What features of drug treatment programs help, or not, with access? a qualitative study of the perspectives of family members and community-based organization staff in Atlantic Canada.

BACKGROUND: Withdrawal management and opioid agonist treatment (OAT) programs help to reduce some of the harms experienced by people who use substances (PWUS). There is literature on how features of drug treatment programs (e.g., policies and practices) are helpful, or not helpful, to PWUS when seeking access to, or in, treatment. There is, however, relatively little literature based on the perspectives of family members/family of choice of PWUS and community-based organization staff within the context of Atlantic Canada. This paper explored the perspectives of these two groups on what was helpful, or not, about drug treatment programs in Atlantic Canada in terms of supporting access to, and retention in, treatment. METHODS: One-on-one qualitative telephone interviews were conducted in 2020 with the two groups. Interviews focused on government-funded withdrawal management and OAT programs. Data were coded using a qualitative data management program (ATLAS.ti) and analyzed inductively for key themes/subthemes using grounded theory techniques. RESULTS: Fifteen family members/family of choice and 16 community-based organization staff members participated (n = 31). Participants spoke about features of drug treatment programs in various places, and noted features that were perceived as helpful (e.g., quick access), as well as not helpful (e.g., wait times, programs located far from where PWUS live). Some participants provided their perceptions of how PWUS felt when seeking or accessing treatment. A number of participants reported taking various actions to help support access to treatment, including providing transportation to programs. A few participants also provided suggestions for change to help support access and retention such as better alignment of mental health and addiction systems. CONCLUSIONS: Participants highlighted several helpful and not helpful features of drug treatment programs in terms of supporting treatment access and retention. Previous studies with PWUS and in other places have reported similar features, some of which (e.g., wait times) have been reported for many years. Changes are needed to reduce barriers to access and retention including the changes recommended by study participants. It is critical that the voices of key groups, (including PWUS) are heard to ensure treatment programs in all places support access and retention.

A Review of Intimate Partner Violence Interventions Relevant to Women During the COVID-19 Pandemic.

Women have experienced increased rates of intimate partner violence (IPV) since the onset of the COVID-19 global pandemic, and at the same time requirements for physical distancing and/or remote delivery of services have created challenges in accessing services. We synthesized research evidence from 4 systematic reviews and 20 individual studies to address how IPV interventions can be adapted within the context of the pandemic. As many interventions have been delivered via various technologies, access to technology is of particular importance during the pandemic. Our results can inform the provision of services during the remainder of the COVID-19 pandemic including how to support women who have little access to in-person services.

Treatment of Opioid Use Disorder in Canadian Psychosocial Addiction Programs: A National Survey of Policy, Attitudes, and Practice.

OBJECTIVE: To describe current approaches in treatment of opioid use disorder (OUD) within Canadian psychosocial outpatient, day, and residential addiction treatment programs, with an emphasis on the use of opioid agonist therapy (OAT). METHOD: An online census survey was conducted in English and French of Canadian psychosocial addiction treatment programs (N = 214). RESULTS: Programs estimated that 25% of their clients have OUD. A slight majority of programs provide some type of specialized services to clients with OUD (58%), most frequently providing or facilitating access to OAT but also specialized counselling, case management, education, and harm reduction services.Most programs reported that they admitted clients on OAT (88%) and only a minority expected or encouraged clients to taper (14%) or discontinue (6%). Programs focusing on client abstinence as the treatment goal were more likely to expect or encourage tapering or discontinuation than programs that focus on helping clients achieve personal consumption goals. Of programs that did not currently facilitate OAT, 44% indicated that they would provide OAT, but lacked the necessary accreditation, physician support, or other resources. No philosophical objections to OAT were noted.OAT initiation was provided by 30% of programs, 23% referred to another service within their organization, and 29% referred to a service outside their organization. The remaining 18% did not facilitate OAT initiation at all, ranging from 0% in Quebec to 23% in the Prairies. Overdose response kits were provided by 86% of programs. The majority not providing kits indicated willingness if policy support and resources were provided (67%). CONCLUSIONS: Overall, the results demonstrate that psychosocial programs provide some specialized services for OUD but desire further support specifically to provide OAT, including training, knowledge, and the expertise of individuals qualified to prescribe and dispense OAT. Many psychosocial treatment programs expressed a need for staff and resources for this purpose.

Safety and danger: Perceptions of the implementation of harm reduction programs in two communities in Nova Scotia, Canada.

People who use substances (PWUS), and specifically individuals who use injection drugs and/or smoke crack cocaine, experience risks which harm reduction programmes can help reduce. Prior to implementing harm reduction programmes, however, it is critical to understand how programme users and others in the community perceive the programmes as their perceptions may influence implementation. A mixed-methods study asked PWUS and key informants about their perceptions of implementing five harm reduction programmes in their communities, including perceptions of the advantages of the programmes, where best to locate them, and community support. Questionnaires were administered to 160 PWUS, and qualitative interviews were conducted with 11 purposefully sampled key informants. Data were collected in one medium-size and one small-size community/municipality in Nova Scotia, Canada, during 2017-2018. SPSS was used to generate descriptive statistics and means from the quantitative data, and the qualitative data were analysed for key themes using thematic analysis. Both PWUS and key informants perceived numerous advantages of the harm reduction programmes, but some key informants suggested that there might be potential opposition to the implementation of additional needle distribution and disposal programmes in some locations and potential opposition to safer consumption sites. Further research is needed to understand why these programmes were viewed as potentially generating opposition, but findings suggest that a key factor is the association of the programmes with 'danger' because the programmes are directly linked with criminalized drug use. In contrast, the three other programmes are linked to 'safety' because naloxone saves lives, peer navigation programmes support access to existing programmes and detoxification programmes are associated with safety through the reduction/elimination of drug use. Legalization/decriminalization of drugs might help to change the association of some programmes with 'danger' and therefore help support the implementation of harm reduction programmes that appear to be perceived by some as linked to danger.

Initiatives to Support Older Women Who Experience Intimate Partner Violence.

To contribute to our knowledge about initiatives to support older women who experience intimate partner violence (IPV), we conducted an internet search, online surveys, and telephone interviews with administrators of programs for women who have experienced IPV. We compiled information on initiatives providing individual in-person and telephone support, educational and/or therapeutic groups, and short- and long-term shelters and housing. The interviews provided insights about the history and rationale for these initiatives, strengths, positive outcomes, challenges, and future program development. Our study results can inform the creation of appropriate services to meet the needs of older women who experience IPV.

Harm Reduction 'On the Move': What Is the Role of Environmental Influences?

Many harm-reduction services are provided through mobile programs (e.g., vans traveling to various locations), and such services are particularly important for reaching people who use substances who are socially and economically marginalized. Mobile harm reduction is not, however, a given but is shaped by the environment within which it occurs. Based on peer-reviewed literature, grey literature, and media reports primarily from Canada and the United States, we point to environmental conditions (e.g., limited funds for harm reduction, stigmatization of substance use) that appear to force mobile harm reduction, and influence (directly or indirectly) the route and speed of mobility, when and how it stops, as well as how it is experienced by harm-reduction workers and people who use substances. It is argued that there is a need to examine how environmental conditions in various places influence mobile harm reduction, including potential differences in impacts on harm-reduction workers' experiences, and service provision.

The application of implementation science theories for population health: A critical interpretive synthesis.

BACKGROUND AND PURPOSE: Over the last decade, the field of implementation science (IS) has yielded an array of theoretical approaches to clarify and understand how factors influence the application and scaling-up of evidence-based practice in health care. These developments have led to questions about whether IS theories and frameworks might be of value to population health researchers and decision makers. The purpose of this research was to conduct a critical interpretive synthesis to explore, if, and how, key IS theories and frameworks might inform population health interventions aimed at reducing the burden of illness across populations. METHODS: An initial list of theories and frameworks was developed based on previous published research and narrowed to focus on theories considered as formative for the field of IS. A standardized data extraction form was used to gather key features of the theories and critically appraise their relevance to population health interventions. RESULTS: Ten theories were included in the review and six deemed most applicable to population health based on their consideration of broader contextual and system-level factors. The remaining four were determined to have less relevant components for population health due to their limited consideration of macro-level factors, often focusing on micro (individual) and meso (organizational) level factors. CONCLUSIONS: Theories and frameworks are important to guide the implementation and sustainability of population health interventions. The articulation of meso level factors common in IS theories may be of value to interventions targeted at the population level. However, some of the reviewed theories were limited in their consideration of broader contextual factors at the macro level (community, policy or societal). This critical interpretive synthesis also found that some theories lacked provision of practical guidance to address interventions targeting structural factors such as key social determinants of health (e.g., housing, income).

Improving Healthcare Providers' Interactions with Trans Patients: Recommendations to Promote Cultural Competence.

Research indicates that trans people face a number of barriers to healthcare, including challenges in finding healthcare providers (HCPs) who are knowledgeable about, and sensitive to, trans identity and health issues. These and other barriers contribute to this population's under-usage of healthcare services and, in turn, their poor overall health outcomes compared to the general population. This article provides research-informed recommendations to improve HCPs' cultural competence, which may increase trans individuals' utilization of healthcare and thus contribute to better health outcomes for this population.

Barriers to primary and emergency healthcare for trans adults.

Trans individuals are less healthy than the general population in part because of their avoidance and underutilisation of healthcare. Using qualitative research methods, the objective of this study was to explore the barriers trans adults encounter when pursuing primary and emergency care in Nova Scotia, Canada. Findings reveal that trans adults often feel discriminated against and socially excluded in primary and emergency care settings. This marginalisation is manifested in relationships with healthcare providers and within both the physical care and social care environments. The findings suggest that there is a 'discrimination continuum' with experiences of discrimination ranging from subtle to overt. Findings indicate that subtle discriminatory experiences may be encountered most frequently. Both kinds of experiences are reported to have detrimental consequences. The findings also indicate that trans adults are often burdened by the expectation that they will take on a more active role in their care than cisgender patients, including educating their healthcare providers and remaining resilient in the face of discrimination.

Key challenges in providing services to people who use drugs: The perspectives of people working in emergency departments and shelters in Atlantic Canada.

AIMS: Many people who use drugs (PWUD) have multiple health and social needs, and research suggests that this population is increasingly accessing emergency departments (EDs) and shelters for health care and housing. This qualitative study explored the practices of those working in EDs and shelters when providing services to PWUD, with a particular focus on key challenges in service provision. METHODS: EDs and shelters were conceptualized as 'micro environments' with various components (i.e. social, physical and resource). One-on-one interviews were conducted with 57 individuals working in EDs and shelters in Atlantic Canada. FINDINGS: The social, physical and resource environments within some EDs and shelters are key forces in shaping the challenges facing those providing services. For example, the social environments within these settings are focused on acute health care in the case of EDs, and housing in the case of shelters. These mandates do not encompass the complex needs of many PWUD. Resource issues within the wider community (e.g. limited drug treatment spaces) further contribute to the challenges. CONCLUSIONS: Structural issues, internal and external to EDs and shelters need to be addressed to reduce the challenges facing many who work in these settings when providing services to PWUD.

Improving psychosocial health and employment outcomes for individuals receiving methadone treatment: a realist synthesis of what makes interventions work.

BACKGROUND: For over 50 years, methadone has been prescribed to opioid-dependent individuals as a pharmacological approach for alleviating the symptoms of opioid withdrawal. However, individuals prescribed methadone sometimes require additional interventions (e.g., counseling) to further improve their health. This study undertook a realist synthesis of evaluations of interventions aimed at improving the psychosocial and employment outcomes of individuals on methadone treatment, to determine what interventions work (or not) and why. METHODS: The realist synthesis method was utilized because it uncovers the processes (or mechanisms) that lead to particular outcomes, and the contexts within which this occurs. A comprehensive search process resulted in 31 articles for review. Data were extracted from the articles, and placed in four templates to assist with analysis. Data analysis was an iterative process and involved comparing and contrasting data within and across each template, and cross checking with original articles to determine key patterns in the data. RESULTS: For individuals on methadone, engagement with an intervention appears to be important for improved psychosocial and/or employment outcomes. The engagement process involves attendance at interventions as well as an investment in what is offered. Three intervention contexts (often in some combination) support the engagement process: a) client-centered contexts (or those where clients' psychosocial and/or employment needs/issues/skills are recognized and/or addressed); b) contexts which address clients' socio-economic conditions and needs; and, c) contexts where there are positive client-counselor and/or peer relationships. There is some evidence that sometimes ongoing engagement is necessary to maintain positive outcomes. There is also some evidence that complete abstinence from drugs (e.g., cocaine, heroin) is not necessary for engagement. CONCLUSIONS: It is important to consider how the contexts of interventions might elicit and/or support clients' engagement. Further research is needed to explore how an individual's background (e.g., involvement with different interventions over an extended period) may influence engagement. Long-term engagement may be necessary to sustain some positive outcomes although how long is unclear and requires further research. Engagement can occur without complete abstinence from such drugs as cocaine or heroin, but additional research is required as engagement may be influenced by the extent and type of drug use.

Hurry up and wait. The experiences of young women in rural Nova Scotia accessing specialized care.

INTRODUCTION: This study explored experiences of waiting to access specialized health care among young women living in selected rural communities on the south shore of Nova Scotia. We asked women about the challenges they faced during wait times and how they perceived the impact of these experiences on their health. METHODS: We conducted qualitative interviews with 10 women aged 21-37 years. We used thematic analysis to identify common experiences among participants. RESULTS: Some women expressed feelings of frustration about waiting, but others resigned themselves to the wait. Women reported challenges such as caregiving for ailing family members who waited for care. Some women took control of their situation by accessing private health care or what they called "the next best thing" (e.g., care from alternative health providers), although in some cases this was financially costly. A few women sought assistance through support networks. Many women reported that wait times affected their health. CONCLUSION: Our results support previous research indicating that young rural women's caregiving roles and support networks influence their experiences with wait times. Our research indicates that waiting to access specialized care can be financially costly for some women and may also affect their health.

Challenges and opportunities to integrating family members of injection drug users into harm reduction efforts within the Atlantic Canadian context.

BACKGROUND: This paper explores injection drug users' (IDUs) relationships with non-drug using family members in order to understand the potential opportunities for, and challenges to, having these family members provide harm reduction services (e.g., clean syringes). METHODS: The qualitative data for this paper were drawn from a larger study of IDUs' relationships with key individuals in their lives (e.g., friends, family members). Interviews were conducted with 115 IDUs from across Atlantic Canada living in both urban and rural areas. RESULTS: IDUs report that their relationships with family members are variable and dynamic, often changing over time. IDUs and family members engage in a variety of strategies to protect themselves from the multiple harms associated with drug use. Several strategies of self-protection (e.g., discontinuing all contact) are antithetical to the provision of harm reduction supports by family members. However, other strategies are based on continued contact, providing a potential opportunity for the integration of harm reduction approaches. Some family members not only have contact but provide supports (e.g., emotional support, housing) thus potentially facilitating the integration of harm reduction. In a few instances, family members already provide harm reduction supports (e.g., safe space to use). CONCLUSIONS: Conceptualizing addictions as a health and social justice issue, and providing appropriate interventions, may reduce some of the harms experienced by users and family members thus encouraging sustained relationships and greater integration of harm reduction approaches into the relationship. Targeted education to family members about harm reduction may also further encourage their involvement in such efforts. Likewise, supporting family members who are already providing harm reduction supports will likely assist in the scaling-up of harm reduction efforts.

Meanings that youth associate with healthy and unhealthy food.

PURPOSE: The symbolic meanings that youth associate with food were explored, as were barriers to accessing healthy foods. METHODS: Qualitative methods and a constructivist approach were employed, and data were collected through semi-structured interviews and a card-sorting activity. Thirteen adolescents aged 13 to 15 (seven girls, six boys) were recruited through public schools and posters displayed in community settings. Thematic analytical techniques were used to analyze the data. RESULTS: Participants classified foods into healthy and unhealthy groups, as well as into an "in-between" group that included nutritionally enhanced foods. Healthy and unhealthy foods were linked to a variety of physical, social, and emotional meanings. Some meanings associated with foods were also discussed in gendered terms, and numerous barriers to accessing healthy foods were reported. CONCLUSIONS: Foods hold multiple meanings for youth. Programs and policies aimed at fostering healthy eating need to capitalize on positive associations related to healthy foods. Negative associations related to healthy foods need to be acknowledged and strategies developed to recast such linkages. Likewise, the positive associations linked to unhealthy foods need to be addressed. Strategies also need to be developed to ensure access to healthy foods in all settings, especially within schools and community leisure settings.

Intimate relationships and women involved in the sex trade: perceptions and experiences of inclusion and exclusion.

This article reports on a qualitative study exploring the intimate (non-work) relationships of women involved in the sex trade. Women working in the sex industry and intimate partners of women in the industry were interviewed in order to understand how intimate relationships are perceived as influencing the women's general health and well-being. The research suggests that intimate relationships can, and do, provide a space for feelings of inclusion and safety that are perceived as positive forces in women's general health and well-being. At the same time, however, feelings and experiences of exclusion (fuelled by the dominant stigmatizing discourse related to prostitution) can enter into intimate relationships, and are perceived as having a negative impact on the women's well-being, particularly their emotional health. Although there are attempts to keep the women's work separate from the intimate relationship, cross-over between the two spheres does occur. The research suggests that health care and service providers need to look beyond the women's working lives, and understand the relationships between work and home, as well as the ways in which intimate relationships can influence women's lives and health through both positive and negative forces.

Evidence-based cardiovascular care. Family physicians' views of obstacles and opportunities.

OBJECTIVE: To explore obstacles to and opportunities for applying specific lifestyle and pharmacologic recommendations on chronic ischemic heart disease. DESIGN: Qualitative study. SETTING: Rural, town, and city settings in Nova Scotia. PARTICIPANTS: Fifty family physicians caring for patients with cardiovascular (CV) disease. METHOD: Nine focus groups were conducted, audiotaped, and transcribed. Seven recommendations had been selected for discussion based on their relevance to primary care, strength, and class of supporting evidence. Analysis was guided by grounded-theory methodology. MAIN FINDINGS: "Ischemic events" can be powerful motivators for change, whereas the asymptomatic nature of CV risks and distant outcomes can form obstacles. Trust built through previous experiences and the opportunity to repeat important messages can facilitate application of evidence, but patient-physician relationships can also pose obstacles. CONCLUSION: Physicians can take steps to improve care, but success at reducing CV risks depends upon active involvement of many health professionals and community resources. Future guideline implementation should focus on patient-oriented issues, such as comorbidity and treatment preferences.

Safer and unsafe injection drug use and sex practices among injection drug users in Halifax, Nova Scotia. An exploratory look at community and interpersonal influences.

OBJECTIVE: This qualitative study sought to explore the community and interpersonal (e.g., peer) influences affecting safer and unsafe injection drug use and sexual practices among injection drug users (IDUs) living in and around Halifax, Nova Scotia. METHODS: Sixty semi-structured interviews were conducted with IDUs, and key themes were identified. Two focus groups were also conducted to obtain feedback on the findings. RESULTS: There are key community and peer influences on drug use and sex practices. Needle exchange provides community access to clean needles, but when the needle exchange is closed, accessibility is an issue. Peers at times assist in reducing sharing by providing clean needles to friends who are without a needle or cannot access needles because of their circumstances (e.g., in prison). Peers also sometimes encourage condom use, but in certain contexts (e.g., with an intimate partner) condom use is often not supported. INTERPRETATION: Expanded and new prevention strategies--especially those utilizing peers--are urgently needed to discourage unsafe practices, and encourage safer practices among this population.

A qualitative study of evidence in primary care: what the practitioners are saying.

BACKGROUND: Little is known about the impact of evidence-based medicine in primary care. Our objective was to explore the influence of evidence on day-to-day family practice, with specific reference to cardiovascular disease. METHODS: A total of 9 focus groups were conducted in rural, semi-urban and urban settings in Nova Scotia. The participants were 50 family physicians who had practised in their communities for more than 1 year and who were treating patients with cardiovascular disease. FINDINGS: Two major themes emerged: evidence in the clinical encounter and the culture of evidence. The family physicians reported thinking about evidence during the clinical encounter but still situated that evidence within the specific context of their patients and their communities. They appreciated evidence that had been appraised, summarized and published as a guideline by an independent national organization. Evidence remained in the forefront of consciousness for a limited time frame. Local specialists, trusted because of their previous successes with shared patient care, were important sources and interpreters of evidence. INTERPRETATION: Day-to-day family practice offers both obstacles and opportunities for the application of evidence. Although evidence is an important part of clinical practice, it is not absolute and is considered along with many other factors.