People who inject drugs in North America often continue to inject while hospitalized, and are at increased risk of premature hospital discharge, unplanned readmission, and death. In-hospital access ...to sterile injection supplies may reduce some harms associated with ongoing injection drug use. However, access to needle and syringe programs in acute care settings is limited. We explored the implementation of a needle and syringe program integrated into a large urban tertiary hospital in Western Canada. The needle and syringe program was administered by an addiction medicine consult team that offers patients access to specialized clinical care and connection to community services.
We utilized a focused ethnographic design and semi-structured interviews to elicit experiences and potential improvements from 25 hospitalized people who inject drugs who were offered supplies from the needle and syringe program.
Participants were motivated to accept supplies to prevent injection-related harms and access to supplies was facilitated by trust in consult team staff. However, fears of negative repercussions from non-consult team staff, including premature discharge or undesired changes to medication regimes, caused some participants to hesitate or refuse to accept supplies. Participants described modifications to hospital policies regarding inpatient drug use or access to an inpatient supervised consumption service as potential ways to mitigate patients' fears.
Acute care needle and syringe programs may aid hospital providers in reducing harms and improving hospital outcomes for people who inject drugs. However, modifications to hospital policies and settings may be necessary.
As a group, people who use illicit drugs and are affected by social disadvantages often experience health inequities and encounter barriers such as stigma and discrimination when accessing health ...care services. Cultural safety has been proposed as one approach to address health inequities and mitigate stigma in health care. Drawing on a qualitative ethnographic approach within an overarching collaborative framework, we sought to gain an understanding of what constitutes culturally safe care for people who use(d) illicit drugs. The findings illustrate that illicit substance use in hospitals is often negatively constructed as (1) an individual failing, (2) a criminal activity, and (3) a disease of "addiction" with negative impacts on access to care, management of pain, and provision of harm-reduction supplies and services. These constructions of illicit substance use impact patients' feelings of safety in hospital and nurses' capacity to provide culturally safe care. On the basis of these findings, we provide recommendations and guidance for the development of culturally safe nursing practice.
Context: Significant attention has been directed toward addressing health inequities at the population health and systems levels, yet little progress has been made in identifying approaches to reduce ...health inequities through clinical care, particularly in a primary health care context. Although the provision of equity-oriented health care (EOHC) is widely assumed to lead to improvements in patients' health outcomes, little empirical evidence supports this claim. To remedy this, we tested whether more EOHC predicts more positive patient health outcomes and identified selected mediators of this relationship. Methods: Our analysis uses longitudinal data from 395 patients recruited from 4 primary health care clinics serving people living in marginalizing conditions. The participants completed 4 structured interviews composed of self-report measures and survey questions over a 2-year period. Using path analysis techniques, we tested a hypothesized model of the process through which patients' perceptions of EOHC led to improvements in self-reported health outcomes (quality of life, chronic pain disability, and posttraumatic stress PTSD and depressive symptoms), including particular covariates of health outcomes (age, gender, financial strain, experiences of discrimination). Findings: Over a 24-month period, higher levels of EOHC predicted greater patient comfort and confidence in the health care patients received, leading to increased confidence to prevent and manage their health problems, which, in turn, improved health outcomes (depressive symptoms, PTSD symptoms, chronic pain, and quality of life). In addition, financial strain and experiences of discrimination had significant negative effects on all health outcomes. Conclusions: This study is among the first to demonstrate empirically that providing more EOHC predicts better patient health outcomes over time. At a policy level, this research supports investments in equity-focused organizational and provider-level processes in primary health care as a means of improving patients' health, particularly for those living in marginalizing conditions. Whether these results are robust in different patient groups and across a broader range of health care contexts requires further study.
There is a higher prevalence of alcohol use and severe alcohol dependence among homeless populations. The combination of alcohol use and lack of housing contributes to increased vulnerability to the ...harms of substance use including stigma, injury, illness, and death. Managed alcohol programs (MAPs) administer prescribed doses of alcohol at regular intervals to people with severe and chronic alcohol dependence and homelessness. As a pilot for a larger national study of MAPs, we conducted an in-depth evaluation of one program in Ontario, Canada. In this paper, we report on housing and quality of life outcomes and experiences of the MAP participants and staff.
We conducted a pilot study using mixed methods. The sample consisted of 38 people enrolled in or eligible for entry into a MAP who completed a structured quantitative survey that included measures related to their housing and quality of life. All of the participants self-identified as Indigenous. In addition, we conducted 11 in-depth qualitative interviews with seven MAP residents and four program staff and analyzed the interviews using constant comparative analysis. The qualitative analysis was informed by Rhodes' risk environment framework.
When compared to controls, MAP participants were more likely to retain their housing and experienced increased safety and improved quality of life compared to life on the streets, in jails, shelters, or hospitals. They described the MAP as a safe place characterized by caring, respect, trust and a nonjudgmental approach with a sense of family and home as well as opportunities to reconnect with family members.
The MAP was, as described by participants, a safer environment and a home with feelings of family and a sense of community that countered stigma, loss, and dislocation with potential for healing and recovery. The MAP environment characterized by caring, respect, trust, a sense of home, "feeling like family", and the opportunities for family and cultural reconnections is consistent with First Nations principles for healing and recovery and principles of harm reduction.
The health care sector has a significant role to play in fostering equity in the context of widening global social and health inequities. The purpose of this paper is to illustrate the process and ...impacts of implementing an organizational-level health equity intervention aimed at enhancing capacity to provide equity-oriented health care.
The theoretically-informed and evidence-based intervention known as 'EQUIP' included educational components for staff, and the integration of three key dimensions of equity-oriented care: cultural safety, trauma- and violence-informed care, and tailoring to context. The intervention was implemented at four Canadian primary health care clinics committed to serving marginalized populations including people living in poverty, those facing homelessness, and people living with high levels of trauma, including Indigenous peoples, recent immigrants and refugees. A mixed methods design was used to examine the impacts of the intervention on the clinics' organizational processes and priorities, and on staff.
Engagement with the EQUIP intervention prompted increased awareness and confidence related to equity-oriented health care among staff. Importantly, the EQUIP intervention surfaced tensions that mirrored those in the wider community, including those related to racism, the impacts of violence and trauma, and substance use issues. Surfacing these tensions was disruptive but led to focused organizational strategies, for example: working to address structural and interpersonal racism; improving waiting room environments; and changing organizational policies and practices to support harm reduction. The impact of the intervention was enhanced by involving staff from all job categories, developing narratives about the socio-historical context of the communities and populations served, and feeding data back to the clinics about key health issues in the patient population (e.g., levels of depression, trauma symptoms, and chronic pain). However, in line with critiques of complex interventions, EQUIP may not have been maximally disruptive. Organizational characteristics (e.g., funding and leadership) and characteristics of intervention delivery (e.g., timeframe and who delivered the intervention components) shaped the process and impact.
This analysis suggests that organizations should anticipate and plan for various types of disruptions, while maximizing opportunities for ownership of the intervention by those within the organization. Our findings further suggest that equity-oriented interventions be paced for intense delivery over a relatively short time frame, be evaluated, particularly with data that can be made available on an ongoing basis, and explicitly include a harm reduction lens.
Introduction and Aims
People with severe alcohol dependence and unstable housing are vulnerable to multiple harms related to drinking and homelessness. Managed Alcohol Programs (MAP) aim to reduce ...harms of severe alcohol use without expecting cessation of use. There is promising evidence that MAPs reduce acute and social harms associated with alcohol dependence. The aim of this paper is to describe MAPs in Canada including key dimensions and implementation issues.
Design and Methods
Thirteen Canadian MAPs were identified through the Canadian Managed Alcohol Program Study. Nine key informant interviews were conducted and analysed alongside program documents and reports to create individual case reports. Inductive content analysis and cross case comparisons were employed to identify six key dimensions of MAPs.
Results
Community based MAPs have a common goal of preserving dignity and reducing harms of drinking while increasing access to housing, health and social services. MAPs are offered as both residential and day programs with differences in six key dimensions including program goals and eligibility, food and accomodation, alcohol dispensing and administration, funding and money management, primary care services and clinical monitoring, and social and cultural connections.
Discussion and Conclusions
MAPs consist of four pillars with the alcohol intervention provided alongside housing interventions, primary care services, social and cultural interventions. Availability of permanent housing and re‐establishing social and cultural connections are central to recovery and healing goals of MAPs. Additional research regarding Indigenous and gendered approaches to program development as well as outcomes related to chronic harms and differences in alcohol management are needed.
Introduction and Aims
We investigated coping strategies used by alcohol‐dependent and unstably housed people when they could not afford alcohol, and how managed alcohol program (MAP) participation ...influenced these. The aim of this study was to investigate potential negative unintended consequences of alcohol being unaffordable.
Design and Methods
A total of 175 MAP residents in five Canadian cities and 189 control participants from nearby shelters were interviewed about the frequency they used 10 coping strategies when unable to afford alcohol. Length of stay in a MAP was examined as a predictor of negative coping while controlling for age, sex, ethnicity, housing stability, spending money and drinks per day. Multivariate binary logistic and linear regression models were used.
Results
Most commonly reported strategies were re‐budgeting (53%), waiting for money (49%) or going without alcohol (48%). A significant proportion used illicit drugs (41%) and/or drank non‐beverage alcohol (41%). Stealing alcohol or property was less common. Long‐term MAP participants (>2 months) exhibited lower negative coping scores than controls (8.76 vs. 10.63, P < 0.001) and were less likely to use illicit drugs odds ratio (OR) 0.50, P = 0.02, steal from liquor stores (OR 0.50, P = 0.04), re‐budget (OR 0.36, P < 0.001) or steal property (OR 0.40, P = 0.07). Long‐term MAP participants were also more likely to seek treatment (OR 1.91, P = 0.03) and less likely to go without alcohol (OR 0.47, P = 0.01).
Discussion and Conclusions
People experiencing alcohol dependence and housing instability more often reduced their alcohol consumption than used harmful coping when alcohol was unaffordable. MAP participation was associated with fewer potentially harmful coping strategies.
People experiencing homelessness and alcohol dependence are at increased risk of a range of harms, including from COVID-19. Managed Alcohol Programmes (MAPs) are an alcohol harm reduction ...intervention specifically for this group. In this paper we report on qualitative findings of a mixed methods study investigating the potential utility of MAPs during the COVID-19 pandemic in Scotland. Interviews, conducted with 40 participants, explored potential views of implementing MAPs during the pandemic. Theoretically, we drew on the Consolidated Framework for Implementation Research (CFIR) to inform data collection and analysis. Six themes were identified which mapped onto three CFIR domains: perceptions of MAPs and the evidence base; necessary components of MAPs; changing culture of alcohol harm reduction; MAPs as a moral and ethical grey area; addressing a service gap; and securing buy-in and partnership working. Participants were generally positive about MAPs and viewed them as a key intervention to address a service gap. Several necessary components were identified for successful implementation of MAPs. Securing buy-in from a range of stakeholders and partnership working were deemed important. Finally, MAPs require careful, long-term planning before implementation. We conclude that MAPs are needed in Scotland and require long-term funding and appropriate resources to ensure they are successful.
Introduction and Aims
Managed alcohol programs (MAP) are intended for people with severe alcohol‐related problems and unstable housing. We investigated whether MAP participation was associated with ...changes in drinking patterns and related harms.
Design and Methods
One hundred and seventy‐five MAP participants from five Canadian cities (Hamilton, Ottawa, Toronto, Thunder Bay and Vancouver) and 189 same‐city controls were assessed for alcohol consumption, health, safety and harm outcomes. Length of stay in a MAP was investigated as a predictor of drinking patterns, non‐beverage alcohol consumption and related harms. Statistical controls were included for housing stability, age, gender, ethnic background and city of residence. Negative binomial regression and logistic regression models were used.
Results
Recently admitted MAP participants (≤2 months) and controls were both high consumers of alcohol, predominantly male, of similar ethnic background, similarly represented across the five cities and equally alcohol dependent (mean Severity of Alcohol Dependence Questionnaire = 29.7 and 31.4). After controlling for ethnicity, age, sex, city and housing stability, long‐term MAP residents (>2 months) drank significantly more days (+5.5) but 7.1 standard drinks fewer per drinking day than did controls over the last 30 days. Long‐term MAP residents reported significantly fewer alcohol‐related harms in the domains of health, safety, social, legal and withdrawal.
Discussion and Conclusions
Participation in a MAP was associated with more frequent drinking at lower quantities per day. Participation was associated with reduced alcohol‐related harms over the past 30 days. Future analyses will examine outcomes longitudinally through follow‐up interviews, police and health care records.
Peer workers (those with lived/living experience of substance use) are at the forefront of overdose response initiatives in British Columbia, Canada. The onset of the coronavirus disease pandemic has ...significantly compounded the impact of the overdose crisis. Peer workers are integral in supporting people who use substances. However, despite the important work they do, peer workers often lack formalized credibility and do not have the same resources available to them as service providers without lived experience. The peer-led project titled the Peer2Peer Project implemented several support programs for peer workers, including providing pulse oximeters to peer workers to supplement their overdose response procedures. This study was a component of a larger evaluation of the pulse oximeter program at two organizations in BC. The study aims to highlight the competencies of peer workers who use pulse oximeters. Telephone interviews were conducted with seven peer workers who were given pulse oximeters. The transcripts were thematically coded using Covert et al.'s framework of core competencies of community health workers to compare our sample with other widely recognized professions. We found that peer workers who used pulse oximeters described several core competencies in their work and these were aligned with Covert et al.'s core competencies for community health workers, including assessment, community health practice, communication, diversity and inclusion, professional practice, and disease prevention and management. By aligning peer workers' skills to those of community health workers, we create awareness on the competencies of peer workers in using oximeters to supplement overdose response and advocate for them to receive more recognition and respect within the workplace. Further, our findings act as groundwork for future research in identifying the professional proficiencies of peer workers.
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