A Place of Encounter: Health and Social Care Workers' Perspectives on Public Gathering Spaces for People Using Drugs

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A Place of Encounter: Health and Social Care Workers' Perspectives on Public Gathering Spaces for People Using Drugs

https://doi.org/10.21203/rs.3.rs-4139802/v1

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In the context of addressing substance use issues in urban areas, public gathering places for individuals who use drugs play a multifaceted role, serving as sites of belonging, support, and potential criminal activity. As these gathering places, often referred to as open drug scenes, are associated with drug dealing, violence, and harm, numerous attempts to close or control them by law enforcement have been made, resulting in increased violence, stigma, and risk of overdoses. This qualitative study explores the experiences of health and social workers regarding a public gathering place, referred to as “the Bench,” in a medium-sized Norwegian city. Through semi-structured interviews with thirteen participants representing various support agencies, four thematic areas emerged: 1) Belonging and a gateway to support and services, 2) Balancing user autonomy at the Bench and systems support, 3) The role of a centralized location, and 4) The preventive role of support workers at the Bench. While the Bench fosters a sense of community and provides access to vital services, concerns about illicit activities persist due to its visibility. Nevertheless, its central location facilitates outreach efforts and ensures easy access to support services. The study underscores the preventive role of healthcare and social workers in stabilizing the environment and mitigating conflicts. Furthermore, it highlights the importance of central locations for public gathering places, emphasizing the proximity to low-threshold services for overdose prevention. Despite some challenges, the Bench represents a crucial venue for establishing relationships and providing assistance to individuals who use drugs, contributing to harm reduction efforts in the community.

In several Western countries, a public health crisis related to substance use, particularly opioid injection and the risk of overdose, is described ^1,2. Common approaches to addressing this crisis include government control and law enforcement aimed at curbing substance use and trafficking in areas frequented by people using drugs ³. Consequently, these efforts often result in individuals who use drugs avoiding medical assistance for fear of encountering law enforcement and may attempt to manage overdoses independently ^1,4.

Despite these measures, public spaces where people who use drugs congregate, referred to as urban or open “drug scenes,” continue to persist in major cities ^5,6. These gathering spots are frequently unwelcome due to illegal activities and their visibility. However, studies have revealed a more nuanced perspective, highlighting these places as social arenas for marginalized individuals who feel disconnected from mainstream society ^7–9.

The relationship between substance use, crime, and violence is complex, with harm reduction strategies demonstrating efficacy in reducing associated risks ². Waal, Clausen, Gjersing, and Gossop ⁵ proposed that coordinated efforts between law enforcement and health and social services represent the most effective intervention strategy for addressing open “drug scenes". However, it is well established that law enforcement strategies often exacerbate violence, stigma, and barriers to access healthcare services ^1,10–12.

Attempts to close urban “drug scenes” have frequently resulted in displaced users relocating to more secluded areas, increasing their vulnerability to various harms and risks ^12,13. In 2020, debates surrounding the establishment of a public outdoor meeting place in Oslo for people with substance dependence underscored the challenges of providing a space where illegal drug transactions occur while also facilitating health and social work interventions ^3,14.

However, there remains a scarcity of studies directly examining the role of healthcare and social care agencies and their experience in managing urban, public gathering places for people who use drugs. Street-level low-threshold services, operated by municipalities or non-profit organizations, play a crucial role in reaching individuals with problematic substance use and serve as an essential harm reduction effort ¹⁵. Community-based organizations are often preferred over larger, distant health services, as individuals who use drugs may avoid formal healthcare settings to evade stigma ¹⁶.

An emerging question pertains to the significance of public gathering places for people who use drugs in shaping the healthcare system's relationship with them. This study aims to enhance understanding of the healthcare system experiences with public gathering places for people who use drugs to inform policy, urban planning, and health and social service strategies. Two research questions have been formulated: 1) What are the perceived advantages and disadvantages of public gathering places for people who use drugs? and 2) What is the significance of the location and accessibility of such gathering places within a city?

A qualitative research design was employed, combining semi-structured focus group interviews and individual interviews. A user representative, who had personal experience in what he referred to as the Bench and the “drug milieu” in the city, participated in designing the study.

Study setting

The study took place in a medium-sized Norwegian city where a public gathering place for people who use drugs had been established for several years. This gathering place, commonly known as “the Bench,” differs from larger “drug scenes” in major cities in that the environment is smaller and relatively manageable. Approximately 70–85 adults, with around 75% being men and an average of 45 years, all of whom use some form of intoxicant such as cannabis, alcohol, various pills, and small amounts of amphetamine and heroin, utilize the gathering place. These individuals typically face significant health challenges and are outside the workforce receiving welfare money. During a city center renovation, new benches with roofs and weather shelters were installed in a separate section of the new city park to accommodate all residents. The term “the Bench” is used to refer to this place. Therefore, in the result section, the public gathering place for people using drugs is referred to as the Bench.

The health and social agencies encompass the municipality’s Department for Drug and Addiction, which includes the FACT (Flexible Assertive Community Treatment) team. Additionally, independent low-threshold services provide health services, overdose prevention measures, hygiene support, and nutrition assistance. The Norwegian Church also participates in outreach activities for individuals struggling with substance use issues.

Recruitment and participants

Inclusion criteria involved providing health or social services to the individuals who frequented the public gathering place and used drugs. Relevant agencies for recruitment were identified in consultation with the study's user representative, and leaders from various agencies were approached and distributed information sheets to eligible employees.

Thirteen participants were recruited, comprising four men and nine women with diverse backgrounds, ages, and education levels. These participants represented various support services aiding individuals with substance use who utilized the public meeting place in the park. Eight participants were engaged in outreach work, and all participants operated premises accessible to users. Further characteristics of the participants, such as specific employment details, are not provided to preserve anonymity, given the relatively small size of the support services.

Data collection

Three focus group interviews and two individual interviews were conducted. The focus group interviews were conducted with individuals who worked at the same agency and lasted for 90 minutes. All interviews occurred at the participants' workplaces according to their preferences. Individual interviews were performed for those who wished or were unable to participate in the focus group interview. The interviews were semi-structured, based on an interview guide developed with the study's user representative. Audio recording was made and transcribed into text, with personally identifiable information removed.

Saturation was discussed during data collection. Following the completion of three focus group interviews, the data were deemed information-rich based on the depth and insights obtained ¹⁷. Subsequently, data collection concluded after conducting two consecutive scheduled individual interviews.

Analysis

Qualitative content analysis was used to analyze the data ^18,19. The interviews were carefully read multiple times and meaning units were extracted and condensed. These condensed meaning units were coded and further abstracted into twelve sub-themes, which were organized into main themes. The initial steps of the analysis dealt with the manifest content of the text, and the steps of coding and design of themes dealt with the latent content of the text ¹⁹. Interpretation of the underlying meaning was discussed by all authors.

Research ethics considerations

The study was approved by the Norwegian Centre for Research Data (reference number 965605). Participation was based on voluntary and informed consent ²⁰, with all participants signing consent forms prior to the interviews. Information about the study was provided both in writing and orally. Participants were informed of their right to withdraw at any time without consequences.

The analysis led to four themes: 1) Belonging and a gateway to support and services, 2) Balancing user autonomy at the Bench and systems support, 3) The role of a centralized location, and 4) The preventive role of support workers at the Bench.

Belonging and a gateway to support and services

In the interviews, it emerged that all participants were well acquainted with the Bench as the city's public gathering place for people using drugs. All thirteen participants had been to the Bench, regardless of whether they conducted outreach work or primarily offered services on their premises. The Bench was described as a meeting point and a social arena where people using drugs, who often were stigmatized and rejected in other settings, felt safe and welcome.

It's a point of reference that they, they know the Bench is always there. So, whether they're there every day or once a month, they know they can go there, and the environment is often the same. I mean, not necessarily that the people are always the same, but they're welcomed there. It's a safe place for them. And it's theirs. (Morten)

The Bench as a gathering place was described as a kind of its own community, and the participants used the word "family" to describe the bond between those who used the space. This meant that the people on the Bench looked after each other and, from the participants- perspective, were safer than if they did not have an open public meeting place. In contrast to people who used drugs who were scattered in secluded and marginalized localities, belonging to the Bench also meant easier access to health and social services. One participant exemplified this by describing how people on the Bench could express concerns for their friends there. In such situations, they could ask them to visit the Bench to help the person about whom they were concerned. Visiting the Bench made the health and social workers also feel that belonged to and were responsible for the place and the people there. The importance of having a place where the participants could seek out the users of their services was emphasized.

As a support worker, I also think about, if we want to get hold of someone. Concrete, wound care, something that needs to be followed up, that we're concerned about, we can ask if they've seen so-and-so down there. Then we can maybe try to go down and see if they're there. Then it's sort of a somewhat concrete place. (Nora)

Several participants stressed the importance of the existence of the Bench and emphasized that the positive aspects outweighed the negative ones. At the same time, they pointed out that it is a meeting place for better and worse. This emerged when the participants talked about public and visible drug use, proximity to youth, and the purchase and sale of illegal drugs.

Several participants also discussed the paradoxical nature of the Bench. They noted that while society tacitly accepts its existence as a gathering place, public drug use remains illegal, and there was a clear perception that illicit drug transactions occur there. Moreover, it was underscored that certain users, such as those enrolled in opioid maintenance therapy (OMT), were unwelcome encounters for the helpers at the Bench. Opinions were divided among the participants regarding whether the Bench could have been supplanted by low-threshold services. Some argued that the Bench held equal importance to their service offerings. Despite highlighting issues associated with it, several participants expressed a positive view of the Bench.

Balancing user autonomy at the Bench and systems support

Although several of the participants expressed a sense of belonging at the Bench themselves, it was consistently emphasized that the Bench belongs to its users. The Bench is their arena, where support systems are guests rather than hosts. Users dictate the dynamics of the space, emphasizing the need for caution and humility when approaching it. Additionally, several participants stressed the significance of people using drugs having a space of their own where they can shield themselves from the support system. Hence, the support system must be conscious of the arena they are in and the role they play. In their premises, the participants said it was natural to set demands, have rules, and take charge, but they would not take the same role at a public meeting place for people using drugs.

I mean, it's a bit harder to sort of control it when you meet them down at the Bench, than when they come here (to the service provider’s premises) because here we're the ones in control. We can say 'OK, we want to have a chat with you', but down there, it's about approaching them differently. (Maria)

The participants also focused on discussing that “users” were more than their mental and physical ailments and that they were ordinary people who had encountered circumstances others could not imagine. One participant recounted how people at the Bench often apologized if they had been excessively intoxicated in the presence of helpers and several participants described a user group that expressed gratitude for the service offerings. The importance of knowing someone at the Bench was emphasized in several ways. It could have a domino effect, where Bench users vouched for the helpers in conversations with other users, but also informed about different service offerings to users who did not have that information. The Bench served as a place to initiate relationships with people in need of support, and it was described as reassuring to know someone at the Bench if there were many people present one day.

And as I experience it right now, this new bench accommodates many people. And that means, I think, that more people sit down around the table than they would have done with less space to sit on. So, it's been crowded down there. Some of them watch us critically as we approach, wondering who we are. And then it's nice to feel confident in those we know. (Astrid)

The role of a centralized location

There was widespread agreement among the participants that the location of the Bench was suitable. The city center was a natural meeting place, and it was meant to be for everyone. Several participants perceived a showcasing of societal diversity at the Bench's location. Its central proximity is close to other venues the users frequent, and one participant expressed thoughts about a decentralized location for a public meeting place for people using drugs as follows:

They gravitate towards the city center. It was suggested another location further north, but then they all (people using the Bench) said that they wouldn't use it but rather head into town. So, I don't think we have a choice. I believe it must be central. (Jacob)

The fact that the Bench is visible and open was highlighted as positive, as it provided the opportunity to monitor and observe the environment. It was also noted that it was easier to have a control function and that there was easy access to emergency services. One participant mentioned it could be difficult to locate people in need of their services if the public meeting place for people using drugs had been more concealed, and that it could have been harder for helpers to establish trust with this vulnerable and stigmatized group of people.

The Bench's visible and natural location was emphasized as positive for those engaged in outreach work. Approaching a meeting place for people using drugs entailed uncertainty, as one did not know in advance what to expect and what the conditions would be like that day. Participants stated that the public location of the Bench could make it safer to approach. They described the Bench as easily accessible, not time-consuming in terms of travel, and visible and natural when passing. The location where the city’s inhabitants naturally pass by gives service providers the choice to approach the Bench and talk, or choose to move on, which would have been more challenging if the Bench's location were more concealed. One participant described this as follows:

There would also be higher thresholds for unwanted events there than in hidden places. Accessibility to drugs, what's circulating... If we observe that there are a lot of pills circulating, then we could choose to wait to visit the Bench until the next day. (Astrid)

Those in the support system who relied on service offerings in their own premises mentioned they believed service users would seek them out regardless of where the Bench was located, and that it would not affect their services to users in that regard as public meeting places for people using drugs is not the natural meeting point for their service offerings.

The preventive role of support workers at the Bench

The fact that the public gathering place for individuals using drugs was situated in a visible and open location facilitated the presence of health and social workers, which was believed to mitigate and prevent unwanted incidents. Without such deterrents, the environment could become more challenging. The role of health and social workers, especially those engaged in outreach work, was highlighted as preventive, which helped stabilize and resolve conflicts. An illustrative incident was recounted by a participant who mentioned observing two young individuals considering a transaction near the Beach on her way home from work one day:

So, one of them says, no, we can't go over there because he (colleague's name) is standing there now. So, the fact that the support system is visible down there, I think it can help a bit, in terms of buying and selling. (Emilie)

Another participant referred to a conversation with someone on the Bench who said the people there did not do anything else wrong in their presence. This was emphasized by several participants who described how the Bench's public and visible location limited the extent of unrest and illegal activity that could occur. Moreover, it provided an opportunity to exert influence on the environment. Another advantage of the support system’s presence was the potential to influence tidiness in the vicinity, as littering was a concern. However, participants expressed reservations about exerting influence at the Bench without being intrusive or overcontrolling. At the same time, they raised concerns about the impression of the support system by the public, fearing that their presence at the Bench without intervening might be misinterpreted.

The participants held different views of whether the Bench served as a recruitment ground for youth. While some highlighted the unfortunate proximity of the Bench to areas frequented by young people, adults present at the Bench were reported to discourage youth from lingering there. One participant refuted the notion that the Bench contributed to youth recruiting, posing a rhetorical question:

If some young teenagers want to try cannabis or something and wonder where to get it or talk about where to get it. Would it be to go down to the open drug scene in the city square where they know police spotters and people are watching, or would it be easier for them to go to a closed and somewhat hidden drug scene and get it? (Kasper)

The multifaceted role of public meeting places for people using drugs is evident in our study, serving as a site of belonging, support, and potential criminality. Despite concerns about illicit activities and visibility, these spaces foster a sense of community and provide access to vital services, highlighting their importance for their users’ well-being. By serving as a place of encounter, the Bench has significant importance for the state of its user’s health. Health and social workers play a crucial role in mitigating conflicts and criminality and stabilizing the environment. emphasizing the preventive function of their presence.

While public support for safe consumption sites has been recognized as a significant harm reduction measure ^2,21, it is essential to distinguish urban “drug scenes” from supervised injection facilities. The gathering place explored in our study primarily functions as a social arena. Illegal drugs are not openly used at the Bench, and its users avoid public injections ⁸. Nonetheless, our results indicate the presence of health-promoting and harm-reduction functions. Social places are shaped by structural factors, and understanding their effect across populations is important for providing necessary care and services ²².

Establishing contact with individuals who use drugs is vital for the support system to provide effective assistance ¹⁵, and public meeting places serve as tangible locations for outreach efforts where support services can approach and establish contact with users who are often difficult to reach, particularly during periods of relapse or escalation of drug use ¹⁶. The location of a public meeting place for those who use drugs holds significance. The proximity between these spaces for people who use drugs and low-threshold services enhances access to life-saving treatment during overdoses, emphasizing the importance of urban, centralized locations ^13,14. Overdose deaths often occur alone in private residences ^23,24, but our study showed how outreach workers were also approached at the Bench with concerns for individuals who were socially connected to the Bench but not present.

Failure to provide specific urban places for individuals who use drugs can lead to the dispersal of users to more marginalized areas, creating dispersed and hidden “drug scenes” that increase stigma and security risks ^6,13. However, public gathering places also pose challenges, including triggers for relapse ⁷ and negative perceptions by the population. Nevertheless, city inhabitants apparently have greater acceptance than previously assumed, as new research has shown lower perceived community stigma in urban areas than in rural areas ²⁵. According to our results, a public gathering place for individuals using drugs is not necessarily a recruitment arena for young people. Previous research confirms this by pointing to internal rules in open “drug scenes” that discourage the involvement of young people ⁸, while young people increasingly turn to social media to buy or sell illegal drugs ²⁶.

Our findings differ from several previous studies reporting drug-related issues such as drug dealing, violence, injections, and overdose fatalities ^3,5,27. This disparity may be attributed to the collaboration between individuals at the Bench and the municipality, which emphasizes user involvement. As a result, there is an agreement where the individuals on the Bench keep the space tidy and refrain from criminal activities, allowing them to take ownership of the space without being troubled by law enforcement. However, it is important to acknowledge the limitation of our study, which is its location in a medium-sized Norwegian city. This may not fully reflect the dynamics of larger urban contexts.

In conclusion, outdoor social venues for people who use drugs can facilitate strong relationships and serve as a foundation for assistance, offering health-promoting functions for vulnerable individuals. The presence of health and social workers in these spaces is perceived as preventive against undesirable events, emphasizing the importance of their visibility. While public gathering places can offer safety and social belonging for individuals using drugs, they also present challenges, such as difficulty in leaving environments characterized by drug use. Despite negative perceptions, central locations are crucial for meeting users’ needs and limiting harm. Overall, understanding the complex dynamics of these spaces is essential for developing effective health and social service strategies.

Acknowledgments

The authors thank the study participants for their contribution to this study and the user representative for his valuable contribution to design and recruitment. We also thank Vilde Holan Bye and Amanda Skjong for their support and discussions.

Author information

Authors and Affiliations

Department of Public Health, Faculty of Health Sciences, University of Stavanger, Stavanger, Norway, Postboks 8600 Forus, 4036 Stavanger, Norway

Stig Bjønness, Amalie Jøntvedt Lie, Trond Grønnestad

SHARE - Centre for Resilience in Healthcare, Faculty of Health Sciences, University of Stavanger, Postboks 8600 Forus, 4036 Stavanger, Norway Stavanger, Norway

Stig Bjønness

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You are reading this latest preprint version

A Place of Encounter: Health and Social Care Workers' Perspectives on Public Gathering Spaces for People Using Drugs

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Version 1

Abstract

Introduction

Method

Study setting

Recruitment and participants

Data collection

Analysis

Research ethics considerations

Results

Belonging and a gateway to support and services

Balancing user autonomy at the Bench and systems support

The role of a centralized location

The preventive role of support workers at the Bench

Discussion

Declarations

References

Status:

Version 1