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Focus on Harm Reduction

A. Harm Reduction And Health Promotion: Achieving Health For All

There has been much talk and activity lately, and increasingly so in Toronto, about the concept of harm reduction. The use of harm reduction strategies and approaches such as needle exchanges is debated, the relative harms of alcohol versus other kinds of drug use compared, and the harms to individuals and society that would result from enforcement of the provisions of Canada's new drug law on individuals who posses small amounts of marijuana are being discussed.

i. Defining the Approach

But what is harm reduction? As a concept, it can be said that harm reduction emerged out of recommendations of the Rolleston Committee of the 1920s, a group of leading British physicians who concluded that in certain cases, maintaining users on drugs may be necessary to help them lead useful lives. Essentially, it is by considering and trying to reduce the consequences, or harms of drug use, that harm reduction differs from drug policy in North America where the latter approach has traditionally focused on reducing the prevalence of drug use and preventing use. A harm reduction framework can be used to consider the

effects or harms of all drugs, including alcohol.

For those already using drugs, harm reduction establishes a hierarchy of goals and tries to achieve the most realistic ones first. Risk free use is considered the immediate goal. Harm reduction has attracted attention in North America because of effects of drug prohibition other than the spread of AIDS. Policy critics have identified violent crime, gang warfare, and prison overcrowding as by-products of a purely abstinence-based approach to drug use issues.

As a strategy of harm reduction, methadone helps keep users stabilized so that use becomes less frequent because it is taken orally as a syrup and has long lasting effects, helps prevent hepatitis and AIDS, and brings users back into the community rather than treating them like outsiders. Methadone allows the user to come into contact with medical and health personnel, seek meaningful work and pursue other aspirations. The user no longer needs to do "anything" (including criminal activities) to pay for and obtain heroin. By coming back into the community through methadone maintenance, there is a chance not only for rehabilitation but to break the drugs-and-crime cycle.

The establishment of needle exchanges is also consistent with the goal of reducing harms associated with drug use for some of the same reasons. Needle exchanges provide information to individuals about the changes to drug using behaviour needed to decrease harms, and with the means to make these changes - in this case, sterile needles and condoms.

At this juncture, you may ask what all of this has to do with health promotion? Much more can be said about harm reduction, of course, and above I offer only a very basic overview. In my own work in the area (oriented towards defining the concept, examining barriers to the adoption of harm reduction in Canada) one of the greatest insights I gained was the extent to which health communication, health promotion and harm reduction had much in common. Let me explain.

ii. Participatory Communication and Harm Reduction

It has long been argued that broad-based health communication in North America is relatively non-participatory since it often uses one-directional means of communication like mass media, employing fear

in attempts to intimidate individuals to adopt healthy behaviours.

Participatory communication addresses many shortcomings that emerge through critical examination of traditional communication approaches, including use of coercion and intimidation, amplification of differences or "deviance" between groups and communities, and the view that health "consumers" are passive recipients of information. What the model of participatory communication also offers is insight into the a tone and values implicit in communication. In this respect it endorses several values and priorities including: the primacy of taking "care" over "cure" approaches, the need to be ethically sensitive to dilemmas related to the use of persuasion and coercion in communication, the importance of respecting and recognising diversity, and reinforcing purposes of freedom, justice and egalitarianism (Nair & White, 1994). Participatory communication also stresses the importance of equality

during communication. It characterizes itself as trusting and mutually agreed to. It tries to reduce the chance of destructive conflict between groups (White & Nair, 1994). It also reinforces equal partnership in all stages, and is culturally and linguistically appropriate.

The values of participatory communication overlap with principles and assumptions of harm reduction. For example, the twin concepts of reducing destructive conflict between groups (participatory communication) and not amplifying deviancy (harm reduction) have much in common. The need to recognize and respect diversity, be sensitive to the use of fear and coercion in communication, and to reinforce trust and equality are also implicit in both approaches. If drug users cannot be "cured" (because they are already using drugs) they can still benefit from communication, since both harm reduction and participatory communication propose a "care" over "cure" approach.

iii. Health Promotion and Harm Reduction

The issue of equity in communication is also important. Besides participatory communication, equity, (as addressed by the former Province of Ontario Premier's Council of Health, Well-Being and Social Justice), is concerned with the distribution of public resources according to individual and community needs. The goals here are to narrow the gap between advantaged and disadvantaged citizens, and to achieve improved levels of health and well-being. Equity as a public policy goal requires the movement towards better access to services,

and participation in decision-making to achieve a more equal distribution of power and better outcomes. Equity in communication guides this research, particularly as it relates to the status of drug users in society, their access to services, resources, and drug information.

In terms of resources and materials created for drug users, equity would be concerned with making drug information available and accessible through channels used by drug users. In terms of better outcomes, equity in communication considers it a priority to provide information drug users could use that would protect them from drug related harms. This would provide a real chance for better health and

well-being for both illicit drug users and the rest of the community.

Harm reduction, I would argue, is an empowering approach to drug use issues among active drug users. Like health promotion, it is concerned with helping individuals "gain control over and improve their health". The only difference is that in terms of harm reduction these "individuals" are often active drug users. Harm reduction is also concerned with a variety of harms, not only on individual, but on

social and environmental levels. In this way there is also a strong link between health promotion and harm reduction.

For information on resources, please see OHPE 31.2

This feature excerpted from a project funded by CDS, Health Canada published as part of my M.Sc. thesis.

Comments and questions welcome: Luba Magdenko, Member, Centre for Health Promotion, Consultant, The Health Communication Unit, (416) 978-0595,

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The Street-Involved Youth Harm Reduction Project (SIYHRP) was developed by the Addiction Research Foundation in collaboration with an Advisory Group of providers from agencies serving street-involved youth in Metro Toronto. The project hired six street-involved youth on a part-time basis for eight months to conduct research among a wide diversity of their peers and to develop harm reduction materials for other street-involved youth. The Concerned Youth Promoting Harm Reduction (CYPHR) team produced a 20-minute video ("Safer with CYPHR") comprising drama, dialogue and animated segments to illustrate drug-related

harms and strategies for drug-related harm reduction among their peers. The harm reduction approach reflected in this video can be controversial to some people in that it is about helping people who use drugs to be safer and healthier, and not necessarily drug-free. The need for a harm reduction approach was highlighted by earlier survey research by the Addiction Research Foundation which indicated that drug-related harms are experienced by a majority of street-involved youth, that these harms are second only to homelessness as an issue of concern to SIY, and that many youth do not interact well with the treatment system (which partly reflects the orientation of the treatment system, but mostly the fact that many SIY use to cope with street life and the factors that led them to be on the street and therefore have little immediate interest in quitting).

The project also included a qualitative research component designed to improve the understanding of those with an interest in the area about using a participatory process with street-involved youth to produce this kind of product. A combination of session debriefing materials, participant observation, analysis of project documentation, and both focus group discussions and individual depth interviews with youth, members of the Advisory Group of frontline service providers, and members of the core project team were used.

The use of multiple methods to collect information from a variety of stakeholder groups and perspectives provided a richer understanding than is often possible in such projects. This information has been

incorporated, together with other sources, into the development of a 'handbook' that tells the story of the project's evolution and implementation together with insights and recommendations, based on the experience of the project participants, as to how others might establish similar projects in their own jurisdictions.

The video and handbook are available, on a modest cost recovery basis, by contacting Elsbeth Tupker at the Addiction Research Foundation (416-595-8743 or ). For more information about the research component of the study, you may contact Blake Poland, Department of Public Health Sciences, University of Toronto (416-978-2087 or ).

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C. Risk Taking: A Grade 8 Lesson Plan....A Work In Progress

Staff working in the area of substance abuse prevention at the City of Toronto Public Health Services have developed and are now piloting a new in-class module on risk taking.

Designed with grade 8 students in mind, the two 1 hour classes are set up to assist students to:

1) understand and explore risk taking (i.e., the dual nature of risk taking - that risk taking may sometimes be associated with harmful outcomes, while taking other risks may promote learning and skill development; and to acknowledge that risk taking can be exciting);

2) develop the capacity to assess risks - both in advance and during a situation; and

3) think through choices and make decisions that minimize harmful consequences.

In the first class, the facilitator (teacher, public health nurse) sets the stage for thinking about the many different types of risk which exist, and how taking risks and developing the ability to assess risk and make choices are important aspects of growing and learning. Several exercises are included in this session from which the facilitator may choose - to match with the class' needs and available time.

A video, The Surprise Party (developed by youth for Parents Against Drugs), is used as a teaching tool. In the video, alcohol, other drug use, and many other physical and social/emotional risk situations are played out for a range of characters. Before watching the video the class is divided into five or six smaller groups. Each group is assigned a pair of characters to follow in the video, thinking about four key questions:

1) What risk(s) did the assigned characters take ?

2) What happened as a result of taking that risk/those risks ?

3) What could have happened ?

4) What else could the characters have done ?

Through a collective discussion, each group reports back on questions 1 to 3; for question 4 they use role plays to show the rest of the class what their characters could have done differently to avoid or minimize the harms associated with the risk(s) taken.

If you would like more information or would be interested in reviewing the Lesson Plan, please contact Elizabeth Kruzel (tel# 416-392-7451 or e-mail

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D. Risk Communications Presentations - Synopsis

i. "High Stress, High Concern: Tools & Principles of Risk Communication" presentation by Dr. Vincent Covello, Director of the Centre for Risk Communication NY, at the Ontario Public Health Association conference November 25, 1997.

Dr. Covello is an impressive speaker - in one hour he engaged an after-lunch crowd of 500 delegates in a lively and comprehensive presentation about the importance of developing the skills of communication, and demonstrated 3 key points that most of that audience will remember. He notes that risk communication is a systematic = approach to communication of issues creating high stress and high concern among the public. Communication is a skill that public health people need to develop - from lead contamination to downloading requires skills and good research to discuss and debate.

Key Point #1 - Provide verbal and non-verbal messages that convey empathy and caring.

Key Point #2 - Be clear, concise and use understandable language in no more than 3 key messages

Key Point #3 - Provide a positive message - remember the negative dominance. One Negative will eliminate three positive statements N=3P

Other useful points

- make only 3 key points and repeat them at least once and no more than 4 times;

- that P = R Perception is equal to = Reality (for most people);

- G = T&C Goal should be Trust & Credibility.

The public health community is seen by Dr. Covello as having a high credibility with the public, and therefore, has an opportunity to keep an open communication link with the public at all times.

ii. "Strategies for Effective Risk Communication on Drinking Water Risks" presentation by Jennifer Yessis, [Waterloo] Institute for Risk Research & Jennifer Hall, Frontline Corporate Communications at the Ontario Public Health Association conference November 25, 1997

Immediately following Dr. Vince Covello's keynote address, there was a workshop on effective risk communication strategies, using Ontario public health case examples. The two presenters provided an engaging, thoughtful and wide-ranging overview of the issues in risk communications, some real-life examples and important points to remember. Unfortunately only a handful of conference delegates participated in this very interesting session. They defined risk communication as: Any public or private exchange of information that informs individuals about the existence, nature, form, severity or acceptability of risks. Why the attention to Risk Communication? Because as Vince Covello noted - perception is reality and the image of your organization and activity will be what people perceive you to be; you only have one chance at a 'first impression' and your Integrity depends on your actions.

Jennifers' Hall & Yessis made several points that stuck with me, in particular the "Level 6 Answer" to an emotional or difficult issue:

1. Allow for venting

2. Express empathy or concern

3. State your conclusion

4. Provide 2 facts

5. Repeat your conclusion

6. Describe future action

The Seven Cardinal Rules of Risk Communications (actually all Communications) included:

1. Accept & involve the public as a legitimate partner

2. Plan carefully & evaluate your efforts

3. Listen to your audience

4. Be honest, candid & open

5. Coordinate & collaborate with other credible sources

6. Meet the needs of the media

7. Speak clearly and with compassion

And above all, remember that we are here to serve the publics' interests. Good words for all of us.

-- [submitted by Alison Stirling]