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Hodgson K, Bowles JM, Mansoor M, Rooke E, Bardwell G. 'I'm on the coast and I'm on methadone': A qualitative study examining access to opioid agonist treatment in rural and coastal British Columbia. CANADIAN JOURNAL OF RURAL MEDICINE 2024; 29:117-124. [PMID: 39155634 DOI: 10.4103/cjrm.cjrm_56_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 03/12/2024] [Indexed: 08/20/2024]
Abstract
INTRODUCTION Despite rural regions being disproportionately impacted by the toxic drug supply, little is known about the contextual factors influencing access to opioid agonist treatment (OAT) specific to rural residents. The present study examines these factors in a rural and coastal setting in British Columbia, Canada. METHODS The qualitative methods were used to examine the barriers and facilitators to OAT access. Between July and October 2021, semi-structured interviews were conducted with people who use drugs who reside in a rural and coastal community. Thematic analysis was used to identify emergent themes and subthemes. Results were corroborated by the research team and a local community advisory board. RESULTS Twenty-seven (n = 27) participants described both limiting and facilitating factors that influenced OAT accessibility. Access was less challenging when participants' OAT dispensing pharmacy was in close proximity, had extended hours of operation, or when pharmacies provided delivery services. Barriers to OAT access identified by participants included the high cost of transportation, residing or working in remote communities and few local OAT prescribers. A variety of treatment motivations and goals that impacted OAT satisfaction are also highlighted. CONCLUSION This study demonstrates that patient satisfaction with OAT service access in a rural and coastal setting is multi-factorial and geographic proximity alone does not fully explain OAT accessibility issues in these settings. Accessibility to OAT may be improved through delivery services, expanded OAT prescribing authorisation beyond physician-only regulations, health authorities covering transportation costs and continual assurance that prescribing practices meet individuals' goals. INTRODUCTION Bien que les régions rurales soient touchées de manière disproportionnée par l'approvisionnement en drogues toxiques, on sait peu de choses sur les facteurs contextuels qui influencent l'accès au traitement par agoniste opioïde (TAO) spécifique aux résidents ruraux. La présente étude examine ces facteurs dans un contexte rural et côtier en Colombie-Britannique, au Canada. MTHODES Des méthodes qualitatives ont été utilisées pour examiner les obstacles et les facilitateurs de l'accès aux TAO. Entre juillet et octobre 2021, des entretiens semi-structurés ont été menés avec des personnes qui consomment des drogues résidant dans une communauté rurale et côtière. L'analyse thématique a été utilisée pour identifier les thèmes et sous-thèmes émergents. Les résultats ont été corroborés par l'équipe de recherche et un comité consultatif communautaire local. RSULTATS Vingt-sept (n = 27) participants ont décrit les facteurs limitants et facilitants qui ont influé sur l'accessibilité au TAO. L'accès était moins difficile lorsque la pharmacie du TAO des participants était proche, avait des heures d'ouverture prolongées ou lorsque les pharmacies offraient des services de livraison. Parmi les obstacles à l'accès au TAO mentionnés par les participants, il y avait le coût élevé du transport, le fait de résider ou de travailler dans des collectivités éloignées et la rareté des prescripteurs locaux du TAO. Les participants ont également fait état de divers objectifs et motivations liés au traitement qui ont eu une incidence sur la satisfaction à l'égard du TAO. CONCLUSION Cette étude démontre que la satisfaction des patients à l'égard de l'accès aux services du TAO en milieu rural et côtier est multifactorielle et que la proximité géographique n'explique pas à elle seule les problèmes d'accessibilité au TAO dans ces milieux. Cette accessibilité peut être améliorée par des services de livraison, l'élargissement de l'autorisation de prescrire un TAO au-delà des règlements réservés aux médecins, la prise en charge des coûts de transport par les autorités sanitaires et l'assurance continue que les pratiques de prescription répondent aux objectifs des individus.
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Affiliation(s)
- Kate Hodgson
- British Columbia Centre on Substance Use, Vancouver, BC, Canada
| | - Jeanette M Bowles
- British Columbia Centre on Substance Use, Vancouver, BC, Canada
- Department of Medicine, St. Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Manal Mansoor
- British Columbia Centre on Substance Use, Vancouver, BC, Canada
| | - Edward Rooke
- The Hope to Health Research and Innovation Centre, British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
- First Nations Health Authority, West Vancouver, BC, Canada
| | - Geoff Bardwell
- British Columbia Centre on Substance Use, Vancouver, BC, Canada
- Department of Medicine, St. Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
- School of Public Health Sciences, Faculty of Health, University of Waterloo, Waterloo ON, Canada
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Brousselle A, Petit G, Giraud MJ, Rietmann M, Boisvert K, Foley V. Using the evaluation process as a lever for improving health and healthcare accessibility: The case of HCV services organization in Quebec. EVALUATION AND PROGRAM PLANNING 2016; 55:134-143. [PMID: 26851873 DOI: 10.1016/j.evalprogplan.2016.01.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Revised: 12/07/2015] [Accepted: 01/10/2016] [Indexed: 06/05/2023]
Abstract
BACKGROUND The evaluation process can be a lever to improve pathways of access to healthcare. The objective of this article is to show how an evaluation strategy can both contribute to knowledge development and have direct impacts on health services provision. We use the case of hepatitis C (HCV) services organization to illustrate the use and the value of this evaluative approach. METHOD Inspired by empowerment evaluation, the transformative-participatory approach involved overlapping phases of knowledge development and discussion with stakeholders. We conducted several knowledge development activities to discern the needs of people with HCV, the resources available, and the facilitators and impediments along the care pathway, starting from prevention and screening, all the way through to treatment. Using an overlapping approach allowed us to regularly transfer acquired knowledge back to the participants in the study settings and also to gather their impressions, interpretations, and suggestions during periods of deliberation. RESULTS The knowledge development activities made it possible to document the needs, resources, and experiences of people affected by HCV. In the discussion sessions, viable solutions were identified to improve health and healthcare access for people with HCV and to prioritize certain actions. This project demonstrated that using the evaluation process can enable an instrumental, conceptual use of results and, in fact, can have a transformative impact on services organization.
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Affiliation(s)
- Astrid Brousselle
- Canada Research Chair in Evaluation and Health System Improvement, Department of Community Health Sciences, Charles-LeMoyne Hospital Research Centre, Université de Sherbrooke, Sherbrooke, Quebec, Canada.
| | - Geneviève Petit
- Estrie Regional Public Health Departement, Department of Community Health Sciences, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Marie-Josée Giraud
- Centre intégré de santé et de services sociaux de l'Estrie-Centre hospitalier universitaire de Sherbrooke
-Installation Centre de réadaptation en Dépendance, Canada
| | - Michèle Rietmann
- Charles-LeMoyne Hospital Research Centre, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Krystel Boisvert
- Psychoeducation, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Véronique Foley
- Clinical Sciences, Université de Sherbrooke, Sherbrooke, Quebec, Canada
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Aidala AA, Wilson MG, Shubert V, Gogolishvili D, Globerman J, Rueda S, Bozack AK, Caban M, Rourke SB. Housing Status, Medical Care, and Health Outcomes Among People Living With HIV/AIDS: A Systematic Review. Am J Public Health 2015; 106:e1-e23. [PMID: 26562123 DOI: 10.2105/ajph.2015.302905] [Citation(s) in RCA: 247] [Impact Index Per Article: 27.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Accumulating evidence suggests responses to HIV that combine individual-level interventions with those that address structural or contextual factors that influence risks and health outcomes of infection. Housing is such a factor. Housing occupies a strategic position as an intermediate structural factor, linking "upstream" economic, social, and cultural determinants to the more immediate physical and social environments in which everyday life is lived. The importance of housing status for HIV prevention and care has been recognized, but much of this attention has focused on homeless individuals as a special risk group. Analyses have less often addressed community housing availability and conditions as factors influencing population health or unstable, inadequate, or unaffordable housing as a situation or temporary state. A focus on individual-level characteristics associated with literal homelessness glosses over social, economic, and policy drivers operating largely outside any specific individual's control that affect housing and residential environments and the health resources or risk exposures such contexts provide. OBJECTIVES We examined the available empirical evidence on the association between housing status (broadly defined), medical care, and health outcomes among people with HIV and analyzed results to inform future research, program development, and policy implementation. SEARCH METHODS We searched 8 electronic health and social science databases from January 1, 1996, through March 31, 2014, using search terms related to housing, dwelling, and living arrangements and HIV and AIDS. We contacted experts for additional literature. SELECTION CRITERIA We selected articles if they were quantitative analyses published in English, French, or Spanish that included at least 1 measure of housing status as an independent variable and at least 1 health status, health care, treatment adherence, or risk behavior outcome among people with HIV in high-income countries. We defined housing status to include consideration of material or social dimensions of housing adequacy, stability, and security of tenure. DATA COLLECTION AND ANALYSIS Two independent reviewers performed data extraction and quality appraisal. We used the Cochrane Risk of Bias Tool for randomized controlled trials and a modified version of the Newcastle Ottawa Quality Appraisal Tool for nonintervention studies. In our quality appraisal, we focused on issues of quality for observational studies: appropriate methods for determining exposure and measuring outcomes and methods to control confounding. RESULTS Searches yielded 5528 references from which we included 152 studies, representing 139,757 HIV-positive participants. Most studies were conducted in the United States and Canada. Studies examined access and utilization of HIV medical care, adherence to antiretroviral medications, HIV clinical outcomes, other health outcomes, emergency department and inpatient utilization, and sex and drug risk behaviors. With rare exceptions, across studies in all domains, worse housing status was independently associated with worse outcomes, controlling for a range of individual patient and care system characteristics. CONCLUSIONS Lack of stable, secure, adequate housing is a significant barrier to consistent and appropriate HIV medical care, access and adherence to antiretroviral medications, sustained viral suppression, and risk of forward transmission. Studies that examined the history of homelessness or problematic housing years before outcome assessment were least likely to find negative outcomes, homelessness being a potentially modifiable contextual factor. Randomized controlled trials and observational studies indicate an independent effect of housing assistance on improved outcomes for formerly homeless or inadequately housed people with HIV. Housing challenges result from complex interactions between individual vulnerabilities and broader economic, political, and legal structural determinants of health. The broad structural processes sustaining social exclusion and inequality seem beyond the immediate reach of HIV interventions, but changing housing and residential environments is both possible and promising.
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Affiliation(s)
- Angela A Aidala
- Angela A. Aidala is with the Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, NY. Michael G. Wilson is with the Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada. Virginia Shubert is with Shubert Botein Policy Associates, New York, NY. At the time of this study, David Gogolishvili, Jason Globerman, Sergio Rueda, and Sean B. Rourke were with the Ontario HIV Treatment Network, Toronto, ON, Canada. Anne K. Bozack is with the Department of Environmental Health Sciences, Mailman School of Public Health. Maria Caban is with the Department of Research and Evaluation, BOOM!Health, New York, NY
| | - Michael G Wilson
- Angela A. Aidala is with the Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, NY. Michael G. Wilson is with the Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada. Virginia Shubert is with Shubert Botein Policy Associates, New York, NY. At the time of this study, David Gogolishvili, Jason Globerman, Sergio Rueda, and Sean B. Rourke were with the Ontario HIV Treatment Network, Toronto, ON, Canada. Anne K. Bozack is with the Department of Environmental Health Sciences, Mailman School of Public Health. Maria Caban is with the Department of Research and Evaluation, BOOM!Health, New York, NY
| | - Virginia Shubert
- Angela A. Aidala is with the Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, NY. Michael G. Wilson is with the Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada. Virginia Shubert is with Shubert Botein Policy Associates, New York, NY. At the time of this study, David Gogolishvili, Jason Globerman, Sergio Rueda, and Sean B. Rourke were with the Ontario HIV Treatment Network, Toronto, ON, Canada. Anne K. Bozack is with the Department of Environmental Health Sciences, Mailman School of Public Health. Maria Caban is with the Department of Research and Evaluation, BOOM!Health, New York, NY
| | - David Gogolishvili
- Angela A. Aidala is with the Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, NY. Michael G. Wilson is with the Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada. Virginia Shubert is with Shubert Botein Policy Associates, New York, NY. At the time of this study, David Gogolishvili, Jason Globerman, Sergio Rueda, and Sean B. Rourke were with the Ontario HIV Treatment Network, Toronto, ON, Canada. Anne K. Bozack is with the Department of Environmental Health Sciences, Mailman School of Public Health. Maria Caban is with the Department of Research and Evaluation, BOOM!Health, New York, NY
| | - Jason Globerman
- Angela A. Aidala is with the Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, NY. Michael G. Wilson is with the Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada. Virginia Shubert is with Shubert Botein Policy Associates, New York, NY. At the time of this study, David Gogolishvili, Jason Globerman, Sergio Rueda, and Sean B. Rourke were with the Ontario HIV Treatment Network, Toronto, ON, Canada. Anne K. Bozack is with the Department of Environmental Health Sciences, Mailman School of Public Health. Maria Caban is with the Department of Research and Evaluation, BOOM!Health, New York, NY
| | - Sergio Rueda
- Angela A. Aidala is with the Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, NY. Michael G. Wilson is with the Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada. Virginia Shubert is with Shubert Botein Policy Associates, New York, NY. At the time of this study, David Gogolishvili, Jason Globerman, Sergio Rueda, and Sean B. Rourke were with the Ontario HIV Treatment Network, Toronto, ON, Canada. Anne K. Bozack is with the Department of Environmental Health Sciences, Mailman School of Public Health. Maria Caban is with the Department of Research and Evaluation, BOOM!Health, New York, NY
| | - Anne K Bozack
- Angela A. Aidala is with the Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, NY. Michael G. Wilson is with the Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada. Virginia Shubert is with Shubert Botein Policy Associates, New York, NY. At the time of this study, David Gogolishvili, Jason Globerman, Sergio Rueda, and Sean B. Rourke were with the Ontario HIV Treatment Network, Toronto, ON, Canada. Anne K. Bozack is with the Department of Environmental Health Sciences, Mailman School of Public Health. Maria Caban is with the Department of Research and Evaluation, BOOM!Health, New York, NY
| | - Maria Caban
- Angela A. Aidala is with the Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, NY. Michael G. Wilson is with the Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada. Virginia Shubert is with Shubert Botein Policy Associates, New York, NY. At the time of this study, David Gogolishvili, Jason Globerman, Sergio Rueda, and Sean B. Rourke were with the Ontario HIV Treatment Network, Toronto, ON, Canada. Anne K. Bozack is with the Department of Environmental Health Sciences, Mailman School of Public Health. Maria Caban is with the Department of Research and Evaluation, BOOM!Health, New York, NY
| | - Sean B Rourke
- Angela A. Aidala is with the Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, NY. Michael G. Wilson is with the Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada. Virginia Shubert is with Shubert Botein Policy Associates, New York, NY. At the time of this study, David Gogolishvili, Jason Globerman, Sergio Rueda, and Sean B. Rourke were with the Ontario HIV Treatment Network, Toronto, ON, Canada. Anne K. Bozack is with the Department of Environmental Health Sciences, Mailman School of Public Health. Maria Caban is with the Department of Research and Evaluation, BOOM!Health, New York, NY
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Santos Cruz M, Andrade T, Bastos FI, Leal E, Bertoni N, Lipman L, Burnett C, Fischer B. Patterns, determinants and barriers of health and social service utilization among young urban crack users in Brazil. BMC Health Serv Res 2013; 13:536. [PMID: 24373346 PMCID: PMC3893546 DOI: 10.1186/1472-6963-13-536] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2013] [Accepted: 12/17/2013] [Indexed: 11/11/2022] Open
Abstract
Background Crack use is prevalent across the Americas, and specifically among marginalized urban street drug users in Brazil. Crack users commonly feature multiple physical and mental health problems, while low rates of and distinct barriers to help service use have been observed in these populations. This study examined profiles and determinants of social and health service utilization, and unmet service needs, in a two-city sample of young (18–24 years), marginalized crack users in Brazil. Methods N = 160 study participants were recruited by community-based methods from impoverished neighborhoods in the cities of Rio de Janeiro (n = 81) and Salvador (n = 79). A mixed methods protocol was used. Participants’ drug use, health, and social and health service utilization characteristics were assessed by an anonymous interviewer-administered questionnaire completed in a community setting; descriptive statistics on variables of interest were computed. Service needs and barriers were further assessed by way of several focus groups with the study population; narrative data were qualitatively analyzed. The study protocol was approved by institutional ethics review boards; data were collected between November 2010 and June 2011. Results The majority of the sample was male, without stable housing, and used other drugs (e.g., alcohol, marijuana). About half the sample reported physical and mental health problems, yet most had not received medical attention for these problems. Only small minorities had utilized locally available social or health services; utilization appeared to be influenced by sex, race and housing characteristics in both sites. Participants cited limited service resources, lack of needs-specific professional skills, bureaucratic barriers and stigma as obstacles to better service access. However, most respondents stated strong interest and need for general social, health and treatment services designed for the study population, for which various key features were emphasized as important. Conclusions The study contributes substantive evidence to current discussions about the development and utilization of health and treatment interventions for crack use in Brazil. Based on our data, crack users’ social, service needs are largely unmet; these gaps appear to partly root in systemic barriers of access to existing services, while improved targeted service offers for the target population seem to be needed also.
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Affiliation(s)
| | | | | | | | | | | | | | - Benedikt Fischer
- Centre for Applied Research in Mental Health and Addiction, Faculty of Health Sciences, Simon Fraser University, 2400 - 515 W Hasting St, Vancouver, BC V6B 5K3, Canada.
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