Challenges of implementing safer supply programs in Canada during the COVID-19 pandemic: A qualitative analysis.

BACKGROUND: Canada is experiencing an unprecedented drug toxicity crisis driven by a highly toxic unregulated drug supply contaminated with fentanyl, benzodiazepine, and other drugs. Safer supply pilot programs provide prescribed doses of pharmaceutical alternatives to individuals accessing the unregulated drug supply and have been implemented to prevent overdose and reduce related harms. Given the recent emergence of these pilot programs and the paucity of data on implementation challenges, we sought to document challenges in their initial implementation phase. METHODS: We obtained organizational progress reports from Health Canada, submitted between 2020 and 2022 by 11 pilot programs located in British Columbia, Ontario, and New Brunswick. We analyzed the data using deductive and inductive approaches via thematic analysis. Analyses were informed by the consolidated framework for implementation research. RESULTS: We obtained 45 progress reports from 11 pilot programs. Six centres were based in British Columbia, four in Ontario, and one in New Brunswick. Four overarching themes were identified regarding the challenges faced during the establishment and implementation of pilot programs: i) Organizational features (e.g., physical space constraints, staff shortages); ii) Outer contexts (e.g., limited operational funds and resources, structural inequities to access, public perceptions); iii) Intervention characteristics (e.g., clients' unmet medication needs); and iv) Implementation process (e.g., pandemic-related challenges, overly medicalized and high-barrier safer supply models). CONCLUSIONS: Safer supply pilot programs in Canada face multiple inner and outer implementation challenges. Given the potential role of safer supply programs in addressing the drug toxicity crisis in Canada and the possibility of future scale-up, services should be well-supported during their implementation phases. Refining service provision within safer supply programs based on the feedback and experiences of clients and program administrators is warranted, along with efforts to ensure that appropriate medications are available to meet the clients' needs.

Partnering with Indigenous Elders in primary care improves mental health outcomes of inner-city Indigenous patients: Prospective cohort study.

OBJECTIVE: To determine whether including Indigenous Elders as part of routine primary care improves depressive symptoms and suicidal ideation in Indigenous patients. DESIGN: Prospective cohort study with quantitative measures at baseline and 1, 3, and 6 months postintervention, along with emergency department (ED) utilization rates before and after the intervention. SETTING: Western Canadian inner-city primary care clinic. PARTICIPANTS: A total of 45 people who were older than age 18, who self-identified as Indigenous, and who had no previous visits with the clinic-based Indigenous Elders program. INTERVENTION: Participants met with an Indigenous Elder as part of individual or group cultural sessions over the 6-month study period. MAIN OUTCOME MEASURES: Changes in depressive symptoms, measured with the PHQ-9 (Patient Health Questionnaire), following Indigenous patients' encounters with Indigenous Elders. Secondary outcomes included changes in suicide risk (measured with the SBQ-R [Suicidal Behaviors Questionnaire-Revised]) and ED use. RESULTS: Characteristics among those who consented to participate were as follows: 71% were female; mean age was 49 years; 31% had attended residential or Indian day school; and 64% had direct experience in the foster care system. At baseline 28 participants had moderate to severe depressive symptoms (PHQ-9 score of ≥ 10). There was a 5-point decrease that was sustained over a 6-month period (P = .001). Fourteen participants had an above-average suicide risk score at baseline (SBQ-R score of ≥ 7), and there was a 2-point decrease in suicide risk that was sustained over a 6-month period (P = .005). For all participants there was a 56% reduction in mental health-related ED visits (80 vs 35) when comparing the 12 months before and after enrolment. CONCLUSION: Encounters with Indigenous Elders, as part of routine primary care, were associated with a clinically and statistically significant reduction in depressive symptoms and suicide risk among Indigenous patients. Emergency department use decreased, which might reduce crisis-oriented mental health care costs. Further expansion and evaluation of the role of Indigenous Elders as part of routine primary care is warranted.

"All my relations": experiences and perceptions of Indigenous patients connecting with Indigenous Elders in an inner city primary care partnership for mental health and well-being.

BACKGROUND: Mental health services in urban settings generally have not been adapted to serve the needs of Indigenous patients. We explored how patients' encounters with Indigenous Elders affected their overall mental health and well-being to identify therapeutic mechanisms underlying improvement. METHODS: We conducted qualitative interviews of participants enrolled in a 6-month prospective mixed-methods evaluation of a program for mental health and well-being that featured the inclusion of Elders in the direct care of Indigenous patients in an inner city primary care clinic. Individual semistructured interviews were conducted to explore patients' experiences and perceptions of their participation in the Elders program. RESULTS: We included 37 participants from at least 20 different First Nations. All but 1 participant described substantial benefits from their encounters with Elders, and none reported being negatively affected. Five overarching themes were identified: experiencing healing after prolonged periods of seeking and desperation; strengthening cultural identity and belonging; developing trust and opening up; coping with losses; and engaging in ceremony and spiritual dimensions of care as a resource for hope. INTERPRETATION: Our evaluation illustrates that the Elders program was perceived by participants to have a broad range of positive impacts on their care and well-being. Although this study was based on experiences at a single urban clinic, these findings support the Truth and Reconciliation Commission of Canada's calls to action regarding the inclusion of Elders as a strategy to improve care of Indigenous patients in Canadian health care systems.

Enhancing health care equity with Indigenous populations: evidence-based strategies from an ethnographic study.

BACKGROUND: Structural violence shapes the health of Indigenous peoples globally, and is deeply embedded in history, individual and institutional racism, and inequitable social policies and practices. Many Indigenous communities have flourished, however, the impact of colonialism continues to have profound health effects for Indigenous peoples in Canada and internationally. Despite increasing evidence of health status inequities affecting Indigenous populations, health services often fail to address health and social inequities as routine aspects of health care delivery. In this paper, we discuss an evidence-based framework and specific strategies for promoting health care equity for Indigenous populations. METHODS: Using an ethnographic design and mixed methods, this study was conducted at two Urban Aboriginal Health Centres located in two inner cities in Canada, which serve a combined patient population of 5,500. Data collection included in-depth interviews with a total of 114 patients and staff (n = 73 patients; n = 41 staff), and over 900 h of participant observation focused on staff members' interactions and patterns of relating with patients. RESULTS: Four key dimensions of equity-oriented health services are foundational to supporting the health and well-being of Indigenous peoples: inequity-responsive care, culturally safe care, trauma- and violence-informed care, and contextually tailored care. Partnerships with Indigenous leaders, agencies, and communities are required to operationalize and tailor these key dimensions to local contexts. We discuss 10 strategies that intersect to optimize effectiveness of health care services for Indigenous peoples, and provide examples of how they can be implemented in a variety of health care settings. CONCLUSIONS: While the key dimensions of equity-oriented care and 10 strategies may be most optimally operationalized in the context of interdisciplinary teamwork, they also serve as health equity guidelines for organizations and providers working in various settings, including individual primary care practices. These strategies provide a basis for organizational-level interventions to promote the provision of more equitable, responsive, and respectful PHC services for Indigenous populations. Given the similarities in colonizing processes and Indigenous peoples' experiences of such processes in many countries, these strategies have international applicability.

Development of health equity indicators in primary health care organizations using a modified Delphi.

OBJECTIVE: The purpose of this study was to develop a core set of indicators that could be used for measuring and monitoring the performance of primary health care organizations' capacity and strategies for enhancing equity-oriented care. METHODS: Indicators were constructed based on a review of the literature and a thematic analysis of interview data with patients and staff (n = 114) using procedures for qualitatively derived data. We used a modified Delphi process where the indicators were circulated to staff at the Health Centers who served as participants (n = 63) over two rounds. Indicators were considered part of a priority set of health equity indicators if they received an overall importance rating of>8.0, on a scale of 1-9, where a higher score meant more importance. RESULTS: Seventeen indicators make up the priority set. Items were eliminated because they were rated as low importance (<8.0) in both rounds and were either redundant or more than one participant commented that taking action on the indicator was highly unlikely. In order to achieve health care equity, performance at the organizational level is as important as assessing the performance of staff. Two of the highest rated "treatment" or processes of care indicators reflects the need for culturally safe and trauma and violence-informed care. There are four indicators that can be used to measure outcomes which can be directly attributable to equity responsive primary health care. DISCUSSION: These indicators and subsequent development of items can be used to measure equity in the domains of treatment and outcomes. These areas represent targets for higher performance in relation to equity for organizations (e.g., funding allocations to ongoing training in equity-oriented care provision) and providers (e.g., reflexive practice, skill in working with the health effects of trauma).

Adoption of the chronic care model to improve HIV care: in a marginalized, largely aboriginal population.

OBJECTIVE: To measure the effectiveness of implementing the chronic care model (CCM) in improving HIV clinical outcomes. DESIGN: Multisite, prospective, interventional cohort study. SETTING: Two urban community health centres in Vancouver and Prince George, BC. PARTICIPANTS: Two hundred sixty-nine HIV-positive patients (18 years of age or older) who received primary care at either of the study sites. INTERVENTION: Systematic implementation of the CCM during an 18-month period. MAIN OUTCOME MEASURES: Documented pneumococcal vaccination, documented syphilis screening, documented tuberculosis screening, antiretroviral treatment (ART) status, ART status with undetectable viral load, CD4 cell count of less than 200 cells/mL, and CD4 cell count of less than 200 cells/mL while not taking ART compared during a 36-month period. RESULTS: Overall, 35% of participants were women and 59% were aboriginal persons. The mean age was 45 years and most participants had a history of injection drug use that was the presumed route of HIV transmission. During the study follow-up period, 39 people died, and 11 transferred to alternate care providers. Compared with their baseline clinical status, study participants showed statistically significant (P < .001 for all) increases in pneumococcal immunization (54% vs 84%), syphilis screening (56% vs 91%), tuberculosis screening (23% vs 38%), and antiretroviral uptake (47% vs 77%), as well as increased viral load suppression rates among those receiving ART (72% vs 90%). Stable housing at baseline was associated with a 4-fold increased probability of survival. Aboriginal ethnicity was not associated with better or worse outcomes at baseline or at follow-up. CONCLUSION: Application of the CCM approach to HIV care in a marginalized, largely aboriginal patient population led to improved disease screening, immunization, ART uptake, and virologic suppression rates. In addition to addressing underlying social determinants of health, a paradigm shift away from an "infectious disease" approach to a "chronic disease management" approach to HIV care for marginalized populations is strongly recommended.

Closing the health equity gap: evidence-based strategies for primary health care organizations.

INTRODUCTION: International evidence shows that enhancement of primary health care (PHC) services for disadvantaged populations is essential to reducing health and health care inequities. However, little is known about how to enhance equity at the organizational level within the PHC sector. Drawing on research conducted at two PHC Centres in Canada whose explicit mandates are to provide services to marginalized populations, the purpose of this paper is to discuss (a) the key dimensions of equity-oriented services to guide PHC organizations, and (b) strategies for operationalizing equity-oriented PHC services, particularly for marginalized populations. METHODS: The PHC Centres are located in two cities within urban neighborhoods recognized as among the poorest in Canada. Using a mixed methods ethnographic design, data were collected through intensive immersion in the Centres, and included: (a) in-depth interviews with a total of 114 participants (73 patients; 41 staff), (b) over 900 hours of participant observation, and (c) an analysis of key organizational documents, which shed light on the policy and funding environments. RESULTS: Through our analysis, we identified four key dimensions of equity-oriented PHC services: inequity-responsive care; trauma- and violence-informed care; contextually-tailored care; and culturally-competent care. The operationalization of these key dimensions are identified as 10 strategies that intersect to optimize the effectiveness of PHC services, particularly through improvements in the quality of care, an improved 'fit' between people's needs and services, enhanced trust and engagement by patients, and a shift from crisis-oriented care to continuity of care. Using illustrative examples from the data, these strategies are discussed to illuminate their relevance at three inter-related levels: organizational, clinical programming, and patient-provider interactions. CONCLUSIONS: These evidence- and theoretically-informed key dimensions and strategies provide direction for PHC organizations aiming to redress the increasing levels of health and health care inequities across population groups. The findings provide a framework for conceptualizing and operationalizing the essential elements of equity-oriented PHC services when working with marginalized populations, and will have broad application to a wide range of settings, contexts and jurisdictions. Future research is needed to link these strategies to quantifiable process and outcome measures, and to test their impact in diverse PHC settings.

Enhancing measurement of primary health care indicators using an equity lens: An ethnographic study.

INTRODUCTION: One important goal of strengthening and renewal in primary healthcare (PHC) is achieving health equity, particularly for vulnerable populations. There has been a flurry of international activity toward the establishment of indicators relevant to measuring and monitoring PHC. Yet, little attention has been paid to whether current indicators: 1) are sensitive enough to detect inequities in processes or outcomes of care, particularly in relation to the health needs of vulnerable groups or 2) adequately capture the complexity of delivering PHC services across diverse groups. The purpose of this paper is to contribute to the discourse regarding what ought to be considered a PHC indicator and to provide some concrete examples illustrating the need for modification and development of new indicators given the goal of PHC achieving health equity. METHODS: Within the context of a larger study of PHC delivery at two Health Centers serving people facing multiple disadvantages, a mixed methods ethnographic design was used. Three sets of data collected included: (a) participant observation data focused on the processes of PHC delivery, (b) interviews with Health Center staff, and (c) interviews with patients. RESULTS: Thematic analysis suggests there is a disjuncture between clinical work addressing the complex needs of patients facing multiple vulnerabilities such as extreme levels of poverty, multiple chronic conditions, and lack of housing and extant indicators and how they are measured. Items could better measure and monitor performance at the management level including, what is delivered (e.g., focus on social determinants of health) and how services are delivered to socially disadvantaged populations (e.g., effective use of space, expectation for all staff to have welcoming and mutually respectful interactions). New indicators must be developed to capture inputs (e.g., stability of funding sources) and outputs (e.g., whole person care) in ways that better align with care provided to marginalized populations. CONCLUSIONS: The current emphasis on achieving greater equity through PHC, the continued calls for the renewal and strengthening of PHC, and the use of monitoring and performance indicators highlight the relevance of ensuring that there are more accurate methods to capture the complex work of PHC organizations.

Outcomes of a remote, decentralized health center-based HIV/AIDS antiretroviral program in Zambia, 2003 to 2007.

A cross-sectional study of patients living with HIV/ AIDS treated during 2003 to 2007 in decentralized, rural health centers in Zambia was performed to measure virological outcomes after 12 months of antiretroviral therapy and identify factors associated with virological failure. Data from 228 patients who started antiretroviral therapy >12 months prior were analyzed. In all, 93% received stavudine + lamivudine + nevirapine regimens, and median antiretroviral therapy duration was 23.5 months (interquartile range 20-28). Of the 205 patients tested for viral load, 177 (86%) had viral load <1000 copies/mL. Probability of developing virological failure (viral load >1000 copies/mL) was 8.9% at 24 months and 19.6% at 32 months. Predictors for virological failure were <100% adherence, body mass index <18.5 kg/m(2), and women <40 years old. Of those with virological failure who underwent 3 to 6 months of intensive adherence counseling, 45% obtained virological success. In a remote, resource-limited setting in decentralized health centers, virological and immunological assessments of patients on antiretroviral therapy >12 months showed that positive health outcomes are achievable.

Determining eligibility for antiretroviral therapy in resource-limited settings using total lymphocyte counts, hemoglobin and body mass index.

BACKGROUND: CD4+ T lymphocyte (CD4) cell count testing is the standard method for determining eligibility for antiretroviral therapy (ART), but is not widely available in sub-Saharan Africa. Total lymphocyte counts (TLCs) have not proven sufficiently accurate in identifying subjects with low CD4 counts. We developed clinical algorithms using TLCs, hemoglobin (Hb), and body mass index (BMI) to identify patients who require ART. METHODS: We conducted a cross-sectional study of HIV-infected adults in Uganda, who presented for assessment for ART-eligibility with WHO clinical stages I, II or III. Two by two tables were constructed to examine TLC thresholds, which maximized sensitivity for CD4 cell counts 350 cells microL. Hb and BMI values were then examined to try to improve model performance. RESULTS: 1787 subjects were available for analysis. Median CD4 cell counts and TLCs, were 239 cells/microL and 1830 cells/microL, respectively. Offering ART to all subjects with a TLCs 3000 cells/microL, and used Hb and/or BMI values to determine eligibility for those with TLC values between 2000 and 3000 cells/microL, marginally improved accuracy. CONCLUSION: TLCs appear useful in predicting who would be eligible for ART based on CD4 cell count criteria. Hb and BMI values may be useful in prioritizing patients for ART, but did not improve model accuracy.