Describing the policy network
Figure 1 depicts the network of participants’ self-nominated contacts with whom they interacted most frequently throughout the development of the drug policy. Circles represent participants in the study, and squares are alters (individuals named by participants who did not participate in the study). We can see that there was a combination of connections within and across groups. Connections were mixed among government, drug policy advocacy groups, PWUD-led advocates and researchers in the middle of the network; however, police (in blue) were located towards the periphery, suggesting that most participants did not interact with them frequently. The network visual provides an imperfect but still informative way to get an overall snapshot of the drug policy-making network.
Drug policy-making network (17 egos and 30 alters)
The network metrics (Table 2) support the network map in showing that each member connected to only a few others around them. On average, each actor had 3.7 connections, and the density score shows that only 8% of all possible connections were present. In terms of centralization, the network was largely decentralized and did not revolve around one or a few individuals. The external–internal (E-I) index was close to zero (0.06), indicating an almost perfect balance of within-group and between-group connections with a slight preference to connect with members of other groups. This E-I index score means that people’s connections were diverse, communicating with others in their own group as much as across groups.
Table 3 shows the five participants who scored the highest in three individual-level measures: degree centrality, in-degree centrality and betweenness centrality. Based on this analysis, Participant 4 was the best positioned in structural terms. This person, a government official, had the most overall connections with other network members (degree centrality = 0.33) and was also the one most often named as a connection by other participants (in-degree centrality = 0.22). They were also the main broker (betweenness centrality = 0.36), connecting otherwise unconnected individuals.
In practice, a central or bridging node in the network does not necessarily equate to decision-making power. Actual brokerage power also depends on the social proximity of the parties involved, as well as on the content or substance of the interactions – it could be that a broker sits in the middle of otherwise weak ties that do not share as much as they would with strong ties [54]. Qualitative data helped expand the network results by examining interactions, and perceptions of power and value.
Questioning decision-making power in drug policy
Separation and lack of information as powerlessness
When we asked participants to score their own degree of decision-making power, most participants reported having a low degree of power, scoring themselves 5/10 or below (Table 4). Only three people ranked their power as higher than 5/10: Participant 4, a government official (6/10); Participant 1, a police officer (6/10); and Participant 10, a drug policy advocacy group member (7/10). The prevailing sense of powerlessness among participants, as reflected in their questionnaire scores, was consistent with qualitative explanations of feeling separated and silenced by others in the network. This disconnection was evident in quotes referring to limited access at the so-called kids’ table and being barred from higher-level conversations happening behind the scenes, so to speak, where decisions were made: “we could never go to that table, you know? I said I didn’t want us to be at the kids’ table, I wanted to be at the decision-making table. We could never go there” (Participant 9, PWUD-led advocacy).
There was a sense of disconnect from more powerful individuals, who were thought to have a separate network where additional conversations and final decisions were made. Lacking access to this group of powerful individuals and to information about the details of the policy design during the policy-making process resulted in a sense of powerlessness:
They had separate tables and collaborations, so they had one table with people with lived experience, but at the end of the decision making, whoever makes those final decisions, we weren’t involved in that, in those conversations. If we’re going to be at the table then put us in the decision-making process to at least not be blind-sided after the fact of – “this is what we’re doing, and we did consult with people with lived and living experience.” Yeah, big deal, you consulted but you didn’t listen. (Participant 25, PWUD-led advocacy).
There was a sense of disappointment from the expectation that they would be able to participate in making decisions, a process that was seen as separate and hard to reach. Many participants believed that the government officials who organized the policy-making process, such as Participants 4 or 34, excluded many of the participants we interviewed.
Adding to the feeling of powerlessness through the separation of groups, many participants felt that not enough information was provided about the role of each participant and where power lay. This uncertainty contributed to a sense of powerlessness as participants were unsure where to direct their efforts and resources:
We had questions about who ultimately decides and where do our comments go and all that. It wasn’t very clear. It was clear that we were at the bottom of a hierarchy. And this is the set of meetings where we weren’t able to access [specific information about policy design], we asked for [it]. We weren’t able to get a kind of clear role on governance, like they were not very transparent about how the decision-making process worked and all that stuff. (Participant 9, PWUD-led advocacy).
Furthermore, lack of communication and an inability to reach individuals with more decision-making power shaped participants’ views about the process:
There was a lot of talking together with each other [participant’s colleagues], you know, sharing our same experience and trying to put together pieces also of what’s happening at this higher level because we don’t – I don’t know, we were sort of totally left in the dark. (Participant 34, government official).
[Police] probably has the greatest amount of influence but maybe some of the smallest numbers of actual meetings about the [drug policy] because we weren’t able to get meetings with [police]. They are pretty closed off to having meetings because they already have it in their head what [policy design] they want and what they really want to agree to. (Participant 8, drug policy advocate).
There was a perceived lack of transparency and communication ultimately produced a sense of secrecy and frustration among participants, who alluded to there being “higher-level” meetings and processes in which they could not participate.Footnote 5 One participant explained this sense of separation and secrecy:
This is a network of people who are advocating and pushing and trying to advance and make changes, but I don’t see them being very connected and integrated into actual government structures and power. So, I think that everybody, like the network, is not a drug policymaking network, it’s a drug policy influencing network. (Participant 22, researcher).
Some participants did not see themselves as participating in the drug policy-making network, but as a separate network “pushing” to change policy and influence an elusive “higher-level” network. This distinction perceived by participants is important; the network map may suggest that they had access to government officials and some of them had advantageous positions, but they felt separated and isolated from those most powerful. For many, having power would have meant belonging to this other network they were excluded from.Footnote 6
“To be fair…”: perspectives of power from the top
In contrast to most participants who rated themselves as having little to no power, the three participants who rated themselves as having slightly more power (above 5/10) perceived the process differently (Table 4). Overall, they saw the process as more balanced or “neutral” than other participants who did not feel they had power, but also acknowledged and were critical of its shortcomings.
For instance, Participant 4 was in a gatekeeping position; they held the power to provide access or connect different parts of the network (for example, police and PWUD) who would otherwise be disconnected, and had the opportunity (or responsibility) of brokering between these different “sides”. This position may explain their “balanced” or neutral perspective. While they acknowledged some of the shortcomings of the process, they regularly framed the overall experience as positive given the circumstances: “I think in an imperfect situation under a really tight timeline the [local government] did do a reasonable job at that [connecting with people who use drugs] and there weren’t any big gaps in terms of stakeholders” (Participant 4, government official).
Participant 10 had a similar reading of the process, which they thought had happened in a “less-than-perfect situation”. As a drug policy advocate, they believed that this policy change, however small, was a step in the right direction:
Those are calculations that do have to be political at times and pragmatic. Do you get what you want, or do you hold out for better? There’s a risk either way and that played out really quite – it wasn’t pretty. [Advocacy group] was really pissed off. The [government official] sort of, like, “Jesus, I’ve gone way out on a limb here and I’m getting shit from all sides now”. Is this the best [policy design] in the world? It might be. It’s a low bar – there’s a lot of really shitty [policy designs] out there. (Participant 10, drug policy advocate).
Compared with other network members, Participant 10 was also well-connected, scoring in the top five highest in-degree and degree centrality measures (Table 4). They were mentioned as frequent contacts by others in the network, and overall, they had more connections than others (either outgoing or incoming). Many of these network ties may have existed for a long time prior to this process and should continue to exist after it; thus, being pragmatic, so to speak, can help foster some of the relationships that are key in advocating for change. This position could be particularly important for this participant who works at a national-level drug policy advocacy organization, which may require coordinating a variety of different local groups to push towards a common goal.
Compared with Participant 4 and 10, Participant 1 (police officer) was slightly more critical of the process and decision-making. They believed police officers’ concerns were not considered, but also thought that the process had been “well-intended” and that some of its shortcomings were understandable given the circumstances: “I’ve talked about it got politicized and kind of ideologically driven, but also too, with that time constraint and the backdrop of politics that, you know, we were running ahead at full steam” (Participant 1, police officer). Furthermore, despite believing their concerns were not considered in designing the policy, this participant believed that, relative to other stakeholders, they had more power and opportunity to participate in higher-level decision-making tables:
… the voice of police has power… we actually have a lot more power than a lot of other stakeholders […] It comes down to police, health, and government. (Participant 1, police officer).
Knowing that police officers believed they were more powerful than other stakeholders provides a better understanding of their network position and the dynamics. While this officer and others were hard to reach (both in the network and for this study), their isolation was not due to lack of power. Instead, it may signal their participation in other, higher-level networks of government (as pointed out by Participant 1).
Across these three participants (#1, #4 and #10), their perspectives reflect a sense of control and power throughout the process in different ways. By connecting with people from different organizations, maintaining a variety of relationships with network members, organizing the policy process itself and having access to higher levels of government, these participants were arguably some of the most important network members in terms of influence in the final policy design.
Perceptions of value in the policy-making process
When participants were asked to rate how much they thought their voices had been valued in the policy-making process, most (11 out of 16) reported a score above 5/10, indicating they felt they had been more than “somewhat valued” (Table 4). These participants represented all five groups (drug policy advocacy, PWUD-led policy advocacy, researchers, police and government). Participant 4, who was in a structurally advantageous position in the network by acting as a broker and having many connections, rated themselves 9/10 in terms of value – the highest rating in the sample.
In framing perceptions of value, we accounted for the way in which underlying power structures influence participants’ experiences within the network. As evidenced in the previous topic domain, police were seen by PWUD advocates and researchers as having had outsized power to influence the final decision-making: “They [police] have tons of power” (Participant 25, PWUD-led advocacy). Participant 1, a police officer, also believed they had power in the network (topic domain 1), and the final policy proposal was indeed influenced by the opinion of the local police department. The power imbalance between PWUD advocates and police or government institutions must be taken into account when interpreting participants’ experiences and expectations.
Finding value in the process and the outcome
While most participants (n = 11) rated their value as above 5/10 (Table 4), the sentiment described in the qualitative interviews was mixed. The idea of feeling heard relied on being invited to participate in the policy process, the quality of the relationships with other stakeholders and the final outcome. Participants appreciated being included in the network and being asked to share their perspectives, which may be reflected in the relatively high or moderate ratings of value and in the network data. The network map shows that participants communicated with a variety of stakeholders across different groups.
However, value was not only a question of inclusion and participation but also of knowing where and how opinions were taken up in decision-making. For many of these participants who believed they had been at least somewhat valued, there was a sense of feeling initially heard, but later dismissed or “watered down” when learning about the final policy design.
You get a lot of like “Wow, your information is great! This is amazing. Oh my God, we’re so happy to be involved in this process”, and so much more pleasantries. But the actual actions that happen almost always go in the direction of the safest route, the easiest route, the most comfortable, which is usually towards policing and usually towards the medical system. So it [drug policy] doesn’t actually take the opinions of people who use drugs […] We water them down and push them through the medical system or the criminal system, and then get a really shoddy version of it. (Participant 18, PWUD-led organization advocate).
Participant 12 expanded on this idea that their perspectives would not be considered or would be considered only in part. They suggested that external political considerations explained why some perspectives and suggestions were not fully considered in the policy design, adding to Participant 18’s concerns about the government doing what is “most comfortable”:
There were a lot of usual political, you know, professing: “well, of course we want to hear about like frontline lived experience of people who use drugs. But not if it’s going to push us as decision mak[ers] – as [city] into a terrain where we’re requesting something that we don’t feel politically comfortable doing.” That was then kind of devalued. (Participant 12, drug policy advocate).
Researchers felt similarly about the way their own contributions were not considered in full by decision-makers. They were confused when government officials requested their expertise and data but did not use this information to draw conclusions that they believed were not fully supported by the data. In their view, their data were not used appropriately by decision-makers:
[Decision-makers] actually made the mistake of including those data and those stated limitations in their report, and then completely ignoring that data and producing [a different decision] than what our data suggested… [then] kind of portrayed it as if they relied on this data from researchers. (Participant 21, researcher).
Overall, perceptions of value were impacted by the way in which the policy-making process unfolded and by the final outcome. There was a sense of distrust of government institutions both during this process and after. While there was initial hope and assumption that participants’ opinions would be considered from beginning to end and that the policy would “meaningfully engage” with community, participants’ expectations were not met.
Relationships matter: the value of connections
The frustrations surrounding feeling devalued provide important context for the network data. Some participants were in structurally advantageous positions, particularly in terms of being able to connect people to others in the network (betweenness), but did not feel as though they were valued. Interestingly, Participant 9, a PWUD-led group advocate, was one of the top-five brokers (betweenness = 0.17; Table 3) who named a high-ranking police officer in their network of most frequent contacts. However, they had the lowest rating of self-perceived value and power (1/10; Table 4). In the qualitative interview, Participant 9 clarified their relationship with the high-ranking police officer:
It was a special [redacted for confidentiality] meeting and that’s where [police officer] lectured to us about what was politically possible and all that stuff. […] We also had an initial meeting before there was even a process, I guess in late [year] [government official] called a meeting of like a handful of people and I talked to [police officer] then. […]Everybody’s very nice [at these meetings], right? Everyone’s like “oh, I’m so glad you came and said these things, it’s really important to listen to lived experience, blah blah blah.” But that’s how people do politics right now. (Participant 9, PWUD-led group advocate).
This quote illustrates a key point: frequent contact, even with high-ranking individuals, did not necessarily translate into feeling valued or creating meaningful relationships, even though this participant appeared to be in an advantageous brokerage position. Contact in formal policy spaces was not sufficient to feel heard and valued in this case.
Moreover, the level of involvement in the policy-making process may have been different for each participant. For Participant 9, these interactions in formal meetings with Participant 16 (police officer) were frequent enough to be considered in their list of top six contacts, but they did not feel truly heard and were “lectured” instead. Thus, the quality of the connection and interactions appears to be important, and it may explain the discrepancy between the high betweenness centrality and the extremely low value (and power) score for someone such as Participant 9.
The importance of relationships and the quality of the connection was reinforced through the qualitative data. A government official who felt as though their own expertise and that of marginalized communities had not been valued explained the importance of relationships in policy-making:
One of the things I’ve learned from working with Indigenous community is when you mess something up with a relationship from the outset you are fighting an uphill battle all the way. Relationships from the outset are everything, working in a relational way is everything, and I think we have a lot of really great lessons learned (Participant 34, government official).
Underlying this topic domain is the idea that a policy process where participants feel valued is one where “evidence” (however that is defined, for example, experience, opinion, quantitative data, qualitative data, etc.) is used to arrive at what participants view as the most logical and fair conclusion. However, feeling valued becomes challenging when individual relationships among participants do not feel genuine. The context in which these relationships exist, often one where there is a significant power imbalance between people with lived experience and official government institutions, shapes experiences of value. The network data show that participants communicated with each other, even across groups that would have had different perspectives (for example, police and PWUD). However, communication and being heard, so to speak, in a diverse policy network are not sufficient to make participants feel valued. The quality of relationships and the access to information about how the outcome will be decided are also important.
Competing for value: a finite resource?
Overall, there was a sense of competition for value among participants. For instance, many participants believed that police officers were more valued by government than the advocates and researchers involved: “in general, it [policy-making network] really overvalued law enforcement’s opinion and it did not adequately include people with lived and living experience” (Participant 26, researcher). The idea of “overvaluing” proposes that there are certain perspectives that can receive too much or excessive value beyond what they should receive. From this perspective, value for those representing the interests of PWUD was assessed in comparison or opposition to that of police officers:
The police force has always had a very strong voice in drug policy decision making whether their views are evidence-based or not. So, I would characterize [the network] again as being aspirational, a bit overreaching? And a little bit too deferential to the opinions of the enforcement community. (Participant 21, researcher).
The degree of value assigned to each group was tied to participants’ own positioning/group, with no consensus across all participants about who was over- or undervalued.
Many participants who represented the interests of PWUD compared their value with that of police officers, while police officers believed that PWUD advocates were overvalued. Participant 6, a police officer, illustrated their frustration around the types of knowledge that were most valued in the policy-making process:
On one hand, I think that lived and living experiences of everybody at the table – our First Nations and all that was critical, health authorities who were there. But I also think at times not everyone’s lived or living experiences was applied equally. It was really more so that the persons who use drugs whose really voice in that one was loudest. (Participant 6, police officer).
Even though most participants, regardless of group, rated their own value in the process as relatively high (above 5/10; Table 4), this did not translate into feeling valued enough compared with other groups. Comparing the value of different voices, so to speak, implied the perception that some were louder than others and, therefore, muted other participants. By competing, so to speak, value is understood as a finite resource that must be distributed among different groups.
This theme raises questions around how to frame value in policy-making. In this case, differing expectations of what participation entailed may have led to a sense of competition to be heard by policy-makers. Framing value as a finite resource in this context may also explain the discrepancy between most participants’ value scores and the qualitative description of policy-makers as having valued some voices over others.
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