Accessing digital harm reduction services—exploring the impact of the “Here4U Scotland” application

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While traditional harm reduction methods exist, the transient nature and unique challenges faced by vulnerable drug users highlight the urgent need for accessible, immediate digital interventions. This paper explores the impact of the Here4U digital drug supervision app, examining relationships between service users and providers, their separate relationships with harm reduction digital solutions and the app’s effects on personal and collaborative service engagement. Methods: The "Here4UScotland" app was piloted in Aberdeen, Scotland. This qualitative study employed focus groups and semi-structured interviews with service users, supporters, and stakeholders. Data was thematically analysed using NVivo 12 to look for associated and relevant codes and themes using the Technology, People, Organisational, and Macro-environmental (TPOM) framework. Results: The pilot indicated improved mutual relationships, personal and social connections, and enhanced harm reduction access among participants. However, key concerns emerged regarding the absence of crucial visual cues for staff and the potential for police involvement. Conclusions: Digital interventions like Here4U Scotland offer significant benefits in enhancing harm reduction engagement and access, fostering new connections and community among vulnerable populations. The presence of digital access is viewed more broadly and encouragingly than simply for the purpose virtual consumption. However, for successful integration of this pilot, it appears crucial to balance technological advantages with ensuring privacy, providing adequate training for staff, and integrating these solutions with existing services, rather than replacing essential human interaction. Digital harm reduction Here4U Scotland app Drug-related-deaths Qualitative research Service users Service providers Visual cues Figures Figure 1 Introduction Worldwide drug-related deaths have become a public health crisis, intensified by synthetics like fentanyl and nitazenes in the street supply ( 1 , 2 ). North America reported 81,083 opioid-related deaths in 2023, disproportionately affecting marginalized communities ( 3 – 5 ). Canada saw 7162 drug-related deaths in 2023, with British Columbia reporting 2511 ( 6 – 8 ). The European Monitoring Agency noted 74% of 2022 drug-related deaths were due to opioids and synthetics ( 2 ). These global trends underscore Scotland's need for unique, effective, and immediately accessible digital harm reduction interventions to address critical public health challenges. In 2023, Scotland registered 1172 drug deaths, an almost 12% rise from the previous year, maintaining its status as Europe's drug death capital ( 9 ). The most deprived areas experience 15 times more fatalities ( 10 ). Current advice includes not using alone, engaging with needle exchange and carrying naloxone ( 11 , 12 ). However, physical services pose logistical challenges for those unable or unwilling to travel to city centre locations or engage in one-to-one communication without anonymity ( 13 ). Vulnerable groups often feel intimidated, apprehensive, or excluded when contacting health services due to stigma and social perception ( 14 – 16 ). Embracing digital evolution offers a potential solution through more transient mediums and services that can assist social anxieties ( 17 ). Digital access can navigate privacy concerns, providing safe, secure, and private connections to supervised consumption and community support for isolated individuals ( 18 ). Remotely supervised consumption is internationally successful via accessible telephone hotlines and digital applications connecting to experienced, peer-led harm reduction support and signposting ( 19 – 21 ). Providers like Safespot (formerly Never Use Alone) have operated in the USA since 2020 ( 19 ), and Canada's National Overdose Response Service (NORS) has offered a telephone hotline since April 2020 ( 20 ). Other apps like "Brave" in Canada allow users to talk to a supporter during drug use until safe ( 21 ). Daneshvar and colleagues reviewed digital applications, including the Lifeguard app, which uses a timer for overdose alerts ( 22 ). Less formal digital services, such as peer spotting via friends/family or user groups, also proved successful ( 23 ). Investigations into further digital service evolution include access to oxygen measurements, vital signs, and respiratory rate for more substantial health data ( 22 ). Digital solutions provide immediate, fluid access to previously static traditional services, fostering new trust and relationships through phone or video calls ( 24 – 26 ). This shift from physical to multi-dimensional digital mediums navigates logistical issues, affording access to anyone with a digital device and internet. It promotes an interconnected, symbiotic relationship between harm reduction services and their users ( 26 ). The Here4UScotland application, piloted in Aberdeen, Scotland, introduced local drug users to accessible remote supervision ( 25 , 26 , 27 ). This formative service based on the Brave overdose response app ( 28 ), encouraged users to contact a supporter via smartphone for supervisory contact during drug use. An emergency plan was arranged to protect individuals from potential overdose. This research examined how this digital service impacted on vulnerable people use drugs, specifically how device and service interaction influenced service user and provider relationships. The research aimed to determine if accessible digital services, developed alongside technology, can enhance engagement and communication within Scottish people who use drugs communities and among providers. More broadly, it explores the Here4UScotland application's impact on participants' lives ( 25 ). Methodology A qualitative approach was applied, using focus groups and semi-structured interviews analysed via thematic analysis ( 29 , 30 ) to explore user experiences in depth. Further analysis from an organisational and macroenvironmental perspective, is presented in a separate paper from the Here4UScotland remote supervised drug consumption app ( 25 ). Ethical approval was secured from the University of Stirling's General University Ethical Approval Panel (GUEP; 7800). Theoretical Framework The study applied the Technology, People, Organisational, and Macro-environmental (TPOM) framework ( 31 ). This formative framework facilitated a thorough investigation of how the pilot and initial contact with digital solutions were received by participants ( 32 ). Given health information technology's increasing role in enabling instant access to critical health services, TPOM's interconnected flexibility was considered most appropriate ( 31 ). Participants The study involved three groups: callers (app users), supporters (those providing harm reduction advice), and stakeholders (community, public, and third-sector groups). Callers : Must have used drugs in the last 12 months, be over 18, and live in Aberdeen. Recruitment used purposeful and snowball sampling. Supporters : Required to be trained, qualified in harm reduction, over 18, and designated. Stakeholders : Included local service management, community, public, third-sector services, or commissioners. Interview and Focus Group Data Collection This study analysed data from service users (Supplementary file 1), focusing on relevant TPOM domains. Semi-structured interviews explored each group's differing experiences, covering relationships, usability, infrastructure, support, barriers, and enablers ( 29 ). All interviews (n = 12) were conducted by GS, whose lived experience of substance use and the shadow world that many in this cohort inhabit, encouraged participant trust and engagement ( 33 ). Two independent online focus groups were held with supporters (n = 3) by GS and HD. An in-person stakeholder focus group (n = 5) was conducted by CM, HD, and GS. All were audio-recorded with permission. Data Analysis Interviews were fully transcribed by an external transcriber, with identifiable information removed and Scottish dialect retained. NVivo 12 assisted large-scale data management (GS and HD). Thematic analysis ( 29 ) within TPOM domains identified perceived benefit categories, reviewed by HD. Coding began with a line-by-line review, focusing on underlying message meanings. An iterative search then identified recurring subthemes across codes, with repeated revisits to find common patterns. Results The Here4UScotland programme was available in Aberdeen from Jan-Dec 2023. There were 25 smartphones provided to some of those most vulnerable and at risk through the Digital Lifelines Scotland programme and partnership with Alcohol & Drug Action (ADA) in Aberdeen. These smartphones were provided with internet connectivity and prepaid credit to ensure participants could engage with the Here4UScotland app. Twenty-one interviews (n = 21) were conducted with some interviews being conducted twice (at different times) with the same participants to investigate and compare temporal experiences related to app engagement. In addition, two focus groups were conducted (n = 8). In total twenty-three (n = 23) interviews and focus groups were conducted and analysed. Table 1 . Number of recordings, and participants involved. Table 1 Number of recordings, and participants involved. Participants Main TPOM Domains Method Number Callers Technological Social/Human factors Interviews 10 (n = 6) Supporters Technological, Social/Human and Organisational factors Interviews 9 (n = 6) Focus group 1 (n = 3) Stakeholders Organisational and wider macroenvironment Interviews 2 (n = 2) Focus group 1 (n = 5) Total recordings 23 Total participants 22 Technology Within the technology component of the TPOM framework, three salient sub-themes emerged: 1. Potential impact of video calling, 2. Location and privacy information , and 3. Usability and Connection. Potential impact of video calling Video calling was viewed positively. It could reduce caller isolation, anxiety and provide reassurance when required: I think it would [be beneficial]. … I think it would affect people that have got no families or whatever or maybe couples as well you know maybe you’ve got two people that are using. (Caller 5). Women having the opportunity to engage with another female via video calls was viewed positively, contrasting with male involvement. Additionally, face-to-face harm reduction advice could prevent critical outcomes: Especially if it’s somebody like you're seeing face-to-face, you know, maybe if it’s like a woman or whatever - but you know if you’ve got a female giving you a face-to-face on the internet, it’s going to make you feel a bit more comfortable and a bit happier. (Caller 5). Video-related digital devices offered security and access to intimate visual cues, potentially facilitating bespoke health information often otherwise unreachable. Broad ambivalence on privacy Contrary to expectations for vulnerable communities, participants were relatively unconcerned about trusted stakeholders accessing their location: When you click on most things on the web now, I just click on ‘accept,’ so I’ve got no idea what’s coming for me in the next few years with that. But I can’t imagine that you guys are going to use it for anything derogatory at all ... (Caller 2). This caller's ambivalence regarding location information highlights their comfort and trust in the service provider. Location tracking was also suggested as a useful measure: I've had it personally myself where a worker or somebody has been worried about your safety, so they’ve sent the police to your house. See if you had a location tracker on you, ken, that would be an amazing thing, I think. (Caller 6). However, not all were comfortable, emphasising the importance of user privacy and limited tracking access: I could only speculate as to why you know maybe some people wouldn’t want some people coming round to their flat, maybe they’re ashamed because of the state their flat is in, maybe they’ve got mental health problems where they just can't speak to people. It could be a number of reasons, couldn’t it? (Caller 5). Mental health and self-esteem concerns emerged as reasons for apprehension about location availability. Improved access and connections Callers generally found the phones and app straightforward to use. Positive views were expressed regarding access to technology and supporter connection: I never actually even thought about, oh, I’d better actually get that onto loudspeaker or whatever, you know. But again, that was fairly easy to - you know fairly easy to do. And I tend to just - I’ll make up [prepare] what I’m going to be using, and then I’ll phone... (Caller 2). The process was understood as easy and appeared to become habitual. Staff assistance further simplified connection and engagement: (SM) was with me when I got the phone, and I installed it straight away. And within five minutes of me having the phone, turning it on, connecting to my Wi-Fi, the app was installed. (Caller 1). This highlights the positive impact of staff-caller relationships, with callers feeling comfortable receiving support. One participant noted this improved connection would be vital if they resumed regular drug use: Say I want to start using drugs again and you know I'm needing something like that. Because when I was using drugs, I would always use them alone. It would be rare that I would use it with any other people. (Caller 5). This emphasised callers' confidence, even if they had previously experienced isolation due to drug use. People Within the people paradigm, three salient sub-themes emerged regarding the tangible difference digital access made to users: 1. Evolution of digital communication, 2. Presence of digital structure , and 3. Immediate access to digital support. Evolution of digital communication The evolution of digital services and device access fostered improved relationships, connections, and availability, reducing reliance on analogue face-to-face methods: So, I think because they'd maybe had conversations with other supporters previously, you know, they were obviously used to how it worked and how much they were using and the fact that they hadn't, you know, had missed their script [prescribed opioid agonist treatment] (Supporter 3). This supporter felt digital app interactions were unrestricted despite multiple supporters, highlighting a recognised risk from missed prescribed medication. The app provided a safety net. The ability to communicate digitally and instantly with a friendly, non-judgemental voice was also highlighted: So, I think if you’re getting that non-judgemental attitude on the phone- I think it’s like if the police come in and see drug users, they often think I’ll arrest you, so then if it’s a friendly person on the phone who understands what’s going on, I think that’s a big difference. (Supporter 4). While primarily piloted as a virtual drug consumption app, an appetite for broader information services was apparent. Presence of digital structure Daily digital structure with services offered psychological scaffolding, potentially aiding identity loss and reshaping hopes/ambitions: I’m kind of lost in myself, and I’m just trying to find more structure and that to my day, so it kind of adds to that as well. You know that, as I say, when I’m using within those times, to make use of the app, I think it’s a great idea. (Caller 2) The caller highlighted feeling psychologically adrift, using the app to improve self-esteem and structure. Digital structure was deemed particularly useful for more systematic, experienced users: They’re probably a little bit more on top of their game [(Older users)] than a lot of the younger ones that are just living in the moment, blasting snowballs, getting arrested and all that…? So, I find those ones would be, in my opinion, more structured in their use, more have a bit of a daily routine. (Supporter 5). Immediate app access and supporter interaction could provide routine and structure, improving psychological wellbeing. Immediate access to digital support Digital devices and services offer a neutral medium for individuals with transient, uncertain lives to comfortably access otherwise difficult services: I think it’s because clients can almost access you whenever they want, and within reason, we can pick that up in our working hours. (Supporter 6). The reassurance of a digital mediator in reducing anxiety during physical communication was a significant benefit, encouraging engagement. The importance of access for those using alone was also emphasised: I spend a lot more time on my own now than I did when I was a wee bit younger, just the people – because a lot of the people that are using or whatever, you know I don’t particularly want to be you know in touch with or speaking to. So sometimes even just, yeah, that voice on the end of the line or whatever. (Caller 2). Immediate access to harm reduction support, if required, could help callers avoid negative social circles. Organisational The organisational factor within the framework explores interactions between various organisations and new digital services. Three main themes emerged: 1) Harm reduction connections, 2) The gravity of responsibility , and 3) Training and service evolution. Harm reduction connections Service providers are responsible for cultivating personal relationships with callers, centred on reciprocal trust and transparent access to harm reduction information via the app. A supporter's interaction exemplified this: So, I just kind of checked in with them that they were maybe not going to use as much as they usually would because their tolerance was down. And they were kind of familiar with that already. They were kind of aware of the risks to themselves around that, so they said that they weren't going to use as much. (Supporter 3). This reciprocal trust regarding disclosure and harm reduction protocols helps cultivate a risk-averse environment. Relationships and the connection between harm reduction and the virtual service were highlighted by repeated calls from the same users: I think there’s been a bit of harm reduction, definitely a bit of harm reduction. There’s been people who have called more than once so there’s that kind of relationship building with the agency, with the service. (Supporters focus group). Providing harm reduction information via this audio platform, while maintaining friendly and trusting relationships, is critical for success and fosters a community feel. The gravity of responsibility Supporters providing client support solely via audio operate without crucial visual and social cues, as elaborated by a supporter: You go off that phone thinking, oh, that was okay, that went really well. I feel quite content. Imagine you came back in the next day, and someone says, “Oh, Joe Bloggs actually had another overdose,” or he died. “What time at?” “1:25.” I’d be like, what time was my call? Oh. You know what I mean. 12:45. But they’ve used again in that time. So, I think we’re putting a massive lot of responsibility onto supporters here. I think it really needs something (Training) a bit more robust, to be honest. (Supporter 2). This environment can create emotional conflict and overwhelming responsibility ( 34 ). The supporter advocated for more robust and proactive training. A participant also suggested a broader harm reduction opportunity: “I’m not sure at the minute. I think I’d try and use it when I’m alone, maybe in a depressed state, I don ‘t know. Lifesaving benefits.” (It has). Overdose. Suicidal. I’m on the spot here, I don’t know. Yeah. Yeah, yeah, it might be like an intervention type of thing as well.” (Caller 3). The suggestion of intervention or support also requires more extensive training for supporters. Training and service evolution The lack of training for audio-only support during immediate drug use, without visual cues, proved problematic: I think probably there would need to be a little bit more training if we were looking for further volunteers, maybe out with that kind of specialist role. Especially around, you know, the signs and symptoms of an overdose because I think when you can see somebody overdosing it’s quite evident but if it’s on the other side of a phone there maybe needs to be a little bit more training around kind of listening out for the signs. (Supporter 3). Employing trained supporters with lived experience and familiarity with colloquial language was viewed positively as a solution. This could be further enhanced by adding a video calling feature: I think video calling, one, because people can say whatever they can say but body language is everything and in recovery we ken [know] when - another addict would pretty much know face-to-face when somebody if they're lying or not, ken. So, aye, I think this would be a good thing. (Caller 6). The participant suggested that individuals experienced with drug use can identify signs unfamiliar to others. Video calling enables a more extensive situational assessment. Macro-environmental Though not a primary focus, macro factors contribute to this service's impact. Police and emergency services intervention UK emergency services must advise police when called to potential overdoses, unlike more successful services in Canada and the USA ( 19 , 20 ). Scottish participants were understandably concerned about police involvement: I’ve certainly heard stories about somebody that had an overdose and then the police administered a log, so the ambulance was on the way and then the police officer searched that person and to detained them under Section 20 and searched them. (Stakeholders FG). Macro concerns were largely limited to police and ambulance, primarily focused on how services might be utilised by authorities for non-public health matters. Discussion This research investigated the impact of new digital devices and services on service users and providers during the Here4U Scotland pilot. Both parties perceived this technology as beneficial for building connections, community, relationships, and improving outcomes. However, concerns arose regarding the lack of visual cues during potential drug injection or overdose, the need for appropriate training when engaging with people who use drugs (PWUD), and potential inappropriate use of powers by police. Participants showed broad ambivalence about privacy, aligning with previous research indicating marginalised groups' willingness to engage digitally despite surveillance concerns for learning, knowledge, and relationships ( 35 – 37 ). Participants warmly discussed the enhanced connections, communication, and engagement opportunities through digital mediums. This echoes previous Scottish and Canadian studies that found digital communication highly beneficial for similar cohorts facing similar issues ( 38 , 39 ). Such communication is vital for solitary PWUDs, as isolation and vulnerability are key drivers of drug-related fatalities ( 24 , 26 – 28 ). However, the significant responsibility associated with this critical contact can heavily burden volunteer supporters, exacerbated by the aforementioned lack of visual cues, necessitating specialised medical training for callers. Internationally, Brave Coop in Canada offers extensive training and psychological support for supporters, preparing them for all eventualities ( 21 , 28 ). An appetite for digital solutions, particularly video calling, was evident due to reasons like access to visual cues, reassurance, increased connection, bespoke health information, and privacy. Adding this to the current audio platform could significantly enhance its appeal. Additionally, the rapid development of Artificial Intelligence (AI) technology is producing a paradigm shift in digital harm reduction, moving beyond generic interactions. While Here4UScotland represents a vital first step AI could revolutionise services by offering highly tailored and bespoke support that could analyse individual patterns, preferences, and risk factors, in real-time, to provide responsive, personalised interventions 24/7/365 ( 40 ). This capability extends beyond simply connecting users; it could proactively offer personalised coping strategies, predict risks based on real-time data from integrated wearables, or even identify optimal support networks. This individualised, continuously adaptive model offers a profound evolution from current human-mediated services. However, this advancement is not without significant challenges: ethical, security, privacy, financial, and informed consent concerns are critical considerations for this AI evolution ( 41 , 42 ). Privacy and confidentiality were important but less critical than anticipated, consistent with previous research ( 25 , 38 ). This might stem from the small cohort size, pre-existing relationships with the host service, and various environmental, cultural, and social factors ( 43 ). Individual attitudes towards privacy were subjective and commonly differ across digital platforms. The potential role of a lived experience researcher in lending credibility to this academic study involving a marginalised group is also worth highlighting ( 33 , 44 ) The evolution of service provision from face-to-face to digital communication was welcomed by callers and supporters, who gained immediate access to people and information previously unavailable. Supporters' experience and empathy towards substance use were considered crucial for overall credibility by both callers and supporters. Immediate access to phone-based digital support positively impacted well-being, offering reassurance, information, and support to individuals accustomed to marginalisation. Conclusion Digital harm reduction technology offers supporters and callers immediate engagement with multiple services, previously unattainable. Unlike historical methods requiring navigation of social anxieties around face-to-face contact, digital access mitigates these obstacles and appears welcome. Despite challenges and subtle interaction within a small community, there was a clear appetite for both digital access and improved harm reduction services. Strengths and Limitations Digital harm reduction is a new concept for most participants, and while uptake of the app was not as popular as hoped, it successfully laid a foundation for future digital harm reduction in Scotland. Here4UScotland was the UK's first incarnation of remote supervised consumption, serving as a bellwether for all future research in this area. However, the concept requires further evolution to bridge the cultural distance between the UK and more established digital environments in Canada and the USA. Limitations include the study's location within a smaller Scottish city and a modest cohort size, recruited through a mixture of purposeful and convenience sampling. Additionally, pre-existing relationships between participants and some supporters may have introduced response bias. The pilot was also hindered by a short timeline and a lack of comprehensive project visibility within the area. Declarations Author Contribution HD and CM led the design of the wider study. GS, HD, and CM conceptualised, designed, and developed this part of the analysis of the study. GS wrote the first draft of the paper. HD, GS, and CM carried out data collection. GS and HD performed the data coding, while GS, HD, and CM conducted the data analysis and prepared the write-up. Our team comprised members of mixed gender, all of whom are educated to master’s or PhD level and have extensive experience working with PWUD and service staff. GS has relevant lived experience. 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The downside of digital inclusion: expectations and experiences of privacy and surveillance among marginal Internet users. First Monday . 2015 Feb 2;20(2). Epstein D, Quinn K. Surveillance Culture: Engagement, Exposure, and Ethics in Digital Modernity. International Journal of Communication . 2020;14:5527–46. Matheson C, Daneshvar H, Carver H, Strachan G, Greenhalgh J. Digital health interventions to prevent drug-related deaths: a rapid review of the evidence. Harm Reduction Journal . 2023 Aug 18;20(1):110. Matheson C, Daneshvar H, Carver H, Strachan G, Greenhalgh J, Schofield J. Evaluation of the Digital Lifelines Scotland Programme. Edinburgh: Scottish Government; 2023 Mar [cited 2025 Jul 4]. Available from: https://digitallifelines.scot/media/1217/digital-lifelines-scotland-evaluation-march-2023.pdf Marshall T, Viste D, Jones S, Kim J, Lee A, Jafri F, et al. Beliefs, attitudes and experiences of virtual overdose monitoring services from the perspectives of people who use substances in Canada: a qualitative study. Harm Reduction Journal. 2023 Jun 24;20(1):80. Claborn, K.R., Creech, S.K., Conway, F.N., Clinton, N.M., Brinkley, K.T., Lippard, E., Ramos, T., Samora, J., Miri, A. and Benzer, J. (2022). Development of a digital platform to improve community response to overdose and prevention among harm reduction organizations. Harm Reduction Journal , 19(1), p.62. Carpenter D, Ezell C. An FDA for AI? Pitfalls and Plausibility of Approval Regulation for Frontier Artificial Intelligence. Proceedings of the AAAI/ACM Conference on AI, Ethics, and Society . 2024;7(1):239–54. Machado H, Silva S, Neiva L. Publics' views on ethical challenges of artificial intelligence: a scoping review. AI and Ethics . 2025;5(1):139–67. Gerber N, Gerber P, Volkamer M. Explaining the privacy paradox: A systematic review of literature investigating privacy attitude and behaviour. Comput Secur. 2018;77:226–61. doi:10.1016/j.cose.2018.04.002 Kelly SM, Stringfellow EJ, Hoffman L, Vess J, Watson DP, Slatko N. Perspectives of researchers with lived experience in implementation science research: Opportunities to close the research-to-practice gap in substance use systems of care. Implement Res Pract. 2023 Jul 6;4. doi:10.1177/26334895231185449. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7121223","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":496230462,"identity":"d898e383-7745-4fb6-87b2-fc0305581797","order_by":0,"name":"Graeme Strachan","email":"data:image/png;base64,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","orcid":"","institution":"University of Sheffield","correspondingAuthor":true,"prefix":"","firstName":"Graeme","middleName":"","lastName":"Strachan","suffix":""},{"id":496230463,"identity":"2ee60081-c41f-44b3-94df-bd51342d5ff6","order_by":1,"name":"Hadi Daneshvar","email":"","orcid":"","institution":"Edinburgh Napier University","correspondingAuthor":false,"prefix":"","firstName":"Hadi","middleName":"","lastName":"Daneshvar","suffix":""},{"id":496230464,"identity":"6d5d48a5-bc06-4bba-bade-e8288ef4dda1","order_by":2,"name":"Catriona Matheson","email":"","orcid":"","institution":"University of Stirling","correspondingAuthor":false,"prefix":"","firstName":"Catriona","middleName":"","lastName":"Matheson","suffix":""}],"badges":[],"createdAt":"2025-07-14 12:38:21","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7121223/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7121223/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12954-026-01418-w","type":"published","date":"2026-02-16T15:59:07+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":88646040,"identity":"eb4d9d27-af98-4c89-9ea6-bb9162e476bd","added_by":"auto","created_at":"2025-08-08 16:32:29","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":17846,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eDiagram of the TPOM evaluation framework\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7121223/v1/53183a4eac01f6a35e85db27.png"},{"id":103251163,"identity":"50bbf6d3-d533-41c8-9089-503489691b6a","added_by":"auto","created_at":"2026-02-23 16:05:30","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":799155,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7121223/v1/875730ce-0d79-4808-b3e6-dcecf9e79dc1.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eAccessing digital harm reduction services—exploring the impact of the “Here4U Scotland” application\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eWorldwide drug-related deaths have become a public health crisis, intensified by synthetics like fentanyl and nitazenes in the street supply (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). North America reported 81,083 opioid-related deaths in 2023, disproportionately affecting marginalized communities (\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e–\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Canada saw 7162 drug-related deaths in 2023, with British Columbia reporting 2511 (\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e–\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). The European Monitoring Agency noted 74% of 2022 drug-related deaths were due to opioids and synthetics (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). These global trends underscore Scotland's need for unique, effective, and immediately accessible digital harm reduction interventions to address critical public health challenges.\u003c/p\u003e\u003cp\u003eIn 2023, Scotland registered 1172 drug deaths, an almost 12% rise from the previous year, maintaining its status as Europe's drug death capital (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). The most deprived areas experience 15 times more fatalities (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Current advice includes not using alone, engaging with needle exchange and carrying naloxone (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). However, physical services pose logistical challenges for those unable or unwilling to travel to city centre locations or engage in one-to-one communication without anonymity (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Vulnerable groups often feel intimidated, apprehensive, or excluded when contacting health services due to stigma and social perception (\u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e–\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eEmbracing digital evolution offers a potential solution through more transient mediums and services that can assist social anxieties (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Digital access can navigate privacy concerns, providing safe, secure, and private connections to supervised consumption and community support for isolated individuals (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Remotely supervised consumption is internationally successful via accessible telephone hotlines and digital applications connecting to experienced, peer-led harm reduction support and signposting (\u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e–\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Providers like Safespot (formerly Never Use Alone) have operated in the USA since 2020 (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e), and Canada's National Overdose Response Service (NORS) has offered a telephone hotline since April 2020 (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Other apps like \"Brave\" in Canada allow users to talk to a supporter during drug use until safe (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Daneshvar and colleagues reviewed digital applications, including the Lifeguard app, which uses a timer for overdose alerts (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Less formal digital services, such as peer spotting via friends/family or user groups, also proved successful (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Investigations into further digital service evolution include access to oxygen measurements, vital signs, and respiratory rate for more substantial health data (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eDigital solutions provide immediate, fluid access to previously static traditional services, fostering new trust and relationships through phone or video calls (\u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e–\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). This shift from physical to multi-dimensional digital mediums navigates logistical issues, affording access to anyone with a digital device and internet. It promotes an interconnected, symbiotic relationship between harm reduction services and their users (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe Here4UScotland application, piloted in Aberdeen, Scotland, introduced local drug users to accessible remote supervision (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). This formative service based on the Brave overdose response app (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e), encouraged users to contact a supporter via smartphone for supervisory contact during drug use. An emergency plan was arranged to protect individuals from potential overdose.\u003c/p\u003e\u003cp\u003eThis research examined how this digital service impacted on vulnerable people use drugs, specifically how device and service interaction influenced service user and provider relationships. The research aimed to determine if accessible digital services, developed alongside technology, can enhance engagement and communication within Scottish people who use drugs communities and among providers. More broadly, it explores the Here4UScotland application's impact on participants' lives (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"Methodology","content":"\u003cp\u003eA qualitative approach was applied, using focus groups and semi-structured interviews analysed via thematic analysis (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e) to explore user experiences in depth. Further analysis from an organisational and macroenvironmental perspective, is presented in a separate paper from the Here4UScotland remote supervised drug consumption app (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Ethical approval was secured from the University of Stirling's General University Ethical Approval Panel (GUEP; 7800).\u003c/p\u003e\u003cp\u003e\u003cb\u003eTheoretical Framework\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe study applied the \u003cb\u003eTechnology, People, Organisational, and Macro-environmental\u003c/b\u003e (TPOM) framework (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). This formative framework facilitated a thorough investigation of how the pilot and initial contact with digital solutions were received by participants (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). Given health information technology's increasing role in enabling instant access to critical health services, TPOM's interconnected flexibility was considered most appropriate (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cb\u003eParticipants\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe study involved three groups: \u003cb\u003ecallers\u003c/b\u003e (app users), \u003cb\u003esupporters\u003c/b\u003e (those providing harm reduction advice), and \u003cb\u003estakeholders\u003c/b\u003e (community, public, and third-sector groups). \u003cb\u003eCallers\u003c/b\u003e: Must have used drugs in the last 12 months, be over 18, and live in Aberdeen. Recruitment used purposeful and snowball sampling. \u003cb\u003eSupporters\u003c/b\u003e: Required to be trained, qualified in harm reduction, over 18, and designated. \u003cb\u003eStakeholders\u003c/b\u003e: Included local service management, community, public, third-sector services, or commissioners.\u003c/p\u003e\u003cp\u003e\u003cb\u003eInterview and Focus Group Data Collection\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis study analysed data from service users (Supplementary file 1), focusing on relevant TPOM domains. Semi-structured interviews explored each group's differing experiences, covering relationships, usability, infrastructure, support, barriers, and enablers (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). All interviews (n = 12) were conducted by GS, whose lived experience of substance use and the shadow world that many in this cohort inhabit, encouraged participant trust and engagement (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). Two independent online focus groups were held with supporters (n = 3) by GS and HD. An in-person stakeholder focus group (n = 5) was conducted by CM, HD, and GS. All were audio-recorded with permission.\u003c/p\u003e\u003ch2\u003eData Analysis\u003c/h2\u003e\u003cp\u003eInterviews were fully transcribed by an external transcriber, with identifiable information removed and Scottish dialect retained. NVivo 12 assisted large-scale data management (GS and HD). Thematic analysis (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e) within TPOM domains identified perceived benefit categories, reviewed by HD. Coding began with a line-by-line review, focusing on underlying message meanings. An iterative search then identified recurring subthemes across codes, with repeated revisits to find common patterns.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe Here4UScotland programme was available in Aberdeen from Jan-Dec 2023. There were 25 smartphones provided to some of those most vulnerable and at risk through the Digital Lifelines Scotland programme and partnership with Alcohol \u0026amp; Drug Action (ADA) in Aberdeen. These smartphones were provided with internet connectivity and prepaid credit to ensure participants could engage with the Here4UScotland app. Twenty-one interviews (n\u0026thinsp;=\u0026thinsp;21) were conducted with some interviews being conducted twice (at different times) with the same participants to investigate and compare temporal experiences related to app engagement. In addition, two focus groups were conducted (n\u0026thinsp;=\u0026thinsp;8). In total twenty-three (n\u0026thinsp;=\u0026thinsp;23) interviews and focus groups were conducted and analysed. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Number of recordings, and participants involved.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eNumber of recordings, and participants involved.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eParticipants\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMain TPOM Domains\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMethod\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNumber\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCallers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTechnological Social/Human factors\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eInterviews\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10 (n\u0026thinsp;=\u0026thinsp;6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eSupporters\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eTechnological, Social/Human and Organisational factors\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eInterviews\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9 (n\u0026thinsp;=\u0026thinsp;6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFocus group\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1 (n\u0026thinsp;=\u0026thinsp;3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eStakeholders\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eOrganisational and wider macroenvironment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eInterviews\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2 (n\u0026thinsp;=\u0026thinsp;2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFocus group\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1 (n\u0026thinsp;=\u0026thinsp;5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eTotal recordings\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e23\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eTotal participants\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eTechnology\u003c/b\u003e\u003c/p\u003e\u003cp\u003eWithin the technology component of the TPOM framework, three salient sub-themes emerged: \u003cb\u003e1. Potential impact of video calling, 2. Location and privacy information\u003c/b\u003e, and \u003cb\u003e3. Usability and Connection.\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003ePotential impact of video calling\u003c/b\u003e\u003c/p\u003e\u003cp\u003eVideo calling was viewed positively. It could reduce caller isolation, anxiety and provide reassurance when required: I think it would [be beneficial]. \u0026hellip; I think it would affect people that have got no families or whatever or maybe couples as well you know maybe you\u0026rsquo;ve got two people that are using. (Caller 5). Women having the opportunity to engage with another female via video calls was viewed positively, contrasting with male involvement. Additionally, face-to-face harm reduction advice could prevent critical outcomes: Especially if it\u0026rsquo;s somebody like you're seeing face-to-face, you know, maybe if it\u0026rsquo;s like a woman or whatever - but you know if you\u0026rsquo;ve got a female giving you a face-to-face on the internet, it\u0026rsquo;s going to make you feel a bit more comfortable and a bit happier. (Caller 5). Video-related digital devices offered security and access to intimate visual cues, potentially facilitating bespoke health information often otherwise unreachable.\u003c/p\u003e\u003cp\u003e\u003cb\u003eBroad ambivalence on privacy\u003c/b\u003e\u003c/p\u003e\u003cp\u003eContrary to expectations for vulnerable communities, participants were relatively unconcerned about trusted stakeholders accessing their location: When you click on most things on the web now, I just click on \u0026lsquo;accept,\u0026rsquo; so I\u0026rsquo;ve got no idea what\u0026rsquo;s coming for me in the next few years with that. But I can\u0026rsquo;t imagine that you guys are going to use it for anything derogatory at all ... (Caller 2). This caller's ambivalence regarding location information highlights their comfort and trust in the service provider. Location tracking was also suggested as a useful measure: I've had it personally myself where a worker or somebody has been worried about your safety, so they\u0026rsquo;ve sent the police to your house. See if you had a location tracker on you, ken, that would be an amazing thing, I think. (Caller 6). However, not all were comfortable, emphasising the importance of user privacy and limited tracking access: I could only speculate as to why you know maybe some people wouldn\u0026rsquo;t want some people coming round to their flat, maybe they\u0026rsquo;re ashamed because of the state their flat is in, maybe they\u0026rsquo;ve got mental health problems where they just can't speak to people. It could be a number of reasons, couldn\u0026rsquo;t it? (Caller 5). Mental health and self-esteem concerns emerged as reasons for apprehension about location availability.\u003c/p\u003e\u003cp\u003e\u003cb\u003eImproved access and connections\u003c/b\u003e\u003c/p\u003e\u003cp\u003eCallers generally found the phones and app straightforward to use. Positive views were expressed regarding access to technology and supporter connection: I never actually even thought about, oh, I\u0026rsquo;d better actually get that onto loudspeaker or whatever, you know. But again, that was fairly easy to - you know fairly easy to do. And I tend to just - I\u0026rsquo;ll make up [prepare] what I\u0026rsquo;m going to be using, and then I\u0026rsquo;ll phone... (Caller 2). The process was understood as easy and appeared to become habitual. Staff assistance further simplified connection and engagement: (SM) was with me when I got the phone, and I installed it straight away. And within five minutes of me having the phone, turning it on, connecting to my Wi-Fi, the app was installed. (Caller 1). This highlights the positive impact of staff-caller relationships, with callers feeling comfortable receiving support. One participant noted this improved connection would be vital if they resumed regular drug use: Say I want to start using drugs again and you know I'm needing something like that. Because when I was using drugs, I would always use them alone. It would be rare that I would use it with any other people. (Caller 5). This emphasised callers' confidence, even if they had previously experienced isolation due to drug use.\u003c/p\u003e\u003cp\u003e\u003cb\u003ePeople\u003c/b\u003e\u003c/p\u003e\u003cp\u003eWithin the people paradigm, three salient sub-themes emerged regarding the tangible difference digital access made to users: \u003cb\u003e1. Evolution of digital communication, 2. Presence of digital structure\u003c/b\u003e, and \u003cb\u003e3. Immediate access to digital support.\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eEvolution of digital communication\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe evolution of digital services and device access fostered improved relationships, connections, and availability, reducing reliance on analogue face-to-face methods: So, I think because they'd maybe had conversations with other supporters previously, you know, they were obviously used to how it worked and how much they were using and the fact that they hadn't, you know, had missed their script [prescribed opioid agonist treatment] (Supporter 3). This supporter felt digital app interactions were unrestricted despite multiple supporters, highlighting a recognised risk from missed prescribed medication. The app provided a safety net. The ability to communicate digitally and instantly with a friendly, non-judgemental voice was also highlighted: So, I think if you\u0026rsquo;re getting that non-judgemental attitude on the phone- I think it\u0026rsquo;s like if the police come in and see drug users, they often think I\u0026rsquo;ll arrest you, so then if it\u0026rsquo;s a friendly person on the phone who understands what\u0026rsquo;s going on, I think that\u0026rsquo;s a big difference. (Supporter 4). While primarily piloted as a virtual drug consumption app, an appetite for broader information services was apparent.\u003c/p\u003e\u003cp\u003e\u003cb\u003ePresence of digital structure\u003c/b\u003e\u003c/p\u003e\u003cp\u003eDaily digital structure with services offered psychological scaffolding, potentially aiding identity loss and reshaping hopes/ambitions: I\u0026rsquo;m kind of lost in myself, and I\u0026rsquo;m just trying to find more structure and that to my day, so it kind of adds to that as well. You know that, as I say, when I\u0026rsquo;m using within those times, to make use of the app, I think it\u0026rsquo;s a great idea. (Caller 2) The caller highlighted feeling psychologically adrift, using the app to improve self-esteem and structure. Digital structure was deemed particularly useful for more systematic, experienced users: They\u0026rsquo;re probably a little bit more on top of their game [(Older users)] than a lot of the younger ones that are just living in the moment, blasting snowballs, getting arrested and all that\u0026hellip;? So, I find those ones would be, in my opinion, more structured in their use, more have a bit of a daily routine. (Supporter 5). Immediate app access and supporter interaction could provide routine and structure, improving psychological wellbeing.\u003c/p\u003e\u003cp\u003e\u003cb\u003eImmediate access to digital support\u003c/b\u003e\u003c/p\u003e\u003cp\u003eDigital devices and services offer a neutral medium for individuals with transient, uncertain lives to comfortably access otherwise difficult services: I think it\u0026rsquo;s because clients can almost access you whenever they want, and within reason, we can pick that up in our working hours. (Supporter 6). The reassurance of a digital mediator in reducing anxiety during physical communication was a significant benefit, encouraging engagement. The importance of access for those using alone was also emphasised: I spend a lot more time on my own now than I did when I was a wee bit younger, just the people \u0026ndash; because a lot of the people that are using or whatever, you know I don\u0026rsquo;t particularly want to be you know in touch with or speaking to. So sometimes even just, yeah, that voice on the end of the line or whatever. (Caller 2). Immediate access to harm reduction support, if required, could help callers avoid negative social circles.\u003c/p\u003e\u003cp\u003e\u003cb\u003eOrganisational\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe organisational factor within the framework explores interactions between various organisations and new digital services. Three main themes emerged: \u003cb\u003e1) Harm reduction connections, 2) The gravity of responsibility\u003c/b\u003e, and \u003cb\u003e3) Training and service evolution.\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eHarm reduction connections\u003c/b\u003e\u003c/p\u003e\u003cp\u003eService providers are responsible for cultivating personal relationships with callers, centred on reciprocal trust and transparent access to harm reduction information via the app. A supporter's interaction exemplified this: So, I just kind of checked in with them that they were maybe not going to use as much as they usually would because their tolerance was down. And they were kind of familiar with that already. They were kind of aware of the risks to themselves around that, so they said that they weren't going to use as much. (Supporter 3). This reciprocal trust regarding disclosure and harm reduction protocols helps cultivate a risk-averse environment. Relationships and the connection between harm reduction and the virtual service were highlighted by repeated calls from the same users: I think there\u0026rsquo;s been a bit of harm reduction, definitely a bit of harm reduction. There\u0026rsquo;s been people who have called more than once so there\u0026rsquo;s that kind of relationship building with the agency, with the service. (Supporters focus group). Providing harm reduction information via this audio platform, while maintaining friendly and trusting relationships, is critical for success and fosters a community feel.\u003c/p\u003e\u003cp\u003e\u003cb\u003eThe gravity of responsibility\u003c/b\u003e\u003c/p\u003e\u003cp\u003eSupporters providing client support solely via audio operate without crucial visual and social cues, as elaborated by a supporter: You go off that phone thinking, oh, that was okay, that went really well. I feel quite content. Imagine you came back in the next day, and someone says, \u0026ldquo;Oh, Joe Bloggs actually had another overdose,\u0026rdquo; or he died. \u0026ldquo;What time at?\u0026rdquo; \u0026ldquo;1:25.\u0026rdquo; I\u0026rsquo;d be like, what time was my call? Oh. You know what I mean. 12:45. But they\u0026rsquo;ve used again in that time. So, I think we\u0026rsquo;re putting a massive lot of responsibility onto supporters here. I think it really needs something (Training) a bit more robust, to be honest. (Supporter 2). This environment can create emotional conflict and overwhelming responsibility (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). The supporter advocated for more robust and proactive training. A participant also suggested a broader harm reduction opportunity: \u0026ldquo;I\u0026rsquo;m not sure at the minute. I think I\u0026rsquo;d try and use it when I\u0026rsquo;m alone, maybe in a depressed state, I don \u0026lsquo;t know. Lifesaving benefits.\u0026rdquo; (It has). Overdose. Suicidal. I\u0026rsquo;m on the spot here, I don\u0026rsquo;t know. Yeah. Yeah, yeah, it might be like an intervention type of thing as well.\u0026rdquo; (Caller 3). The suggestion of intervention or support also requires more extensive training for supporters.\u003c/p\u003e\u003cp\u003e\u003cb\u003eTraining and service evolution\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe lack of training for audio-only support during immediate drug use, without visual cues, proved problematic: I think probably there would need to be a little bit more training if we were looking for further volunteers, maybe out with that kind of specialist role. Especially around, you know, the signs and symptoms of an overdose because I think when you can see somebody overdosing it\u0026rsquo;s quite evident but if it\u0026rsquo;s on the other side of a phone there maybe needs to be a little bit more training around kind of listening out for the signs. (Supporter 3). Employing trained supporters with lived experience and familiarity with colloquial language was viewed positively as a solution. This could be further enhanced by adding a video calling feature: I think video calling, one, because people can say whatever they can say but body language is everything and in recovery we ken [know] when - another addict would pretty much know face-to-face when somebody if they're lying or not, ken. So, aye, I think this would be a good thing. (Caller 6). The participant suggested that individuals experienced with drug use can identify signs unfamiliar to others. Video calling enables a more extensive situational assessment.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMacro-environmental\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThough not a primary focus, macro factors contribute to this service's impact.\u003c/p\u003e\u003cp\u003e\u003cb\u003ePolice and emergency services intervention\u003c/b\u003e\u003c/p\u003e\u003cp\u003eUK emergency services must advise police when called to potential overdoses, unlike more successful services in Canada and the USA (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Scottish participants were understandably concerned about police involvement: I\u0026rsquo;ve certainly heard stories about somebody that had an overdose and then the police administered a log, so the ambulance was on the way and then the police officer searched that person and to detained them under Section 20 and searched them. (Stakeholders FG). Macro concerns were largely limited to police and ambulance, primarily focused on how services might be utilised by authorities for non-public health matters.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis research investigated the impact of new digital devices and services on service users and providers during the Here4U Scotland pilot. Both parties perceived this technology as beneficial for building connections, community, relationships, and improving outcomes. However, concerns arose regarding the lack of visual cues during potential drug injection or overdose, the need for appropriate training when engaging with people who use drugs (PWUD), and potential inappropriate use of powers by police. Participants showed broad ambivalence about privacy, aligning with previous research indicating marginalised groups' willingness to engage digitally despite surveillance concerns for learning, knowledge, and relationships (\u003cspan additionalcitationids=\"CR36\" citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). Participants warmly discussed the enhanced connections, communication, and engagement opportunities through digital mediums. This echoes previous Scottish and Canadian studies that found digital communication highly beneficial for similar cohorts facing similar issues (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). Such communication is vital for solitary PWUDs, as isolation and vulnerability are key drivers of drug-related fatalities (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan additionalcitationids=\"CR27\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). However, the significant responsibility associated with this critical contact can heavily burden volunteer supporters, exacerbated by the aforementioned lack of visual cues, necessitating specialised medical training for callers. Internationally, Brave Coop in Canada offers extensive training and psychological support for supporters, preparing them for all eventualities (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAn appetite for digital solutions, particularly video calling, was evident due to reasons like access to visual cues, reassurance, increased connection, bespoke health information, and privacy. Adding this to the current audio platform could significantly enhance its appeal. Additionally, the rapid development of Artificial Intelligence (AI) technology is producing a paradigm shift in digital harm reduction, moving beyond generic interactions. While Here4UScotland represents a vital first step AI could revolutionise services by offering highly tailored and bespoke support that could analyse individual patterns, preferences, and risk factors, in real-time, to provide responsive, personalised interventions 24/7/365 (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). This capability extends beyond simply connecting users; it could proactively offer personalised coping strategies, predict risks based on real-time data from integrated wearables, or even identify optimal support networks. This individualised, continuously adaptive model offers a profound evolution from current human-mediated services. However, this advancement is not without significant challenges: ethical, security, privacy, financial, and informed consent concerns are critical considerations for this AI evolution (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e).\u003c/p\u003e\u003cp\u003ePrivacy and confidentiality were important but less critical than anticipated, consistent with previous research (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). This might stem from the small cohort size, pre-existing relationships with the host service, and various environmental, cultural, and social factors (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). Individual attitudes towards privacy were subjective and commonly differ across digital platforms. The potential role of a lived experience researcher in lending credibility to this academic study involving a marginalised group is also worth highlighting (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eThe evolution of service provision from face-to-face to digital communication was welcomed by callers and supporters, who gained immediate access to people and information previously unavailable. Supporters' experience and empathy towards substance use were considered crucial for overall credibility by both callers and supporters. Immediate access to phone-based digital support positively impacted well-being, offering reassurance, information, and support to individuals accustomed to marginalisation.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eDigital harm reduction technology offers supporters and callers immediate engagement with multiple services, previously unattainable. Unlike historical methods requiring navigation of social anxieties around face-to-face contact, digital access mitigates these obstacles and appears welcome. Despite challenges and subtle interaction within a small community, there was a clear appetite for both digital access and improved harm reduction services.\u003c/p\u003e\u003cp\u003e\u003cb\u003eStrengths and Limitations\u003c/b\u003e\u003c/p\u003e\u003cp\u003eDigital harm reduction is a new concept for most participants, and while uptake of the app was not as popular as hoped, it successfully laid a foundation for future digital harm reduction in Scotland. Here4UScotland was the UK's first incarnation of remote supervised consumption, serving as a bellwether for all future research in this area. However, the concept requires further evolution to bridge the cultural distance between the UK and more established digital environments in Canada and the USA. Limitations include the study's location within a smaller Scottish city and a modest cohort size, recruited through a mixture of purposeful and convenience sampling. Additionally, pre-existing relationships between participants and some supporters may have introduced response bias. The pilot was also hindered by a short timeline and a lack of comprehensive project visibility within the area.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eHD and CM led the design of the wider study. GS, HD, and CM conceptualised, designed, and developed this part of the analysis of the study. GS wrote the first draft of the paper. HD, GS, and CM carried out data collection. GS and HD performed the data coding, while GS, HD, and CM conducted the data analysis and prepared the write-up. Our team comprised members of mixed gender, all of whom are educated to master\u0026rsquo;s or PhD level and have extensive experience working with PWUD and service staff. GS has relevant lived experience. We discussed the data collection process and analysis as a team, ensuring our findings were grounded in participants' experiences. All authors participated in reviewing, editing, and finalising the manuscript, and all approved the final version.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eUnited Nations Office on Drugs and Crime. World Drug Report 2023 [Internet]. 2023 [cited 2025 May 25]. Available from: https://www.unodc.org/unodc/en/data-and-analysis/world-drug-report-2023.html\u003c/li\u003e\n\u003cli\u003eEuropean Union Drugs Agency. 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Publics\u0026apos; views on ethical challenges of artificial intelligence: a scoping review. \u003cem\u003eAI and Ethics\u003c/em\u003e. 2025;5(1):139\u0026ndash;67.\u003c/li\u003e\n\u003cli\u003eGerber N, Gerber P, Volkamer M. Explaining the privacy paradox: A systematic review of literature investigating privacy attitude and behaviour. Comput Secur. 2018;77:226\u0026ndash;61. doi:10.1016/j.cose.2018.04.002\u003c/li\u003e\n\u003cli\u003eKelly SM, Stringfellow EJ, Hoffman L, Vess J, Watson DP, Slatko N. Perspectives of researchers with lived experience in implementation science research: Opportunities to close the research-to-practice gap in substance use systems of care. Implement Res Pract. 2023 Jul 6;4. doi:10.1177/26334895231185449.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"harm-reduction-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"harj","sideBox":"Learn more about [Harm Reduction Journal](http://harmreductionjournal.biomedcentral.com/)","snPcode":"12954","submissionUrl":"https://submission.nature.com/new-submission/12954/3","title":"Harm Reduction Journal","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Digital harm reduction, Here4U Scotland app, Drug-related-deaths, Qualitative research, Service users, Service providers, Visual cues","lastPublishedDoi":"10.21203/rs.3.rs-7121223/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7121223/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e The global rise of synthetic drugs and poor quality of drug supply has added to the current global drug death crisis, particularly, disproportionately affecting those in North America and Scotland and those from the lowest socioeconomic settings. While traditional harm reduction methods exist, the transient nature and unique challenges faced by vulnerable drug users highlight the urgent need for accessible, immediate digital interventions. This paper explores the impact of the Here4U digital drug supervision app, examining relationships between service users and providers, their separate relationships with harm reduction digital solutions and the app’s effects on personal and collaborative service engagement.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e The \"Here4UScotland\" app was piloted in Aberdeen, Scotland. This qualitative study employed focus groups and semi-structured interviews with service users, supporters, and stakeholders. Data was thematically analysed using NVivo 12 to look for associated and relevant codes and themes using the Technology, People, Organisational, and Macro-environmental (TPOM) framework.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e The pilot indicated improved mutual relationships, personal and social connections, and enhanced harm reduction access among participants. However, key concerns emerged regarding the absence of crucial visual cues for staff and the potential for police involvement.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e Digital interventions like Here4U Scotland offer significant benefits in enhancing harm reduction engagement and access, fostering new connections and community among vulnerable populations. The presence of digital access is viewed more broadly and encouragingly than simply for the purpose virtual consumption. However, for successful integration of this pilot, it appears crucial to balance technological advantages with ensuring privacy, providing adequate training for staff, and integrating these solutions with existing services, rather than replacing essential human interaction.\u003c/p\u003e","manuscriptTitle":"Accessing digital harm reduction services—exploring the impact of the “Here4U Scotland” application","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-08 16:32:24","doi":"10.21203/rs.3.rs-7121223/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-08-18T13:32:34+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-18T04:31:29+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-11T21:37:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"337385557850080951595498456892355624692","date":"2025-08-05T21:51:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"154731087033964149762638024666491323824","date":"2025-08-05T21:13:44+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-05T09:47:04+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-15T12:15:36+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-15T12:12:07+00:00","index":"","fulltext":""},{"type":"submitted","content":"Harm Reduction Journal","date":"2025-07-14T12:32:07+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"harm-reduction-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"harj","sideBox":"Learn more about [Harm Reduction Journal](http://harmreductionjournal.biomedcentral.com/)","snPcode":"12954","submissionUrl":"https://submission.nature.com/new-submission/12954/3","title":"Harm Reduction Journal","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"48f20112-af80-4d19-944a-4044cdc71c07","owner":[],"postedDate":"August 8th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-02-23T16:02:50+00:00","versionOfRecord":{"articleIdentity":"rs-7121223","link":"https://doi.org/10.1186/s12954-026-01418-w","journal":{"identity":"harm-reduction-journal","isVorOnly":false,"title":"Harm Reduction Journal"},"publishedOn":"2026-02-16 15:59:07","publishedOnDateReadable":"February 16th, 2026"},"versionCreatedAt":"2025-08-08 16:32:24","video":"","vorDoi":"10.1186/s12954-026-01418-w","vorDoiUrl":"https://doi.org/10.1186/s12954-026-01418-w","workflowStages":[]},"version":"v1","identity":"rs-7121223","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7121223","identity":"rs-7121223","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}