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.

"COVID affected us all:" the birth and postnatal health experiences of resettled Syrian refugee women during COVID-19 in Canada.

BACKGROUND: Prior to COVID-19, postnatal resettled refugee women in Canada reported barriers to healthcare and low levels of social support, contributing to maternal health morbidities. The COVID-19 pandemic appears to be further exacerbating health inequities for marginalized populations. The experiences of resettled refugee women are not fully known. AIM: To understand Syrian refugee women's experiences accessing postnatal healthcare services and supports during the COVID-19 pandemic. METHODS: Semi-structured, virtual interviews were conducted with eight resettled Syrian refugee women living in Nova Scotia (Canada) who were postnatal between March and August 2020. Data analysis was informed by constructivist grounded theory. FINDINGS: Three themes emerged: "the impacts of COVID-19 on postnatal healthcare;" "loss of informal support;" and "grief and anxiety." Women experienced difficult healthcare interactions, including socially and physically isolated deliveries, challenges accessing in-person interpreters, and cancelled or unavailable in-home services (e.g., public health nurse and doula visits). Increased childcare responsibilities and limited informal supports due to pandemic restrictions left women feeling overwhelmed and exhausted. Stay-at-home orders resulted in some women reporting feelings of isolation and loss, as they were unable to share in person postnatal moments with friends and family, ultimately impacting their mental wellness. CONCLUSIONS: COVID-19 and associated public health restrictions had significant impacts on postnatal Syrian refugee women. Data presented in this study demonstrated the ways in which the pandemic environment and related restrictions amplified pre-existing barriers to care and postnatal health inequalities for resettled refugee women-particularly a lack of postnatal informal supports and systemic barriers to care.

Geographically mobile healthcare workers and the conditions of their travel: The perspectives of managers.

Many healthcare workers are "on the road" traveling to and from fixed sites (eg, patients'/clients' homes). Qualitative interviews with nine Nova Scotian managers of mobile healthcare workers explored the conditions of workers' travel. Findings highlight challenges such as changing schedules, as well as positive features including flexibility over the travel schedule. Some managers noted worker mobility-related responsibilities including having to decide if travel is too dangerous due to poor weather. A few managers suggested that workers may not receive adequate economic reimbursement for travel costs (eg, wear and tear on vehicle), and in some instances, workers need to use a benefit (eg, vacation day) or are not paid if they cannot drive due to poor weather. Reported organizational supports for workers' travel were variable. This research indicates a need for supportive mobility-related policies and practices across all organizations, including policies that cover economic costs related to travel for all workers.

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.

Revisualising 'porn': how young adults' consumption of sexually explicit Internet movies can inform approaches to Canadian sexual health promotion.

The Internet offers an invaluable opportunity to re-imagine ideas, constructs and disciplines to create innovative sexual health promotion interventions. To gain insight into what young adults (aged 19-28) may be seeking in online sexual resources and approaches, this study explored how young people perceived their sexual health to be influenced by their consumption of the highly utilised sexual medium of Sexually Explicit Internet Movies [SEIM]. Employing an exploratory, qualitative methodology, data were collected through semi-structured interviews with 12 urban, heterosexual young adults, who self-identified as having consumed SEIM for a period of at least one year. All interviews were audiotaped with permission, transcribed verbatim and the data were analysed to identify emergent thematic concepts. Participants described utilising SEIM as an all-inclusive sexual forum to learn more about the positive aspects of sexual health, in a context that they viewed as being devoid of alternatives. Young adults' perceptions of the utility of SEIM suggest that it would be beneficial to create novel, sex-positive online sexual health interventions. Further exploration is clearly warranted on how Internet resources that are related to sexual health, such as SEIM, can be utilised to facilitate innovative approaches to online sexual health promotion.

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.

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.

Screening for poverty and related social determinants to improve knowledge of and links to resources (SPARK): development and cognitive testing of a tool for primary care.

BACKGROUND: Healthcare organizations are increasingly exploring ways to address the social determinants of health. Accurate data on social determinants is essential to identify opportunities for action to improve health outcomes, to identify patterns of inequity, and to help evaluate the impact of interventions. The objective of this study was to refine a standardized tool for the collection of social determinants data through cognitive testing. METHODS: An initial set of questions on social determinants for use in healthcare settings was developed by a collaboration of hospitals and a local public health organization in Toronto, Canada during 2011-2012. Subsequent research on how patients interpreted the questions, and how they performed in primary care and other settings led to revisions. We administered these questions and conducted in-depth cognitive interviews with all the participants, who were from Saskatchewan, Manitoba, Ontario, and Newfoundland and Labrador. Cognitive interviewing was used, with participants invited to verbalize thoughts and feelings as they read the questions. Interview notes were grouped thematically, and high frequency themes were addressed. RESULTS: Three hundred and seventy-five individuals responded to the study advertisements and 195 ultimately participated in the study. Although all interviews were conducted in English, participants were diverse. For many, the value of this information being collected in typical healthcare settings was unclear, and hence, we included descriptors for each question. In general, the questions were understood, but participants highlighted a number of ways the questions could be changed to be even clearer and more inclusive. For example, more response options were added to the question of sexual orientation and the "making ends meet" question was completely reworded in light of challenges to understand the informal phrasing cited by English as a Second Language (ESL) users of the tool. CONCLUSION: In this work we have refined an initial set of 16 sociodemographic and social needs questions into a simple yet comprehensive 18-question tool. The changes were largely related to wording, rather than content. These questions require validation against accepted, standardized tools. Further work is required to enable community data governance, and to ensure implementation of the tool as well as the use of its data is successful in a range of organizations.

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.

The postnatal experiences of resettled Syrian refugee women: Access to healthcare and social support in Nova Scotia, Canada.

AIM: The purpose of this qualitative study was to understand Syrian refugee women's perceptions and experiences of access to formal health services and informal supports during the postpartum period in Nova Scotia, Canada and to identify valued and missing services and supports in the community. BACKGROUND: The postnatal period is a critical time when mothers may need access to health services (e.g., family physicians, psychologists) and informal supports (e.g., friends, family) to support their positive mental and physical health after birth. Resettled refugee women commonly encounter barriers when accessing care during the postnatal period and often have limited social supports. METHODS: Semi-structured, telephone or virtual interviews were conducted with 11 resettled Syrian refugee women who gave birth in Nova Scotia, Canada within the past five years. Data were collected in the summer of 2020. This study was conducted using elements of constructivist grounded theory. FINDINGS: Four key themes were identified from women's experiences: (i) postpartum social support was critical, but often lacking, (ii) structural barriers (e.g., irregular interpreter services, limited childcare options) impeded women's access to healthcare, (iii) paternalistic healthcare providers limited women's decision-making autonomy, and (iv) the value and need for culturally competent, integrated care (e.g., newcomer specific healthcare centres), in-home services, and family support. CONCLUSION: Resettled Syrian refugee women in Nova Scotia, Canada experience a range of barriers that limits their access to postnatal healthcare. Policy change, program development, and/or interventions are needed to improve access to postnatal services and supports for resettled Syrian women in Canada.

Factors associated with not seeking professional help or disclosing intent prior to suicide: a study of medical examiners' records in Nova Scotia.

OBJECTIVE: Individual-level data from clinical settings lack information on people who did not seek professional help prior to suicide. We used records of the Nova Scotia Medical Examiner Service (NSMES) to compare people who had contact with a health professional prior to suicide with those who did not. METHOD: We linked data from the NSMES to routine administrative data of the province. RESULTS: The NSMES recorded 108 suicides in Nova Scotia from January 1, 2006, to December 31, 2006; there were 90 male and 18 female suicide deaths. Mean and median age at death were 44.73 (SD 13.33) and 44 years, respectively. Patients aged 40 to 49 years made up one-third of the cases (n = 35) and this was the decade of life with the highest number of suicides. This was also the group least likely to have suicidal intent recorded in the NSMES files (χ(2) = 3.86, df = 1, P = 0.05). Otherwise, there were no significant differences between people who sought help, or disclosed intent, prior to suicide and people who did not. The samples in all cases were predominately male and single. CONCLUSIONS: People aged 40 to 49 years were the age group with the highest absolute number of suicides, but were the least likely to have suicidal intent recorded in the NSMES files. This finding merits further investigation. Medical examiner or coroner data may provide additional information not obtained elsewhere for the surveillance of suicide.

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.

"You have to be okay with okay": experiences of flourishing among university students transitioning directly from high school.

Mental health is central to overall wellbeing and, for students attending university, mental health is critical for learning and academic success. A wealth of research has focused on young people who experience psychosocial declines during academic and developmental transitions, but little is known about how young people flourish in this transition. The first to explore the experiences of flourishing among first-year Canadian university students making the transition directly from high school, this study sought to develop an understanding of: 1) the factors that promote flourishing amidst this academic and developmental transition, and 2) how first-year students define and experience flourishing. An interpretive phenomenological approach underpinned by Gadamerian hermeneutic philosophy was used to explore experiences of flourishing, using semi-structured interviews, in a sample of nine full-time, first-year university students, ages 18-20 years. What it meant to flourish amidst this developmental and academic transition and how participants defined flourishing offer new understandings of the concept associated with: 1) personal/individual aspects of flourishing, 2) contextual nature of flourishing, 3) temporality of flourishing, 4) dialectic aspects of flourishing. Implications for practice, policy, and research in light of these new understandings are discussed.

Does moving from a high-poverty to lower-poverty neighborhood improve mental health? A realist review of 'Moving to Opportunity'.

Ray Pawson's realist review method was used to analyse 22 evaluations/reviews of the Moving to Opportunity (MTO) housing intervention. MTO was a randomized controlled trial that moved families from high-poverty to low-poverty neighborhoods in five US cities between 1994 and 2006. This realist review focussed on mental health outcomes of families who moved, as well as the mechanisms through which moving influenced mental health. It identified and assessed the effectiveness of the underlying theory driving MTO, and suggests revising the existing theory. This realist review suggests that, even when moves are voluntary, there are potentially negative mental health outcomes from these types of social interventions. Directing resources towards the improvement of existing communities is one way of improving health outcomes for all community residents.

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.

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.

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.

The Relationship of Safety with Burnout for Mobile Health Employees.

OBJECTIVE: The study examined the relationship of occupational safety with job burnout. DESIGN: The study used a cross-sectional survey design. SETTING: The setting was Nova Scotia, Canada. PARTICIPANTS: Mobile health employees (N = 156) completed surveys on road safety, workload, burnout and supervisor incivility. MAIN OUTCOME MEASURE: The main outcome measure was the Maslach Burnout Inventory. RESULTS: Results found that safety concerns improved the prediction of exhaustion beyond that provided by workload concerns alone. Further, confidence in safety buffered the relationship of exhaustion with cynicism such that the exhaustion/cynicism relationship was stronger for employees who had lower confidence in road safety. CONCLUSIONS: Employees' confidence in occupational safety while addressing work responsibilities on the road has implications for their experience of job burnout.