available to support individuals who use drugs. The gaps in local services make it a challenge to link individuals to care.
- Reaching Labrador and extending work in other areas. Labrador and Conception Bay North on the island are areas of the province that have extremely limited access to harm reduction services. The Mail Out Distribution Program recognizes the need to expand its services in these areas; however, this will require the program to receive more funding and expand its staffing.
Evaluation
In 2014, an independent firm was hired to do an evaluation and needs assessment of the overall SWAP program, including some elements of the Mail Out Distribution Program. All data was collected between January and July 2013.
The evaluation and needs assessment were primarily conducted through surveys with clients of the SWAP program. Fifty-five clients were engaged in the evaluation. Five percent of respondents used the Mail Out Distribution Program.
Of all respondents:
- 60% were male and 40% were female
- the majority were between the ages of 24 – 33, with a range of 18 to 61
- 58% received income support
The evaluation and needs assessment found that SWAP had many positive impacts on clients. This included providing
- access to a confidential service for harm reduction materials
- access to information, education, and support to reduce HIV and Hep C risk
- connections to other community and government services,
- education to community/government agencies about harm reduction approaches
During the evaluation period, 24,900 needles were distributed through the mail. Staff have also gathered anecdotal evidence from Mail Out Distribution Program clients about the program’s impact on their health and well-being. Clients have reported using new equipment and helping others to do so to prevent the spread of diseases. In addition, some clients reported receiving successful advocacy support; others reported staff connected them to social workers and other supports in their region.
Lessons Learned
- Harm reduction services are critical in rural areas. Injection drug use and drug use overall is not limited to major cities but is a reality in rural areas. Individuals who use drugs in rural areas face stigma and discrimination by healthcare providers, which deters them from seeking health care and accessing supports.
- Canada Post is an effective way to send drug use equipment to remote areas. Canada Post has been a reliable and effective mechanism to send drug use equipment to individuals living in rural remote areas. There have not been any restrictions or difficulties using this method of delivery. The packaging allows individuals to pick up the equipment without exposing themselves as people who use drugs.
- Breadth of innovative partnerships. With limited funding and limited organizations working from a harm reduction model, it has been critical to explore unconventional and innovative partnerships to have the resources and supports to achieve the goals of the program. For example, ACNL partners with Memorial University’s School of Medicine. Medical students volunteer, learn about the value of harm reduction approaches, and help to distribute new drug use equipment. By working with medical students who may work across the province, ACNL is educating future healthcare providers on the importance of harm reduction.
- Empowering Natural Helpers to engage, educate, and support individuals in their network is an effective way to reach more people. Peers, community members, and service providers who support harm reduction approaches have been essential partners to the program. Individuals who use drugs and their allies in rural and remote communities have been eager and willing to order equipment and access information for others in their community.
- Educating healthcare providers in rural areas on harm reduction approaches. Every community in Newfoundland has a primary care public health nurse. These nurses could be an accessible point of care for people who use drugs in rural areas. Staff provide trainings on harm reduction for public health nurses in rural communities. This helps people who use drugs have a safe and reliable service provider working from a harm reduction framework.
- Advocacy work is critical to support people who use drugs in rural areas. Individuals in rural areas face stigma and discrimination from service providers. It is critical to help them to advocate for their rights and needs in the health and social service systems. Advocating with and for individuals and addressing professionals who are mistreating people who use drugs is a critical tool for ensuring that people who use drugs in rural areas are able to access care and support.
Other Useful Materials
Resources
Best Practice Recommendations for Canadian Harm Reduction Programs that Provide Service to People Who Use Drugs and are at Risk for HIV, HCV, and Other Harms: Part 1
2013, Working Group on Best Practice for Harm Reduction Programs in Canada
Guideline or manual
English, French
More information
Nothing About Us Without Us - Greater, meaningful involvement of people who use illegal drugs : a public health, ethical, and human rights imperative
2005, HIV Legal Network
Report
English, French
More information
Contact Information
Tree Walsh, Harm Reduction Manager
SWAPCoordinatorSJ@acnl.net
1-800-563-1575