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Open AcceResearchA qualitative assessment of stakeholder perceptions and socio-cultural influences on the acceptability of harm reduction programs in Tijuana, MexicoMorgan M Philbin1, Remedios Lozada2, María Luisa Zúñiga1, Andrea Mantsios1, Patricia Case3, Carlos Magis-Rodriguez4, Carl A Latkin5 and Steffanie A Strathdee*1

Address: 1Division of International Health, School of Medicine, University of California San Diego, La Jolla, California, USA, 2Pro-COMUSIDA, Tijuana, Mexico, 3The Fenway Institute, Fenway Community Health, Boston, MA, USA, 4Centro Nacional para la Prevención del VIH/SIDA (CENSIDA), Ministry of Health, Mexico and 5The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA

Email: Morgan M Philbin - mphilbin@jhsph.edu; Remedios Lozada - mrlozada@hotmail.com; María Luisa Zúñiga - mzuniga@ucsd.edu; Andrea Mantsios - amantsio@health.nyc.gov; Patricia Case - pcase@fenwayhealth.org; Carlos Magis-Rodriguez - cmagis@salud.gob.mx; Carl A Latkin - clatkin@jhsph.edu; Steffanie A Strathdee* - sstrathdee@ucsd.edu

* Corresponding author

AbstractBackground: The Mexico-U.S. border region is experiencing rising rates of blood-borneinfections among injection drug users (IDUs), emphasizing the need for harm reductioninterventions.

Methods: We assessed the religious and cultural factors affecting the acceptability and feasibilityof three harm reduction interventions – Needle exchange programs (NEPs), syringe vendingmachines, and safer injection facilities (SIFs) – in Tijuana, Mexico. In-depth qualitative interviewswere conducted with 40 community stakeholders to explore cultural and societal-related themes.

Results: Themes that emerged included Tijuana's location as a border city, family values, andculture as a mediator of social stigma and empathy towards IDUs. Perception of low levels of bothawareness and socio-cultural readiness for harm reduction interventions was noted. Religiousculture emerged as a theme, highlighting the important role religious leaders play in determiningcommunity responses to harm reduction and rehabilitation strategies for IDUs. The influence ofreligious culture on stakeholders' opinions concerning harm reduction interventions was evidencedby discussions of family and social values, stigma, and resulting policies.

Conclusion: Religion and politics were described as both a perceived benefit and deterrent,highlighting the need to further explore the overall influences of culture on the acceptability andimplementation of harm reduction programs for drug users.

IntroductionTijuana's rate of illegal drug use is the highest in Mexico,with 14.7% of the city's population reporting a lifetime

prevalence of ever having used an illegal drug (includingmarijuana), three times that of the national average(5.3%) [1]. Tijuana is situated on a major international

Published: 20 November 2008

Harm Reduction Journal 2008, 5:36 doi:10.1186/1477-7517-5-36

Received: 24 September 2008Accepted: 20 November 2008

This article is available from: http://www.harmreductionjournal.com/content/5/1/36

© 2008 Philbin et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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drug trafficking route, and Mexico is one of the mostimportant producers of heroin and methamphetamineentering the United States [2]. Due in part to its locationon major routes for drug trafficking and migration,Tijuana has one of Mexico's fastest growing injection drugusing (IDU) populations [3,4]. In 2003, there were anestimated 6,000 active IDUs and 200 shooting galleries inTijuana, although the actual number of IDUs is likelymuch larger [5]. While syringes can legally be purchasedin pharmacies in Tijuana, IDUs often report being refusedor charged exorbitant prices [5]. Reduced HIV transmis-sion among IDUs has been linked to access to needleexchange programs (NEPs) [6-8].

In this study, we asked respondents about the feasibilityand acceptability of three harm reduction interventionsincluding 1) NEPs, 2) syringe vending machines, and 3)safer injection facilities (SIFs). The structure and imple-mentation of these programs differ markedly, but eachintervention aims to decrease the circulation of contami-nated injection equipment and transmission of blood-borne infections [7,9]. Beyond the provision of sterilesyringes, both NEPs and SIFs provide the opportunity forintegrated care, educational services, syringe disposal, andreferrals for drug treatment, medical care and HIV testing[10,11]. These three interventions have been evaluatedextensively and found to be effective in preventing thetransmission of HIV and other blood borne pathogenswithout promoting or increasing levels of drug use, dis-carded syringes, or crime [12,6-8].

Although Mexico's federal Ministry of Health has pub-lished a document supporting NEPs, there appear to besmall-scale programs operating in only six states – BajaCalifornia, Coahuila, Nuevo Leon, Oaxaca, Sinaloa,Zacatecas – with the most active being led by non-govern-mental organizations (NGO) in Ciudad Juarez andTijuana [13]. At the time of writing, there were no knownsyringe vending machines or SIFs operating in Mexico.

Numerous articles discuss the empirical evidence forharm reduction interventions, but few describe barriersencountered prior to their approval [14,15]. For countrieslacking a social and cultural environment amenable toharm reduction, there is a dearth of literature describingmethods for facilitating the implementation of such inter-ventions. Furthermore, few studies describe ways in whichcommunity stakeholders describe and define the problemof drug abuse, and how these views potentially affect theirendorsement of harm reduction interventions. Previously,we described levels of acceptability and feasibility forimplementing NEPs, syringe vending machines, and SIFsand factors that may influence their implementation inTijuana, Mexico [16]. Herein, we specifically explored reli-gious and cultural factors affecting the acceptability and

feasibility of these harm reduction interventions inTijuana, in an effort to inform the future development ofculturally appropriate interventions in Mexico and poten-tially other countries.

MethodsBetween August 2006 and March 2007, trained Mexicanand American interviewers recruited 40 key stakeholderswho had direct or indirect interaction with IDUs inTijuana, Mexico. In order to create a more completeunderstanding of attitudes toward these interventions, weused sampling methods adapted from the Rapid PolicyAssessment and Response (RPAR) approach. The RPARmethod, as operationalized by Lazzarini and colleagues,[17] combines traditional legal analysis with empiricaldata collection to assess how structural factors can impactcommunity-level health interventions. This mixed meth-ods approach, which integrates qualitative data on imple-mentation of laws, policies and practices with locallyimportant policy questions was recently used in fourcountries (Poland Russia, Ukraine, and Kazakhstan) andfound to be useful in identifying policy issues and guidinginterventions [18-21].

We adapted RPAR sampling methods by constructing atargeted sampling grid and interviewed local stakeholdersat two levels (system and interactor) in order to obtaindiverse perspectives. These stakeholders included inter-viewees from five sectors; health, religion, legal, phar-macy, and rehabilitation. Systems level stakeholders werechosen because they possess oversight of critical compo-nents within a given system and included respondents ineach of the five sectors. Interactor level informants operatein sectors that affect IDUs' attitudes, behaviors, and accessto syringes, and typically have daily contact with IDUs.Interactors provide practical on-the-ground informationabout the implementation of drug policies and the limitsof risk reduction interventions and offer a unique perspec-tive because of their understanding derived from interact-ing both with IDUs and policy makers.

The targeted sample was constructed after a master list wascreated of all Tijuana stakeholders who were involvedwith drug use policy, health policy, or program imple-mentation at the systems or interactor level in each of thefive sectors. From this list, key informants were chosenbased on their level of experience, time spent in Tijuana,and willingness to be interviewed. Specific informants –politicians, judges, pharmacy owners and clerks, pastors,methadone clinic doctors, ministry of health officials, anddirectors of drug treatment programs – were interviewedbased on their understanding of, and ability to affectchange in, the drug injecting risk environment. Partici-pants were not reimbursed for their participation in inter-views.

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After being recruited for the study and providing volun-tary and informed written consent, each participant wasasked 10 quantitative questions to assess socio-demo-graphic information such as age, gender, and educationlevel. The interviews were semi-structured and providedopportunities for the interviewers to probe further intotopics about which the interviewee had particular exper-tise or opinions. The topic guide allowed flexibility tofocus on specific interventions (i.e. NEPs, syringe vendingmachines, SIFs), social-cultural barriers and facilitators ofimplementation, and suggestions for future programs.Prior to intervention-specific questions, definitions of keyinterview terms were given to each participant to promoterespondent understanding of interview terminology. Spe-cific questions included "Which harm reduction interven-tions do you see as feasible in Tijuana's current socio-political context?" "What are possible cultural and socialobstacles to implementation?" And, "How does Tijuana'slocation as a border city affect its drug culture?" Interviewswere conducted in private locations including homes,offices, or places of work. This study was approved byInstitutional Review Boards at University of California atSan Diego and Tijuana General Hospital.

Interviews were approximately one hour long, conductedin Spanish, and digitally recorded. The audio files of theinterviews and transcripts were anonymous, and identi-fied only by code numbers. Audio files were destroyedafter transcription and translation. Native Spanish speak-ers conducted verbatim transcription and translation ofthe in-depth interviews. Translations were validated bytwo bilingual individuals. A "do not translate" list includ-ing street jargon and slang words was created, along witha corresponding glossary, in order to preserve the conno-tations and meaning of the original Spanish-language ver-sion.

Content analysis was conducted concurrently with datacollection to allow revision of the interview guide toreflect new information. The analyses focused on generat-ing themes such as acceptance of harm reduction in theMexican context, cultural and political barriers to imple-mentation, and the socio-cultural feasibly of, and sugges-tions for, the implementation of harm reductioninterventions. Transcripts were first hand-coded by twoinvestigators who, after reading a cross-section of theinterviews, created a preliminary codebook containingkey concepts and categories. The investigators thenapplied these codes to ten interviews in order to modifyand create more nuanced versions of the codes. Usingqualitative data analysis software, ATLAS.ti [22], inter-views were uploaded and coded by two members of thestudy team using the preliminary codes. Any discrepanciesbetween coders were discussed among the investigatorsand resolved.

ResultsA total of 40 stakeholders were interviewed from the fol-lowing sectors: health (n = 13), rehabilitation (n = 8),legal (n = 11), pharmacy (n = 3), and religious (n = 5).Well over half of respondents were male (67%), with amedian age of 42 years (range 31–71 years). When askedabout their political orientation, 28% responded liberal,52% moderate, and 20% conservative. None describedthemselves as 'very liberal' or 'very conservative'.

Of the three interventions, NEPs were seen as the mostacceptable with 75% supporting, followed by vendingmachines (65%) and SIFs (58%). Levels of perceived fea-sibility were much lower than acceptance; half of partici-pants (53%) believing the implementation of NEPs to bepossible, followed by 38% for vending machines, and25% for SIFs. The analyzed themes, response and contextof harm reduction, religious barriers, political barriers,and suggestions for implementation are described below.

Interviewees consistently described Tijuana as a city witha unique mix of cultural, geographic, and social factorsthat contribute to high levels of drug use; factors includeda large transient population, high numbers of deportedindividuals, and a physical location along a drug traffick-ing route. One health sector interviewee said:

Tijuana is a city with a large floating population,where people often come with the intention of cross-ing into the United States. And when they cannot ordo not, many of them remain anchored here in thecity, without family, without a place to live, they startloitering in public; then they make contact with peo-ple who have these problems, and they often go so faras to acquire the illness or the problem (Male, 45,Health Sector).

Socio-political Context of Harm Reduction InterventionLevels of acceptance and support for harm reductioninterventions differed by interview sector; those in thehealth sector expressed the most support, the religioussector the least. The majority of individuals, however,accepted at least one form of the three harm reductioninterventions. Investigators observed a dichotomy withinrespondents themselves: individuals who personally sup-ported harm reduction interventions, yet did not see themas feasible within Mexico's current socio-political context.As a female in the health sector explains,

Because of the beliefs within our culture, it wouldn'tbe practical. Maybe in other countries, but not here.That said, I think it would be very practical because theperson, the drug user wouldn't have a problem andthey can go at whichever moment is convenient forthem ... it would be very good, but the reality is that I

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don't see it as likely to be implemented (Female, 42,Health Sector).

Along with this individual in the health sector, a legal sec-tor respondent didn't feel that Mexico was prepared toaccept harm reduction. Her rationale was that people inthe current socio-political context were not open to suchan idea, in comparison to more liberal countries, and thuswould be prejudiced, in allowing these interventions.

Look, if the community was prepared intellectuallyand culturally and if we didn't have so much prejudicethen the programs would work, but [unfortunately]we are not prepared. First of all, we need people towork on this law, and need to modify it because weneed to have a law that support such programs. Per-sonally, I like the idea ... but we are still not ready forthis (Female, 42, Legal Sector).

Another aspect of socio-political environment that wasdiscussed as a potential barrier was the political systemand its lack of openness to harm reduction. As one indi-vidual described,

I see it as something difficult to implement because ofthe same; the culture. And it is not just in Tijuana, Iguess I see it as a bit too difficult because of politicsand for the government to be open to such establish-ments, and the society, too. There would be a struggleto open such establishments, little by little with timeit could be implemented ... and would be accepted bythe society (Female, 35, Legal Sector).

Respondents representing religious sectors also men-tioned that the government was not interested in provid-ing support for harm reduction programs.

I think the government is not interested because itfeels that there is no solution for these people, they arenot interested that many people have a drug problem... if you watch the news you are not going to hearabout a program concerned with drug users or alco-holics. No, you don't hear this and I think it is becausethe government is not interested in these types of peo-ple (Female, 55, Religious Sector).

Many participants felt that the cultural context of Tijuanawas not amenable to the harm reduction interventionsproposed in the interview. One respondent alluded totheir perception that

The culture that we have is the barrier, and maybe theprincipal barrier, because the political decisions arederived from it, as well as personal actions. We havethese concepts in our culture that drug users continueto be delinquents, and these then become impair-

ments because it affects politics on various levels(Female, 42, Health Sector).

Throughout the discussion of the role of culture in theacceptance and feasibility of harm reduction, the mostsalient factors to emerge concerned the influence of reli-gion and politics on the rules and norms of Mexican cul-ture. These are further described below.

Religion as a Barrier to and Facilitator of Harm ReductionWe interviewed individuals from both the Catholic andEvangelical Churches, though the majority of peoplereferred simply to "The Church," and not a specificdenomination in their interview. When the topic of reli-gion was discussed by informants, there was a distinctdivide between those involved in the religious sector andthose outside of it. Those who did not represent a particu-lar religion (or were not identified as a representative of aparticular religion) named The Church as a barrier tothese harm reduction interventions; interviewees whorepresented specific religious denominations appeared tosee themselves as providing services superior to standardharm reduction interventions. As an individual in therehabilitation field described:

I think we all agree that there is delinquency, thatTijuana as a society has a problem with both the circu-lation and distribution of drugs ... but what about thechurch? Many times I feel that they are in oppositionto this type of program because they are not yet awareof the problems that are outside the church (Male, 35,Rehabilitation Sector).

In contrast, those involved with The Church saw them-selves as nurturers providing a much-needed service. Amember of the religious sector described his role as fol-lows,

Well, the church sees these people as precioushumans, we see the potential that they have that theydon't seem to know ... They come and they recover andthey reenter society as different people, as people thatare valued by society, their decisions are accepted bysociety and their actions are believable, they endorsewhat they speak because they have been prepared, andthey have been instructed in the word of God (Male,35, Religious Sector).

Some individuals who represented a religious perspectiveonly saw harm reduction as something dangerous orrisky, while others noted its potential as a way to stem dis-ease. An individual in the religious sector voiced that hewould not support harm reduction interventions, whilesimultaneously acknowledging a lack of understanding ofthe problem as a whole.

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It is like saying to a child here you have a gun and useit, and the risk is there that the child will shoot it or useit, it is very risky, dangerous, delicate, too much expo-sure. I will repeat that I feel that there is a lack of cul-ture, preparation, even a consciousness on this matter,and that is why we haven't talked much about theproblem, it is not known (Male, 46, Religious Sector).

In contrast, an individual in the religious sector voicedsupport for harm reduction, saying he had worked previ-ously with drug users and understood the potential prob-lems.

[I think harm reduction] is good, but people wouldsay we are condoning drug use, or approving it, but Iwant to ask whether the persons who are helping theaddicts not take drugs are any different? Sometimesone says that if I approve this intervention it meansthat I am approving taking drugs. It is not that (Male,59, Religious Sector).

Some respondents suggested a practical approach to reli-gious individuals who may impede the development ofthese or other health-related programs, by asking themsimply not to act to stop programs. As one individual inthe health sector suggested,

I think there are questions or health issues that do notconcern the church, therefore, the church should notput any obstacles when it comes to the health or thelives of a whole community. We can respect their ide-ology, but ask them when it comes to health issues forthem to respect the work that we are doing (Female,50, Health Sector).

Politics as a Barrier and Facilitator of Harm ReductionMany respondents criticized the Mexican government forwhat they saw as a lack of initiative and willingness to pro-vide programs for drug users. What they saw as the gov-ernment's reason for lack of interest varied, however. Oneindividual in the religious sector believed that,

The government is not interested because it feels thatthere is no solution for these people, they are notinterested that many people have a drug problem ...The government doesn't seem to worry. If you watchthe news you are not going to hear about a programthat has concerns about drug users or alcoholics, doyou understand? I think it is because the governmentis not interested in these types of people (Male, 46,Religious Sector).

In contrast, an individual in the pharmacy sector saw it astied to corruption and lack of financial will, something hecontrasted with the U.S. government.

I wish that the government [could do something], Ibelieve that the American government can do some-thing, in Mexico however many times there is corrup-tion and many programs are not done because theyjust want to make money on these types of things andthis is precisely what should not happen, but there aremany corrupt officials (Male, 71, Pharmacy Sector).

The majority of individuals mentioned the government asa possible barrier to the implementation of harm reduc-tion, or suggested that the political sector should beavoided. As one individual in the legal sector noted,

I think we need to fight for the social context only, andavoid the political context, because these are generaltopics that don't concern political parties, age, or sex.So then, it would please me if there was some politicalwill among the politicians to forget color and supportprograms for the sake of all society (Male, 32, LegalSector).

An individual in the health sector had a more optimisticapproach about the possibility of working within the gov-ernment to create harm reduction programs, thoughacknowledged it would not be easy. As she explained,

I think we need to work and show its necessity; inde-pendent of the ideology of the political parties or theadministration that is governing here. It is not partic-ularly easy right now because a very conservative partyruns the government. As a result, we need to work in avery objective way, proving the necessity for publichealth, so they can independently support our ideol-ogy (Female, 50, Health Sector).

Socio-Cultural Readiness and SuggestionsAlong with numerous criticisms of current policies andbarriers to implementing harm reduction, individuals dis-cussed Tijuana's socio-cultural readiness for harm reduc-tion and what could be done to facilitate itsimplementation. One individual in the rehabilitation sec-tor identified a need for legislative change:

First of all there should be a law that addresses howthese programs should be organized so it can be donefrom a legal framework. The addiction problems andthe delinquency problems in the community shouldall be connected in order to bring these types of healthproblems together ... We have to make a lot of modifi-cations in terms of what the law allows (Male, 44,Rehabilitation Sector).

A health official also suggested what he could do withinhis own job capacity to inform and increase awareness forthose in decision making roles. He highlighted that it was

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a joint responsibility to provide politicians with theknowledge to make informed decisions,

[We need to] establish more clear politics to avoidconfusion when it comes to decision makers, but if Idon't provide them with a well written document atthe time of their making decisions, then we are notgoing to be able to move forward ... I am convincedthat we cannot do this alone. As a society we have toget informed, to read about it, and to know that thesepeople are not isolated from the rest of us, that theyare integrated with our society; we need to accept themand help them in some way (Male, 47, Health Sector).

Along with politicians, individuals from the other sectorsstressed the importance of working within The Church,and integrating religious leaders into existing programs tohelp foster support.

As one individual in the rehabilitation sector described,

The most effective way would be the participation ofeveryone, to make them aware of the problem that wehave, make public policies that contribute to familyvalues, make a regulation or a law that controls theresources or the designation of resources to all therehabilitation centers ... We need to do a campaignand find political alliances. We need an ally even inthe Catholic Church to reduce the radicalism of thesegroups right? And society too, cause the governmentcan't really do something without society's support,and the more society is involved the less the govern-ment the better things get done, so with better socialorganization of course (Male, 44, Rehabilitation Sec-tor).

Though the Mexican government has begun to showsmall scale support, individuals stressed that a great dealstill needs to be accomplished, and suggested ways of sup-porting the development and implementation of pro-grams. One person responded with a series of specificsuggestions, saying:

We can show the results of the studies that we havemade so far, and show them that in Tijuana we are see-ing behaviors very similar to other countries where theepidemic has had very serious complications. We canconvince them by showing the cost effectiveness andbenefit of these programs, that it is cheaper to pro-mote or give information and give away syringes andcondoms, than spend millions of dollars in treat-ment...As for the implementation strategy, we need todo this gradually, with well planned changes so itwon't create resistance, because of the mentality of the

government, or the mentality of the conservative party(Female, 50, Health Sector).

DiscussionThis research focused on societal level factors as previousresearch with IDUs has suggested that the transmission ofblood borne infections is strongly shaped by socio-cul-tural norms, politics, and religion [23,9]. This qualitativestudy among key stakeholders who may be able to influ-ence policy examined the barriers to, and acceptance of,harm reduction interventions – needle exchange pro-grams, syringe vending machines, and safer injection facil-ities – in Tijuana, Mexico. Certain themes were repeatedlymentioned by different participants, suggesting that thedata had reached saturation. Though the majority ofrespondents supported harm reduction, some sectors,including religion, were almost unanimously opposed.These findings indicated the important role socio-culturalcontext plays in determining the acceptance of harmreduction, including religious and political opposition.Individuals also outlined key suggestions – raising aware-ness, creating new laws, working with community leaders– to increase feasibility and thus promote the implemen-tation of harm reduction interventions. One factor toemerge from this research was the differing questions ofwhat the "problem" in in relation to injection drug use,and who should define this problem.

Many interviewees described Mexican culture – specifi-cally discussed within the context of religion and politics– as a barrier. The research team observed that the term"culture" was applied in a variety of ways, including 'drugculture' and 'culture of acceptance of interventions'. Twodistinct patterns emerged in the way individual's used thewords "Mexican Culture." The first described harm reduc-tion as something that would be successful in other coun-tries that were "more developed," but not in Mexico itself.The second described culture as something that containedmultiple factors that were still taboo to discuss (e.g., sex,drugs) and stressed a general lack of awareness among thegeneral population. These issues alluded to the perceptionthat it is currently "culturally unacceptable" for harmreduction to be implemented as it was seen as at oddswith Mexican socio-cultural norms. This issue of harmreduction being contrary to a specific culture was alsofound in Russia. Tkatchenko-Schmidt et al [24] found thata key barrier to harm reduction scale-up was culturalunacceptability, and was related to two factors; the legacyof policies of the communist past and the involvement ofinternational agencies in harm reduction programs [24].

Although we did not specifically ask about religion, thistheme was repeatedly mentioned as both a barrier andfacilitator. Religion was consistently mentioned as a bar-rier, and religious sector interviewees continuously

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repeated that harm reduction was not only insufficient,but that it would promote further drug use. One of the keyfactors in determining receptivity to harm reduction ishow the problem of drug use is framed, which in turnaffects what people see as the most reasonable approachesto solving the problem. For example, the majority ofstakeholders saw the problem from a health standpoint,in that any intervention that would lower risk for diseasesor drug related harm should be implemented; religiousstakeholders saw drug use as something that must bestopped immediately. Many mentioned abstinence as theonly acceptable option, a finding consistent with previousresearch that religious organizations associate harmreduction with what they deem risky and immoral behav-ior [25]. Our research is supported by other findingsdescribing the integral role of religion in communities,and how critical the support of the church and clergy is tothe success of government-sanctioned harm reductionprograms [15,26,16,24,27]. More specifically, whileresearching the feasibility of NEPs, Vlahov et al (2001)found that leaders among African American Churcheswere particularly opposed [27]. The Catholic Church andMexican culture are intricately intertwined – 88% of thepopulation considers themselves Catholics – and individ-uals working in the health care field can find themselvesdivided between personal support for harm reduction andtheir religion's denunciation of such strategies [28].

A similar divide also occurred during the abortion debatein the early 1990s as Catholic bishops in the state of Chi-apas threatened excommunication of lawmakers whomay have approved a bill legalizing abortion [29]. In thiscase, many individuals felt the Catholic Church over-stepped its influence, and the majority of Catholicsreported feeling that a politician's personal religiousbeliefs should not affect their legislative decisions onhealth issues and that efforts should be focused ondecreasing the Church's political influence [30]. Regard-less of this assertion, it is difficult to avoid the Church'sinfluence as it plays such a large role in Mexican culture[30].

Previous studies in other settings have examined how anindividual's relationship to religious institutions, and per-ceived spiritual support, can reduce risk behaviors and isalso an independent predictor of abstinence from illicitsubstances [31,32]. Research in Brazil found that variousChristian religions interacted with drug use and rehabili-tation in different ways; religions with an evangelical ori-entation were more likely to use religion as an exclusiveform of treatment, even eschewing medical interventionand pharmaceuticals, while Catholics were less likely toreject a doctor's intervention [33]. Interviewees alsoreported that, along with religious faith, other factors thathelped drug users remain drug free were the support and

positive pressure provided by the program staff [33].Though research has focused on the role religion can playin an individual's life, little research has been conductedexamining the role a church or religious leader plays indetermining acceptance of harm reduction [34,35].

Many interviewees noted that a lack of political will andgovernment support served as a barrier to implementingharm reduction. As our research was conducted during anelection year, it was not surprising that politicians werehesitant to openly support harm reduction. The impor-tance of political support in creating a system amenable toharm reduction interventions has been noted in otherlocales, including Russia, Malaysia, Vietnam, and China[36-38,24]. Bluthenthal et al [39] found a 46% increase inthe total number of California's NEPs after the passage ofan assembly bill eliminating criminal prosecution for thedistributions of syringes. Likewise, after China decided toembrace harm reduction – in the form of methadonemaintenance – the numbers of clinics and attendeesincreased drastically [40].

Tijuana is located at the Mexico-US border, a fluid andliminal boundary through which people, media broad-casts, new coverage, and policies flow towards the northand south. Unsurprisingly, the policy environment ofTijuana may be as affected by harm reduction policyapproaches from the United States – specifically SanDiego – as it is by the policy approaches of the MexicanGovernment. The central harm reduction approach in theUnited States is methadone-based drug treatment andstate-operated or privately run NEPs. An illegal needleexchange program was implemented and operated in SanDiego for many years prior to the implementation of alegal NEP in 2000 [41], at which time NEPs were legalizedin 2000 in California if a local health emergency wasdeclared. San Diego declared a health emergency in 2000,and in 2002, San Diego implemented a legal pilot NEP[42] that is operating today. Significant media broadcastsof the implementation of NEP in San Diego occurred inboth the English-language and Spanish-language newsmedia. Thus, the perception of stakeholders in Tijuana,who were surely aware of the barriers that NEP implemen-tation had faced in San Diego, may have been influencedby the policy of the United States. This possibility isreflected in our results, with 75% of the respondents find-ing NEP to be the most acceptable, and over half findingNEP to be the most feasible. The harm reduction interven-tions that are not implemented in the United States (SIFsand vending machines) were seen as less acceptable andless feasible.

Additional studies have stressed the importance of notsimply creating policy, but also closely observing itsimplementation to assure it is having the intended affect.

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For example, while Australia has extensive policy commit-ments to harm reduction, studies have shown that insome locations policing practices exert a powerful influ-ence on IDU risk behavior, resulting in a reported fear ofcarrying needles or attending NEPs [43,44]. Though manyof the respondents listed culture as a barrier to harmreduction, previous studies have critiqued this act of list-ing culture as a barrier and instead stressed the impor-tance of integrating systems of local knowledge intointerventions [45]. For example, studies targeting malariahave found it important to first generate a list of localterms associated with malarial symptoms, as often timesthe translation and western description of "malaria" doesnot match indigenous cultural understandings [46].Other studies have stressed the importance of understand-ing culture as a fluid and malleable entity that both affectspeople and is affected and changed by them [47,48]. Fur-ther exploring local systems of meanings, symbols, andindigenous health knowledge will allow interventions tobe more applicable and integrated into cultural under-standings [49,50,48]. For example, persuading a church tohost a NEP or distribute condoms among its parish maybe a powerful symbolic approach that mediates the per-ception that "religion" is a barrier, In this way, culture canboth be acknowledged and integrated into existing pro-gram to serve as a benefit as opposed to a barrier.

This study has important limitations. Interviews were con-ducted with diverse participants across various sectors;participants represented both policy and decision makersand those who interacted daily with IDUs. While we builta diverse sample, we could only speak with those whoconsented to be interviewed – and some sectors weremissing. For example, we were not able to interview high-level officers in the police department as they refused ourinterview requests. These results are not generalizable tostakeholders in other cities in Mexico, as our study by def-inition explored local perceptions; perceptions likelyinfluenced by the geographic position of Tijuana as a bor-der city and by its location as an important way-station ona drug trafficking route. We did not use a theoretical sam-pling framework, but we reached a saturation of the keythemes, providing confidence in our results.

One factor that was both a limitation and an importantfinding of this study was that some of the intervieweeshad not previously heard of the three harm reductioninterventions, making it potentially difficult to form acomplete opinion after hearing a brief description. Ourresults suggest that harm reduction interventions areneeded in Tijuana and that some stakeholders believe itcrucial to increase awareness and understanding prior toimplementation. In order to raise awareness, there mustbe a facilitation of intersectoral collaboration and discus-sion between stakeholders, and careful acknowledgement

of the socio-cultural factors specific to Tijuana in order toincrease the possibilities of implementation. As these sug-gested changes are implemented, the NEP in Tijuana willcontinue providing sterile injection equipment in order toslow the spread of blood-borne diseases among injectiondrug users, and serve as a successful example for futureinterventions throughout Mexico.

Competing interestsThe authors declare that they have no competing interests.

Authors' contributionsMMP contributed to the data collection, analysis anddrafting of the manuscript. RL and AM aided in the collec-tion and analysis of interview data. CAL participated inthe design of the study and all authors read and approvedthe final manuscript. SAS conceived of the study, partici-pated in its design and coordination, and helped with thedrafting and editing of the manuscript. PC contributed tothe conception, theory, and design of the study, and aidedsubstantially in the development of the manuscript. MLZhelped with the coding of the data and the developmentof the manuscript. CMR contributed to the developmentand design of the study, provided advice on key stake-holders who should be contacted and offered technicalsupport.

AcknowledgementsProyecto El Cuete was funded by the National Institute on Drug Abuse (NIDA) (R01 DA019829). Ms. Philbin was partially supported by grant number 5R25TW007506 from the Fogarty International Center at the National Institutes of Health. This work was also supported in part by the National Institutes of Mental Health, grant # 1K01MH072353. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the National Institutes of Health. The authors gratefully acknowledge the contributions of study participants and PRO-COMUSIDA and Prevencasa staff for assistance with data collection; Centro Nacional para la Prevención y el Control del VIH/SIDA (CENSIDA); and Instituto de Servicios de Salud de Estado de Baja California (ISESALUD).

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