On the outside looking in: Finding a place for managed alcohol programs in the harm reduction movement.

Alcohol policy in North America is dominated by moderation and abstinence-based modalities that focus on controlling population-level alcohol consumption and modifying individual consumption patterns to prevent and reduce alcohol-related harms. However, conventional alcohol policies and interventions do not adequately address harms associated with high-risk drinking among individuals experiencing severe alcohol use disorder (AUD) and structural vulnerability such as poverty and homelessness. In this commentary we address this gap in alcohol harm reduction, and highlight the lack of, and distinct need for, alcohol-specific harm reduction for people experiencing structural vulnerability and severe AUD. These individuals, doubly impacted by structural oppression and severe AUD, engage in various high-risk drinking practices that contribute to a unique set of harms that conventional abstinence-based treatments and interventions fail to adequately attend to. Managed alcohol programs (MAPs) have been established to address these multiple intersecting harms, and though gaining momentum across Canada, have had a hard time finding their place within the harm reduction movement. We illustrate how MAPs play a crucial role in the harm reduction movement in their ability to not only address high-risk drinking practices among structurally marginalized individuals, but to respond to harms associated with broader structural inequities such as poverty and homelessness.

Community managed alcohol programs in Canada: Overview of key dimensions and implementation.

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.

Low-Income Children, Adolescents, and Caregivers Facing Respiratory Problems: Support Needs and Preferences.

UNLABELLED: Burdens of poverty are often compounded by respiratory problems. This study aimed to identify the support needs and intervention preferences for low-income families facing this challenge. DESIGN AND METHODS: Interviews were conducted in two Canadian provinces with low-income children/adolescents (n=32) diagnosed with respiratory health problems and their parents or family caregiver (n=37). RESULTS: These vulnerable children and parents described non-supportive interactions with some health service providers and inadequate information. They reported isolation and support deficits, exacerbated by limited resources and health restrictions. Children/adolescents felt isolated and excluded and wanted to connect with peers. Group or dyadic level support, delivered by peers and health professionals, was desired. The importance of logistics to enhance accessibility and appeal of group or dyadic support interventions was clearly identified. CONCLUSIONS: The findings of this study reveal that low-income children and their families encounter challenges to accessing support and to utilizing support resources. PRACTICE IMPLICATIONS: Partnerships with low-income children/adolescents and family caregivers in provision of education and social support can combat isolation and ignorance. Reducing inequities for this high risk population could be achieved by providing support from experienced peers, in combination with health professional guidance, and knowledge about pulmonary health.

Questioning context: a set of interdisciplinary questions for investigating contextual factors affecting health decision making.

OBJECTIVE: To combine insights from multiple disciplines into a set of questions that can be used to investigate contextual factors affecting health decision making. BACKGROUND: Decision-making processes and outcomes may be shaped by a range of non-medical or 'contextual' factors particular to an individual including social, economic, political, geographical and institutional conditions. Research concerning contextual factors occurs across many disciplines and theoretical domains, but few conceptual tools have attempted to integrate and translate this wide-ranging research for health decision-making purposes. METHODS: To formulate this tool we employed an iterative, collaborative process of scenario development and question generation. Five hypothetical health decision-making scenarios (preventative, screening, curative, supportive and palliative) were developed and used to generate a set of exploratory questions that aim to highlight potential contextual factors across a range of health decisions. FINDINGS: We present an exploratory tool consisting of questions organized into four thematic domains - Bodies, Technologies, Place and Work (BTPW) - articulating wide-ranging contextual factors relevant to health decision making. The BTPW tool encompasses health-related scholarship and research from a range of disciplines pertinent to health decision making, and identifies concrete points of intersection between its four thematic domains. Examples of the practical application of the questions are also provided. CONCLUSIONS: These exploratory questions provide an interdisciplinary toolkit for identifying the complex contextual factors affecting decision making. The set of questions comprised by the BTPW tool may be applied wholly or partially in the context of clinical practice, policy development and health-related research.