Operationalizing recipient-centeredness

Abstract

BACKGROUND: Syringe services programs (SSPs) offer critical, evidence-based services for people who use drugs (PWUD), including infectious disease and overdose prevention. SSPs operate from harm reduction and health equity frameworks, prioritizing non-coercive care and client autonomy; these values foster engagement among a community often stigmatized or discriminated against in traditional healthcare settings. As SSPs increasingly expand their clinical service offerings, they may encounter tensions among their core values, internal or funder-driven pressures for service expansion, and partnerships with external healthcare systems. Accordingly, we undertook a qualitative study to understand how SSP staff uphold core values and practice recipient-centeredness, as defined by the Consolidated Framework for Implementation Research (CFIR), when engaging PWUD in health services within harm reduction settings.

METHODS: From May 2023 to February 2024, we conducted qualitative interviews with 41 representatives of 27 SSPs serving diverse U.S. jurisdictions. Guided by the CFIR, trained interviewers used semi-structured interview guides to explore SSPs' health services delivery models. From interviews, recipient-centeredness emerged as a central theme, leading us to employ thematic and narrative analysis to further explore how SSPs defined and operationalized this construct in their programs' health-related services.

RESULTS: SSP staff consistently emphasized the centrality of core values guiding their services, particularly recipient-centeredness. SSPs operationalized recipient-centeredness through three primary facets: accessibility, consistency, and non-coerciveness. These facets informed direct service delivery and referral processes, enabling programs to build trust and meet clients' complex needs. To uphold these facets, SSPs implemented low-barrier service access, mobile outreach, client-centered referrals, and predictable service schedules despite dynamic and sometimes unsupportive contexts.

CONCLUSIONS: This study offers a specific operationalization of recipient-centeredness for the unique and understudied setting of SSPs, identifying accessibility, consistency, and non-coerciveness as key facets of this organizational culture. Understanding these facets yields actionable guidance for supporting SSPs in implementing values-driven public health and prevention programming. These findings may also be relevant for other harm reduction and low-barrier care settings seeking to preserve trust, dignity, autonomy, and effectiveness while delivering evidence-based services.

TRIAL REGISTRATION: NCT06025435.