Co-Designing the PATH Harm Reduction Training for the Peer Workforce: A Community-Based Participatory Approach

Co-Designing the PATH Harm Reduction Training for the Peer Workforce: A Community-Based Participatory Approach | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Co-Designing the PATH Harm Reduction Training for the Peer Workforce: A Community-Based Participatory Approach Garland Gerber, Dennis P. Watson, Keoni K. Bermoy, Lisa D. Taylor, and 8 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8138704/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Background Opioid use disorder and related overdoses remain a leading US public health challenge. Peer Recovery Specialists (PRS), individuals with lived experience who support others in recovery, frequently deliver harm reduction services but face high job demands, stigma, and role conflict due to abstinence-oriented norms. These stressors contribute to burnout, turnover, and diminished service quality. Despite growing recognition of PRSs’ role in harm reduction, few interventions address their workforce development or resilience needs. To strengthen harm reduction delivery and workforce sustainability, we developed Peer Advanced Training in Harm reduction (PATH), a blended educational intervention co-designed with community partners using a Community-Based Participatory Research (CBPR) framework. Methods PATH was designed to enhance PRSs’ personal and job-related resources through (1) three one-hour eLearning modules that apply adult learning and narrative storytelling to shift stigmatizing attitudes and strengthen harm reduction skills, and (2) an ECHO–based case discussion series to build confidence, policy literacy, and organizational alignment. A Community Board (CB) of eight members with lived recovery, harm reduction, and related service experience guided iterative content prioritization across six meetings (February–June 2025). CB members brainstormed, ranked, and refined eLearning and ECHO topics through surveys and facilitated discussions. Cultural exchange surveys assessed perceptions of collaboration, communication, and trust between CB members and researchers at two time points. Results CB deliberations identified relational harm reduction—emphasizing empathy, authenticity, and participant autonomy—as the unifying theme across all training modules. Four final eLearning modules emerged: Embracing the Harm Reduction Approach, Integrating Harm Reduction into Participant Recovery Plans, Supporting PRSs to Do Harm Reduction Work, and Advancing Harm Reduction. ECHO priorities were also refined to reflect the pragmatic nature of peer work as perceived by CB members. Cultural exchange ratings were uniformly high (mean > 5.5 on a 6-point scale), reflecting strong mutual respect, shared learning, and perceived impact. Conclusion Through CBPR co-design, PATH demonstrates how centering people with lived/living experience can yield a culturally grounded, practice-ready workforce intervention that strengthens harm-reduction capacity and sustainability. Findings establish feasibility and guide the forthcoming pilot and subsequent clinical trial to assess PATH’s impact on PRS workforce outcomes and service quality. Harm Reduction Peer Supports Recovery Rervices Community-Based Participatory Research Community Board Co-design Behavioral Health Workforce BACKGROUND Substance use disorders (SUD) remain a major US public health threat, contributing to an estimated 220,511 deaths from October 2023 to September 2024, with 40% being attributed to opioids [ 1 ]. For people who use drugs (PWUD), harm reduction is the first line of overdose defense. Expanding access to harm reduction services requires supporting the often underprepared and under-supported workforce that delivers them [ 2 – 5 ]. These individuals work in stressful conditions associated with a high burnout risk [ 6 , 7 ], which can lead to poorer job performance and lower service quality [ 8 , 9 ]. Peer Recovery Specialists (PRS)—professionals with lived recovery experience who provide mentoring, coaching, and social support—may be a particularly vulnerable class of harm reduction workers. PRSs frequently deliver or intersect with harm reduction services [ 10 – 12 ]. Yet, the demanding nature of their work raises workforce sustainability concerns. PRSs often experience elevated job stress, which is concerning given their status as people who are also managing their personal SUD recovery [ 13 ]. A recent scoping review found wide-ranging negative workforce outcomes associated with PRS work in the literature—including burnout, vicarious trauma, compassion fatigue, turnover intention, and return to uncontrolled substance use [ 14 , 15 ]. These risks may be heightened in harm reduction service settings, where workers frequently encounter situations exposing them to vicarious trauma, stress, and stigma toward people who are or have ever used substances [ 7 , 16 , 17 ]. Systemic (e.g., drug criminalization, abstinence-oriented policy) and organizational (e.g., marginalized roles, limited training) barriers can further contribute to stress by impeding harm reduction services delivery [ 2 , 3 ]. Because many states require abstinence for PRS certification, peers may also enter practice with abstinence-aligned orientations that can result in conflict with harm reduction-focused roles. For instance, one survey (N = 260) indicated that endorsing abstinence-only treatment was associated with 55% lower odds of supporting harm reduction-focused safe consumption sites [ 18 ]. Even when PRSs and other clinicians endorse harm reduction, uptake remains challenging due to limited guidance and individualized outcome expectations [ 19 , 20 ], and harm reduction policies alone do not ensure service integrity [ 19 , 20 ]. These misalignments may foster “don’t-ask–don’t-tell” environments that obscure recovery pathways and increase substance-use–related risk [ 19 , 21 ]. Strengthening PRSs’ personal and job-related resources can help prevent burnout and improve harm reduction service delivery [ 22 ]. Evidence from PRS and harm reduction studies shows that increased resources (e.g., coping strategies, clear roles, and supportive supervision) can mitigate burnout, enhance job satisfaction, and promote retention [ 23 , 24 ]. Appropriate supports may also help PRSs reframe job demands as meaningful challenges, enabling “job crafting” to optimize work conditions and identify small but important client improvements [ 19 , 20 , 22 , 25 ]. Because continuing education is essential for developing these competencies [ 5 , 26 ], targeted approaches are needed to build harm reduction delivery skills, counter abstinence-informed beliefs that might undermine harm reduction efforts, and ensure alignment between policy and supervision [ 19 , 20 , 25 , 27 , 28 ]. Educational strategies have demonstrated effectiveness in improving key personal and organizational resources that could reduce burnout and turnover among PRS and harm reduction workers [ 29 – 33 ]. To address these challenges, we designed Peer Advanced Training in Harm reduction (PATH) as a workforce intervention to enhance the personal and job-related resources PRSs need to manage job demands, reduce burnout, and strengthen harm reduction service delivery. Rooted in the Lead Investigator’s (DPW) prior work [ 5 , 19 , 34 ], PATH integrates two core strategies: (1) virtual education, delivered through one-hour modular eLearning content incorporating adult-learning methods and narrative case stories to build harm reduction knowledge, shift stigmatizing attitudes, and support organizational harm reduction integration; and (2) an ECHO model [ 35 ], a form of case-based group training demonstrated to improve clinical and community impact [ 36 ] to develop PRSs’ skills further and assist supervisors and administrators in strengthening harm reduction-aligned policies and supports. Collectively, PATH was structured as a 15-hour blended program (3 hours of eLearning and 12 hours of ECHO participation over approximately 3 months). This manuscript describes the Community-Based Participatory Research (CBPR) approach we used to refine PATH’s eLearning and ECHO content (information about the larger PATH study can be found at https://pathstudy.info/ ). The strategy centers on researchers’ partnership with a Community Board (CB)—a group comprised of people with lived/living experience (PWLLE) in recovery, PRS service delivery, and harm reduction—who provided structured guidance throughout intervention development. We followed this approach because it promotes shared decision-making and trust between researchers and affected communities [ 37 – 39 ], helping ensure our work centers the lived expertise of people in recovery and PRS throughout the research process [ 39 – 42 ]. To address common risks in CBPR work, such as power imbalances, failure to recognize lived expertise, and tokenism, the researchers integrated iterative feedback structures and engaged CB Members early to ensure authentic rather than symbolic participation [ 43 , 44 , 44 – 47 ]. Through this collaboration, PATH’s CB is shaping content and the broader study to reflect the realities of PRS practice and lived expertise, ensuring authenticity in the narratives, examples, and strategies being developed. As demonstrated below, working with the CB helped ensure PATH content reflected community priorities and supported PRS capacity to deliver harm-reduction services. In the spirit of this work, researchers and CB Members co-authored this manuscript. METHODS Community Board Member Recruitment Process Following methods detailed in an online toolkit [ 48 ], the Research Team recruited CB applicants via an email and flyer, with targeted distribution to 19 US-based harm reduction and peer organizations. Interested individuals were asked to complete a brief online application, which collected demographics, including location of primary residence; personal or professional experience with harm reduction, criminal-legal system, and mutual aid groups; professional experience with recovery organizations; personal experience with recovery; and details of how experiences would inform work as a Board Member. Following a three-week recruitment period, the team comprising six researchers (two with lived experience) and three Community Partners (all with lived experience) screened applications for initial eligibility, scoring them using a 3-point scale applied to three specific factors: harm reduction experience (1/”no experience”, 2/”delivered or received harm reduction services”, 3/”delivered and received harm reduction services”), recovery or harm reduction pathway (1/”not in recovery or not actively using harm reduction”, 2/”in recovery or actively using harm reduction”, 3/”considers self in recovery and is actively using harm reduction”), and recovery work experience (1/”no experience working in a recovery setting”, 2/”experience working in at least one recovery setting”, 3/”experience working in more than one recovery setting”). Applications were then sorted by average score, region of residence, and overall completeness. Two members of our research team then reviewed the highest-scoring applicants from each region and selected individuals for follow-up calls based on overall appropriateness, experience, and completeness of their applications. Each call was conducted by two research team members using a structured script. Researchers also took notes pertaining to each section of the script. After the call, the interviewers created a consensus score for the applicant using a four-point scale: 1/”very poor fit”, 2/”poor fit”, 3/”good fit”, 4/”strong fit”. In the final stage, the entire team of researchers met to review the candidates, weighing final selection based on scores as well as demographic and geographic diversity. Community Board Meetings Board meetings were held virtually via Zoom. They were co-facilitated by the study’s Principal Investigator and a Board Chair who was elected by the other members (a co-Chair who helps facilitate meetings in the Chair’s absence was also elected). Meetings are not recorded to ensure CB Members are comfortable sharing their lived experience; however, the study’s Project Manager takes detailed notes that are distributed by email after each meeting. CB Members are also asked to complete tasks between meetings, which researchers aim to limit to no more than 30 minutes. Per the recommended ethical guidelines for facilitating CBs [ 49 ], Members are compensated for time spent in meetings and completing tasks, and submit monthly invoices to the research team. The content prioritization process spanned 6 meetings from 2/19/2025 to 6/2/2025. Our approach was adapted from a three-step process for prioritizing research priorities with CB Members previously developed by the JEAP Initiative as part of its goals to advance addiction recovery science [ 48 ]. We applied this three-step process separately for (a) eLearning modules, (b) eLearning lessons, and (c) ECHO training topics. Brainstorming (Step 1) was accomplished over one meeting through a combination of guided discussions and breakouts. The meeting began with researchers providing an overview of the topics proposed in the original grant application. Researchers then organized the Board into breakout rooms of 2–3 members and asked them to review the content and brainstorm suggestions, including what topics to drop or add and what content should be covered as part of the topics. The Board then reconvened, and each breakout group provided a report back to the larger group. Prioritization (Step 2) was completed using an online survey delivered between meetings. CB Members were asked to rank the importance of each topic, provide additional topic suggestions, and use text boxes to specify any content they believed was necessary to cover. Refinement (Step 3) occurred in a meeting following the prioritization survey. Researchers presented a summary of the survey results, and CB Members provided their final feedback through open discussions. The three-step process was completed separately for eLearning modules (2/19/25 to 3/3/25), eLearning lessons (3/3/25 to 3/19/25), and ECHO training topics (5/7/25 to 6/2/25), and the eLearning module results informed the initial brainstorming for the eLearning lessons. These activities are not considered human subjects research, as CB Members contributed their expertise to intervention development as paid consultants. Cultural Exchange Survey We used an adapted version of the cultural exchange survey to assess CB Members’ perceptions of collaboration and communication related to the prioritization process [ 50 ]. The survey was developed to assess knowledge, attitudes, and practices exchanged between individuals from different organizations collaborating to implement an evidence-based practice [ 51 ]. The instrument was previously adapted by the JEAP Initiative to assess research relationships from the perspective of Community CB Members. The adapted instrument includes 22 questions that CB Members are asked to rate on a scale from 1/”not at all” to 6/”a great deal”: four questions focus on the CB Members’ understanding and commitment; three questions focus on their relationships with other CB Members; and 13 questions focus on their relationships with researchers. There are also two open-ended questions where respondents can comment on collaborations with fellow CB Members and researchers, respectively. We also included two additional questions developed by the CB Chair to assess respondents’ perceptions of the CB recruitment process and desire to continue participation in CB activities. All surveys were anonymous. All questions are listed in Table 4. We administered the survey electronically at two time points: immediately after the meeting’s finalization (1) the eLearning lesson content and (2) the ECHO training topics. Cultural exchange surveys are conducted anonymously with the Board, with no ability to connect completed surveys to respondents. As such, we obtained a waiver of consent for this activity (Chestnut IRB #2025-52), and consent was not required for data collection. Our analysis summarized the survey data using descriptive statistics (mean and standard deviation), and we calculated differences in average scores across surveys to assess whether perceptions of the CB’s collaboration or communication changed. We also summarized open-ended responses. RESULTS Final Board Member Selection Table 1 presents the characteristics of the CB Applicants, those who completed follow-up calls, and the final selected CB Members. Eighty-nine completed the recruitment survey within the initial three-week application window. Researchers invited 23 total applicants to participate in follow-up calls. Of these, five did not reply to our requests, four no-showed the scheduled call, and 14 completed the call. Of the original eight candidates selected, one declined participation, and an alternate was chosen in their place. Each of the eight selected individuals participated in an initial onboarding meeting, during which we described CB expectations, meeting schedules, and compensation, and then completed expert consultant paperwork that the researchers had modified from standard organizational templates specifically for CB members. Table 1 Community Board Applicant and Selected Member characteristics Demographics Applicants (N = 89 ) Invited for Follow-up Call ( n = 23) Selected Community Board Members ( n = 8) Age (Mean/SD) 44.97 (10.32) 47.35 (9.15) 43.13 (7.04) Gender N (%) N (%) Male 33 (37.1) 9 (39.1) 4 (50.0) Female 51 (57.3) 12 (52.2) 4 (50.0) Other 4 (4.5) 2 (8.7) -- Race White 66 (74.2) 14 (60.9) 6 (75.0) Black or African American 13 (14.6) 4 (17.4) American Indian or Alaska Native 2 (2.2) 2 (8.7) 1 (12.5) More than one race 3 (3.4) 2 (8.7) 1 (12.5) Unknown 5 (5.6) 1 (4.3) -- Ethnicity Latino 13 (14.6) 5 (21.7) 1 (12.5) Not Latino 71 (79.8) 17 (73.9) 7 (87.5) Unknown 5 (5.6) 1 (4.3) -- US region located Northeast 17 (19.1) 4 (17.4) 2 (25.0) Midwest 22 (24.7) 6 (26.1) 1 (12.5) South 36 (40.4) 6 (26.1) 2 (25.0) West 14 (60.1) 7 (30.4) 3 (37.5) Notes: Details regarding recovery status and harm reduction experience are omitted due to privacy concerns regarding the small Community Board size. PATH Content Prioritization Results eLearning prioritization results . The initial module brainstorming discussion included six CB Members. The discussion focused on the need for clarification regarding the modules proposed in the original grant application, including what the content of each module might look like. After the Principal Investigator answered their questions, CB Members voiced that all three original topics included in the grant application were important. After the breakout session following this discussion, one group reported that they discussed the importance of harm reduction advocacy. They defined this as including information to support advocacy efforts of (a) recovery organizations and (b) individual peers and (c) teaching service participants to advocate for their individually chosen recovery path, particularly if it includes harm reduction. The (a) module and (b) lesson prioritization surveys were delivered separately. Both surveys included the three original module topics and lessons and the newly suggested topic of harm reduction advocacy. Results are shown in Table 2. All 8 CB Members completed the module prioritization survey, and 7 completed the lesson prioritization survey. The average scores indicated that CB Members found all four suggested Module topics to be of high priority. History of Harm Reduction and the Compatibility of Harm Reduction with the 12 Steps were the only lesson topics that received an average rating below 3, indicating they were of less priority for CB members. Table 2. Average prioritization scores for eLearning modules and lessons Module topic Mean (SD) 1 Lesson topic Mean (SD) 1 Revised after group discussion 1. Embracing the harm reduction approach 3.88 (0.33) No change 1a. History of harm reduction 2.86 (0.83) No change 1b. Harm reduction principles 3.43 (0.73) No change 1c. Harm reduction and stages of change 3.14 (0.64) Relational harm reduction 2 1d. Compatibility of harm reduction with the 12 steps 2.57 (0.90) No change 2. Integrating harm reduction into participant recovery plans 3.63 (0.48) No change 2a. An overview of harm reduction strategies 3.57 (0.49) No change 2b. Motivational interviewing and harm reduction 3.29 (0.45) Stages of change and harm reduction 2c. Talking openly about drug use to identify high-risk behaviors 3.71 (0.45) No change 2d. Setting harm reduction goals 3.57 (0.49) No change 2e. Celebrating any positive success 3.29 (0.45) No change 3. Supporting PRS to do harm reduction work 3.63 (0.48) No change 3a. Harm reduction-friendly policies 3.57 (0.49) No change 3b. Employee supervision 3.71 0.45) No change 3c. Identifying and addressing community barriers to harm reduction work 3.29 (0.70) No change 3d. Speaking with community stakeholders about harm reduction 3.43 (0.73) No change 4. Advancing harm reduction 2 3.25 (0.83) No change 4a. Introduction to being a harm reduction champion 2 3.29 (0.88) An introduction to being a harm reduction champion 4b. Strategies for promoting harm reduction 2 3.29 (0.45) Harm reduction champion strategies and activities 4c. Supporting Participants’ Voices 2 3.71 (0.45) Supporting participants to be champions of their personal recovery 1 Scale from 1/”not important” to 4/”extremely important” 2 Topic was not included in the originally funded grant application. ----- Table 2 about here ----- All 8 CB Members attended the (a) module refinement discussion, and 6 attended the (b) lesson refinement discussion. At each meeting, the Principal Investigator presented the prioritization results and a summary of open-ended feedback from the relevant prioritization survey conducted prior to the meeting. Afterwards, the CB Members verbally affirmed their agreement with the scores and the qualitative summaries, as well as expanded on information that they thought needed to be covered. Discussions around the newly proposed advocacy module and its corresponding lessons were less concrete, suggesting this module might require more focused development than the others. These discussions also led to the rewording of five lesson titles to reflect their adjusted focus, as shown in the far-right column of Table 2. The rest of this section presents a combined summary of the discussion results from both meetings as they pertain to each module and its corresponding lessons. CB Members reached a clear consensus on the importance of beginning the training with a strong foundation in harm reduction philosophy and practice. They agreed that Module 1, Overview of the Harm Reduction Approach , should orient learners to the central tenets of harm reduction, address common misconceptions, and contextualize the approach relative to abstinence-based and recovery-oriented models. They emphasized that Lesson 1a, History of Harm Reduction , should emphasize the historical roots of harm reduction, including its emergence in response to the HIV/AIDS epidemic and its application across diverse populations. Lesson 1b, Harm Reduction Principles , was discussed as needing to focus on the foundational philosophical and ethical principles of harm reduction, such as autonomy, non-coercion, and compassion, and that the content should be guided by the National Harm Reduction Coalition’s 8 Guiding Principles [ 52 ]. CB Members decided that Lesson 1c should be changed to be Introduction to Relational Harm Reduction— an approach that centers the quality of the relationship between a service provider and a person who uses drugs as a core mechanism of support and change [ 53 ] — and that the original stages of change topic should be combined with the Module 2 lesson on motivational interviewing. This discussion also pointed to the need to focus the lesson mostly on the stages through which behavioral change is theorized to occur and how it can be applied within the context of harm reduction. This was because (a) most peers are already familiar with the stages of behavior change within an abstinence framework, (b) Motivational Interviewing is too large a topic to cover adequately in an eLearning format, and (c) most peers have already received Motivational Interviewing training. CB Members expressed that the concept of relational harm reduction, which none had been introduced to prior to their work on the PATH CB, was so important that it needed to be woven throughout the rest of the training after its introduction. Finally, although it received a lower prioritization score than other lessons, the Board affirmed the value of Lesson 1d, Compatibility of Harm Reduction with the 12-Steps , to challenge stigma and broaden perspectives around 12-step compatibility and other mutual aid approaches. CB Members emphasized that Module 2, Integrating Harm Reduction into Participant Recovery Plans , was critical for supporting peers in applying harm reduction strategies in direct service contexts. They stressed that the lessons should help peers navigate personal boundaries while fostering nonjudgmental, client-centered communication. They expressed that Lesson 2a, An Overview of Harm Reduction Strategies , should introduce core harm reduction strategies and real-world scenarios to support skill-building. As discussed above, CB Members recommended merging information on the stages of behavior change (initially in Module 1, Lesson 3) and making it a greater focus of the lesson, transforming Lesson 2b into Stages of Change and Harm Reduction. Lesson 2c, Talking Openly About Drug Use to Identify High-Risk Behaviors , was discussed as needing to teach peers how to talk openly about drugs when working with service participants who were engaged in abstinence-focused programs such as drug courts, with careful attention to legal and ethical disclaimers and clarity around peer roles. For Lesson 2d, Setting Harm Reduction Goals , CB Members supported a focus on participant-directed goal setting, incorporating SMART (specific, measurable, achievable, relevant, time-bound) goals where appropriate and helping participants understand all available recovery pathways while acknowledging the influence of peer biases in recovery coaching and planning activities. Lesson 2e, Celebrating Any Positive Success , was discussed as requiring challenging abstinence-only definitions of success by celebrating incremental progress and alternative markers of improvement, such as reduced use or restored relationships. The discussion of Module 3, Supporting PRS to Do Harm Reduction Work , focused on organizational and supervisory challenges. CB Members agreed this module should be primarily targeted at supervisors and organizational leaders, with a focus on reducing stigma, strengthening supervisory practices, and fostering workplace environments that support harm reduction delivery. CB Members proposed Lesson 3a, Harm Reduction-Friendly Policies , center on policies that reinforce the legitimacy of non-abstinence-based outcomes for participants and staff and tensions between harm reduction-friendly policies and the requirements and scope of peer certification. Lesson 3b, Employee Supervision , was discussed as needing to address hierarchical dynamics, prevent burnout, and ensure peers are adequately supported through training and equitable workloads. In discussing Lesson 3c, Identifying and Addressing Community Barriers to Harm Reduction Work , CB Members identified barriers at the community level—such as denial or stigma—and recommended preparing peers with relevant data and messaging strategies. CB Members emphasized that Lesson 3d, Speaking with Community Stakeholders about Harm Reduction , should focus on using narrative stories and evidence when engaging stakeholders, aiming to increase public understanding and organizational buy-in. In contrast to the other modules, the conversation around Module 4, Advancing Harm Reduction , was more exploratory, with CB Members acknowledging the value of the content but recognizing that further development is needed. They agreed the module should empower peers and participants to engage in harm reduction efforts, especially given the widespread misconceptions and resistance. Discussions indicated that Lesson 4a, Introduction to being a harm reduction champion , was reframed to address specific strategies for championing harm reduction within organizations and communities, emphasizing the importance of teaching peers about different methods for community education, as well as various harm reduction activities of focus. Lesson 4b, Strategies for promoting harm reduction , should serve more as an introduction to advocacy efforts, focusing on the history of advocacy and emphasizing the importance of human rights and dignity. The lesson should provide peers with an overview of evidence-based, participant-centered advocacy approaches. In discussing Lesson 4c, Supporting Participants’ Voices , CB Members confirmed a need to support participants who struggle with low self-efficacy or confidence in advocating for their personal recovery or harm reduction path. Further, discussions with CB Members prompted a change in language choice for these lessons, moving away from the term ‘advocacy’ and utilizing ‘championship’ in its place. This decision centered around ensuring training materials feel accessible and resonate with diverse groups of peers, better reflecting peer-led leadership activities that are approachable and do not require policy-level or system-facing work. ECHO prioritization results. The ECHO prioritization survey included eight ECHO didactic training topics suggested in the grant application. All 8 CB Members completed the survey. The average scores indicated that they found seven of the topics to be of moderate importance. The lowest-scoring topic, indicating it was only considered of slight importance, was Supporting Colleagues to Deliver Harm Reduction. The ECHO topic refinement discussion included 6 CB Members. The discussion resulted in merging two topics, rewording the others to reflect a modified focus, and adding one new topic. These changes are reflected in the far-right column of Table 3 . During these discussions, Topic 1, Relational Harm Reduction , emerged as a top priority, with strong support for emphasizing autonomy, empathy, and trauma-informed, dignity-affirming care. Members highlighted the need to focus on building trust with service participants as central to effective harm reduction work. Topic 2, Managing Boundaries with Clients , was reconceptualized to include self-care, recognizing that boundaries are a form of self-care and that peers receive exposure to self-care topics from numerous other sources. Discussions emphasized the protective and sustaining function of boundaries for peer workers, especially in smaller communities and dual-role relationships. Self-care was framed as both a personal and organizational responsibility, modeled by supervisors and supported through mentorship. Topic 3, Supporting Colleagues to Deliver Harm Reduction , was reframed to focus on creative problem-solving and mutual support in team settings. Though it received a lower prioritization score, CB Members emphasized its value in promoting a nonjudgmental work culture and navigating team stigma, especially around medications for opioid use disorder. Topic 4, Harm Reduction with Participants Experiencing Homelessness , was endorsed as a critical topic, with attention to trust-building, field-based engagement, and the navigation of legal and systemic barriers. Topic 5, Low-Threshold Treatment and Medication-Assisted Recovery , was updated to reflect a broader focus on medical interventions across substance use disorders. CB Members stressed the need for timely access, reduced barriers, and the importance of framing treatment within participant-centered, evidence-based, and non-stigmatizing approaches. Topic 6, Harm Reduction in Rural Low-Resource Areas , was slightly reworded to broaden its relevance while still addressing challenges specific to rural and other under-resourced communities, including transportation, relationship-building, and the use of national harm reduction resources. Topic 7, Harm Reduction with Criminal-Legal System-Involved Clients , remained unchanged. Discussion emphasized state-level policy differences, working within mandated systems, and supporting clients in navigating legal requirements while maintaining harm reduction principles. Finally, the new Topic 8, Harm Reduction Policy and Legal Structure , was added to address a noted gap in the structural context impacting harm reduction services. This session will provide an overview of relevant laws, historical and emerging policy trends, and advocacy strategies, while maintaining sensitivity to political dynamics across service settings. Table 3 ECHO prioritization scores and summary of open-ended feedback ECHO training topic Mean (SD) Revised topics 1. Relational harm reduction 3.63 (0.48) 1. No changes 2. Managing boundaries with service participants 3.63 (0.70) 2. Managing boundaries with clients (will integrate self-care) 3. Selfcare 3.13 (0.78) 4. Supporting colleagues to deliver harm reduction 2.88 (0.78) 3. Supporting colleagues to deliver harm reduction: Developing creative solutions together 5. Harm reduction with participants experiencing homelessness 3.63 (0.48) 4. No changes 6. Low-threshold treatment and Medication Assisted Recovery (MAR) 3.50 (0.71) 5. Low-threshold treatment and medications 7. Harm reduction in rural and low-resource areas 3.13 (0.60) 6. Harm reduction in low-resource areas 8. Harm reduction with criminal-legal system-involved participants 3.38 (0.70) 7. No changes n/a n/a 8. Harm reduction policy and legal structure Notes: Scale from 1/”not important” to 4/”extremely important.” Cultural Exchange Survey Results Table 4 presents the means and standard deviations for all the Cultural Exchange Survey questions the researchers requested that the CB Members complete. Not all CB Members completed the survey, which is understandable since this was an optional activity to assess CB engagement quality that was outside of the assigned between-meeting prep work. Ratings for all questions indicated strong agreement, and minimal changes between the two time points indicate general stability in opinions. Open-ended feedback was similarly positive. Comments about working with the other CB Members indicated they enjoyed interactions with each other and have respect for their fellow CB Members’ different points of view and experience: “I am pleasantly surprised by how much I enjoy working with everyone on this board. I look forward to every one of our meetings.” “Awesome group of people who bring different ideas and knowledge to the table.” “I have so much respect for the diversity and expertise of this group!!!!”. Comments directed toward researchers indicated CB Members appreciate the respect demonstrate toward them, the perspective they bring, and their efforts to explain technical information in an accessible manner: “I appreciate the research team’s respect for the variety of experience and circumstances the CB Members have.” “The research team is wonderful, I have learned so much about how a project like this comes together.” “The research team has done a great job of explaining and relating the info to the board.” Specific processes that CB Members commented on as being effective included the recruitment process, attention researchers pay to the value of CB Members’ time, the breakout rooms used in meetings, and the time in meetings dedicated to allowing the CB Members to interact without researcher presence: “It shows that a lot of thought and work went into the selection through the advertising, interviewing, and selection process.” “The constant mindfulness of my time and experience.” “The breakout rooms have been a good opportunity to get to know the other board members as well as work on the project.” “I like that the research team has now incorporated time for Board to meet just us without the research team.” Lastly, one comment expressed that a Board Member was struggling with other members' behaviors, which they expressed demonstrated a lack of participation. However, there was no indication of what these behaviors were. Table 4. Cultural Exchange Survey Results Post Module Prioritization ( n = 7) Post ECHO Training Prioritization ( n = 6) Change mean sd mean sd mean Self-directed questions I believe I have a clear understanding of what this collaboration is trying to accomplish. 5.9 0.4 5.8 0.4 0.0 I feel committed to this work. 5.7 0.5 5.8 0.4 0.1 I believe I am devoting the right amount of time and energy to maintain this collaboration. 5.4 0.8 5.3 0.5 -0.1 During the time I have been on the Board, I feel that my contributions have made an impact. 5.4 0.5 5.5 0.8 0.1 Composite score 5.6 0.6 5.6 0.6 0.0 Fellow board member-directed questions I believe we are working well together. 5.9 0.4 5.8 0.4 0.0 I believe we respect one another. 5.9 0.4 5.8 0.4 0.0 I believe my fellow Board members are committed to this work. 5.6 0.8 5.8 0.4 0.3 Composite score 5.8 0.5 5.8 0.4 0.1 Research team-directed questions I believe we are working well together. 5.9 0.4 5.8 0.4 0.0 I believe we respect one another. 5.7 0.5 5.8 0.4 0.1 I believe we trust one another. 5.7 0.5 5.8 0.4 0.1 I believe the research team is devoting the right amount of time and energy to maintain this collaboration. 5.9 0.4 5.7 0.5 -0.2 I believe the research team communicates openly with me. 5.9 0.4 5.8 0.4 0.0 I believe I communicate openly with the research team. 5.7 0.5 5.8 0.4 0.1 I believe the research team is committed to this work. 5.9 0.4 5.8 0.4 0.0 I believe the research team is learning something from me. 5.6 0.5 5.8 0.4 0.3 I believe I am learning something from the research team. 5.7 0.5 5.8 0.4 0.1 I believe the research team is changing their perspectives about something because of me. 5.4 0.8 5.8 0.4 0.4 I believe I am changing my perspective about something because of the research team. 5.1 0.9 5.7 0.5 0.5 I believe the research team is open to my concerns or wishes. 5.9 0.4 5.8 0.4 0.0 I believe that I am open to the concerns or wishes of the research team. 5.9 0.4 5.8 0.4 0.0 Composite score 5.7 0.5 5.8 0.4 0.1 Additional Chair-Recommended Questions I believe the community board selection process demonstrated respect for the perspectives of people with lived experience. 5.9 0.4 5.8 0.4 0.0 I would like the opportunity to engage in the continued research activities of this community board work (learning how to publish research, inform policy, etc.) 5.7 0.8 5.8 0.4 0.1 Notes: Questions asked using a scale of 1/”Not at all” to 6/”A great deal” ----- Table 4 about here ----- DISCUSSION In this early phase of our work, we examined the development of the PATH curricula through a community-engaged process that centered PWLLE of substance use, harm reduction, and related service provision. Consistent with participatory curriculum design research, centering PWLLE enhanced cultural relevance and acceptability while strengthening trust and shared ownership between researchers and community partners [ 1 – 3 ]. Our study aligns with a national shift, reflected in NIH investments such as the Justice Community Overdose Innovation Network (JCOIN) and the JEAP Initiative, which institutionalize CBPR models embedding PWLLE as core partners [ 54 , 55 ]. CB deliberations underscored relational harm reduction as a foundational for the entire curriculum. Relational harm reduction recognizes that reducing substance use-related risk is more than just distributing safer-use and overdose-prevention supplies. It prioritizes trusting, nonjudgmental relationships in which providers partner with people who use drugs to promote safety, autonomy, and wellbeing, recognizing that connection itself is a core intervention [ 53 ]. Because relational harm reduction centers connection as a core intervention, CB members emphasized that peer services should prioritize authenticity, nonjudgment, and participant autonomy. This aligns with emerging PRS and harm reduction workforce literature that emphasizes trust-building and boundary management as prerequisites to effective service delivery [ 7 , 13 , 15 , 16 , 23 , 24 , 56 ]. At the same time, CB members noted ongoing tension between harm-reduction and abstinence-oriented recovery philosophies, highlighting a need for organizational structures that model non-punitive supervision and recognize multiple recovery pathways. CB Members also recommended integrating historical and philosophical context throughout modules to highlight the compatibility of harm reduction and abstinence-based recovery, reducing stigma and bridging cultural divides. These insights parallel studies documenting moral distress and burnout among behavioral health, legal, and harm reduction professionals whose work requires them to navigate competing value systems [ 7 , 16 , 17 , 19 , 57 ]. CB feedback highlighted how language shapes empowerment and inclusion throughout the curriculum. For example, renaming the “Advocacy” module to “Championship” illustrated how subtle linguistic shifts can recalibrate cultural tone—echoing research showing that non-stigmatizing terminology enhances psychological safety and engagement [ 58 , 59 ]. This process of co-creation reflects broader principles of trauma-informed facilitation and community-driven implementation, where shared interpretation transforms descriptive feedback into actionable guidance [ 60 ]. Through the integration of quantitative prioritization and qualitative deliberation, the CB process we followed demonstrates how mixed methods can operationalize equity and produce practice-ready interventions [ 34 , 61 ]. After reviewing the findings from the co-development process described above, the CB Members who are listed as co-authors on this manuscript (GG, AC, HO, SP, RRS, and VS) emphasized the importance of grounding Module 2’s content in an integrated framework that connects social determinants of health with recovery capital. Framing recovery capital through the structural conditions that shape health (e.g., housing stability, employment opportunities, and social connection) aligns with research highlighting the intertwined social, structural, and relational dimensions of recovery [ 62 , 63 ]. This integration reinforces calls for multi-level interventions that link peer-delivered care with organizational and policy supports addressing systemic inequities. By embedding social determinants of health, recovery capital, and relational harm reduction, within eLearning and ECHO sessions, PATH will position training as empowerment rather than compliance—an approach consistent with evidence that peer-led education and mentorship enhance confidence, resilience, and fidelity to harm-reduction principles [ 64 , 65 ]. The Cultural Exchange Survey provided an additional layer of confirmation that the CB functioned as a psychologically safe and collaborative environment [ 40 , 66 ]. High mean ratings across all domains indicated strong alignment between CB Members and researchers. Open-ended feedback emphasized appreciation for equitable facilitation, time sensitivity, and opportunities for peer-only discussion. These findings echo prior studies showing that when PWLLE perceive genuine respect and shared power, collaboration quality and project retention improve substantially [ 38 ]. Breakout sessions and peer-led portions of meetings were particularly valued, highlighting that structural design elements of meetings are as important as the substantive content under discussion. As in other participatory studies, ensuring consistent engagement throughout our CBPR process presented notable challenges [ 49 ]. Fluctuating participation, technology barriers, and competing demands reflected structural realities rather than a lack of commitment among CB members. Addressing these barriers required adaptive facilitation, equitable compensation, and flexible participation options—strategies recognized as essential for sustaining engagement in CBPR. Collectively, these adaptations underscore that responsiveness and flexibility are not merely logistical adjustments but active mechanisms of equity within participatory research [ 67 ]. Although our CB was relatively small, its membership represented diverse harm-reduction and recovery settings across the United States, and this representiveness enhances the contextual breadth and potential generalizability of PATH. The next step in this work is to pilot PATH within two Recovery Community Organizations (RCOs). This pilot will assess the acceptability, appropriateness, and feasibility of PATH as a PRS workforce intervention, as well as satisfaction with its eLearning and ECHO training components. Findings from this pilot and continued CB partnership will inform refinements to PATH and may lead to additional modifications to enhance its usability and fit across diverse organizational contexts. The revised intervention will then guide the design of a subsequent stepped-wedge clinical trial evaluating PATH’s impact on workforce outcomes and service quality among PRS employed at ten additional RCOs. CONCLUSIONS This early-phase study demonstrates how centering PWLLE through a CBPR process can produce a culturally grounded, practice-ready harm reduction training that reflects both scientific rigor and community wisdom. The co-development process is marked by shared decision-making, reflexive adaptation, and sustained representation across stages and illustrates how collaboration with PWLLE can strengthen intervention design and implementation readiness. Findings from this formative phase lay the groundwork for future testing of PATH’s feasibility and impact on workforce outcomes among PRS who deliver harm reduction services, organizational practices, and service quality across diverse recovery and harm-reduction settings. Abbreviations CB community board CBPR community based participatory research PATH Peer Advanced Training in Harm reduction PRS peer recovery specialist PWLLE people with lived/living experience SUD substance use disorder Declarations Ethics approval and consent to participate All survey data for this study were collected anonymously, with no ability to connect completed surveys to respondents. In compliance with the Declaration of Helsinki, the Chestnut Institutional Review Board granted this study an exemption from requiring ethics approval (Chestnut IRB #2025-52). As the activities were exempt, the researchers were not required to obtain consent. Consent for publication Not applicable. Competing interests The authors declare that they have no competing interests. Funding This work was supported by the National Institute on Drug Abuse of the National Institutes of Health under award numbers R61DA061340 and R24DA051950, which were funded as part of the NIH HEAL Initiative. The content is solely the responsibility of the authors and does not necessarily represent the official views of NIH, NIDA, or the HEAL Initiative. Author Contribution Garland Gerber: Conceptualization; Writing – original draft; Writing – review & editing; Dennis P. Watson: Conceptualization; Formal analysis; Writing – original draft; Writing – review & editing; Keoni Bermoy: Conceptualization; Writing – original draft; Writing – review & editing; Lisa D. Taylor: Formal analysis; Writing – review & editing; Ashli Sheidow: Conceptualization; Writing – review & editing; Patrick F. Hibbard: Writing – review & editing; Justin S. Bell: Conceptualization; Writing – review & editing; Adam Caba: Validation; Writing – review & editing; Community engagement; Heather Ogdon: Validation; Writing – review & editing; Community engagement; Samuel Peterson: Validation; Writing – review & editing; Community engagement; Robert Richard-Snipes: Validation; Writing – review & editing; Community engagement; Venus Staton: Validation; Writing – review & editing; Community engagement. Acknowledgement The authors extend their sincere gratitude to Community Board Members Robert Gasior and Rebecca Sanchez, whose insight and lived expertise were instrumental in shaping the direction and relevance of this work. We also thank Justin Beattey, Gina Fears, Heather Rodriguez, and Jennifer Van Nuys of Mental Health America of Indiana (MHAI) for their steadfast partnership and commitment throughout the project. We are deeply appreciative of Dr. Emma Kay and Dr. Mary Hawk for their valuable contributions to the development of the training content. We further acknowledge our project partners—Dr. Emily Ahonen, Dr. Kate Browne, Maggie Kaufmann, and Andrea Janota—for their meaningful collaboration and continued support of the broader initiative. We also wish to acknowledge the power and healing that emerge when researchers work alongside individuals with lived/living experience. Equitable partnerships with clearly defined roles and financial remuneration for community members not only enriches the scientific process but also embodies the very principles of equality, recovery, hope, and collective transformation that this work seeks to advance. We hope that more research continues to be conducted in this spirit. Data Availability All materials developed for the study are available upon request. References Centers for Disease Control and Prevention, National Center for Health Statistics. Multiple cause of death 1999–2022 [data file]. Marshall Z, Dechman MK, Minichiello A, Alcock L, Harris GE. Peering into the literature: A systematic review of the roles of people who inject drugs in harm reduction initiatives. Drug Alcohol Depend. 2015;151:1–14. https://doi.org/10.1016/j.drugalcdep.2015.03.002 . Chang J, Shelly S, Busz M, Stoicescu C, Iryawan AR, Madybaeva D, et al. Peer driven or driven peers? A rapid review of peer involvement of people who use drugs in HIV and harm reduction services in low- and middle-income countries. Harm Reduct J. 2021;18:15. https://doi.org/10.1186/s12954-021-00461-z . Gugala E, Briggs O, Moczygemba LR, Brown CM, Hill LG. Opioid harm reduction: A scoping review of physician and system-level gaps in knowledge, education, and practice. Substance abuse. 2022;43:972–87. https://doi.org/10.1080/08897077.2022.2060423 . Watson DP, Young J, Ahonen E, Xu H, Henderson M, Shuman V, et al. Development and testing of an implementation strategy for a complex housing intervention: Protocol for a mixed methods study. Implement Sci. 2014;9:138. https://doi.org/10.1186/s13012-014-0138-4 . Olding M, Boyd J, Kerr T, McNeil R. And we just have to keep going: Task shifting and the production of burnout among overdose response workers with lived experience. Soc Sci Med. 2021;270:113631. https://doi.org/10.1016/j.socscimed.2020.113631 . Unachukwu IC, Abrams MP, Dolan A, Oyekemi K, Meisel ZF, South EC, et al. The new normal has become a nonstop crisis: A qualitative study of burnout among Philadelphia’s harm reduction and substance use disorder treatment workers during the COVID-19 pandemic. Harm Reduct J. 2023;20:32. https://doi.org/10.1186/s12954-023-00752-7 . Taris TW. Is there a relationship between burnout and objective performance? A critical review of 16 studies. Work Stress. 2006;20:316–34. https://doi.org/10.1080/02678370601065893 . Mansour AEG, Mohamed Elmorsey R. Occupational stress: Measuring its impact on employee performance and turnover. Eur J Bus Manage. 2016;8:12–21. Mercer F, Miler JA, Pauly B, Carver H, Hnízdilová K, Foster R, et al. Peer support and overdose prevention responses: A systematic state-of-the-art review. Int J Environ Res Public Health. 2021;18:12073. https://doi.org/10.3390/ijerph182212073 . Hagaman A, Foster K, Kidd M, Pack R. An examination of peer recovery support specialist work roles and activities within the recovery ecosystems of Central Appalachia. Addict Res Theory. 2023. McGuire AB, Powell KG, Treitler PC, Wagner KD, Smith KP, Cooperman N, et al. Emergency department-based peer support for opioid use disorder: Emergent functions and forms. J Subst Abuse Treat. 2019. https://doi.org/10.1016/j.jsat.2019.06.013 . Bell JS, Hagaman A, Beattey J, Fears G, White WL, Watson DP. Advancing peer support workforce research: Insights and recommendations through the lens of professionalization. J Subst Use Addict Treat. 2025;170:209612. https://doi.org/10.1016/j.josat.2024.209612 . Bell JS, Griffin T, Castedo De Martell S, Kay ES, Hawk M, Hudson M, et al. Workforce outcomes among substance use peer supports and their contextual determinants: A scoping review protocol. PLoS ONE. 2024;19:e0311821. https://doi.org/10.1371/journal.pone.0311821 . Bell JS, Watson D, Griffin T, Castedo De Martell S, Kay ES, Hawk M, et al. Workforce outcomes among substance use peer supports: A scoping review of individual and organizational influences. Front Public Health. 2024;12. https://doi.org/10.3389/fpubh.2024.1515264 . Mamdani Z, McKenzie S, Pauly B, Cameron F, Conway-Brown J, Edwards D, et al. Running myself ragged: Stressors faced by peer workers in overdose response settings. Harm Reduct J. 2021;18:18. https://doi.org/10.1186/s12954-020-00449-1 . Nixon L, Kelly M, Punungwe F, Sampson M, Gray M. Working in harm reduction: Using chaos narratives to support and sustain frontline staff. Ann Fam Med. 2023;21(Suppl 1). https://doi.org/10.1370/afm.21.s1.4062 . Pasman E, Brown S, Agius E, Resko SM. Support for safe consumption sites among peer recovery coaches. J Behav Health Serv Res. 2023. https://doi.org/10.1007/s11414-023-09846-3 . Watson DP, Ahonen EQ, Shuman V, Brown M, Tsemberis S, Huynh P, et al. The Housing First Technical Assistance and Training implementation strategy: Outcomes from a mixed methods study of three programs. Subst Abuse Treat Prev Policy. 2018;13:32. https://doi.org/10.1186/s13011-018-0172-3 . Mancini MA, Linhorst DM, Broderick F, Bayliff S. Challenges to implementing the harm reduction approach. J Social Work Pract Addictions. 2008;8:380–408. https://doi.org/10.1080/15332560802224576 . Pauly B, Wallace B, Barber K. Turning a blind eye: Implementation of harm reduction in a transitional programme setting. Drugs: Educ Prev Policy. 2018;25:21–30. https://doi.org/10.1080/09687637.2017.1337081 . Demerouti E, Bakker AB, Nachreiner F, Schaufeli WB. The job demands–resources model of burnout. J Appl Psychol. 2001;86:499–512. https://doi.org/10.1037/0021-9010.86.3.499 . Brady LA, Wozniak ML, Brimmer MJ, Terranova E, Moore C, Kahn L, et al. Coping strategies and workplace supports for peers with substance use disorders. Subst Use Misuse. 2022;57:1772–8. https://doi.org/10.1080/10826084.2022.2112228 . Abraham KM, Erickson PS, Sata MJ, Lewis SB. Job satisfaction and burnout among peer support specialists: The contributions of supervisory mentorship, recovery-oriented workplaces, and role clarity. Adv Mental Health. 2022;20:38–50. https://doi.org/10.1080/18387357.2021.1977667 . Foy S. Harm reduction: An introduction. In: Foy S, editor. Solution Focused Harm Reduction: Working effectively with people who misuse substances. Cham: Springer International Publishing; 2017. pp. 33–52. https://doi.org/10.1007/978-3-319-72335-8_3 . Felton JW, Abidogun TM, Senters K, Maschino LD, Montgomery BW, Tyson R, et al. Peer recovery coaches’ perceptions of their work and implications for training, support, and personal recovery. Commun Ment Health J. 2023;59:962–71. https://doi.org/10.1007/s10597-022-01080-z . Stack E, Hildebran C, Leichtling G, Waddell EN, Leahy JM, Martin E, et al. Peer recovery support services across the continuum: In community, hospital, corrections, and treatment and recovery agency settings—a narrative review. J Addict Med. 2022;16:93–100. https://doi.org/10.1097/ADM.0000000000000810 . Almeida M, Day A, Smith B, Bianco C, Fortuna K. Actionable items to address challenges incorporating peer support specialists within an integrated mental health and substance use disorder system: Co-designed qualitative study. J Participatory Med. 2020;12:e17053. https://doi.org/10.2196/17053 . Anvari MS, Kleinman MB, Dean D, Rose AL, Bradley VD, Hines AC, et al. A pilot study of training peer recovery specialists in behavioral activation in the United States: Preliminary outcomes and predictors of competence. Int J Environ Res Public Health. 2023;20:3902. https://doi.org/10.3390/ijerph20053902 . Jawa R, Laks J, Saravanan N, Demers L, Wishik-Miller G. Physician trainees’ compassion satisfaction, burnout, and self-efficacy when caring for people who inject drugs. Substance abuse. 2022;43:675–81. https://doi.org/10.1080/08897077.2021.1986881 . Lennox R, Lamarche L, O’Shea T. Peer support workers as a bridge: A qualitative study exploring the role of peer support workers in the care of people who use drugs during and after hospitalization. Harm Reduct J. 2021;18:19. https://doi.org/10.1186/s12954-021-00467-7 . Levine S, Medley A, Norton A. Putting Indigenous harm reduction to work: Developing and evaluating Not Just Naloxone. Int J Indigenous Health. 2021;16. https://doi.org/10.32799/ijih.v16i2.33346 . McCormick KA, Stanton M, Ali S, Chavez S. Outcomes of a harm reduction shared learning intervention pilot in the U.S. South. J HIV/AIDS Social Serv. 2022;21:216–30. https://doi.org/10.1080/15381501.2023.2189198 . Ahonen EQ, Watson DP, Adams EL, McGuire A. Alpha test results for a Housing First eLearning strategy: The value of multiple qualitative methods for intervention design. Pilot Feasibility Stud. 2017;3:46. https://doi.org/10.1186/s40814-017-0187-y . Project ECHO. Moving knowledge, not people. Available from: https://hsc.unm.edu/echo/ . Accessed 18 Sept 2023. Osei-Twum J-A, Wiles B, Killackey T, Mahood Q, Lalloo C, Stinson JN. Impact of Project ECHO on patient and community health outcomes: A scoping review. Acad Med. 2022;97:1393–402. https://doi.org/10.1097/ACM.0000000000004749 . Viswanathan M, Ammerman A, Eng E, Garlehner G, Lohr KN, Griffith D et al. Community-based participatory research: Assessing the evidence. Evid Rep Technol Assess (Summ). 2004;1–8. Key KD, Furr-Holden D, Lewis EY, Cunningham R, Zimmerman MA, Johnson-Lawrence V, et al. The continuum of community engagement in research: A roadmap for understanding and assessing progress. Progress Community Health Partnerships: Res Educ Action. 2019;13:427–34. Israel BA, Schulz AJ, Parker EA, Becker AB. Review of community-based research: Assessing partnership approaches to improve public health. Annu Rev Public Health. 1998;19:173–202. https://doi.org/10.1146/annurev.publhealth.19.1.173 . Palinkas LA, Aarons GA, Chorpita BF, Hoagwood K, Landsverk J, Weisz JR. Cultural exchange and the implementation of evidence-based practices: Two case studies. Res Social Work Pract. 2009;19:602–12. https://doi.org/10.1177/1049731509335529 . Salimi Y, Shahandeh K, Malekafzali H, Loori N, Kheiltash A, Jamshidi E, et al. Is community-based participatory research (CBPR) useful? A systematic review. Int J Prev Med. 2012;3:386–93. Sacks JJ, Gonzales KR, Bouchery EE, Tomedi LE, Brewer RD. 2010 national and state costs of excessive alcohol consumption. Am J Prev Med. 2015;49:e73–9. https://doi.org/10.1016/j.amepre.2015.05.031 . Canadian HIVAIDS, Legal Network. Nothing about us without us: Greater, meaningful involvement of people who use illegal drugs: A public health, ethical and human rights imperative. Toronto (ON): Canadian HIV/AIDS Legal Network; 2008. Closson K, McNeil R, McDougall P, Fernando S, Collins AB, Baltzer Turje R, et al. Meaningful engagement of people living with HIV who use drugs: Methodology for the design of a peer research associate hiring model. Harm Reduct J. 2016;13:26. https://doi.org/10.1186/s12954-016-0116-z . Grill C. Involving stakeholders in research priority setting: A scoping review. Res Involv Engagem. 2021;7:75. https://doi.org/10.1186/s40900-021-00318-6 . Jozaghi E, Greer AM, Lampkin H, Buxton JA. Activism and scientific research: Twenty years of community action by the Vancouver Area Network of Drug Users. Subst Abuse Treat Prev Policy. 2018;13:18. https://doi.org/10.1186/s13011-018-0158-1 . Souleymanov R, Kuzmanović D, Marshall Z, Scheim AI, Mikiki M, Worthington C, et al. The ethics of community-based research with people who use drugs: Results of a scoping review. BMC Med Ethics. 2016;17:25. https://doi.org/10.1186/s12910-016-0108-2 . The JEAP, Initiative. A toolkit for generating research priorities through community-based participatory research. 2022. Sheidow AJ, Bermoy KK, Cruz MA, Buell EN, Weedman DR, Drazdowski TK et al. Community-engaged substance use research: Effective community board partnerships using community-based participatory research (CBPR). 2025. The JEAP, Initiative. Cultural exchange survey examples (Version 2). 2024. Palinkas LA, Garcia A, Aarons G, Finno-Velasquez M, Fuentes D, Holloway I, et al. Measuring collaboration and communication to increase implementation of evidence-based practices: The cultural exchange inventory. Evid Policy. 2018. https://doi.org/10.1332/174426417X15034893021530 . National Harm Reduction Coalition. Harm reduction principles. Available from: https://harmreduction.org/about-us/principles-of-harm-reduction/ . Accessed 23 Aug 2022. Hawk M, Kay ES, Jawa R. Relational harm reduction for internists: A call to action. J Gen Intern Med. 2024;39:1746–8. https://doi.org/10.1007/s11606-024-08693-y . JEAP Initiative. Welcome to the JEAP Initiative. Available from: https://www.jeapinitiative.org/ . Accessed 28 May 2025. National Institute on Drug Abuse. Expired RFA-DA-25-026: HEAL Initiative: JCOIN Phase II Community Engaged Research Resource Center (U24 Clinical Trial Optional).. 2024. Available from: https://grants.nih.gov/grants/guide/rfa-files/RFA-DA-25-026.html . Accessed 12 Nov 2025. McCormick K, Shah R, Kulkarni S, Ali SB, Creeck SK, Claborn KR. Caught between crisis and criminalization: Unveiling occupational stressors affecting harm reduction workers. J Soc Social Work Res. 2025. https://doi.org/10.1086/736304 . Gerber GE, Bazzi AR, Beletsky L, Pitpitan EV, Reed MB, Smith LR. Occupational stress and substance use-related stigma among criminal attorneys. Soc Sci Med. 2025;118757. https://doi.org/10.1016/j.socscimed.2025.118757 . Kelly JF, Westerhoff CM. Does it matter how we refer to individuals with substance-related conditions? A randomized study of two commonly used terms. Int J Drug Policy. 2010;21:202–7. https://doi.org/10.1016/j.drugpo.2009.10.010 . Ashford RD, Brown AM, Ashford A, Curtis B. Recovery dialects: A pilot study of stigmatizing and nonstigmatizing label use by individuals in recovery from substance use disorders. Exp Clin Psychopharmacol. 2019;27:530–5. https://doi.org/10.1037/pha0000286 . Aarons GA, Ehrhart MG, Farahnak LR, Sklar M. Aligning leadership across systems and organizations to develop a strategic climate for evidence-based practice implementation. Annu Rev Public Health. 2014;35:255–74. https://doi.org/10.1146/annurev-publhealth-032013-182447 . Aschbrenner KA, Kruse G, Gallo JJ, Plano Clark VL. Applying mixed methods to pilot feasibility studies to inform intervention trials. Pilot Feasibility Stud. 2022;8:217. https://doi.org/10.1186/s40814-022-01178-x . Cloud W, Granfield R. Conceptualizing recovery capital: Expansion of a theoretical construct. Subst Use Misuse. 2008;43:1971–86. https://doi.org/10.1080/10826080802289762 . Park JN, Rouhani S, Beletsky L, Vincent L, Saloner B, Sherman SG. Situating the continuum of overdose risk in the social determinants of health: A new conceptual framework. Milbank Q. 2020;98:700–46. https://doi.org/10.1111/1468-0009.12470 . Tracy K, Wallace SP. Benefits of peer support groups in the treatment of addiction. Subst Abuse Rehabilitation. 2016;7:143–54. https://doi.org/10.2147/SAR.S81535 . Tracy K, Wachtel L, Goldmann E, Nissenfeld J, Burton M, Galanter M, et al. Mentorship for Addiction Problems (MAP): A new behavioral intervention to assist in the treatment of substance use disorders. J Stud Alcohol Drug. 2020;81:664–72. https://doi.org/10.15288/jsad.2020.81.664 . Omale LE, Viola J. Cultural attunement approach for enhanced uptake of harm reduction services: A qualitative study in marginalized U.S. communities. J Prev Interv Community. 2025:1–28. https://doi.org/10.1080/10852352.2025.2496208 Rabbani RS. Strategy to address systemic racism and violence as public health priorities: Training and supporting community health workers to advance equity and violence prevention (Policy Number 20227). 2022. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 30 Dec, 2025 Reviews received at journal 21 Dec, 2025 Reviewers agreed at journal 10 Dec, 2025 Reviewers agreed at journal 09 Dec, 2025 Reviewers agreed at journal 08 Dec, 2025 Reviewers invited by journal 08 Dec, 2025 Editor assigned by journal 26 Nov, 2025 Submission checks completed at journal 26 Nov, 2025 First submitted to journal 26 Nov, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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-8138704","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":558440851,"identity":"35ed9467-fdad-4184-86be-93855ca72f7c","order_by":0,"name":"Garland Gerber","email":"","orcid":"","institution":"Northeastern University","correspondingAuthor":false,"prefix":"","firstName":"Garland","middleName":"","lastName":"Gerber","suffix":""},{"id":558440852,"identity":"5a5156ec-aee4-45a7-bed5-8d12d8c1fc4f","order_by":1,"name":"Dennis P. Watson","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5UlEQVRIiWNgGAWjYDCCA1Can4GHFC0gLNkA0pLAQIROmBaDA8Rq4bvdY/j5wx+bPOPjZw8+/PnjTuJ+BuZjH7/g0SJ554yxxMG2tGKzM3nJxjwJzxJ7GNiSZ8vg0WJwI3eDxMGGw4nbbvCYSTMkHAZq4TFmlsCvZfOPA38OJ26ewWP+8weRWrZJHGA7nLhBgseMgQeqhfEDXr+c/2Zxti0tccaZHGNpnrTDxj2H2ZKZ8egAhlhb8o2KPzaJ/e1nDD/+sDks297efJjxBz49mK4GWsGMN3KwehS/LaNgFIyCUTDSAACdr1UkzQnETQAAAABJRU5ErkJggg==","orcid":"","institution":"Chestnut Health Systems","correspondingAuthor":true,"prefix":"","firstName":"Dennis","middleName":"P.","lastName":"Watson","suffix":""},{"id":558440853,"identity":"618000dd-c57e-45ad-b4ac-ee015975f8d8","order_by":2,"name":"Keoni K. Bermoy","email":"","orcid":"","institution":"Chestnut Health Systems","correspondingAuthor":false,"prefix":"","firstName":"Keoni","middleName":"K.","lastName":"Bermoy","suffix":""},{"id":558440854,"identity":"cf545236-3fb0-4201-8b3b-112c016d0544","order_by":3,"name":"Lisa D. Taylor","email":"","orcid":"","institution":"Chestnut Health Systems","correspondingAuthor":false,"prefix":"","firstName":"Lisa","middleName":"D.","lastName":"Taylor","suffix":""},{"id":558440861,"identity":"ac66e3e0-ca2b-4e92-bfcd-36456c934bf1","order_by":4,"name":"Ashli J. Sheidow","email":"","orcid":"","institution":"Chestnut Health Systems","correspondingAuthor":false,"prefix":"","firstName":"Ashli","middleName":"J.","lastName":"Sheidow","suffix":""},{"id":558440867,"identity":"51ee0241-8923-416d-ab7a-a655edc68fe7","order_by":5,"name":"Patrick F. Hibbard","email":"","orcid":"","institution":"Chestnut Health Systems","correspondingAuthor":false,"prefix":"","firstName":"Patrick","middleName":"F.","lastName":"Hibbard","suffix":""},{"id":558440872,"identity":"612bde57-3b61-4dab-ac35-dd7d282d0548","order_by":6,"name":"Justin S. Bell","email":"","orcid":"","institution":"Chestnut Health Systems","correspondingAuthor":false,"prefix":"","firstName":"Justin","middleName":"S.","lastName":"Bell","suffix":""},{"id":558440873,"identity":"860e5bdf-38e6-4444-8c6f-ec63eb16b49c","order_by":7,"name":"Adam Caba","email":"","orcid":"","institution":"AND Services, LLC","correspondingAuthor":false,"prefix":"","firstName":"Adam","middleName":"","lastName":"Caba","suffix":""},{"id":558440874,"identity":"4188572c-03c9-43d8-b09d-880860ec1ec7","order_by":8,"name":"Heather Ogdon","email":"","orcid":"","institution":"Heartistic Recovery, LLC, Hadden Township","correspondingAuthor":false,"prefix":"","firstName":"Heather","middleName":"","lastName":"Ogdon","suffix":""},{"id":558440875,"identity":"def45993-f253-4cd8-b654-42eb79b39073","order_by":9,"name":"Samuel Peterson","email":"","orcid":"","institution":"Four Rivers Behavioral Health","correspondingAuthor":false,"prefix":"","firstName":"Samuel","middleName":"","lastName":"Peterson","suffix":""},{"id":558440882,"identity":"534efac4-4c84-40b2-8012-328aac8e3b20","order_by":10,"name":"Robert J. Richard-Snipes","email":"","orcid":"","institution":"Greater Nashua Mental Health","correspondingAuthor":false,"prefix":"","firstName":"Robert","middleName":"J.","lastName":"Richard-Snipes","suffix":""},{"id":558440883,"identity":"7698b4f6-7799-4ac1-b091-3319dba311a2","order_by":11,"name":"Venus Staton","email":"","orcid":"","institution":"Alaskan AIDS Assistance Association","correspondingAuthor":false,"prefix":"","firstName":"Venus","middleName":"","lastName":"Staton","suffix":""}],"badges":[],"createdAt":"2025-11-17 19:53:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8138704/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8138704/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":98423845,"identity":"b85e84f7-5a07-48b4-b201-b866d36c8518","added_by":"auto","created_at":"2025-12-17 16:32:41","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":147659,"visible":true,"origin":"","legend":"","description":"","filename":"eLearningDevelopmentManuscriptFINAL111725.docx","url":"https://assets-eu.researchsquare.com/files/rs-8138704/v1/5219778e122e784d1826653a.docx"},{"id":97976691,"identity":"af961ae6-4386-4988-bc8d-8696739506bf","added_by":"auto","created_at":"2025-12-11 12:03:23","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":15124,"visible":true,"origin":"","legend":"","description":"","filename":"87ac6aee929147f094dac322fc33d851.json","url":"https://assets-eu.researchsquare.com/files/rs-8138704/v1/8b626c24041c6e3cddda1db1.json"},{"id":97976695,"identity":"8d8503dc-58f2-4240-8b5e-82631150bfba","added_by":"auto","created_at":"2025-12-11 12:03:23","extension":"xml","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":202155,"visible":true,"origin":"","legend":"","description":"","filename":"87ac6aee929147f094dac322fc33d8511enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-8138704/v1/233590068aae4b1b46116996.xml"},{"id":97976693,"identity":"1cd9cf6b-822c-43d7-a129-356a64adf316","added_by":"auto","created_at":"2025-12-11 12:03:23","extension":"xml","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":199685,"visible":true,"origin":"","legend":"","description":"","filename":"87ac6aee929147f094dac322fc33d8511structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8138704/v1/c28e41d10b839931afc979a9.xml"},{"id":97976694,"identity":"ff619039-c8a2-477e-8afa-c5ae40762331","added_by":"auto","created_at":"2025-12-11 12:03:23","extension":"html","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":216103,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8138704/v1/9e3e87b436a40fda99376381.html"},{"id":98443687,"identity":"b5773c36-5fdc-4aca-a168-e488356558d2","added_by":"auto","created_at":"2025-12-17 17:14:05","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1250921,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8138704/v1/9461a298-1a76-4733-aa4c-497bd994b77d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Co-Designing the PATH Harm Reduction Training for the Peer Workforce: A Community-Based Participatory Approach","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003eSubstance use disorders (SUD) remain a major US public health threat, contributing to an estimated 220,511 deaths from October 2023 to September 2024, with 40% being attributed to opioids [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. For people who use drugs (PWUD), harm reduction is the first line of overdose defense. Expanding access to harm reduction services requires supporting the often underprepared and under-supported workforce that delivers them [\u003cspan additionalcitationids=\"CR3 CR4\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. These individuals work in stressful conditions associated with a high burnout risk [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], which can lead to poorer job performance and lower service quality [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Peer Recovery Specialists (PRS)\u0026mdash;professionals with lived recovery experience who provide mentoring, coaching, and social support\u0026mdash;may be a particularly vulnerable class of harm reduction workers.\u003c/p\u003e\u003cp\u003ePRSs frequently deliver or intersect with harm reduction services [\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Yet, the demanding nature of their work raises workforce sustainability concerns. PRSs often experience elevated job stress, which is concerning given their status as people who are also managing their personal SUD recovery [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. A recent scoping review found wide-ranging negative workforce outcomes associated with PRS work in the literature\u0026mdash;including burnout, vicarious trauma, compassion fatigue, turnover intention, and return to uncontrolled substance use [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. These risks may be heightened in harm reduction service settings, where workers frequently encounter situations exposing them to vicarious trauma, stress, and stigma toward people who are or have ever used substances [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Systemic (e.g., drug criminalization, abstinence-oriented policy) and organizational (e.g., marginalized roles, limited training) barriers can further contribute to stress by impeding harm reduction services delivery [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Because many states require abstinence for PRS certification, peers may also enter practice with abstinence-aligned orientations that can result in conflict with harm reduction-focused roles. For instance, one survey (N\u0026thinsp;=\u0026thinsp;260) indicated that endorsing abstinence-only treatment was associated with 55% lower odds of supporting harm reduction-focused safe consumption sites [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Even when PRSs and other clinicians endorse harm reduction, uptake remains challenging due to limited guidance and individualized outcome expectations [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], and harm reduction policies alone do not ensure service integrity [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. These misalignments may foster \u0026ldquo;don\u0026rsquo;t-ask\u0026ndash;don\u0026rsquo;t-tell\u0026rdquo; environments that obscure recovery pathways and increase substance-use\u0026ndash;related risk [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eStrengthening PRSs\u0026rsquo; personal and job-related resources can help prevent burnout and improve harm reduction service delivery [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Evidence from PRS and harm reduction studies shows that increased resources (e.g., coping strategies, clear roles, and supportive supervision) can mitigate burnout, enhance job satisfaction, and promote retention [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Appropriate supports may also help PRSs reframe job demands as meaningful challenges, enabling \u0026ldquo;job crafting\u0026rdquo; to optimize work conditions and identify small but important client improvements [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Because continuing education is essential for developing these competencies [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], targeted approaches are needed to build harm reduction delivery skills, counter abstinence-informed beliefs that might undermine harm reduction efforts, and ensure alignment between policy and supervision [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Educational strategies have demonstrated effectiveness in improving key personal and organizational resources that could reduce burnout and turnover among PRS and harm reduction workers [\u003cspan additionalcitationids=\"CR30 CR31 CR32\" citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eTo address these challenges, we designed Peer Advanced Training in Harm reduction (PATH) as a workforce intervention to enhance the personal and job-related resources PRSs need to manage job demands, reduce burnout, and strengthen harm reduction service delivery. Rooted in the Lead Investigator\u0026rsquo;s (DPW) prior work [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e], PATH integrates two core strategies: (1) virtual education, delivered through one-hour modular eLearning content incorporating adult-learning methods and narrative case stories to build harm reduction knowledge, shift stigmatizing attitudes, and support organizational harm reduction integration; and (2) an ECHO model [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e], a form of case-based group training demonstrated to improve clinical and community impact [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e] to develop PRSs\u0026rsquo; skills further and assist supervisors and administrators in strengthening harm reduction-aligned policies and supports. Collectively, PATH was structured as a 15-hour blended program (3 hours of eLearning and 12 hours of ECHO participation over approximately 3 months).\u003c/p\u003e\u003cp\u003eThis manuscript describes the Community-Based Participatory Research (CBPR) approach we used to refine PATH\u0026rsquo;s eLearning and ECHO content (information about the larger PATH study can be found at \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://pathstudy.info/\u003c/span\u003e\u003cspan address=\"https://pathstudy.info/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e). The strategy centers on researchers\u0026rsquo; partnership with a Community Board (CB)\u0026mdash;a group comprised of people with lived/living experience (PWLLE) in recovery, PRS service delivery, and harm reduction\u0026mdash;who provided structured guidance throughout intervention development. We followed this approach because it promotes shared decision-making and trust between researchers and affected communities [\u003cspan additionalcitationids=\"CR38\" citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e], helping ensure our work centers the lived expertise of people in recovery and PRS throughout the research process [\u003cspan additionalcitationids=\"CR40 CR41\" citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. To address common risks in CBPR work, such as power imbalances, failure to recognize lived expertise, and tokenism, the researchers integrated iterative feedback structures and engaged CB Members early to ensure authentic rather than symbolic participation [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan additionalcitationids=\"CR45 CR46\" citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. Through this collaboration, PATH\u0026rsquo;s CB is shaping content and the broader study to reflect the realities of PRS practice and lived expertise, ensuring authenticity in the narratives, examples, and strategies being developed. As demonstrated below, working with the CB helped ensure PATH content reflected community priorities and supported PRS capacity to deliver harm-reduction services. In the spirit of this work, researchers and CB Members co-authored this manuscript.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eCommunity Board Member Recruitment Process\u003c/h2\u003e\u003cp\u003eFollowing methods detailed in an online toolkit [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e], the Research Team recruited CB applicants via an email and flyer, with targeted distribution to 19 US-based harm reduction and peer organizations. Interested individuals were asked to complete a brief online application, which collected demographics, including location of primary residence; personal or professional experience with harm reduction, criminal-legal system, and mutual aid groups; professional experience with recovery organizations; personal experience with recovery; and details of how experiences would inform work as a Board Member. Following a three-week recruitment period, the team comprising six researchers (two with lived experience) and three Community Partners (all with lived experience) screened applications for initial eligibility, scoring them using a 3-point scale applied to three specific factors: harm reduction experience (1/\u0026rdquo;no experience\u0026rdquo;, 2/\u0026rdquo;delivered or received harm reduction services\u0026rdquo;, 3/\u0026rdquo;delivered and received harm reduction services\u0026rdquo;), recovery or harm reduction pathway (1/\u0026rdquo;not in recovery or not actively using harm reduction\u0026rdquo;, 2/\u0026rdquo;in recovery or actively using harm reduction\u0026rdquo;, 3/\u0026rdquo;considers self in recovery and is actively using harm reduction\u0026rdquo;), and recovery work experience (1/\u0026rdquo;no experience working in a recovery setting\u0026rdquo;, 2/\u0026rdquo;experience working in at least one recovery setting\u0026rdquo;, 3/\u0026rdquo;experience working in more than one recovery setting\u0026rdquo;). Applications were then sorted by average score, region of residence, and overall completeness. Two members of our research team then reviewed the highest-scoring applicants from each region and selected individuals for follow-up calls based on overall appropriateness, experience, and completeness of their applications. Each call was conducted by two research team members using a structured script. Researchers also took notes pertaining to each section of the script. After the call, the interviewers created a consensus score for the applicant using a four-point scale: 1/\u0026rdquo;very poor fit\u0026rdquo;, 2/\u0026rdquo;poor fit\u0026rdquo;, 3/\u0026rdquo;good fit\u0026rdquo;, 4/\u0026rdquo;strong fit\u0026rdquo;. In the final stage, the entire team of researchers met to review the candidates, weighing final selection based on scores as well as demographic and geographic diversity.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eCommunity Board Meetings\u003c/h3\u003e\n\u003cp\u003eBoard meetings were held virtually via Zoom. They were co-facilitated by the study\u0026rsquo;s Principal Investigator and a Board Chair who was elected by the other members (a co-Chair who helps facilitate meetings in the Chair\u0026rsquo;s absence was also elected). Meetings are not recorded to ensure CB Members are comfortable sharing their lived experience; however, the study\u0026rsquo;s Project Manager takes detailed notes that are distributed by email after each meeting. CB Members are also asked to complete tasks between meetings, which researchers aim to limit to no more than 30 minutes. Per the recommended ethical guidelines for facilitating\u003c/p\u003e\u003cp\u003eCBs [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e], Members are compensated for time spent in meetings and completing tasks, and submit monthly invoices to the research team.\u003c/p\u003e\u003cp\u003eThe content prioritization process spanned 6 meetings from 2/19/2025 to 6/2/2025. Our approach was adapted from a three-step process for prioritizing research priorities with CB Members previously developed by the JEAP Initiative as part of its goals to advance addiction recovery science [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. We applied this three-step process separately for (a) eLearning modules, (b) eLearning lessons, and (c) ECHO training topics. \u003cb\u003eBrainstorming\u003c/b\u003e (Step 1) was accomplished over one meeting through a combination of guided discussions and breakouts. The meeting began with researchers providing an overview of the topics proposed in the original grant application. Researchers then organized the Board into breakout rooms of 2\u0026ndash;3 members and asked them to review the content and brainstorm suggestions, including what topics to drop or add and what content should be covered as part of the topics. The Board then reconvened, and each breakout group provided a report back to the larger group. \u003cb\u003ePrioritization\u003c/b\u003e (Step 2) was completed using an online survey delivered between meetings. CB Members were asked to rank the importance of each topic, provide additional topic suggestions, and use text boxes to specify any content they believed was necessary to cover. \u003cb\u003eRefinement\u003c/b\u003e (Step 3) occurred in a meeting following the prioritization survey. Researchers presented a summary of the survey results, and CB Members provided their final feedback through open discussions. The three-step process was completed separately for eLearning modules (2/19/25 to 3/3/25), eLearning lessons (3/3/25 to 3/19/25), and ECHO training topics (5/7/25 to 6/2/25), and the eLearning module results informed the initial brainstorming for the eLearning lessons. These activities are not considered human subjects research, as CB Members contributed their expertise to intervention development as paid consultants.\u003c/p\u003e\n\u003ch3\u003eCultural Exchange Survey\u003c/h3\u003e\n\u003cp\u003eWe used an adapted version of the cultural exchange survey to assess CB Members\u0026rsquo; perceptions of collaboration and communication related to the prioritization process [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. The survey was developed to assess knowledge, attitudes, and practices exchanged between individuals from different organizations collaborating to implement an evidence-based practice [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]. The instrument was previously adapted by the JEAP Initiative to assess research relationships from the perspective of Community CB Members. The adapted instrument includes 22 questions that CB Members are asked to rate on a scale from 1/\u0026rdquo;not at all\u0026rdquo; to 6/\u0026rdquo;a great deal\u0026rdquo;: four questions focus on the CB Members\u0026rsquo; understanding and commitment; three questions focus on their relationships with other CB Members; and 13 questions focus on their relationships with researchers. There are also two open-ended questions where respondents can comment on collaborations with fellow CB Members and researchers, respectively. We also included two additional questions developed by the CB Chair to assess respondents\u0026rsquo; perceptions of the CB recruitment process and desire to continue participation in CB activities. All surveys were anonymous. All questions are listed in Table\u0026nbsp;4.\u003c/p\u003e\u003cp\u003eWe administered the survey electronically at two time points: immediately after the meeting\u0026rsquo;s finalization (1) the eLearning lesson content and (2) the ECHO training topics. Cultural exchange surveys are conducted anonymously with the Board, with no ability to connect completed surveys to respondents. As such, we obtained a waiver of consent for this activity (Chestnut IRB #2025-52), and consent was not required for data collection.\u003c/p\u003e\u003cp\u003eOur analysis summarized the survey data using descriptive statistics (mean and standard deviation), and we calculated differences in average scores across surveys to assess whether perceptions of the CB\u0026rsquo;s collaboration or communication changed. We also summarized open-ended responses.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003eFinal Board Member Selection\u003c/h2\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e presents the characteristics of the CB Applicants, those who completed follow-up calls, and the final selected CB Members. Eighty-nine completed the recruitment survey within the initial three-week application window. Researchers invited 23 total applicants to participate in follow-up calls. Of these, five did not reply to our requests, four no-showed the scheduled call, and 14 completed the call. Of the original eight candidates selected, one declined participation, and an alternate was chosen in their place. Each of the eight selected individuals participated in an initial onboarding meeting, during which we described CB expectations, meeting schedules, and compensation, and then completed expert consultant paperwork that the researchers had modified from standard organizational templates specifically for CB members.\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\u003eCommunity Board Applicant and Selected Member characteristics\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=\"char\" char=\".\" 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\u003eDemographics\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eApplicants\u003c/p\u003e\u003cp\u003e\u003cem\u003e(N\u0026thinsp;=\u003c/em\u003e\u0026thinsp;89 )\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eInvited for Follow-up Call\u003c/p\u003e\u003cp\u003e(\u003cem\u003en\u0026thinsp;=\u003c/em\u003e\u0026thinsp;23)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSelected Community Board Members\u003c/p\u003e\u003cp\u003e(\u003cem\u003en\u0026thinsp;=\u003c/em\u003e\u0026thinsp;8)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge (Mean/SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e44.97 (10.32)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e47.35 (9.15)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e43.13 (7.04)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eN (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eN (%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eMale\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e33 (37.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e9 (39.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4 (50.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eFemale\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e51 (57.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e12 (52.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4 (50.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eOther\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 (4.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2 (8.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e--\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRace\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eWhite\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e66 (74.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e14 (60.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6 (75.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eBlack or African American\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e13 (14.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4 (17.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eAmerican Indian or Alaska Native\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (2.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2 (8.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1 (12.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eMore than one race\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 (3.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2 (8.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1 (12.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eUnknown\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 (5.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1 (4.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e--\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEthnicity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eLatino\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e13 (14.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e5 (21.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1 (12.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eNot Latino\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e71 (79.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e17 (73.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7 (87.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eUnknown\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 (5.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1 (4.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e--\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUS region located\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eNortheast\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e17 (19.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4 (17.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2 (25.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eMidwest\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e22 (24.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e6 (26.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1 (12.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eSouth\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e36 (40.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e6 (26.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2 (25.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eWest\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e14 (60.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e7 (30.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3 (37.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cem\u003eNotes: Details regarding recovery status and harm reduction experience are omitted due to privacy concerns regarding the small Community Board size.\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003ePATH Content Prioritization Results\u003c/h2\u003e\u003cp\u003e\u003cb\u003eeLearning prioritization results\u003c/b\u003e. The initial module brainstorming discussion included six CB Members. The discussion focused on the need for clarification regarding the modules proposed in the original grant application, including what the content of each module might look like. After the Principal Investigator answered their questions, CB Members voiced that all three original topics included in the grant application were important. After the breakout session following this discussion, one group reported that they discussed the importance of harm reduction advocacy. They defined this as including information to support advocacy efforts of (a) recovery organizations and (b) individual peers and (c) teaching service participants to advocate for their individually chosen recovery path, particularly if it includes harm reduction.\u003c/p\u003e\u003cp\u003eThe (a) module and (b) lesson prioritization surveys were delivered separately. Both surveys included the three original module topics and lessons and the newly suggested topic of harm reduction advocacy. Results are shown in Table\u0026nbsp;2. All 8 CB Members completed the module prioritization survey, and 7 completed the lesson prioritization survey. The average scores indicated that CB Members found all four suggested Module topics to be of high priority. History of Harm Reduction and the Compatibility of Harm Reduction with the 12 Steps were the only lesson topics that received an average rating below 3, indicating they were of less priority for CB members.\u003c/p\u003e\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 82.6923%;\"\u003e\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;\u003c/strong\u003e Table 2. Average prioritization scores for eLearning modules and lessons\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.3077%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 22.1154%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eModule topic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.4615%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean (SD)\u003csup\u003e1\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.9231%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLesson topic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.1923%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean (SD)\u003csup\u003e1\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.3077%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRevised after group discussion\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 22.1154%;\"\u003e\n \u003cp\u003e1. Embracing the harm reduction approach\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.4615%;\"\u003e\n \u003cp\u003e3.88 (0.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.9231%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.1923%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.3077%;\"\u003e\n \u003cp\u003eNo change\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 22.1154%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.4615%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.9231%;\"\u003e\n \u003cp\u003e1a. History of harm reduction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.1923%;\"\u003e\n \u003cp\u003e2.86 (0.83)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.3077%;\"\u003e\n \u003cp\u003eNo change\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 22.1154%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.4615%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.9231%;\"\u003e\n \u003cp\u003e1b. Harm reduction principles\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.1923%;\"\u003e\n \u003cp\u003e3.43 (0.73)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.3077%;\"\u003e\n \u003cp\u003eNo change\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 22.1154%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.4615%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.9231%;\"\u003e\n \u003cp\u003e1c. \u0026nbsp;Harm reduction and stages of change\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.1923%;\"\u003e\n \u003cp\u003e3.14 (0.64)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.3077%;\"\u003e\n \u003cp\u003eRelational harm reduction\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 22.1154%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.4615%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.9231%;\"\u003e\n \u003cp\u003e1d. \u0026nbsp;Compatibility of harm reduction with the 12 steps\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.1923%;\"\u003e\n \u003cp\u003e2.57 (0.90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.3077%;\"\u003e\n \u003cp\u003eNo change\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 22.1154%;\"\u003e\n \u003cp\u003e2. Integrating harm reduction into participant recovery plans\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.4615%;\"\u003e\n \u003cp\u003e3.63 (0.48)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.9231%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.1923%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.3077%;\"\u003e\n \u003cp\u003eNo change\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 22.1154%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.4615%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.9231%;\"\u003e\n \u003cp\u003e2a. An overview of harm reduction strategies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.1923%;\"\u003e\n \u003cp\u003e3.57 (0.49)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.3077%;\"\u003e\n \u003cp\u003eNo change\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 22.1154%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.4615%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.9231%;\"\u003e\n \u003cp\u003e2b. \u0026nbsp;Motivational interviewing and harm reduction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.1923%;\"\u003e\n \u003cp\u003e3.29 (0.45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.3077%;\"\u003e\n \u003cp\u003eStages of change and harm reduction\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 22.1154%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.4615%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.9231%;\"\u003e\n \u003cp\u003e2c. Talking openly about drug use to identify high-risk behaviors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.1923%;\"\u003e\n \u003cp\u003e3.71 (0.45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.3077%;\"\u003e\n \u003cp\u003eNo change\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 22.1154%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.4615%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.9231%;\"\u003e\n \u003cp\u003e2d. \u0026nbsp;Setting harm reduction goals\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.1923%;\"\u003e\n \u003cp\u003e3.57 (0.49)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.3077%;\"\u003e\n \u003cp\u003eNo change\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 22.1154%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.4615%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.9231%;\"\u003e\n \u003cp\u003e2e. \u0026nbsp;Celebrating any positive success\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.1923%;\"\u003e\n \u003cp\u003e3.29 (0.45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.3077%;\"\u003e\n \u003cp\u003eNo change\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 22.1154%;\"\u003e\n \u003cp\u003e3. Supporting PRS to do harm reduction work\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.4615%;\"\u003e\n \u003cp\u003e3.63 (0.48)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.9231%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.1923%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.3077%;\"\u003e\n \u003cp\u003eNo change\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 22.1154%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.4615%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.9231%;\"\u003e\n \u003cp\u003e3a. Harm reduction-friendly policies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.1923%;\"\u003e\n \u003cp\u003e3.57 (0.49)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.3077%;\"\u003e\n \u003cp\u003eNo change\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 22.1154%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.4615%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.9231%;\"\u003e\n \u003cp\u003e3b. Employee supervision\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.1923%;\"\u003e\n \u003cp\u003e3.71 0.45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.3077%;\"\u003e\n \u003cp\u003eNo change\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 22.1154%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.4615%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.9231%;\"\u003e\n \u003cp\u003e3c. Identifying and addressing community barriers to harm reduction work\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.1923%;\"\u003e\n \u003cp\u003e3.29 (0.70)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.3077%;\"\u003e\n \u003cp\u003eNo change\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 22.1154%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.4615%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.9231%;\"\u003e\n \u003cp\u003e3d. Speaking with community stakeholders about harm reduction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.1923%;\"\u003e\n \u003cp\u003e3.43 (0.73)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.3077%;\"\u003e\n \u003cp\u003eNo change\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 22.1154%;\"\u003e\n \u003cp\u003e4. Advancing harm reduction\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.4615%;\"\u003e\n \u003cp\u003e3.25 (0.83)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.9231%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.1923%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.3077%;\"\u003e\n \u003cp\u003eNo change\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 22.1154%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.4615%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.9231%;\"\u003e\n \u003cp\u003e4a. Introduction to being a harm reduction champion\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.1923%;\"\u003e\n \u003cp\u003e3.29 (0.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.3077%;\"\u003e\n \u003cp\u003eAn introduction to being a harm reduction champion\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 22.1154%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.4615%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.9231%;\"\u003e\n \u003cp\u003e4b. Strategies for promoting harm reduction\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.1923%;\"\u003e\n \u003cp\u003e3.29 (0.45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.3077%;\"\u003e\n \u003cp\u003eHarm reduction champion strategies and activities\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 22.1154%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.4615%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.9231%;\"\u003e\n \u003cp\u003e4c. Supporting Participants\u0026rsquo; Voices \u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.1923%;\"\u003e\n \u003cp\u003e3.71 (0.45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.3077%;\"\u003e\n \u003cp\u003eSupporting participants to be champions of their personal recovery\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 82.6923%;\"\u003e\n \u003cp\u003e\u003cem\u003e\u003csup\u003e1\u003c/sup\u003e\u003c/em\u003e\u003cem\u003eScale from 1/\u0026rdquo;not important\u0026rdquo; to 4/\u0026rdquo;extremely important\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u003csup\u003e2\u003c/sup\u003e\u003c/em\u003e\u003cem\u003eTopic was not included in the originally funded grant application.\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.3077%;\"\u003e\n \u003cp\u003e\u003cem\u003e\u003csup\u003e\u0026nbsp;\u003c/sup\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\u003cp\u003e----- \u003cem\u003eTable\u0026nbsp;2 about here\u003c/em\u003e -----\u003c/p\u003e\u003cp\u003eAll 8 CB Members attended the (a) module refinement discussion, and 6 attended the (b) lesson refinement discussion. At each meeting, the Principal Investigator presented the prioritization results and a summary of open-ended feedback from the relevant prioritization survey conducted prior to the meeting. Afterwards, the CB Members verbally affirmed their agreement with the scores and the qualitative summaries, as well as expanded on information that they thought needed to be covered. Discussions around the newly proposed advocacy module and its corresponding lessons were less concrete, suggesting this module might require more focused development than the others. These discussions also led to the rewording of five lesson titles to reflect their adjusted focus, as shown in the far-right column of Table\u0026nbsp;2. The rest of this section presents a combined summary of the discussion results from both meetings as they pertain to each module and its corresponding lessons.\u003c/p\u003e\u003cp\u003eCB Members reached a clear consensus on the importance of beginning the training with a strong foundation in harm reduction philosophy and practice. They agreed that Module 1, \u003cem\u003eOverview of the Harm Reduction Approach\u003c/em\u003e, should orient learners to the central tenets of harm reduction, address common misconceptions, and contextualize the approach relative to abstinence-based and recovery-oriented models. They emphasized that Lesson 1a, \u003cem\u003eHistory of Harm Reduction\u003c/em\u003e, should emphasize the historical roots of harm reduction, including its emergence in response to the HIV/AIDS epidemic and its application across diverse populations. Lesson 1b, \u003cem\u003eHarm Reduction Principles\u003c/em\u003e, was discussed as needing to focus on the foundational philosophical and ethical principles of harm reduction, such as autonomy, non-coercion, and compassion, and that the content should be guided by the National Harm Reduction Coalition\u0026rsquo;s 8 Guiding Principles [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. CB Members decided that Lesson 1c should be changed to be \u003cem\u003eIntroduction to Relational Harm Reduction\u0026mdash;\u003c/em\u003ean approach that centers the quality of the relationship between a service provider and a person who uses drugs as a core mechanism of support and change [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]\u003cem\u003e\u0026mdash;\u003c/em\u003eand that the original stages of change topic should be combined with the Module 2 lesson on motivational interviewing. This discussion also pointed to the need to focus the lesson mostly on the stages through which behavioral change is theorized to occur and how it can be applied within the context of harm reduction. This was because (a) most peers are already familiar with the stages of behavior change within an abstinence framework, (b) Motivational Interviewing is too large a topic to cover adequately in an eLearning format, and (c) most peers have already received Motivational Interviewing training. CB Members expressed that the concept of relational harm reduction, which none had been introduced to prior to their work on the PATH CB, was so important that it needed to be woven throughout the rest of the training after its introduction. Finally, although it received a lower prioritization score than other lessons, the Board affirmed the value of Lesson 1d, \u003cem\u003eCompatibility of Harm Reduction with the 12-Steps\u003c/em\u003e, to challenge stigma and broaden perspectives around 12-step compatibility and other mutual aid approaches.\u003c/p\u003e\u003cp\u003eCB Members emphasized that Module 2, \u003cem\u003eIntegrating Harm Reduction into Participant Recovery Plans\u003c/em\u003e, was critical for supporting peers in applying harm reduction strategies in direct service contexts. They stressed that the lessons should help peers navigate personal boundaries while fostering nonjudgmental, client-centered communication. They expressed that Lesson 2a, \u003cem\u003eAn Overview of Harm Reduction Strategies\u003c/em\u003e, should introduce core harm reduction strategies and real-world scenarios to support skill-building. As discussed above, CB Members recommended merging information on the stages of behavior change (initially in Module 1, Lesson 3) and making it a greater focus of the lesson, transforming Lesson 2b into \u003cem\u003eStages of Change and Harm Reduction.\u003c/em\u003e Lesson 2c, \u003cem\u003eTalking Openly About Drug Use to Identify High-Risk Behaviors\u003c/em\u003e, was discussed as needing to teach peers how to talk openly about drugs when working with service participants who were engaged in abstinence-focused programs such as drug courts, with careful attention to legal and ethical disclaimers and clarity around peer roles. For Lesson 2d, \u003cem\u003eSetting Harm Reduction Goals\u003c/em\u003e, CB Members supported a focus on participant-directed goal setting, incorporating SMART (specific, measurable, achievable, relevant, time-bound) goals where appropriate and helping participants understand all available recovery pathways while acknowledging the influence of peer biases in recovery coaching and planning activities. Lesson 2e, \u003cem\u003eCelebrating Any Positive Success\u003c/em\u003e, was discussed as requiring challenging abstinence-only definitions of success by celebrating incremental progress and alternative markers of improvement, such as reduced use or restored relationships.\u003c/p\u003e\u003cp\u003eThe discussion of Module 3, \u003cem\u003eSupporting PRS to Do Harm Reduction Work\u003c/em\u003e, focused on organizational and supervisory challenges. CB Members agreed this module should be primarily targeted at supervisors and organizational leaders, with a focus on reducing stigma, strengthening supervisory practices, and fostering workplace environments that support harm reduction delivery. CB Members proposed Lesson 3a, \u003cem\u003eHarm Reduction-Friendly Policies\u003c/em\u003e, center on policies that reinforce the legitimacy of non-abstinence-based outcomes for participants and staff and tensions between harm reduction-friendly policies and the requirements and scope of peer certification. Lesson 3b, \u003cem\u003eEmployee Supervision\u003c/em\u003e, was discussed as needing to address hierarchical dynamics, prevent burnout, and ensure peers are adequately supported through training and equitable workloads. In discussing Lesson 3c, \u003cem\u003eIdentifying and Addressing Community Barriers to Harm Reduction Work\u003c/em\u003e, CB Members identified barriers at the community level\u0026mdash;such as denial or stigma\u0026mdash;and recommended preparing peers with relevant data and messaging strategies. CB Members emphasized that Lesson 3d, \u003cem\u003eSpeaking with Community Stakeholders about Harm Reduction\u003c/em\u003e, should focus on using narrative stories and evidence when engaging stakeholders, aiming to increase public understanding and organizational buy-in.\u003c/p\u003e\u003cp\u003eIn contrast to the other modules, the conversation around Module 4, \u003cem\u003eAdvancing Harm Reduction\u003c/em\u003e, was more exploratory, with CB Members acknowledging the value of the content but recognizing that further development is needed. They agreed the module should empower peers and participants to engage in harm reduction efforts, especially given the widespread misconceptions and resistance. Discussions indicated that Lesson 4a, \u003cem\u003eIntroduction to being a harm reduction champion\u003c/em\u003e, was reframed to address specific strategies for championing harm reduction within organizations and communities, emphasizing the importance of teaching peers about different methods for community education, as well as various harm reduction activities of focus. Lesson 4b, \u003cem\u003eStrategies for promoting harm reduction\u003c/em\u003e, should serve more as an introduction to advocacy efforts, focusing on the history of advocacy and emphasizing the importance of human rights and dignity. The lesson should provide peers with an overview of evidence-based, participant-centered advocacy approaches. In discussing Lesson 4c, \u003cem\u003eSupporting Participants\u0026rsquo; Voices\u003c/em\u003e, CB Members confirmed a need to support participants who struggle with low self-efficacy or confidence in advocating for their personal recovery or harm reduction path. Further, discussions with CB Members prompted a change in language choice for these lessons, moving away from the term \u0026lsquo;advocacy\u0026rsquo; and utilizing \u0026lsquo;championship\u0026rsquo; in its place. This decision centered around ensuring training materials feel accessible and resonate with diverse groups of peers, better reflecting peer-led leadership activities that are approachable and do not require policy-level or system-facing work.\u003c/p\u003e\u003cp\u003e\u003cb\u003eECHO prioritization results.\u003c/b\u003e The ECHO prioritization survey included eight ECHO didactic training topics suggested in the grant application. All 8 CB Members completed the survey. The average scores indicated that they found seven of the topics to be of moderate importance. The lowest-scoring topic, indicating it was only considered of slight importance, was \u003cem\u003eSupporting Colleagues to Deliver Harm Reduction.\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe ECHO topic refinement discussion included 6 CB Members. The discussion resulted in merging two topics, rewording the others to reflect a modified focus, and adding one new topic. These changes are reflected in the far-right column of Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\u003cp\u003eDuring these discussions, Topic 1, \u003cem\u003eRelational Harm Reduction\u003c/em\u003e, emerged as a top priority, with strong support for emphasizing autonomy, empathy, and trauma-informed, dignity-affirming care. Members highlighted the need to focus on building trust with service participants as central to effective harm reduction work. Topic 2, \u003cem\u003eManaging Boundaries with Clients\u003c/em\u003e, was reconceptualized to include self-care, recognizing that boundaries are a form of self-care and that peers receive exposure to self-care topics from numerous other sources. Discussions emphasized the protective and sustaining function of boundaries for peer workers, especially in smaller communities and dual-role relationships. Self-care was framed as both a personal and organizational responsibility, modeled by supervisors and supported through mentorship. Topic 3, \u003cem\u003eSupporting Colleagues to Deliver Harm Reduction\u003c/em\u003e, was reframed to focus on creative problem-solving and mutual support in team settings. Though it received a lower prioritization score, CB Members emphasized its value in promoting a nonjudgmental work culture and navigating team stigma, especially around medications for opioid use disorder. Topic 4, \u003cem\u003eHarm Reduction with Participants Experiencing Homelessness\u003c/em\u003e, was endorsed as a critical topic, with attention to trust-building, field-based engagement, and the navigation of legal and systemic barriers. Topic 5, \u003cem\u003eLow-Threshold Treatment and Medication-Assisted Recovery\u003c/em\u003e, was updated to reflect a broader focus on medical interventions across substance use disorders. CB Members stressed the need for timely access, reduced barriers, and the importance of framing treatment within participant-centered, evidence-based, and non-stigmatizing approaches. Topic 6, \u003cem\u003eHarm Reduction in Rural Low-Resource Areas\u003c/em\u003e, was slightly reworded to broaden its relevance while still addressing challenges specific to rural and other under-resourced communities, including transportation, relationship-building, and the use of national harm reduction resources. Topic 7, \u003cem\u003eHarm Reduction with Criminal-Legal System-Involved Clients\u003c/em\u003e, remained unchanged. Discussion emphasized state-level policy differences, working within mandated systems, and supporting clients in navigating legal requirements while maintaining harm reduction principles. Finally, the new Topic 8, \u003cem\u003eHarm Reduction Policy and Legal Structure\u003c/em\u003e, was added to address a noted gap in the structural context impacting harm reduction services. This session will provide an overview of relevant laws, historical and emerging policy trends, and advocacy strategies, while maintaining sensitivity to political dynamics across service settings.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eECHO prioritization scores and summary of open-ended feedback\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\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\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eECHO training topic\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMean (SD)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eRevised topics\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1. Relational harm reduction\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3.63 (0.48)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1. No changes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2. Managing boundaries with service participants\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3.63 (0.70)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e2. Managing boundaries with clients (will integrate self-care)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3. Selfcare\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3.13 (0.78)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4. Supporting colleagues to deliver harm reduction\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.88 (0.78)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3. Supporting colleagues to deliver harm reduction: Developing creative solutions together\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5. Harm reduction with participants experiencing homelessness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3.63 (0.48)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4. No changes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6. Low-threshold treatment and Medication Assisted Recovery (MAR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3.50 (0.71)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5. Low-threshold treatment and medications\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e7. Harm reduction in rural and low-resource areas\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3.13 (0.60)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6. Harm reduction in low-resource areas\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e8. Harm reduction with criminal-legal system-involved participants\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3.38 (0.70)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7. No changes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003en/a\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003en/a\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8. Harm reduction policy and legal structure\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003cem\u003eNotes: Scale from 1/\u0026rdquo;not important\u0026rdquo; to 4/\u0026rdquo;extremely important.\u0026rdquo;\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eCultural Exchange Survey Results\u003c/h3\u003e\n\u003cp\u003eTable\u0026nbsp;4 presents the means and standard deviations for all the Cultural Exchange Survey questions the researchers requested that the CB Members complete. Not all CB Members completed the survey, which is understandable since this was an optional activity to assess CB engagement quality that was outside of the assigned between-meeting prep work. Ratings for all questions indicated strong agreement, and minimal changes between the two time points indicate general stability in opinions.\u003c/p\u003e\u003cp\u003eOpen-ended feedback was similarly positive. Comments about working with the other CB Members indicated they enjoyed interactions with each other and have respect for their fellow CB Members\u0026rsquo; different points of view and experience:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e\u0026ldquo;I am pleasantly surprised by how much I enjoy working with everyone on this board. I look forward to every one of our meetings.\u0026rdquo;\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u0026ldquo;Awesome group of people who bring different ideas and knowledge to the table.\u0026rdquo;\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u0026ldquo;I have so much respect for the diversity and expertise of this group!!!!\u0026rdquo;.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eComments directed toward researchers indicated CB Members appreciate the respect demonstrate toward them, the perspective they bring, and their efforts to explain technical information in an accessible manner:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e\u0026ldquo;I appreciate the research team\u0026rsquo;s respect for the variety of experience and circumstances the CB Members have.\u0026rdquo;\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u0026ldquo;The research team is wonderful, I have learned so much about how a project like this comes together.\u0026rdquo;\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u0026ldquo;The research team has done a great job of explaining and relating the info to the board.\u0026rdquo;\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eSpecific processes that CB Members commented on as being effective included the recruitment process, attention researchers pay to the value of CB Members\u0026rsquo; time, the breakout rooms used in meetings, and the time in meetings dedicated to allowing the CB Members to interact without researcher presence:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e\u0026ldquo;It shows that a lot of thought and work went into the selection through the advertising, interviewing, and selection process.\u0026rdquo;\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u0026ldquo;The constant mindfulness of my time and experience.\u0026rdquo;\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u0026ldquo;The breakout rooms have been a good opportunity to get to know the other board members as well as work on the project.\u0026rdquo;\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u0026ldquo;I like that the research team has now incorporated time for Board to meet just us without the research team.\u0026rdquo;\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eLastly, one comment expressed that a Board Member was struggling with other members' behaviors, which they expressed demonstrated a lack of participation. However, there was no indication of what these behaviors were.\u003c/p\u003e\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"564\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 100%;\" colspan=\"8\"\u003e\n \u003cp\u003eTable 4. Cultural Exchange Survey Results\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 43.617%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 18.0851%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePost Module Prioritization\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(\u003cem\u003en\u003c/em\u003e = 7)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.38298%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 17.0213%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePost ECHO Training Prioritization\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(\u003cem\u003en\u003c/em\u003e = 6)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4.25532%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6383%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eChange\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 43.617%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.7021%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003emean\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6.38298%;\"\u003e\n \u003cp\u003e\u003cstrong\u003esd\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6.38298%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 9.57447%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003emean\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 7.44681%;\"\u003e\n \u003cp\u003e\u003cstrong\u003esd\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4.25532%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 10.6383%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003emean\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 43.617%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eSelf-directed questions\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.7021%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.38298%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.38298%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.57447%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.44681%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4.25532%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6383%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 43.617%;\"\u003e\n \u003cp\u003eI believe I have a clear understanding of what this collaboration is trying to accomplish.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.7021%;\"\u003e\n \u003cp\u003e5.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.38298%;\"\u003e\n \u003cp\u003e0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.38298%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.57447%;\"\u003e\n \u003cp\u003e5.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.44681%;\"\u003e\n \u003cp\u003e0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4.25532%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6383%;\"\u003e\n \u003cp\u003e0.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 43.617%;\"\u003e\n \u003cp\u003eI feel committed to this work.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.7021%;\"\u003e\n \u003cp\u003e5.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.38298%;\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.38298%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.57447%;\"\u003e\n \u003cp\u003e5.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.44681%;\"\u003e\n \u003cp\u003e0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4.25532%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6383%;\"\u003e\n \u003cp\u003e0.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 43.617%;\"\u003e\n \u003cp\u003eI believe I am devoting the right amount of time and energy to maintain this collaboration.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.7021%;\"\u003e\n \u003cp\u003e5.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.38298%;\"\u003e\n \u003cp\u003e0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.38298%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.57447%;\"\u003e\n \u003cp\u003e5.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.44681%;\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4.25532%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6383%;\"\u003e\n \u003cp\u003e-0.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 43.617%;\"\u003e\n \u003cp\u003eDuring the time I have been on the Board, I feel that my contributions have made an impact.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.7021%;\"\u003e\n \u003cp\u003e5.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.38298%;\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.38298%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.57447%;\"\u003e\n \u003cp\u003e5.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.44681%;\"\u003e\n \u003cp\u003e0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4.25532%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6383%;\"\u003e\n \u003cp\u003e0.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 43.617%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eComposite score\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.7021%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e5.6\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.38298%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.6\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.38298%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.57447%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e5.6\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.44681%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.6\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4.25532%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6383%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.0\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 43.617%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eFellow board member-directed questions\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.7021%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.38298%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.38298%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.57447%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.44681%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4.25532%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6383%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 43.617%;\"\u003e\n \u003cp\u003eI believe we are working well together.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.7021%;\"\u003e\n \u003cp\u003e5.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.38298%;\"\u003e\n \u003cp\u003e0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.38298%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.57447%;\"\u003e\n \u003cp\u003e5.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.44681%;\"\u003e\n \u003cp\u003e0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4.25532%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6383%;\"\u003e\n \u003cp\u003e0.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 43.617%;\"\u003e\n \u003cp\u003eI believe we respect one another.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.7021%;\"\u003e\n \u003cp\u003e5.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.38298%;\"\u003e\n \u003cp\u003e0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.38298%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.57447%;\"\u003e\n \u003cp\u003e5.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.44681%;\"\u003e\n \u003cp\u003e0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4.25532%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6383%;\"\u003e\n \u003cp\u003e0.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 43.617%;\"\u003e\n \u003cp\u003eI believe my fellow Board members are committed to this work.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.7021%;\"\u003e\n \u003cp\u003e5.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.38298%;\"\u003e\n \u003cp\u003e0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.38298%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.57447%;\"\u003e\n \u003cp\u003e5.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.44681%;\"\u003e\n \u003cp\u003e0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4.25532%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6383%;\"\u003e\n \u003cp\u003e0.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 43.617%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eComposite score\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.7021%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e5.8\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.38298%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.5\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.38298%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.57447%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e5.8\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.44681%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.4\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4.25532%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6383%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 43.617%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eResearch team-directed questions\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.7021%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.38298%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.38298%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.57447%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.44681%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4.25532%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6383%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 43.617%;\"\u003e\n \u003cp\u003eI believe we are working well together.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.7021%;\"\u003e\n \u003cp\u003e5.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.38298%;\"\u003e\n \u003cp\u003e0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.38298%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.57447%;\"\u003e\n \u003cp\u003e5.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.44681%;\"\u003e\n \u003cp\u003e0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4.25532%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6383%;\"\u003e\n \u003cp\u003e0.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 43.617%;\"\u003e\n \u003cp\u003eI believe we respect one another.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.7021%;\"\u003e\n \u003cp\u003e5.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.38298%;\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.38298%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.57447%;\"\u003e\n \u003cp\u003e5.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.44681%;\"\u003e\n \u003cp\u003e0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4.25532%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6383%;\"\u003e\n \u003cp\u003e0.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 43.617%;\"\u003e\n \u003cp\u003eI believe we trust one another.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.7021%;\"\u003e\n \u003cp\u003e5.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.38298%;\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.38298%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.57447%;\"\u003e\n \u003cp\u003e5.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.44681%;\"\u003e\n \u003cp\u003e0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4.25532%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6383%;\"\u003e\n \u003cp\u003e0.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 43.617%;\"\u003e\n \u003cp\u003eI believe the research team is devoting the right amount of time and energy to maintain this collaboration.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.7021%;\"\u003e\n \u003cp\u003e5.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.38298%;\"\u003e\n \u003cp\u003e0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.38298%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.57447%;\"\u003e\n \u003cp\u003e5.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.44681%;\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4.25532%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6383%;\"\u003e\n \u003cp\u003e-0.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 43.617%;\"\u003e\n \u003cp\u003eI believe the research team communicates openly with me.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.7021%;\"\u003e\n \u003cp\u003e5.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.38298%;\"\u003e\n \u003cp\u003e0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.38298%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.57447%;\"\u003e\n \u003cp\u003e5.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.44681%;\"\u003e\n \u003cp\u003e0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4.25532%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6383%;\"\u003e\n \u003cp\u003e0.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 43.617%;\"\u003e\n \u003cp\u003eI believe I communicate openly with the research team.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.7021%;\"\u003e\n \u003cp\u003e5.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.38298%;\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.38298%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.57447%;\"\u003e\n \u003cp\u003e5.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.44681%;\"\u003e\n \u003cp\u003e0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4.25532%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6383%;\"\u003e\n \u003cp\u003e0.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 43.617%;\"\u003e\n \u003cp\u003eI believe the research team is committed to this work.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.7021%;\"\u003e\n \u003cp\u003e5.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.38298%;\"\u003e\n \u003cp\u003e0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.38298%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.57447%;\"\u003e\n \u003cp\u003e5.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.44681%;\"\u003e\n \u003cp\u003e0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4.25532%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6383%;\"\u003e\n \u003cp\u003e0.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 43.617%;\"\u003e\n \u003cp\u003eI believe the research team is learning something from me.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.7021%;\"\u003e\n \u003cp\u003e5.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.38298%;\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.38298%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.57447%;\"\u003e\n \u003cp\u003e5.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.44681%;\"\u003e\n \u003cp\u003e0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4.25532%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6383%;\"\u003e\n \u003cp\u003e0.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 43.617%;\"\u003e\n \u003cp\u003eI believe I am learning something from the research team.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.7021%;\"\u003e\n \u003cp\u003e5.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.38298%;\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.38298%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.57447%;\"\u003e\n \u003cp\u003e5.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.44681%;\"\u003e\n \u003cp\u003e0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4.25532%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6383%;\"\u003e\n \u003cp\u003e0.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 43.617%;\"\u003e\n \u003cp\u003eI believe the research team is changing their perspectives about something because of me.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.7021%;\"\u003e\n \u003cp\u003e5.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.38298%;\"\u003e\n \u003cp\u003e0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.38298%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.57447%;\"\u003e\n \u003cp\u003e5.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.44681%;\"\u003e\n \u003cp\u003e0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4.25532%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6383%;\"\u003e\n \u003cp\u003e0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 43.617%;\"\u003e\n \u003cp\u003eI believe I am changing my perspective about something because of the research team.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.7021%;\"\u003e\n \u003cp\u003e5.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.38298%;\"\u003e\n \u003cp\u003e0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.38298%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.57447%;\"\u003e\n \u003cp\u003e5.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.44681%;\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4.25532%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6383%;\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 43.617%;\"\u003e\n \u003cp\u003eI believe the research team is open to my concerns or wishes.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.7021%;\"\u003e\n \u003cp\u003e5.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.38298%;\"\u003e\n \u003cp\u003e0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.38298%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.57447%;\"\u003e\n \u003cp\u003e5.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.44681%;\"\u003e\n \u003cp\u003e0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4.25532%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6383%;\"\u003e\n \u003cp\u003e0.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 43.617%;\"\u003e\n \u003cp\u003eI believe that I am open to the concerns or wishes of the research team.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.7021%;\"\u003e\n \u003cp\u003e5.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.38298%;\"\u003e\n \u003cp\u003e0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.38298%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.57447%;\"\u003e\n \u003cp\u003e5.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.44681%;\"\u003e\n \u003cp\u003e0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4.25532%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6383%;\"\u003e\n \u003cp\u003e0.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 43.617%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eComposite score\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.7021%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e5.7\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.38298%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.5\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.38298%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.57447%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e5.8\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.44681%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.4\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4.25532%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6383%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 43.617%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eAdditional Chair-Recommended Questions\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.7021%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.38298%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.38298%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.57447%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.44681%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4.25532%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6383%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 43.617%;\"\u003e\n \u003cp\u003eI believe the community board selection process demonstrated respect for the perspectives of people with lived experience.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.7021%;\"\u003e\n \u003cp\u003e5.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.38298%;\"\u003e\n \u003cp\u003e0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.38298%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.57447%;\"\u003e\n \u003cp\u003e5.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.44681%;\"\u003e\n \u003cp\u003e0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4.25532%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6383%;\"\u003e\n \u003cp\u003e0.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 43.617%;\"\u003e\n \u003cp\u003eI would like the opportunity to engage in the continued research activities of this community board work (learning how to publish research, inform policy, etc.)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.7021%;\"\u003e\n \u003cp\u003e5.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.38298%;\"\u003e\n \u003cp\u003e0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.38298%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.57447%;\"\u003e\n \u003cp\u003e5.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.44681%;\"\u003e\n \u003cp\u003e0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4.25532%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.6383%;\"\u003e\n \u003cp\u003e0.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"8\" valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003e\u003cem\u003eNotes: Questions asked using a scale of 1/\u0026rdquo;Not at all\u0026rdquo; to 6/\u0026rdquo;A great deal\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\u003cp\u003e-----\u003cem\u003eTable\u0026nbsp;4 about here\u003c/em\u003e-----\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eIn this early phase of our work, we examined the development of the PATH curricula through a community-engaged process that centered PWLLE of substance use, harm reduction, and related service provision. Consistent with participatory curriculum design research, centering PWLLE enhanced cultural relevance and acceptability while strengthening trust and shared ownership between researchers and community partners [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Our study aligns with a national shift, reflected in NIH investments such as the Justice Community Overdose Innovation Network (JCOIN) and the JEAP Initiative, which institutionalize CBPR models embedding PWLLE as core partners [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eCB deliberations underscored relational harm reduction as a foundational for the entire curriculum. Relational harm reduction recognizes that reducing substance use-related risk is more than just distributing safer-use and overdose-prevention supplies. It prioritizes trusting, nonjudgmental relationships in which providers partner with people who use drugs to promote safety, autonomy, and wellbeing, recognizing that connection itself is a core intervention [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. Because relational harm reduction centers connection as a core intervention, CB members emphasized that peer services should prioritize authenticity, nonjudgment, and participant autonomy. This aligns with emerging PRS and harm reduction workforce literature that emphasizes trust-building and boundary management as prerequisites to effective service delivery [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e]. At the same time, CB members noted ongoing tension between harm-reduction and abstinence-oriented recovery philosophies, highlighting a need for organizational structures that model non-punitive supervision and recognize multiple recovery pathways. CB Members also recommended integrating historical and philosophical context throughout modules to highlight the compatibility of harm reduction and abstinence-based recovery, reducing stigma and bridging cultural divides. These insights parallel studies documenting moral distress and burnout among behavioral health, legal, and harm reduction professionals whose work requires them to navigate competing value systems [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eCB feedback highlighted how language shapes empowerment and inclusion throughout the curriculum. For example, renaming the \u0026ldquo;Advocacy\u0026rdquo; module to \u0026ldquo;Championship\u0026rdquo; illustrated how subtle linguistic shifts can recalibrate cultural tone\u0026mdash;echoing research showing that non-stigmatizing terminology enhances psychological safety and engagement [\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e, \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e]. This process of co-creation reflects broader principles of trauma-informed facilitation and community-driven implementation, where shared interpretation transforms descriptive feedback into actionable guidance [\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e]. Through the integration of quantitative prioritization and qualitative deliberation, the CB process we followed demonstrates how mixed methods can operationalize equity and produce practice-ready interventions [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e After reviewing the findings from the co-development process described above, the CB Members who are listed as co-authors on this manuscript (GG, AC, HO, SP, RRS, and VS) emphasized the importance of grounding Module 2\u0026rsquo;s content in an integrated framework that connects social determinants of health with recovery capital. Framing recovery capital through the structural conditions that shape health (e.g., housing stability, employment opportunities, and social connection) aligns with research highlighting the intertwined social, structural, and relational dimensions of recovery [\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e, \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e]. This integration reinforces calls for multi-level interventions that link peer-delivered care with organizational and policy supports addressing systemic inequities. By embedding social determinants of health, recovery capital, and relational harm reduction, within eLearning and ECHO sessions, PATH will position training as empowerment rather than compliance\u0026mdash;an approach consistent with evidence that peer-led education and mentorship enhance confidence, resilience, and fidelity to harm-reduction principles [\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e, \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe Cultural Exchange Survey provided an additional layer of confirmation that the CB functioned as a psychologically safe and collaborative environment [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e]. High mean ratings across all domains indicated strong alignment between CB Members and researchers. Open-ended feedback emphasized appreciation for equitable facilitation, time sensitivity, and opportunities for peer-only discussion. These findings echo prior studies showing that when PWLLE perceive genuine respect and shared power, collaboration quality and project retention improve substantially [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Breakout sessions and peer-led portions of meetings were particularly valued, highlighting that structural design elements of meetings are as important as the substantive content under discussion.\u003c/p\u003e\u003cp\u003eAs in other participatory studies, ensuring consistent engagement throughout our CBPR process presented notable challenges [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. Fluctuating participation, technology barriers, and competing demands reflected structural realities rather than a lack of commitment among CB members. Addressing these barriers required adaptive facilitation, equitable compensation, and flexible participation options\u0026mdash;strategies recognized as essential for sustaining engagement in CBPR. Collectively, these adaptations underscore that responsiveness and flexibility are not merely logistical adjustments but active mechanisms of equity within participatory research [\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e]. Although our CB was relatively small, its membership represented diverse harm-reduction and recovery settings across the United States, and this representiveness enhances the contextual breadth and potential generalizability of PATH.\u003c/p\u003e\u003cp\u003eThe next step in this work is to pilot PATH within two Recovery Community Organizations (RCOs). This pilot will assess the acceptability, appropriateness, and feasibility of PATH as a PRS workforce intervention, as well as satisfaction with its eLearning and ECHO training components. Findings from this pilot and continued CB partnership will inform refinements to PATH and may lead to additional modifications to enhance its usability and fit across diverse organizational contexts. The revised intervention will then guide the design of a subsequent stepped-wedge clinical trial evaluating PATH\u0026rsquo;s impact on workforce outcomes and service quality among PRS employed at ten additional RCOs.\u003c/p\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003eThis early-phase study demonstrates how centering PWLLE through a CBPR process can produce a culturally grounded, practice-ready harm reduction training that reflects both scientific rigor and community wisdom. The co-development process is marked by shared decision-making, reflexive adaptation, and sustained representation across stages and illustrates how collaboration with PWLLE can strengthen intervention design and implementation readiness. Findings from this formative phase lay the groundwork for future testing of PATH\u0026rsquo;s feasibility and impact on workforce outcomes among PRS who deliver harm reduction services, organizational practices, and service quality across diverse recovery and harm-reduction settings.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCB\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ecommunity board\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCBPR\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ecommunity based participatory research\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePATH\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePeer Advanced Training in Harm reduction\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePRS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003epeer recovery specialist\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePWLLE\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003epeople with lived/living experience\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSUD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003esubstance use disorder\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003cp\u003eAll survey data for this study were collected anonymously, with no ability to connect completed surveys to respondents. In compliance with the Declaration of Helsinki, the Chestnut Institutional Review Board granted this study an exemption from requiring ethics approval (Chestnut IRB #2025-52). As the activities were exempt, the researchers were not required to obtain consent.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003cp\u003eNot applicable.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eCompeting interests\u003c/h2\u003e\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eThis work was supported by the National Institute on Drug Abuse of the National Institutes of Health under award numbers R61DA061340 and R24DA051950, which were funded as part of the NIH HEAL Initiative. The content is solely the responsibility of the authors and does not necessarily represent the official views of NIH, NIDA, or the HEAL Initiative.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eGarland Gerber: Conceptualization; Writing \u0026ndash; original draft; Writing \u0026ndash; review \u0026amp;amp; editing; Dennis P. Watson: Conceptualization; Formal analysis; Writing \u0026ndash; original draft; Writing \u0026ndash; review \u0026amp;amp; editing; Keoni Bermoy: Conceptualization; Writing \u0026ndash; original draft; Writing \u0026ndash; review \u0026amp;amp; editing; Lisa D. Taylor: Formal analysis; Writing \u0026ndash; review \u0026amp;amp; editing; Ashli Sheidow: Conceptualization; Writing \u0026ndash; review \u0026amp;amp; editing; Patrick F. Hibbard: Writing \u0026ndash; review \u0026amp;amp; editing; Justin S. Bell: Conceptualization; Writing \u0026ndash; review \u0026amp;amp; editing; Adam Caba: Validation; Writing \u0026ndash; review \u0026amp;amp; editing; Community engagement; Heather Ogdon: Validation; Writing \u0026ndash; review \u0026amp;amp; editing; Community engagement; Samuel Peterson: Validation; Writing \u0026ndash; review \u0026amp;amp; editing; Community engagement; Robert Richard-Snipes: Validation; Writing \u0026ndash; review \u0026amp;amp; editing; Community engagement; Venus Staton: Validation; Writing \u0026ndash; review \u0026amp;amp; editing; Community engagement.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors extend their sincere gratitude to Community Board Members Robert Gasior and Rebecca Sanchez, whose insight and lived expertise were instrumental in shaping the direction and relevance of this work. We also thank Justin Beattey, Gina Fears, Heather Rodriguez, and Jennifer Van Nuys of Mental Health America of Indiana (MHAI) for their steadfast partnership and commitment throughout the project. We are deeply appreciative of Dr. Emma Kay and Dr. Mary Hawk for their valuable contributions to the development of the training content. We further acknowledge our project partners\u0026mdash;Dr. Emily Ahonen, Dr. Kate Browne, Maggie Kaufmann, and Andrea Janota\u0026mdash;for their meaningful collaboration and continued support of the broader initiative. We also wish to acknowledge the power and healing that emerge when researchers work alongside individuals with lived/living experience. Equitable partnerships with clearly defined roles and financial remuneration for community members not only enriches the scientific process but also embodies the very principles of equality, recovery, hope, and collective transformation that this work seeks to advance. We hope that more research continues to be conducted in this spirit.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eAll materials developed for the study are available upon request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCenters for Disease Control and Prevention, National Center for Health Statistics. \u003cem\u003eMultiple cause of death 1999\u0026ndash;2022\u003c/em\u003e [data file].\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMarshall Z, Dechman MK, Minichiello A, Alcock L, Harris GE. Peering into the literature: A systematic review of the roles of people who inject drugs in harm reduction initiatives. Drug Alcohol Depend. 2015;151:1\u0026ndash;14. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.drugalcdep.2015.03.002\u003c/span\u003e\u003cspan address=\"10.1016/j.drugalcdep.2015.03.002\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChang J, Shelly S, Busz M, Stoicescu C, Iryawan AR, Madybaeva D, et al. Peer driven or driven peers? A rapid review of peer involvement of people who use drugs in HIV and harm reduction services in low- and middle-income countries. Harm Reduct J. 2021;18:15. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12954-021-00461-z\u003c/span\u003e\u003cspan address=\"10.1186/s12954-021-00461-z\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGugala E, Briggs O, Moczygemba LR, Brown CM, Hill LG. Opioid harm reduction: A scoping review of physician and system-level gaps in knowledge, education, and practice. Substance abuse. 2022;43:972\u0026ndash;87. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/08897077.2022.2060423\u003c/span\u003e\u003cspan address=\"10.1080/08897077.2022.2060423\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWatson DP, Young J, Ahonen E, Xu H, Henderson M, Shuman V, et al. Development and testing of an implementation strategy for a complex housing intervention: Protocol for a mixed methods study. Implement Sci. 2014;9:138. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s13012-014-0138-4\u003c/span\u003e\u003cspan address=\"10.1186/s13012-014-0138-4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOlding M, Boyd J, Kerr T, McNeil R. And we just have to keep going: Task shifting and the production of burnout among overdose response workers with lived experience. Soc Sci Med. 2021;270:113631. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.socscimed.2020.113631\u003c/span\u003e\u003cspan address=\"10.1016/j.socscimed.2020.113631\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eUnachukwu IC, Abrams MP, Dolan A, Oyekemi K, Meisel ZF, South EC, et al. The new normal has become a nonstop crisis: A qualitative study of burnout among Philadelphia\u0026rsquo;s harm reduction and substance use disorder treatment workers during the COVID-19 pandemic. Harm Reduct J. 2023;20:32. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12954-023-00752-7\u003c/span\u003e\u003cspan address=\"10.1186/s12954-023-00752-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTaris TW. Is there a relationship between burnout and objective performance? A critical review of 16 studies. Work Stress. 2006;20:316\u0026ndash;34. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/02678370601065893\u003c/span\u003e\u003cspan address=\"10.1080/02678370601065893\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMansour AEG, Mohamed Elmorsey R. Occupational stress: Measuring its impact on employee performance and turnover. Eur J Bus Manage. 2016;8:12\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMercer F, Miler JA, Pauly B, Carver H, Hn\u0026iacute;zdilov\u0026aacute; K, Foster R, et al. Peer support and overdose prevention responses: A systematic state-of-the-art review. Int J Environ Res Public Health. 2021;18:12073. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3390/ijerph182212073\u003c/span\u003e\u003cspan address=\"10.3390/ijerph182212073\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHagaman A, Foster K, Kidd M, Pack R. An examination of peer recovery support specialist work roles and activities within the recovery ecosystems of Central Appalachia. Addict Res Theory. 2023.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMcGuire AB, Powell KG, Treitler PC, Wagner KD, Smith KP, Cooperman N, et al. Emergency department-based peer support for opioid use disorder: Emergent functions and forms. J Subst Abuse Treat. 2019. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jsat.2019.06.013\u003c/span\u003e\u003cspan address=\"10.1016/j.jsat.2019.06.013\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBell JS, Hagaman A, Beattey J, Fears G, White WL, Watson DP. Advancing peer support workforce research: Insights and recommendations through the lens of professionalization. J Subst Use Addict Treat. 2025;170:209612. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.josat.2024.209612\u003c/span\u003e\u003cspan address=\"10.1016/j.josat.2024.209612\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBell JS, Griffin T, Castedo De Martell S, Kay ES, Hawk M, Hudson M, et al. Workforce outcomes among substance use peer supports and their contextual determinants: A scoping review protocol. PLoS ONE. 2024;19:e0311821. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1371/journal.pone.0311821\u003c/span\u003e\u003cspan address=\"10.1371/journal.pone.0311821\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBell JS, Watson D, Griffin T, Castedo De Martell S, Kay ES, Hawk M, et al. Workforce outcomes among substance use peer supports: A scoping review of individual and organizational influences. Front Public Health. 2024;12. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3389/fpubh.2024.1515264\u003c/span\u003e\u003cspan address=\"10.3389/fpubh.2024.1515264\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMamdani Z, McKenzie S, Pauly B, Cameron F, Conway-Brown J, Edwards D, et al. Running myself ragged: Stressors faced by peer workers in overdose response settings. Harm Reduct J. 2021;18:18. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12954-020-00449-1\u003c/span\u003e\u003cspan address=\"10.1186/s12954-020-00449-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNixon L, Kelly M, Punungwe F, Sampson M, Gray M. Working in harm reduction: Using chaos narratives to support and sustain frontline staff. Ann Fam Med. 2023;21(Suppl 1). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1370/afm.21.s1.4062\u003c/span\u003e\u003cspan address=\"10.1370/afm.21.s1.4062\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePasman E, Brown S, Agius E, Resko SM. Support for safe consumption sites among peer recovery coaches. J Behav Health Serv Res. 2023. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s11414-023-09846-3\u003c/span\u003e\u003cspan address=\"10.1007/s11414-023-09846-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWatson DP, Ahonen EQ, Shuman V, Brown M, Tsemberis S, Huynh P, et al. The Housing First Technical Assistance and Training implementation strategy: Outcomes from a mixed methods study of three programs. Subst Abuse Treat Prev Policy. 2018;13:32. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s13011-018-0172-3\u003c/span\u003e\u003cspan address=\"10.1186/s13011-018-0172-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMancini MA, Linhorst DM, Broderick F, Bayliff S. Challenges to implementing the harm reduction approach. J Social Work Pract Addictions. 2008;8:380\u0026ndash;408. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/15332560802224576\u003c/span\u003e\u003cspan address=\"10.1080/15332560802224576\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePauly B, Wallace B, Barber K. Turning a blind eye: Implementation of harm reduction in a transitional programme setting. Drugs: Educ Prev Policy. 2018;25:21\u0026ndash;30. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/09687637.2017.1337081\u003c/span\u003e\u003cspan address=\"10.1080/09687637.2017.1337081\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDemerouti E, Bakker AB, Nachreiner F, Schaufeli WB. The job demands\u0026ndash;resources model of burnout. J Appl Psychol. 2001;86:499\u0026ndash;512. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1037/0021-9010.86.3.499\u003c/span\u003e\u003cspan address=\"10.1037/0021-9010.86.3.499\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBrady LA, Wozniak ML, Brimmer MJ, Terranova E, Moore C, Kahn L, et al. Coping strategies and workplace supports for peers with substance use disorders. Subst Use Misuse. 2022;57:1772\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/10826084.2022.2112228\u003c/span\u003e\u003cspan address=\"10.1080/10826084.2022.2112228\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAbraham KM, Erickson PS, Sata MJ, Lewis SB. Job satisfaction and burnout among peer support specialists: The contributions of supervisory mentorship, recovery-oriented workplaces, and role clarity. Adv Mental Health. 2022;20:38\u0026ndash;50. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/18387357.2021.1977667\u003c/span\u003e\u003cspan address=\"10.1080/18387357.2021.1977667\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFoy S. Harm reduction: An introduction. In: Foy S, editor. Solution Focused Harm Reduction: Working effectively with people who misuse substances. Cham: Springer International Publishing; 2017. pp. 33\u0026ndash;52. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/978-3-319-72335-8_3\u003c/span\u003e\u003cspan address=\"10.1007/978-3-319-72335-8_3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFelton JW, Abidogun TM, Senters K, Maschino LD, Montgomery BW, Tyson R, et al. Peer recovery coaches\u0026rsquo; perceptions of their work and implications for training, support, and personal recovery. Commun Ment Health J. 2023;59:962\u0026ndash;71. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s10597-022-01080-z\u003c/span\u003e\u003cspan address=\"10.1007/s10597-022-01080-z\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eStack E, Hildebran C, Leichtling G, Waddell EN, Leahy JM, Martin E, et al. Peer recovery support services across the continuum: In community, hospital, corrections, and treatment and recovery agency settings\u0026mdash;a narrative review. J Addict Med. 2022;16:93\u0026ndash;100. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/ADM.0000000000000810\u003c/span\u003e\u003cspan address=\"10.1097/ADM.0000000000000810\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAlmeida M, Day A, Smith B, Bianco C, Fortuna K. Actionable items to address challenges incorporating peer support specialists within an integrated mental health and substance use disorder system: Co-designed qualitative study. J Participatory Med. 2020;12:e17053. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.2196/17053\u003c/span\u003e\u003cspan address=\"10.2196/17053\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAnvari MS, Kleinman MB, Dean D, Rose AL, Bradley VD, Hines AC, et al. A pilot study of training peer recovery specialists in behavioral activation in the United States: Preliminary outcomes and predictors of competence. Int J Environ Res Public Health. 2023;20:3902. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3390/ijerph20053902\u003c/span\u003e\u003cspan address=\"10.3390/ijerph20053902\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJawa R, Laks J, Saravanan N, Demers L, Wishik-Miller G. Physician trainees\u0026rsquo; compassion satisfaction, burnout, and self-efficacy when caring for people who inject drugs. Substance abuse. 2022;43:675\u0026ndash;81. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/08897077.2021.1986881\u003c/span\u003e\u003cspan address=\"10.1080/08897077.2021.1986881\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLennox R, Lamarche L, O\u0026rsquo;Shea T. Peer support workers as a bridge: A qualitative study exploring the role of peer support workers in the care of people who use drugs during and after hospitalization. Harm Reduct J. 2021;18:19. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12954-021-00467-7\u003c/span\u003e\u003cspan address=\"10.1186/s12954-021-00467-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLevine S, Medley A, Norton A. Putting Indigenous harm reduction to work: Developing and evaluating Not Just Naloxone. Int J Indigenous Health. 2021;16. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.32799/ijih.v16i2.33346\u003c/span\u003e\u003cspan address=\"10.32799/ijih.v16i2.33346\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMcCormick KA, Stanton M, Ali S, Chavez S. Outcomes of a harm reduction shared learning intervention pilot in the U.S. South. J HIV/AIDS Social Serv. 2022;21:216\u0026ndash;30. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/15381501.2023.2189198\u003c/span\u003e\u003cspan address=\"10.1080/15381501.2023.2189198\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAhonen EQ, Watson DP, Adams EL, McGuire A. Alpha test results for a Housing First eLearning strategy: The value of multiple qualitative methods for intervention design. Pilot Feasibility Stud. 2017;3:46. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s40814-017-0187-y\u003c/span\u003e\u003cspan address=\"10.1186/s40814-017-0187-y\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eProject ECHO. Moving knowledge, not people. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://hsc.unm.edu/echo/\u003c/span\u003e\u003cspan address=\"https://hsc.unm.edu/echo/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 18 Sept 2023.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOsei-Twum J-A, Wiles B, Killackey T, Mahood Q, Lalloo C, Stinson JN. Impact of Project ECHO on patient and community health outcomes: A scoping review. Acad Med. 2022;97:1393\u0026ndash;402. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/ACM.0000000000004749\u003c/span\u003e\u003cspan address=\"10.1097/ACM.0000000000004749\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eViswanathan M, Ammerman A, Eng E, Garlehner G, Lohr KN, Griffith D et al. Community-based participatory research: Assessing the evidence. Evid Rep Technol Assess (Summ). 2004;1\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKey KD, Furr-Holden D, Lewis EY, Cunningham R, Zimmerman MA, Johnson-Lawrence V, et al. The continuum of community engagement in research: A roadmap for understanding and assessing progress. Progress Community Health Partnerships: Res Educ Action. 2019;13:427\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eIsrael BA, Schulz AJ, Parker EA, Becker AB. Review of community-based research: Assessing partnership approaches to improve public health. Annu Rev Public Health. 1998;19:173\u0026ndash;202. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1146/annurev.publhealth.19.1.173\u003c/span\u003e\u003cspan address=\"10.1146/annurev.publhealth.19.1.173\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePalinkas LA, Aarons GA, Chorpita BF, Hoagwood K, Landsverk J, Weisz JR. Cultural exchange and the implementation of evidence-based practices: Two case studies. Res Social Work Pract. 2009;19:602\u0026ndash;12. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/1049731509335529\u003c/span\u003e\u003cspan address=\"10.1177/1049731509335529\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSalimi Y, Shahandeh K, Malekafzali H, Loori N, Kheiltash A, Jamshidi E, et al. Is community-based participatory research (CBPR) useful? A systematic review. Int J Prev Med. 2012;3:386\u0026ndash;93.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSacks JJ, Gonzales KR, Bouchery EE, Tomedi LE, Brewer RD. 2010 national and state costs of excessive alcohol consumption. Am J Prev Med. 2015;49:e73\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.amepre.2015.05.031\u003c/span\u003e\u003cspan address=\"10.1016/j.amepre.2015.05.031\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCanadian HIVAIDS, Legal Network. Nothing about us without us: Greater, meaningful involvement of people who use illegal drugs: A public health, ethical and human rights imperative. Toronto (ON): Canadian HIV/AIDS Legal Network; 2008.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eClosson K, McNeil R, McDougall P, Fernando S, Collins AB, Baltzer Turje R, et al. Meaningful engagement of people living with HIV who use drugs: Methodology for the design of a peer research associate hiring model. Harm Reduct J. 2016;13:26. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12954-016-0116-z\u003c/span\u003e\u003cspan address=\"10.1186/s12954-016-0116-z\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGrill C. Involving stakeholders in research priority setting: A scoping review. Res Involv Engagem. 2021;7:75. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s40900-021-00318-6\u003c/span\u003e\u003cspan address=\"10.1186/s40900-021-00318-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJozaghi E, Greer AM, Lampkin H, Buxton JA. Activism and scientific research: Twenty years of community action by the Vancouver Area Network of Drug Users. Subst Abuse Treat Prev Policy. 2018;13:18. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s13011-018-0158-1\u003c/span\u003e\u003cspan address=\"10.1186/s13011-018-0158-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSouleymanov R, Kuzmanović D, Marshall Z, Scheim AI, Mikiki M, Worthington C, et al. The ethics of community-based research with people who use drugs: Results of a scoping review. BMC Med Ethics. 2016;17:25. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12910-016-0108-2\u003c/span\u003e\u003cspan address=\"10.1186/s12910-016-0108-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eThe JEAP, Initiative. \u003cem\u003eA toolkit for generating research priorities through community-based participatory research.\u003c/em\u003e 2022.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSheidow AJ, Bermoy KK, Cruz MA, Buell EN, Weedman DR, Drazdowski TK et al. \u003cem\u003eCommunity-engaged substance use research: Effective community board partnerships using community-based participatory research (CBPR).\u003c/em\u003e 2025.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eThe JEAP, Initiative. \u003cem\u003eCultural exchange survey examples\u003c/em\u003e (Version 2). 2024.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePalinkas LA, Garcia A, Aarons G, Finno-Velasquez M, Fuentes D, Holloway I, et al. Measuring collaboration and communication to increase implementation of evidence-based practices: The cultural exchange inventory. Evid Policy. 2018. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1332/174426417X15034893021530\u003c/span\u003e\u003cspan address=\"10.1332/174426417X15034893021530\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNational Harm Reduction Coalition. \u003cem\u003eHarm reduction principles.\u003c/em\u003e Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://harmreduction.org/about-us/principles-of-harm-reduction/\u003c/span\u003e\u003cspan address=\"https://harmreduction.org/about-us/principles-of-harm-reduction/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 23 Aug 2022.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHawk M, Kay ES, Jawa R. Relational harm reduction for internists: A call to action. J Gen Intern Med. 2024;39:1746\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s11606-024-08693-y\u003c/span\u003e\u003cspan address=\"10.1007/s11606-024-08693-y\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJEAP Initiative. \u003cem\u003eWelcome to the JEAP Initiative.\u003c/em\u003e Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.jeapinitiative.org/\u003c/span\u003e\u003cspan address=\"https://www.jeapinitiative.org/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 28 May 2025.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNational Institute on Drug Abuse. Expired RFA-DA-25-026: HEAL Initiative: JCOIN Phase II Community Engaged Research Resource Center (U24 Clinical Trial Optional).. 2024. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://grants.nih.gov/grants/guide/rfa-files/RFA-DA-25-026.html\u003c/span\u003e\u003cspan address=\"https://grants.nih.gov/grants/guide/rfa-files/RFA-DA-25-026.html\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 12 Nov 2025.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMcCormick K, Shah R, Kulkarni S, Ali SB, Creeck SK, Claborn KR. Caught between crisis and criminalization: Unveiling occupational stressors affecting harm reduction workers. J Soc Social Work Res. 2025. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1086/736304\u003c/span\u003e\u003cspan address=\"10.1086/736304\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGerber GE, Bazzi AR, Beletsky L, Pitpitan EV, Reed MB, Smith LR. Occupational stress and substance use-related stigma among criminal attorneys. Soc Sci Med. 2025;118757. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.socscimed.2025.118757\u003c/span\u003e\u003cspan address=\"10.1016/j.socscimed.2025.118757\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKelly JF, Westerhoff CM. Does it matter how we refer to individuals with substance-related conditions? A randomized study of two commonly used terms. Int J Drug Policy. 2010;21:202\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.drugpo.2009.10.010\u003c/span\u003e\u003cspan address=\"10.1016/j.drugpo.2009.10.010\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAshford RD, Brown AM, Ashford A, Curtis B. Recovery dialects: A pilot study of stigmatizing and nonstigmatizing label use by individuals in recovery from substance use disorders. Exp Clin Psychopharmacol. 2019;27:530\u0026ndash;5. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1037/pha0000286\u003c/span\u003e\u003cspan address=\"10.1037/pha0000286\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAarons GA, Ehrhart MG, Farahnak LR, Sklar M. Aligning leadership across systems and organizations to develop a strategic climate for evidence-based practice implementation. Annu Rev Public Health. 2014;35:255\u0026ndash;74. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1146/annurev-publhealth-032013-182447\u003c/span\u003e\u003cspan address=\"10.1146/annurev-publhealth-032013-182447\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAschbrenner KA, Kruse G, Gallo JJ, Plano Clark VL. Applying mixed methods to pilot feasibility studies to inform intervention trials. Pilot Feasibility Stud. 2022;8:217. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s40814-022-01178-x\u003c/span\u003e\u003cspan address=\"10.1186/s40814-022-01178-x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCloud W, Granfield R. Conceptualizing recovery capital: Expansion of a theoretical construct. Subst Use Misuse. 2008;43:1971\u0026ndash;86. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/10826080802289762\u003c/span\u003e\u003cspan address=\"10.1080/10826080802289762\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePark JN, Rouhani S, Beletsky L, Vincent L, Saloner B, Sherman SG. Situating the continuum of overdose risk in the social determinants of health: A new conceptual framework. Milbank Q. 2020;98:700\u0026ndash;46. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/1468-0009.12470\u003c/span\u003e\u003cspan address=\"10.1111/1468-0009.12470\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTracy K, Wallace SP. Benefits of peer support groups in the treatment of addiction. Subst Abuse Rehabilitation. 2016;7:143\u0026ndash;54. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.2147/SAR.S81535\u003c/span\u003e\u003cspan address=\"10.2147/SAR.S81535\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTracy K, Wachtel L, Goldmann E, Nissenfeld J, Burton M, Galanter M, et al. Mentorship for Addiction Problems (MAP): A new behavioral intervention to assist in the treatment of substance use disorders. J Stud Alcohol Drug. 2020;81:664\u0026ndash;72. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.15288/jsad.2020.81.664\u003c/span\u003e\u003cspan address=\"10.15288/jsad.2020.81.664\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOmale LE, Viola J. Cultural attunement approach for enhanced uptake of harm reduction services: A qualitative study in marginalized U.S. communities. J Prev Interv Community. 2025:1\u0026ndash;28. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/10852352.2025.2496208\u003c/span\u003e\u003cspan address=\"10.1080/10852352.2025.2496208\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRabbani RS. \u003cem\u003eStrategy to address systemic racism and violence as public health priorities: Training and supporting community health workers to advance equity and violence prevention\u003c/em\u003e (Policy Number 20227). 2022.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Harm Reduction, Peer Supports, Recovery Rervices, Community-Based Participatory Research, Community Board, Co-design, Behavioral Health Workforce","lastPublishedDoi":"10.21203/rs.3.rs-8138704/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8138704/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eOpioid use disorder and related overdoses remain a leading US public health challenge. Peer Recovery Specialists (PRS), individuals with lived experience who support others in recovery, frequently deliver harm reduction services but face high job demands, stigma, and role conflict due to abstinence-oriented norms. These stressors contribute to burnout, turnover, and diminished service quality. Despite growing recognition of PRSs\u0026rsquo; role in harm reduction, few interventions address their workforce development or resilience needs. To strengthen harm reduction delivery and workforce sustainability, we developed Peer Advanced Training in Harm reduction (PATH), a blended educational intervention co-designed with community partners using a Community-Based Participatory Research (CBPR) framework.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003ePATH was designed to enhance PRSs\u0026rsquo; personal and job-related resources through (1) three one-hour eLearning modules that apply adult learning and narrative storytelling to shift stigmatizing attitudes and strengthen harm reduction skills, and (2) an ECHO\u0026ndash;based case discussion series to build confidence, policy literacy, and organizational alignment. A Community Board (CB) of eight members with lived recovery, harm reduction, and related service experience guided iterative content prioritization across six meetings (February\u0026ndash;June 2025). CB members brainstormed, ranked, and refined eLearning and ECHO topics through surveys and facilitated discussions. Cultural exchange surveys assessed perceptions of collaboration, communication, and trust between CB members and researchers at two time points.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eCB deliberations identified relational harm reduction\u0026mdash;emphasizing empathy, authenticity, and participant autonomy\u0026mdash;as the unifying theme across all training modules. Four final eLearning modules emerged: Embracing the Harm Reduction Approach, Integrating Harm Reduction into Participant Recovery Plans, Supporting PRSs to Do Harm Reduction Work, and Advancing Harm Reduction. ECHO priorities were also refined to reflect the pragmatic nature of peer work as perceived by CB members. Cultural exchange ratings were uniformly high (mean\u0026thinsp;\u0026gt;\u0026thinsp;5.5 on a 6-point scale), reflecting strong mutual respect, shared learning, and perceived impact.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eThrough CBPR co-design, PATH demonstrates how centering people with lived/living experience can yield a culturally grounded, practice-ready workforce intervention that strengthens harm-reduction capacity and sustainability. Findings establish feasibility and guide the forthcoming pilot and subsequent clinical trial to assess PATH\u0026rsquo;s impact on PRS workforce outcomes and service quality.\u003c/p\u003e","manuscriptTitle":"Co-Designing the PATH Harm Reduction Training for the Peer Workforce: A Community-Based Participatory Approach","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-11 12:03:18","doi":"10.21203/rs.3.rs-8138704/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-12-30T17:32:12+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-21T20:49:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"170973264323366464404028599401972046953","date":"2025-12-10T20:10:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"39807194767844284972932266321522713862","date":"2025-12-09T20:01:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"131781719611775656226007405895485922983","date":"2025-12-08T22:10:09+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-12-08T17:39:21+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-27T04:00:30+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-26T17:12:02+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2025-11-26T17:06:26+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"cc317c4c-d3ef-4989-8266-f3feb1dfdd34","owner":[],"postedDate":"December 11th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-12-11T12:03:18+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-11 12:03:18","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8138704","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8138704","identity":"rs-8138704","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}