Developing a comprehensive inventory to define harm reduction housing.

Background: The City of Boston has faced unprecedented challenges with substance use amidst changes to the illicit drug supply and increased visibility of homelessness. Among its responses, Boston developed six low threshold harm reduction housing (HRH) sites geared towards supporting the housing needs of people who use drugs (PWUD) and addressing health and safety concerns around geographically concentrated tent encampments. HRH sites are transitional supportive housing that adhere to a "housing first" approach where abstinence is not required and harm reduction services and supports are co-located. Despite the importance of HRH, the specific characteristics and operations of these sites are not well understood. This study sought to address this gap by cataloging the common features of Boston's HRH sites to generate a comprehensive inventory tool for evaluating implementation of harm reduction strategies at transitional housing locations.

Methods: We collected data between June and September 2023 and included semi-structured qualitative interviews with HRH staff (n = 19), ethnographic observations and photos at six HRH sites. Candidate inventory components were derived through triangulation of the data. Two expert medical staff unaffiliated with data collection reviewed a draft inventory measuring awareness and utility of HRH inventory components. We then pilot tested the inventory with three HRH residents across two sites for readability and reliability. Awareness, frequency of use, and perceived helpfulness of key inventory items were further tested in a survey to 106 residents.

Results: HRH staff identified best practices, resources, and policies in HRH sites that were further contextualized with ethnographic field notes. Common to all were overdose prevention protocols, behavioral policies, security measures, and distribution of harm reduction supplies. The initial 44-item inventory of services, policies and site best practices was further refined with expert and participant feedback and application, then finalized to generate a 32-item inventory. Residents identified and valued harm reduction services; medical supports were highly valued but less utilized.

Conclusion: The HRH inventory comprehensively assesses harm reduction provision and residents' awareness and perceived helpfulness of HRH operational components in staying safe from drug-related harms. Characterizing the critical components of HRH through this tool will aid in standardizing the concept and practice of HRH for PWUD and may assist other cities in planning and implementing HRH.