A Gendered Analysis of Implemention and Impacts of Prescribed Safer Supply in BC: A Qualitative Exploration during Dural Public Health Emergencies

Women and gender diverse persons often remain underserved by harm reduction programs and initiatives (e.g., needle distribution, supervised consumption services, prescribed safer supply programs). A lack of attention to gender and other intersecting factors in the design of harm reduction programs means that the needs of women and gender diverse persons may be overlooked or unmet. This research provides a gendered analysis of the design, implementation, and impacts of prescribed safer supply during the dual public health emergencies (overdose emergency and the COVID-19 pandemic) in British Columbia (BC), Canada. A qualitative methodology informed by critical, feminist, and implementation theory guided this dissertation. The research questions were: (1) Do the existing clinical guidance and policy direction on prescribed safer supply address the unique needs of women and gender diverse persons in BC? (2) Using prescribed safer supply as a case study, how could health equity be integrated into the Consolidated Framework for Implementation Research (CFIR)? (3) What were women’s and gender diverse person’s experiences accessing or attempting to access prescribed safer supply in BC during the dual public health emergencies (overdose emergency and COVID-19 pandemic)? The dissertation is organized into three papers, one for each research question. In paper one, I examine how BC’s prescribed safer supply initiatives (as represented in the Risk Mitigation Guidance [RMG] and prescribed safer supply policy direction) respond to the unique intersecting needs of women and gender diverse persons who use drugs. This study drew on intersectionality-based policy analysis (IBPA) developed by Hankivsky et al. (2012). Findings revealed that the documents were primarily gender silent. When gender was mentioned, it was in the context of reproduction. None of the documents mentioned specific considerations for women or gender diverse persons seeking or receiving prescribed safer supply. In paper two, based on my experience using the CFIR to organize a study evaluating prescribed safer supply in BC, I conducted a critical analysis of the framework with specific attention to equity and gender. Findings from the critical analysis were used to generate recommendations on how to further integrate health equity and gender considerations into the CFIR and implementation science (IS), more generally. Based on my experience, I see community-based participatory research as a potential approach that can help to operationalize equity considerations in the CFIR In paper three interpretive description (ID) was used to analyze 21 in-depth interviews with women and gender diverse persons who accessed prescription opioids or stimulants under the RMG during the dual crisis of drug overdose during the COVID-19 pandemic. Interviews were conducted as part of a larger evaluation of the RMG in BC in 2020-21. Findings highlight that women and gender diverse persons experienced a lack of gender-responsive supports when accessing or attempting to access prescribed safer supply. Together, this research offers novel evidence that can be used to improve women’s and gender diverse persons’ access to harm reduction services, specifically prescribed safer supply programs. The findings from this research extend our understanding of current overdose responses and inform ongoing public health and harm reduction efforts in BC, Canada, and beyond. Findings from this research highlight that current policy documents and emerging models of prescribed safer supply are predominately gender silent and do not address the unique and specific barriers faced by women and gender diverse persons who use drugs. Further research is needed to specifically examine how gender intersects with race, class, and sexuality to influence people’s access to safe supply. Implications for nursing policy, practice, research, and education include specialized training and education around harm reduction for nurses and student nurses, expanding registered nurse prescribing to include medications for safer supply, and future research examining nurse’s role (including nurse practitioners) in safer supply responses.

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