SisterSpaceMAY2017UPDATEREPORT

Thefirstreportaspartofathree-monthdevelopmentalevaluation

Preparedby:MadisonThulienMPHPracticumStudent,UniversityofBritishColumbia

TasnimNathooMSc,MSW,PracticumSupervisor

INTRODUCTIONSisterSpace,theworld’sfirstwomen-only,community-accessibleoverdosepreventionsite,openedonMay16th,2017inVancouver’sDowntownEastside(DTES).TheprogramisrunbyAtiraWomen’sResourceSociety,inpartnershipwithVancouverCoastalHealth(VCH),theCityofVancouver,B.C.Housing,B.C.Women’sHospital,andtheProvincialHealthServicesAuthority. Todescribeearlyprogramactivities,outcomes,andlessonslearned,athree-monthdevelopmentalevaluationisbeingconducted.Asthefirstreportoftheevaluation,thisupdateprovidesadiscussiononhowwomenintheDTESarebeingaffectedbytheoverdosecrisis,asummaryoftheevaluationapproach,adescriptionoftrendsintheuseofSisterSpaceservices,andanoverviewofprogramactivities.Throughoutthereport,NextStepsboxespointoutwherechangesaredevelopingineithertheevaluationplanorinSisterSpace.

CONTEXT:WOMENANDTHEOVERDOSECRISISOnApril14th,2016,thechiefmedicalofficerofBritishColumbiaannouncedapublichealthemergencyinresponsetoincreasinglyhighratesofopioid-relatedoverdosedeathsacrosstheprovince(1).Astheyearwenton,thedeathratescontinuedtoriseeachmonth.Overall,therewere19.4overdosedeathsforevery100,000peopleinBCin2016.Thismadeaccidentalillicitdrugoverdosethe8thhighestcauseofdeathinBCthatyear;aboveAlzheimer’sdisease,chronicliverdisease,andsuicide(2). In2017,overdoseandoverdosedeathratescontinuetobehigh.InVancouveralone,therewere100suspectedoverdosedeathsduetoillicitsubstanceusefromJanuary1sttoMarch31st,and2,782overdosesinVancouverCoastalHealthregionemergencydepartments(3).30%oftheseoverdosecaseswerewomen,themajorityofwhomliveinVancouverCityCentreortheDTES. DeclaringapublichealthemergencygivestheMinisterofHealthadditionalauthoritytoaddressthecrisis.ThisallowedfortheauthorizationofOverdosePreventionSites(OPS)inDecember2016(4).ThemainpurposeofanOPSistoprovideaspacewherepeoplecanusesubstancesinthepresenceofotherswhoaretrainedinoverdoseintervention.Thestructure,organization,andservicesprovidedateachOPSvarydependingonthecommunity’sneedsandresources.FromtheirexperienceworkingwithwomenintheDTES,Atirahasfoundthatsomewomenhavedifficultyaccessingmixed-genderOPS’sbecauseoftheirneedtoavoidmenwhohavehurtthemorwhowanttohurtthem.Furthermore,researchindicatesthatforwomen,substanceuseandexperiencesofgender-basedviolenceareofteninterconnected(5,6).Thismeansthatwomenwhousesubstancesmighthavespecificneedsrelatedtotheirexperiencesoftraumathatmixed-genderspacesareunabletoaddress(5,6).Theneedforawomen-onlyspaceismagnifiedbythefactthat62%oftheDTESpopulationismale(6),and70%ofpeoplewhouseInsitearemale(7).Therefore,mixed-genderprograms,especiallyharmreductionprograms,aretypicallymale-dominatedspaces. Basedonaliteraturesearch,theonlyotherwomen-onlyoverdosepreventionprogramislocatedinHamburg,Germany.CalledRAGAZZA,theprogramspecificallyservesfemalesexworkerswhousesubstances.Anevaluationfoundthat80%ofwomenwhousedRAGAZZA’sservicesfeltmorecomfortableandsafebecausetherewereonlyfemalestaff,and90%feltthattheycouldspeakmoreopenlyabouttheirproblemsandtruststaffmorereadily(8).Theseresultsreinforcetheconclusionthatwomen-onlyharmreductionprogramsareimportantforwomenwhousesubstances.

EVALUATIONAPPROACHTheevaluationwilltakeplaceoverthreemonths,withdatacollectionoccurringbetweenMay16thandAugust11th.Asadevelopmentalevaluation,datacollection,analysis,andreportingwillbedoneinthreemonthlycycles.Thisiterativeprocesswillallowtheevaluationtoadapttochangesintheprogramandsocialcontextastheyoccur.Italsoprovidesanopportunityfortheevaluationtoinformprogramdevelopment.Threereportswillbewrittenoverthecourseoftheevaluation.Thefirsttworeports(ofwhichthisisthefirst)willberoughly5pageseachandwillfocusondescribingprogramactivities.Thefinalreportwillbearoughly25pagedocumentthatincludesareviewoftheevaluationapproachandreportsonallsignificantfindings.ThereportswillbesubmitteddirectlytoAtirainmid-June,mid-July,andwhentheevaluationendsonAugust25th.Theevaluationhasthreecentralquestions:

1. Howhastheprogramevolvedoverthefirstthreemonths?2. Whatistheimpactoftheprogramattheindividualandprogramlevel?3. Whathavewelearnedaboutpromisingstrategiesforwomen-onlyoverdosepreventionsites?

Datasources

Toanswertheevaluationquestions,quantitativeandqualitativedatawillbecollected.Datasourcesinclude:

• DatacollectionformsprovidedbyVCH,whichrecordthenumberofwomenwhoregisteratSisterSpace,thenumberoftimeswomenusesubstancesinSisterSpace,andthenumberofoverdosesthatoccurinSisterSpace

• Focusgroupswithpeersupportworkers• SurveyswithwomenwhouseSisterSpaceservices• ObservationofdailyactivitiesinSisterSpace,staff

meetings,andstafftraining• Peersupportworkerlogbook

Implement/Adjust

Collectdata

Analyzedata

Report

Nextsteps:VCHhasdevelopednewdatacollectionformsthatalsocollectinformationonthesubstancesbeingused.Thisdatawillbeincludedinfuturereports.Nextsteps:ThedatacollectionformsprovidedbyVCHonlycountvisitsfromwomenwhousesubstancesatSisterSpace.However,ithasbecomeclearthatmanywomenaccessservicesinSisterSpacebutdonotusesubstancesduringtheirvisit.Tocountthesevisits,aseparatedatacollectionformhasbeendevelopedbytheresearcher,andwillstartbeingusedinJune.

Whatisdevelopmentalevaluation?Thisevaluationapproachiscalleddevelopmentalevaluation.Developmentalevaluationdiffersfromtraditionalevaluationbecauseitoccursintandemwiththeearlystagesofprogramdelivery,ratherthanafterprogramdeliveryhasbeenestablished(9).Thisapproachisusefulforinformingthedevelopmentofinnovativeprograms,whichmightnotbeabletomodelthemselvesafterexistinginitiatives.ThisisthecaseforSisterSpace,whichisthefirstprogramofitskindintheworld.Developmentalevaluationalsolendsitselfwelltoprogramsthatexistinchangingsocialcontexts.Asotherservicesandprogramsdevelop,researchispublished,newopioidsbecomeavailable,andpolicieschange,thecontextoftheworkbeingdoneinSisterSpaceevolves.Bytakingadevelopmentalapproach,theevaluationwillbeabletoadjustaccordingly.

SISTERSPACEBYTHENUMBERSHowmanywomencametoSisterSpaceinMay?Intotal,womenaccessedSisterSpacetousesubstancesapproximately1381timesbetweenMay15thandMay31st.Thisnumberdoesnotincludevisitswherewomendidnotusesubstancesbutaccessedotherserviceslikeharmreductionsuppliesorreferrals.Therewerenooverdoses.Figure1showsthenumberoftimeswomenusedsubstancesatSisterSpaceeachdayinMay.Eveningswerebusierthanmorningsthroughoutthemonth,althoughearlyresultsfromJunesuggestthatmorningsarebecomingmorepopular.Inaddition,useofSisterSpacewashighestinthedaysfollowingemploymentassistancepaymentsonMay24th,knownaschequeweek.Otherresearchhasfoundthatoverdoseratesarehighestduringchequeweek(10),sotheevaluationwillcontinuetoinvestigatehowtrendsintheuseofSisterSpacechangeduringthistime. HowmanywomenregisteredatSisterSpaceinMay? WomenvisitingSisterSpaceforthefirsttimeareaskedtoregisterbyfillingoutaUserAgreementform.Intotal,40womenregisteredatSisterSpacebetweenMay15andMay31.BasedonthenumberofwomenwhoregisteredandthenumberoftimeswomenusedsubstancesinSisterSpace,71%ofvisitstoSisterSpaceinMayweremadebywomenwhohadbeentherebefore.Thissuggeststhatsomewomenarebecoming‘regulars’atSisterSpace.Figure2showsthatregistrationofnewusersdecreasedduringchequeweek,eventhoughthenumberofwomenvisitingSisterSpacewashighestonthesedays.ThissuggeststhatwomenarelesslikelytoaccessSisterSpaceforthefirsttimeoverchequeweek.HowoldarethewomenusingSisterSpace?TheUserAgreementformaskswomentoprovidetheirdateofbirth.Ofthe40womenwhoregistered,34chosetoprovidethisinformation(85%).Ofthese34women,74.5%arebetweentheagesof30and49yearsold,andnoneofthemareunder20orover60yearsofage.1ThedatacollectionformforMay23rdwentmissing.Toestimatethenumberofvisitsonthisday,theaveragenumberofmorningandeveningvisitsforallotherdaysinMaywasused.

0

2

4

6

8

10

12

14

16

18

15 16 17 18 19 20 21 22 2324*25 26 27 28 29 30 31

Date

Figure1:NumberofwomenwhousedsubstancesinSisterSpaceinMay

Morningvisits

Eveningvisits

0

1

2

3

4

5

6

7

15 16 17 18 19 20 21 22 2324*25 26 27 28 29 30 31Date

Figure2:NumberofwomenwhoregisteredatSisterSpaceinMay

PROGRAMOVERVIEW AsanOPS,SisterSpaceprovideswomenwhousesubstanceswithasafeandsupportiveenvironmentwheretheycanusesubstancesinthepresenceofpeersupportworkerswhoaretrainedinoverdoseresponse.Itisatrans-inclusiveprogram,andtranswomen,genderqueerwomen,andnon-binarypeoplewhoaresignificantlyfemme-identifiedarewelcome. Hours:SisterSpaceisopenfrom6am-12pm,andthenagainfrom6pm-12am.Thesehourswerechosentofillgapsinexistingservicesintheneighborhood.SisterSpaceistheonlyOPSinVancouverthatisregularlyopenbefore7amandafter11pm. Itisalsoopenearlierthananyotherwomen-onlyprogramintheneighborhood. Thebuilding:Thespaceislocatedat135Dunlevy,whichisattachedtoawomen’sonlyhousingresidencecalledSereena’s,whichisalsorunbyAtira.Thenewly-renovatedsiteconsistsofamainroomwherewomencanusesubstances,akitchen,andanurse’soffice.Abathroomisalsoavailableonsite.

WhatservicesandresourcesdowomenaccessatSisterSpace?MostwomenwhoaccessedSisterSpaceusedtheprogramasaspacetousesubstancesinasafe,controlled,andobservedenvironment.However,SisterSpacealsoprovidedmanyotherservicesandresourcestowomen.Theseincluded: • Harmreductionsupplies:InjectingsuppliesareavailableinSisterSpace,

includingneedles,sterilewater,cookers,tourniquets,alcoholswabs,andvitaminCpackets.Condomsandlubricantarealsoavailable.

• Snacks:Fruit,cookies,andcerealareavailableforwomen,asaredrinksincludingtea,coffee,andjuice.SomewomenhavesaidthattheyenjoycomingtoSisterSpacetousesubstancesbecauseofthesnacks.OfferingsnackshasalsobeenagreattoolformakingwomenfeelwelcomewhentheycometoSisterSpace,especiallyforthefirsttime.

• Referralsandinformationaboutotherservices:InMay,peersupport

workershelpedwomenfindshelterbeds,accesssubstancetreatmentprograms,andfindsafespacesaftergender-basedviolenceandsexualassault.Evenwhenspecificreferralsweren’tmade,thepeerworkersfrequentlyansweredquestionsandprovidedinformationaboutprogramsoperatingintheDTES.OutreachworkersfromotherorganizationsandservicesinthecommunityhavecometoSisterSpacethroughoutthefirstmonth.TheserelationshipswillbeimportantforreferringwomentoSisterSpace,aswellasformakingreferralstotheseservices.

• Socialinteractionandsupport:WhileinSisterSpace,womenoftenhadconversationswitheachotherandwiththepeersupportworkers.Usually,thesewerelight-hearted,friendlyconversationsaboutplansfortherestoftheday,showingoffnewclothes,ormutualfriends.Othertimes,womenchosetoopenupaboutsensitivetopicsincludingbeingbulliedonthestreet,mentalwellness,homelessness,andtheirhistorywithsubstanceuse.Thesemorepersonalconversationswereusuallybetweenthewomenandthepeersupportworkers,andthepeersrespondedbyvalidatingwomen’sexperiences.Thepeersupportworkershavesuggestedthatwomenchoosetoopenupbecausetheywanttobeheardbysomeonewhotheytrustnottojudgethem.TheevaluationwillcontinuetoinvestigatetheseinteractionstounderstandtheirimpactsonthewomeninSisterSpace.

Nextsteps:SisterSpacestarteddistributingsafersmokingkits(whichincludepipes,mouthpieces,screens,andpushsticks)towomeninJune.

Nextsteps:Inthefuture,anurseornursepractitionerwillberegularlyvisitingSisterSpacetoprovidemedicalcare.

WhatisitliketobeapeerinSisterSpace? ThepeersupportworkersarewomenwhosharelivedexperiencewiththewomenusingSisterSpaceservices.Theyarealmostallcurrentorformerillicitsubstanceusers,andmostofthemalsoliveintheDTES.Theirsharedexperienceencouragestheformationoftrusting,respectful,andnon-judgementalrelationshipsbetweenpeerworkersandwomenwhouseSisterSpaceservices.Theirexpertiseandknowledgeaboutsubstanceuse,harmreduction,andtheDTEShavebeencentraltothesuccessofSisterSpace. PeersupportworkersatSisterSpaceworkinpairs,andshiftsaretypicallysixhourslong.BeforestartingatSisterSpace,thepeersupportworkersreceivedtraininginoverdoseresponseandnon-violentcrisisintervention.Theworkisfairlydemanding,andnotallwomenhavebeenabletocommittoit.Onafewoccasions,womenwhowerehiredaspeersupportworkershavenotshownupforshiftsandtheprogrammanagerhasbeenunabletocontactthem.ThewomenthathavecontinuedtoworkinSisterSpaceareaverydedicatedandmotivatedteam,butmorepeersupportworkersareneeded.PromotingSisterSpace AkeyprogramactivityinMaywastopromoteSisterSpaceinthecommunity.Thiswasaccomplishedby: • Apressreleaseinvolvingofficial

announcementsontheAtiraandVCHwebsites,newsarticles(11-13),andaradiointerview(14)

• Wordofmouth• Flyers• Asidewalksignmadebythepeer

supportworkersThephysicalspaceandfurniture

Themainroomisfurnishedanddecoratedwiththeintentionofcreatinga‘livingroom’atmospherewherewomenfeelcomfortableandwelcome.ManywomenhavecommentedonhowmuchtheylikethefurnishinganddécorofSisterSpace.

AtiraisaimingtomakeSisterSpaceaslow-barrieraspossiblebyavoidinghavingrulesinthespace.Withthisinmind,womenareallowedtousesubstancesinwhateverareaofSisterSpacetheyfeelmostcomfortable,andareallowedtorearrangethefurnitureastheychoose.

Nextsteps:InMay,thefurnitureinSisterSpacewastemporaryuntilpermanentfurniture(depictedabove)couldarriveinJune.Thenextreportwillexploreinfurtherdetailhowthefurnitureandlayoutcontributestohowwomenrespondtothespace.

Nextsteps:ManywomenfromthecommunityhaveexpressedinterestinworkinginSisterSpace,andtheprogrammanagerisintheprocessofhiringnewpeersupportworkerswhowillstartinJune.

Nextsteps:InJune,theprogrammanagerbeganholdingmeetingswithpeersupportworkerseveryotherweek.Thesemeetingswillbeusedasanopportunitytoaddressconcernsandprovideadditionaltraining.

Tolearnmore…TolearnmoreaboutSisterSpace,pleasevisittheAtirawebsiteathttp://www.atira.bc.ca/sisterspace-overdose-prevention-siteForfurtherinformationabouttheevaluation,pleasecontactMadisonThulienatmadison.thulien71@gmail.com

REFERENCES1. BCCDC.(2016).PublichealthemergencyinBC.Availablefrom:http://www.bccdc.ca/about/news-

stories/stories/public-health-emergency-in-bc2. KendallP.R.W.,&StevensonL.(2017).Guidanceforsupportivehousingproviders,homelessshelterproviders

andregionalhealthauthoritiesonoverdosepreventionandresponse.Availablefrom:http://www2.gov.bc.ca/assets/gov/health/about-bc-s-health-care-system/office-of-the-provincial-health-officer/guidelines-and-resources-for-supportive-housing-providers-letter-feb2017.pdf

3. BCCentreforDiseaseControl.(2017).TheBCpublichealthopioidoverdoseemergency:March2017update.Availablefrom:http://www.bccdc.ca/resource-gallery/Documents/Educational%20Materials/Epid/Other/Public%20Surveillance%20Report_2017_03_17.pdf

4. VancouverCoastalHealth.(2017).Overdosestatistics–April2017.Availablefrom:http://www.vch.ca/about-us/news/overdose-statistics-april-2017

5. PooleN,UrquhartC,TalbotC.(2010).Genderingthenationalframework:Women-centredharmreduction.Availablefrom:http://bccewh.bc.ca/wp-content/uploads/2012/05/2010_GenderingNatFrameworkWomencentredHarmReduction.pdf

6. VancouverCoastalHealth.(2016).Women’shealthandsafetyintheDowntownEastside:Companionpapertothesecondgenerationstrategydesignpaper.Availablefrom:http://mpap.vch.ca/wp-content/uploads/sites/6/2016/11/DTES_Womens_Companion_Paper_WEBFINAL.pdf

7. ExpertAdvisoryCommitteeonSupervisedInjectionSiteResearch.(2008).Vancouver’sINSITEserviceandothersupervisedinjectionsites:Whathasbeenlearnedfromresearch?Availablefrom:https://www.canada.ca/en/health-canada/corporate/about-health-canada/reports-publications/vancouver-insite-service-other-supervised-injection-sites-what-been-learned-research.html#a1

8. Schäffer,D.,&Stöver,H.(2014).DrugconsumptionroomsinEurope:Models,bestpracticeandchallenges.Availablefrom:http://www.eurohrn.eu/images/stories/pdf/publications/dcr_europe.pdf

9. Gamble,J.A.A.(2008).Adevelopmentalevaluationprimer.Availablefrom:http://www.mcconnellfoundation.ca/de/resources/publication/a-developmental-evaluation-primer

10. VancouverCoastalHealth.(2017).VCHoverdosesurveillanceupdates:April23-29,2017(Week17).Availablefrom:http://www.vch.ca/Documents/overdose-surveillance-week-17.pdf

11. Talmazan,Yuliya.(2017,May16).B.C.’sfirstoverdosepreventionsiteforwomenonlyopensonVancouver’sDowntownEastside.GlobalNews.Availablefrom:http://globalnews.ca/news/3455288/b-c-s-first-overdose-prevention-site-for-women-only-opens-on-vancouvers-downtown-eastside/

12. CBCNews.(2017,May16).Women-onlyoverdosepreventionsiteopensinVancouver’sDowntownEastside.Availablefrom:http://www.cbc.ca/news/canada/british-columbia/women-only-overdose-prevention-site-sisterspace-1.4098450

13. Li,Wanyee.(2017,May16).Vancouvergetsfirstwomen-onlysupervisedinjectionsite.MetroNewsVancouver.Availablefrom:http://www.metronews.ca/news/vancouver/2017/05/16/vancouver-gets-first-women-only-supervised-injection-site.html

14. Roundhouse98.3Vancouver.(2017,May16).JaniceandCoryinterview.Availablefrom:http://www.atira.bc.ca/sites/default/files/Roundhouse983_SisterSpace_May2017.mp3