An action-oriented public health framework to reduce financial strain and promote financial wellbeing in high-income countries.

BACKGROUND: Perceived financial security impacts physical, mental, and social health and overall wellbeing at community and population levels. Public health action on this dynamic is even more critical now that the COVID-19 pandemic has exacerbated financial strain and reduced financial wellbeing. Yet, public health literature on this topic is limited. Initiatives targeting financial strain and financial wellbeing and their deterministic effects on equity in health and living conditions are missing. Our research-practice collaborative project addresses this gap in knowledge and intervention through an action-oriented public health framework for initiatives targeting financial strain and wellbeing. METHODS: The Framework was developed using a multi-step methodology that involved review of theoretical and empirical evidence alongside input from a panel of experts from Australia and Canada. In an integrated knowledge translation approach, academics (n = 14) and a diverse group of experts from government and non-profit sectors (n = 22) were engaged throughout the project via workshops, one-on-one dialogues, and questionnaires. RESULTS: The validated Framework provides organizations and governments with guidance for the design, implementation, and assessment of diverse financial wellbeing- and financial strain-related initiatives. It presents 17 priority actionable areas (i.e., entry points for action) likely to have long-lasting, positive effects on people's financial circumstances, contributing to improved financial wellbeing and health. The 17 entry points relate to five domains: Government (All Levels), Organizational & Political Culture, Socioeconomic & Political Context, Social & Cultural Circumstances, and Life Circumstances. CONCLUSIONS: The Framework reveals the intersectionality of root causes and consequences of financial strain and poor financial wellbeing, while also reinforcing the need for tailored actions to promote socioeconomic and health equity for all people. The dynamic, systemic interplay of the entry points illustrated in the Framework suggest opportunities for multi-sectoral, collaborative action across government and organizations towards systems change and the prevention of unintended negative impacts of initiatives.

A Policy-Ready Public Health Guidebook of Strategies and Indicators to Promote Financial Well-Being and Address Financial Strain in Response to COVID-19.

INTRODUCTION: The COVID-19 pandemic has adversely affected the financial well-being of populations globally, escalating concerns about links with health care and overall well-being. Governments and organizations need to act quickly to protect population health relative to exacerbated financial strain. However, limited practice- and policy-relevant resources are available to guide action, particularly from a public health perspective, that is, targeting equity, social determinants of health, and health-in-all policies. Our study aimed to create a public health guidebook of strategies and indicators for multisectoral action on financial well-being and financial strain by decision makers in high-income contexts. METHODS: We used a multimethod approach to create the guidebook. We conducted a targeted review of existing theoretical and conceptual work on financial well-being and strain. By using rapid review methodology informed by principles of realist review, we collected data from academic and practice-based sources evaluating financial well-being or financial strain initiatives. We performed a critical review of these sources. We engaged our research-practice team and government and nongovernment partners and participants in Canada and Australia for guidance to strengthen the tool for policy and practice. RESULTS: The guidebook presents 62 targets, 140 evidence-informed strategies, and a sample of process and outcome indicators. CONCLUSION: The guidebook supports action on the root causes of poor financial well-being and financial strain. It addresses a gap in the academic literature around relevant public health strategies to promote financial well-being and reduce financial strain. Community organizations, nonprofit organizations, and governments in high-income countries can use the guidebook to direct initiative design, implementation, and assessment.

Investigating the association between income inequality in youth and deaths of despair in Canada: a population-based cohort study from 2006 to 2019.

BACKGROUND: Deaths due to suicide, drug overdose and alcohol-related liver disease, collectively known as 'deaths of despair', have been markedly increasing since the early 2000s and are especially prominent in young Canadians. Income inequality has been linked to this rise in deaths of despair; however, this association has not yet been examined in a Canadian context, nor at the individual level or in youth. The study objective was to examine the association between income inequality in youth and deaths of despair among youth over time. METHODS: We conducted a population-based longitudinal study of Canadians aged 20 years or younger using data from the Canadian Census Health and Environment Cohorts. Baseline data from the 2006 Canadian Census were linked to the Canadian Vital Statistics Database up to 2019. We employed multilevel survival analysis models to quantify the association between income inequality in youth and time-to deaths of despair. RESULTS: The study sample included 1.5 million Canadians, representing 7.7 million Canadians between the ages of 0 and 19 at baseline. Results from the weighted, adjusted multilevel survival models demonstrated that income inequality was associated with an increased hazard of deaths of despair (adjusted HR (AHR) 1.35; 95% CI 1.04 to 1.75), drug overdose (AHR 2.38; 95% CI 1.63 to 3.48) and all-cause deaths (AHR 1.10; 95% CI 1.04 to 1.18). Income inequality was not significantly associated with suicide deaths (AHR 1.23, 95% CI 0.93 to 1.63). CONCLUSION: The results show that higher levels of income inequality in youth are associated with an increased hazard of all-cause death, deaths of despair and drug overdose in young Canadians. This study is the first to reveal the association between income inequality and deaths of despair in youth and does so using a population-based longitudinal cohort involving multilevel data. The results of this study can inform policies related to income inequality and deaths of despair in Canada.

Philanthropic donor perspectives about providing harm reduction services for people living with HIV/AIDS in a hospital setting.

BACKGROUND: Hospital-based harm reduction services are needed to reduce drug-related harms, facilitate retention in care, and increase medical treatment adherence for people who use drugs. Philanthropic donor support plays a key role in delivering such innovative services which might fall outside current funding streams. However, little is known about how the principles, implementation, and practice of harm reduction services, which are often highly stigmatized, may impact donor behaviours. We explored this issue within Casey House, a speciality hospital in Toronto, Canada. METHODS: Our mixed methods study utilized an explanatory sequential design. A convenience sample of n = 106 philanthropic individual donors, recruited via email, completed an anonymous web-based survey, between July and October 2020, which assessed their knowledge of harm reduction services and the potential impact of implementing new hospital-based harm reduction services on donors' future support. Following this, we conducted semi-structured qualitative interviews with n = 12 of the donors who completed a survey and volunteered to be interviewed. Interviews examined donors' perspectives about harm reduction and their hopes/concerns for such programming at Casey House. Data were analysed using descriptive statistics and participatory-based thematic analysis. RESULTS: Survey data show a high level of support for hospital-based harm reduction services, with participants reporting that they "strongly agree/agree" with providing harm reduction equipment (85%), supervised consumption services (82%), and prescription opioid treatment (76%) at Casey House. A majority of participants (66%) claimed that implementing new harm reduction services at the hospital would not impact their future donation, while 6% said they would be less inclined to donate. Interview participants were supportive of harm reduction services at Casey House, recognizing the benefits of providing such services for hospital clients and the wider community. However, some spoke of the potential impact that implementing hospital-based harm reduction services may have on "other" donors who might be opposed. Although some believed harm reduction services should be fully funded by the government, most saw a role for donors in supporting such services. CONCLUSIONS: Our findings show support of hospital-based harm reduction services among philanthropic donors and provide insight into how donor support may be affected when such services are introduced.

Perceived unmet substance use and mental health care needs of acute care patients who use drugs: A cross-sectional analysis using the Behavioral Model for Vulnerable Populations.

INTRODUCTION: The perceived unmet service needs of acute care-seeking people who use illegal drugs (PWUD) have been poorly documented, despite evidence of frequent hospital utilisation. This study applies the Behavioral Model for Vulnerable Populations to investigate correlates of unmet service needs in this subpopulation. METHODS: Survey data from 285 PWUD at three urban Canadian acute care centres were examined. The survey included the Perceived Need for Care Questionnaire, which measured service seeking and care satisfaction for mental health and substance use concerns across seven types of services, as well as barriers to having care needs met. The Behavioral Model for Vulnerable Populations was applied in hierarchical setwise logistic regression to examine associations between high unmet service need and socio-structural predictors (i.e. predisposing, enabling and need factors). RESULTS: Almost half (46%) of participants reported a high level of unmet service need, despite seeking services during the past year. Participants reporting recent criminal activity, adverse childhood experiences, transitory sleeping, having no community support worker, and meeting screening criteria for depression were more likely to report a high level of unmet service needs. Structural barriers to care (57%) were more commonly reported than motivational barriers (43%). DISCUSSION AND CONCLUSIONS: Acute care-seeking PWUD experience high rates of unmet service needs for their mental health and substance use problems. Strategies that can help overcome structural barriers to care are necessary to help address the service needs of this population.

Social values for health technology assessment in Canada: a scoping review of hepatitis C screening, diagnosis and treatment.

BACKGROUND: Health care system decision makers face challenges in allocating resources for screening, diagnosis and treatment of hepatitis C. Approximately 240,000 individuals are infected with the hepatitis C virus (HCV) in Canada. Populations most affected by HCV include Indigenous people, people who inject drugs, immigrants and homeless or incarcerated populations as well as those born between 1946 and 1965. Curative but expensive drug regimens of novel direct acting antivirals (DAAs) are available. We aim to identify social values from academic literature for inclusion in health technology assessments. METHODS: We conducted a scoping review of academic literature to identify and analyze the social values and evidence-based recommendations for screening, diagnosis and treatment of HCV in Canada. After applying inclusion/exclusion criteria, we abstracted: type of intervention(s), population(s) affected, study location, screening methods, diagnostics and treatments. We then abstracted and applied qualitative codes for social values. We extracted social value statements and clustered them into one of 4 categories: (1) equity and justice, (2) duty to provide care, (3) maximization of population benefit, and (4) individual versus community interests. RESULTS: One hundred and eighteen articles met our inclusion criteria on screening, diagnosis and treatment of HCV in Canada. Of these, 54 (45.8%) discussed screening, 4 (3.4%) discussed diagnosis and 60 (50.8%) discussed treatment options. Most articles discussed the general population and other non-vulnerable populations. Articles that discussed vulnerable populations focused on people who inject drugs. We coded 1243 statements, most of which fell into the social value categories of equity and justice, duty to provide care and maximization of population benefit. CONCLUSION: The academic literature identified an expanded set of social values to be taken into account by resource allocation decision makers in financially constrained environments. In the context of hepatitis C, authors called for greater consideration of equity and justice and the duty to provide care in making evidence-based recommendations for screening, diagnosis and treatment for different populations and in different settings that also account for individual and community interests.

Media coverage of harm reduction, 2000-2016: A content analysis of tone, topics, and interventions in Canadian print news.

BACKGROUND: Harm reduction interventions reduce mortality and morbidity for people who use drugs (PWUD), but are contentious and haphazardly implemented. This study describes volume and content of Canadian newspaper coverage of harm reduction produced from 2000 to 2016. METHODS: Searches of 54 English-language newspapers identified 5681 texts, coded for type (news reports, opinion pieces), tone (positive, negative, or neutral/balanced coverage), topic (health, crime, social welfare, and political perspectives on harm reduction), and seven harm reduction interventions. RESULTS: Volume of coverage doubled in 2008 (after removal of harm reduction from federal drug policy and legal challenges to Vancouver's supervised consumption program) and quadrupled in 2016 (tracking Canada's opioid emergency). Health perspectives on harm reduction were most common (39% of texts) while criminal perspectives were rare (3%). Negative coverage was over 10 times more common in opinion pieces (31%) compared to news reports (3%); this trend was more pronounced in British Columbia and Alberta, a region particularly affected by Canada's opioid emergency. Supervised drug consumption accounted for 49% of all newspaper coverage. CONCLUSIONS: Although federal policy support for harm reduction waxed and waned over 17 years, Canadian newspapers independently shaped public discourse, frequently characterizing harm reduction positively/neutrally and from a health perspective. However, issue framing and agenda setting was also evident: supervised drug consumption offered in a single Canadian city crowded out coverage of all other harm reduction services, except for naloxone. This narrow sense of 'newsworthiness' obscured public discourse on the full spectrum of evidence-based harm reduction services that could benefit PWUD.

Willingness to participate in hepatitis C vaccine trials among socially marginalized people who use drugs.

A major complicating factor for hepatitis C virus (HCV) vaccine clinical trial design and implementation is engagement and retention of people who use drugs (PWUD). Informed willingness to participate (WTP) in vaccine trials has emerged as a critical issue to describe, understand, and promote among populations at increased risk of communicable disease incidence. The present study addressed this topic by examining correlates of WTP among 320 socially marginalized PWUD as part of the Edmonton Drug Use and Health Survey (EDUHS). WTP was analyzed in relation to: gender, age, housing stability, ethnicity; self-reported hospital care in the past six months, self-reported injection drug use in the past 6 months, lifetime addiction treatment for alcohol or drugs, severity of drug use problems, and unmet healthcare needs. EDUHS participants reported high rates of current injection drug use (91%), and about two-thirds (67.3%) reported a lifetime HCV positive status. HCV positive respondents were older, had more severe substance use problems, and reported injecting drugs more frequently, compared to HCV negative respondents. Among the subsample of HCV negative respondents, 81% affirmed that they would be willing to enroll in a HCV vaccine prevention trial. Those reporting WTP were more likely to have had a recent hospital admission, to report more total unmet healthcare needs, and greater unmet needs for information, hospital care, and counseling, compared to HCV negative respondents not willing to enroll in a vaccine trial. No association was observed between WTP and other assessed variables. Results suggest that connecting PWUD not infected with HCV to local healthcare resources may be important in motivating vaccine trial participation.

Canadian harm reduction policies: A comparative content analysis of provincial and territorial documents, 2000-2015.

BACKGROUND: Access to harm reduction interventions among substance users across Canada is highly variable, and largely within the policy jurisdiction of the provinces and territories. This study systematically described variation in policy frameworks guiding harm reduction services among Canadian provinces and territories as part of the first national multimethod case study of harm reduction policy. METHODS: Systematic and purposive searches identified publicly-accessible policy texts guiding planning and organization of one or more of seven targeted harm reduction services: needle distribution, naloxone, supervised injection/consumption, low-threshold opioid substitution (or maintenance) treatment, buprenorphine/naloxone (suboxone), drug checking, and safer inhalation kits. A corpus of 101 documents written or commissioned by provincial/territorial governments or their regional health authorities from 2000 to 2015 were identified and verified for relevance by a National Reference Committee. Texts were content analyzed using an a priori governance framework assessing managerial roles and functions, structures, interventions endorsed, client characteristics, and environmental variables. RESULTS: Nationally, few (12%) of the documents were written to expressly guide harm reduction services or resources as their primary named purpose; most documents included harm reduction as a component of broader addiction and/or mental health strategies (43%) or blood-borne pathogen strategies (43%). Most documents (72%) identified roles and responsibilities of health service providers, but fewer declared how services would be funded (56%), specified a policy timeline (38%), referenced supporting legislation (26%), or received endorsement from elected members of government (16%). Nonspecific references to 'harm reduction' appeared an average of 12.8 times per document-far more frequently than references to specific harm reduction interventions (needle distribution=4.6 times/document; supervised injection service=1.4 times/document). Low-threshold opioid substitution, safer inhalation kits, drug checking, and buprenorphine/naloxone were virtually unmentioned. Two cases (Quebec and BC) produced about half of all policy documents, while 6 cases - covering parts of Atlantic and Northern Canada - each produced three or fewer. CONCLUSION: Canada exhibited wide regional variation in policies guiding the planning and organization of Canadian harm reduction services, with some areas of the country producing few or no policies. Despite a wealth of effectiveness and health economic research demonstrating the value of specific harm reduction interventions, policies guiding Canada from 2000 to 2015 did not stake out harm reduction interventions as a distinct, legitimate health service domain.

The role of consumer perspectives in estimating population need for substance use services: a scoping review.

BACKGROUND: A growing body of research assesses population need for substance use services. However, the extent to which survey research incorporates expert versus consumer perspectives on service need is unknown. We conducted a large, international review to (1) describe extant research on population need for substance use services, and the extent to which it incorporates expert and consumer perspectives on service need, (2) critically assess methodological and measurement approaches used to study consumer-defined need, and (3) examine the potential for existing research that prioritizes consumer perspectives to inform substance use service system planning. METHODS: Systematic searches of seven databases identified 1930 peer-reviewed articles addressing population need for substance use services between January 1980 and May 2015. Empirical studies (n = 1887) were categorized according to source(s) of data used to derive population estimates of service need (administrative records, biological samples, qualitative data, and/or quantitative surveys). Quantitative survey studies (n = 1594) were categorized as to whether service need was assessed from an expert and/or consumer perspective; studies employing consumer-defined need measures (n = 217) received further in-depth quantitative coding to describe study designs and measurement strategies. RESULTS: Almost all survey studies (96%; n = 1534) used diagnostically-oriented measures derived from an expert perspective to assess service need. Of the small number (14%, n = 217) of survey studies that assessed consumer's perspectives, most (77%) measured perceived need for generic services (i.e. 'treatment'), with fewer (42%) examining self-assessed barriers to service use, or informal help-seeking from family and friends (10%). Unstandardized measures were commonly used, and very little research was longitudinal or tested hypotheses. Only one study used a consumer-defined need measure to estimate required service system capacity. CONCLUSIONS: Rhetorical calls for including consumer perspectives in substance use service system planning are belied by the empirical literature, which is dominated by expert-driven approaches to measuring population need. Studies addressing consumer-defined need for substance use services are conceptually underdeveloped, and exhibit methodological and measurement weaknesses. Further scholarship is needed to integrate multidisciplinary perspectives in this literature, and fully realize the promise of incorporating consumer perspectives into substance use service system planning.

Perceived unmet need and barriers to care amongst street-involved people who use illicit drugs.

INTRODUCTION AND AIMS: Research on perceived unmet need for care for mental health and substance use problems focuses on general populations to the detriment of hidden populations. This study describes prevalence and correlates of perceived unmet need for care in a community-based sample of street-involved people who use illicit drugs and identifies barriers to care. DESIGN AND METHODS: A sample of 320 street-involved people who use drugs participated in a structured, interviewer-assisted survey in Edmonton, Canada. The survey included the Perceived Need for Care Questionnaire, which assessed unmet need for care for mental health and substance use problems across seven service types. Logistic regression examined the associations between perceived unmet need, extent of socioeconomic marginalisation and problem severity. Barriers underlying unmet service needs were also examined. RESULTS: Most (82%) participants reported unmet need for one or more services during the past year. Odds of reporting one or more unmet needs were elevated amongst participants reporting substantial housing instability (adjusted odds ratio = 2.37; 95% confidence interval 1.19-4.28) and amongst participants meeting criteria for drug dependence (adjusted odds ratio = 1.22; 95% confidence interval 1.03-1.50), even after adjustment for sociodemographic covariates. Structural, rather than motivational barriers were the most commonly reported reasons underlying unmet service needs. DISCUSSION AND CONCLUSION: Street-involved people who use drugs experience very high rates of perceived unmet need for care for mental health and substance use problems. General population studies on perceived unmet need are insufficient for understanding needs and barriers to care in hidden populations.[Hyshka E, Anderson JT, Wild TC. Perceived unmet need and barriers to care amongst street-involved people who use illicit drugs. Drug Alcohol Rev 2017;36:295-304].

A common public health-oriented policy framework for cannabis, alcohol and tobacco in Canada?

Support for a public health approach to cannabis policy as an alternative to prohibition and criminalization is gaining momentum. Recent drug policy changes in the United States suggest growing political feasibility for legal regulation of cannabis in other North American jurisdictions. This commentary discusses the outcomes of an interdisciplinary policy meeting with Canadian experts and knowledge users in the area of substance use interventions. The meeting explored possibilities for applying cross-substance learning on policy interventions for alcohol, tobacco and cannabis, towards the goal of advancing a public health framework for reducing harms associated with substance use in Canada. The meeting also explored how the shift in approach to cannabis policy can provide an opportunity to explore potential changes in substance use policy more generally, especially in relation to tobacco and alcohol as legally regulated substances associated with a heavy burden of illness. Drawing from the contributions and debates arising from the policy meeting, this commentary identifies underlying principles and opportunities for learning from policy interventions across tobacco, alcohol and cannabis, as well as research gaps that need to be addressed before a public health framework can be effectively pursued across these substances.