Social service providers' perspectives on caring for structurally vulnerable hospital patients who use drugs: a qualitative study.

BACKGROUND: People who use drugs and are structurally vulnerable (e.g., experiencing unstable and/or lack of housing) frequently access acute care. However, acute care systems and providers may not be able to effectively address social needs during hospitalization. Our objectives were to: 1) explore social service providers' perspectives on addressing social needs for this patient population; and 2) identify what possible strategies social service providers suggest for improving patient care. METHODS: We completed 18 semi-structured interviews with social service providers (e.g., social workers, transition coordinators, peer support workers) at a large, urban acute care hospital in Western Canada between August 8, 2018 and January 24, 2019. Interviews explored staff experiences providing social services to structurally vulnerable patients who use drugs, as well as continuity between hospital and community social services. We conducted latent content analysis and organized our findings in relation to the socioecological model. RESULTS: Tensions emerged on how participants viewed patient-level barriers to addressing social needs. Some providers blamed poor outcomes on perceived patient deficits, while others emphasized structural factors that impede patients' ability to secure social services. Within the hospital, some participants felt that acute care was not an appropriate location to address social needs, but most felt that hospitalization affords a unique opportunity to build relationships with structurally vulnerable patients. Participants described how a lack of housing and financial supports for people who use drugs in the community limited successful social service provision in acute care. They identified potential policy solutions, such as establishing housing supports that concurrently address medical, income, and substance use needs. CONCLUSIONS: Broad policy changes are required to improve care for structurally vulnerable patients who use drugs, including: 1) ending acute care's ambivalence towards social services; 2) addressing multi-level gaps in housing and financial support; 3) implementing hospital-based Housing First teams; and, 4) offering sub-acute care with integrated substance use management.

"I have such a hard time hitting myself, I thought it'd be easier": perspectives of hospitalized patients on injecting drugs into vascular access devices.

BACKGROUND: Hospital patients who use drugs may require prolonged parenteral antimicrobial therapy administered through a vascular access device (VAD). Clinicians' concerns that patients may inject drugs into these devices are well documented. However, the perspectives of patients on VAD injecting are not well described, hindering the development of informed clinical guidance. This study was conducted to elicit inpatient perspectives on the practice of injecting drugs into VADs and to propose strategies to reduce associated harms. METHODS: Researchers conducted a focused ethnography and completed semi-structured interviews with 25 inpatients at a large tertiary hospital in Western Canada that experiences a high rate of drug-related presentations annually. RESULTS: A few participants reported injecting into their VAD at least once, and nearly all had heard of the practice. The primary reason for injecting into a VAD was easier venous access since many participants had experienced significant vein damage from injection drug use. Several participants recognized the risks associated with injecting into VADs, and either refrained from the practice or took steps to maintain their devices while using them to inject drugs. Others were uncertain how the devices functioned and were unaware of potential harms. CONCLUSIONS: VADs are important for facilitating completion of parenteral antimicrobial therapy and for other medically necessary care. Prematurely discharging patients who inject into their VAD from hospital, or discontinuing or modifying therapy, results in inequitable access to health care for a structurally vulnerable patient population. Our findings demonstrate a need for healthcare provider education and non-stigmatizing clinical interventions to reduce potential harms associated with VAD injecting. Those interventions could include providing access to specialized pain and withdrawal management, opioid agonist treatment, and harm reduction services, including safer drug use education to reduce or prevent complications from injecting drugs into VADs.

Development of the Inner City attitudinal assessment tool (ICAAT) for learners across Health care professions.

BACKGROUND: Many health professions learners report feeling uncomfortable and underprepared for professional interactions with inner city populations. These learners may hold preconceptions which affect therapeutic relationships and provision of care. Few tools exist to measure learner attitudes towards these populations. This article describes the development and validity evidence behind a new tool measuring health professions learner attitudes toward inner city populations. METHODS: Tool development consisted of four phases: 1) Item identification and generation informed by a scoping review of the literature; 2) Item refinement involving a two stage modified Delphi process with a national multidisciplinary team (n = 8), followed by evaluation of readability and response process validity with a focus group of medical and nursing students (n = 13); 3) Pilot testing with a cohort of medical and nursing students; and 4) Analysis of psychometric properties through factor analysis and reliability. RESULTS: A 36-item online version of the Inner City Attitudinal Assessment Tool (ICAAT) was completed by 214 of 1452 undergraduate students (67.7% from medicine; 32.3% from nursing; response rate 15%). The resulting tool consists of 24 items within a three-factor model - affective, behavioural, and cognitive. Reliability (internal consistency) values using Cronbach alpha were 0.87, 0.82, and 0.82 respectively. The reliability of the whole 24-item ICAAT was 0.90. CONCLUSIONS: The Inner City Attitudinal Assessment Tool (ICAAT) is a novel tool with evidence to support its use in assessing health care learners' attitudes towards caring for inner city populations. This tool has potential to help guide curricula in inner city health.

Caring for patients with lived experience of homelessness.

OBJECTIVE: To guide family physicians working in a range of primary care clinical settings on how to provide care and support for patients who are vulnerably housed or experiencing homelessness. SOURCES OF INFORMATION: The approach integrates recommendations from evidence-based clinical guidelines, the views of persons with lived experience of homelessness, the theoretical tenets of the Patient's Medical Home framework, and practical lessons learned from family physicians working in a variety of clinical practice settings. MAIN MESSAGE: Family physicians can use simple and effective approaches to identify patients who are homeless or vulnerably housed; take initial steps to initiate access to housing, income assistance, case management, and treatment for substance use; and work collaboratively using trauma-informed and anti-oppressive approaches to better assist individuals with health and social needs. Family physicians also have a powerful advocacy voice and can partner with local community organizations and people with lived experience of homelessness to advocate for policy changes to address social inequities. CONCLUSION: Family physicians can directly address the physical health, mental health, and social needs of patients who are homeless or vulnerably housed. Moreover, they can champion outreach and onboarding programs that assist individuals who have experienced homelessness in accessing patient medical homes and can advocate for broader action on the underlying structural causes of homelessness.

Technology to support relational care for people who use drugs at home: Literature review and key informant content.

Canada's opioid crisis is a public health emergency that disproportionately affects people who use drugs alone at home, requiring the mobilization of health systems to implement timely, effective, and innovative programs. The purpose of this review is to provide a synthesis of recent literature relating to technology-enabled harm reduction strategies. The results of the literature review are corroborated with key informants, including family members of people who use drugs and policy-makers in the area of opioid use. Based on this, it is recommended that technology-enabled support programs for people who use drugs at home must deliver support at whatever point the person is along their drug use continuum, must transfer frontline relational skills, must be co-developed with community members and service providers, and must deliver predictable and reliable services that are safe from stigma.

Patient vs. Community Engagement: Emerging Issues.

BACKGROUND: The value proposition of including patients at each step of the research process is that patient perspectives and preferences can have a positive impact on both the science and the outcomes of comparative effectiveness research. How to accomplish engagement and the extent to which approaches to community engagement inform strategies for effective patient engagement need to be examined to address conducting and accelerating comparative effectiveness research. OBJECTIVES: To examine how various perspectives and diverse training lead investigators and patients to conflicting positions on how best to advance patient engagement. RESEARCH DESIGN: Qualitative methods were used to collect perspectives and models of engagement from a diverse group of patients, researchers and clinicians. The project culminated with a workshop involving these stakeholders. The workshop used a novel approach, combining World Café and Future Search techniques, to compare and contrast aspects of patient engagement and community engagement. SUBJECTS: Participants included patients, researchers, and clinicians. MEASURES: Group and workshop discussions provided the consensus on topics related to patient and community engagement. RESULTS: Participants developed and refined a framework that compares and contrasts features associated with patient and community engagement. CONCLUSIONS: Although patient and community engagement may share a similar approach to engagement based on trust and mutual benefit, there may be distinctive aspects that require a unique lexicon, strategies, tactics, and activities.

The BETTER WISE protocol: building on existing tools to improve cancer and chronic disease prevention and screening in primary care for wellness of cancer survivors and patients - a cluster randomized controlled trial embedded in a mixed methods design.

BACKGROUND: There is a pressing need to reduce the burden of chronic disease and improve healthcare system sustainability through improved cancer and chronic disease prevention and screening (CCDPS) in primary care. We aim to create an integrated approach that addresses the needs of the general population and the special concerns of cancer survivors. Building on previous research, we will develop, implement, and test the effectiveness of an approach that proactively targets patients to attend an individualized CCDPS intervention delivered by a Prevention Practitioner (PP). The objective is to determine if patients randomized to receive an individualized PP visit (vs standard care) have improved cancer surveillance and CCDPS outcomes. Implementation frameworks will help identify and address facilitators and barriers to the approach and inform future dissemination and uptake. METHODS/DESIGN: The BETTER WISE project is a pragmatic two-arm cluster randomized controlled trial embedded in a mixed methods design, including a qualitative evaluation and an economic assessment. The intervention, informed by the expanded chronic care model and previous research, will be refined by engaging researchers, practitioners, policy makers, and patients. The BETTER WISE tool kit includes blended care pathways for cancer survivors (breast, colorectal, prostate) and CCDPS including lifestyle risk factors and screening for poverty. Patients aged 40-65, including both cancer survivors and general population patients, will be randomized at the physician level to an intervention group or to a wait-list control group. Once the intervention is completed, patients randomized to wait-list control will be invited to receive a prevention visit. The main outcome, calculated at 12-months follow-up, will be an individual patient-level summary composite index, defined as the proportion of CCDPS actions achieved relative to those for which the patient was eligible at baseline. A qualitative evaluation will capture information related to program outcome, implementation (facilitators and barriers), and sustainability. An economic assessment will examine the projected cost-benefit impact of investing in the BETTER WISE approach. DISCUSSION: This project builds on existing work and engages end users throughout the process to develop, implement, and determine the effectiveness of a multi-faceted intervention that addresses CCDPS and cancer survivorship in primary care settings. TRIAL REGISTRATION: ISRCTN21333761 . Registered on December 19, 2016.

Moderate mental illness as a predictor of chronic disease prevention and screening.

BACKGROUND: Primary care plays a pivotal role in the provision of both mental health care and chronic disease prevention and screening (CDPS). Unfortunately, moderate mental illness (MMI) is associated with poorer general health outcomes. Part of this burden of illness may be due to reduced CDPS uptake. The Building on the Existing Tools to Improve Chronic Disease Prevention in Primary Care (BETTER) trial recruited 777 participants ages 40-65 from 32 family practice panels, of whom 135 (18.2%) had elevated GAD scores, 118 (16.4%) had elevated PHQ scores, and 264 (34.0%) had electronic medical record (EMR)-documented MMI. We hypothesized that patients with screen-positive or chart-documented MMI are 1) eligible for more CDPS actions, and 2) able to complete a lower proportion of CDPS actions than patients unaffected by MMI. METHODS: This study was a secondary analysis of data from the BETTER trial. Participants were stratified by both EMR-documented MMI and screen-positive evidence of MMI (using the General Anxiety Disorders (GAD-7) and Patient Health Questionnaire (PHQ-9) instruments for anxiety and depression screening, respectively). The primary outcome was the proportion of CDPS actions for which the patient was eligible completed at follow-up, using a composite index. RESULTS: After adjusting for age, gender, and social support, patients with evidence of MMI had a lower composite index than patients without evidence of MMI (p < 0.05). The lower composite index is primarily due to higher eligibility for CDPS at baseline; ability to complete CDPS was not statistically different. CONCLUSIONS: Patients affected by MMI are eligible for more CDPS actions than their unaffected counterparts. Although they are able to complete a similar number of CDPS actions, they are not able to eliminate their baseline CDPS gap. Primary care teams need to be aware of this increased CDPS eligibility for patients with MMI and ensure best practices in CDPS supports are available to this patient population. Further study is needed to determine the ideal suite of targeted supports.

Soigner les patients ayant connu l'itinérance.

OBJECTIF: Guider les médecins de famille de divers types de pratique familiale quant à la façon de dispenser des soins et du soutien aux patients logés précairement ou qui vivent l'itinérance. SOURCES D'INFORMATION: L'approche intègre les recommandations tirées des lignes directrices cliniques fondées sur les données probantes, l'opinion des personnes avec une expérience vécue de l'itinérance, les principes théoriques du cadre de travail du Centre de médecine de famille et des leçons pratiques provenant de médecins de famille qui travaillent dans des contextes cliniques variés. MESSAGE PRINCIPAL: Les médecins de famille peuvent utiliser des approches simples et efficaces pour identifier les patients itinérants ou logés précairement; franchir les premières étapes pour faciliter l'accès au logement, à l'aide financière, à la gestion de cas et au traitement de la toxicomanie; et collaborer en faisant appel à des approches anti-oppressives et qui tiennent compte des traumatismes pour mieux venir en aide aux personnes qui ont des besoins sur les plans social et sanitaire. Les médecins de famille ont un solide pouvoir de plaidoyer et peuvent s'associer aux organisations communautaires locales et aux personnes ayant vécu l'itinérance pour revendiquer des réformes politiques qui tiennent compte des iniquités sociales. CONCLUSION: Les médecins de famille ont la capacité de répondre directement aux besoins sociaux et aux besoins en matière de santé physique et de santé mentale des patients itinérants ou logés précairement. En outre, ils peuvent promouvoir les programmes d'approche et d'intégration qui aident les personnes avec une expérience vécue de l'itinérance à accéder aux centres de médecine de famille et peuvent militer pour l'adoption de mesures générales visant à contrer les causes structurelles sous-jacentes de l'itinérance.

Finding a BETTER way: a qualitative study exploring the prevention practitioner intervention to improve chronic disease prevention and screening in family practice.

BACKGROUND: Our randomized controlled trial (The BETTER Trial) found that training a clinician to become a Prevention Practitioner (PP) in family practices improved chronic disease prevention and screening (CDPS). PPs were trained on CDPS and provided prevention prescriptions tailored to participating patients. For this embedded qualitative study, we explored perceptions of this new role to understand the PP intervention. METHODS: We used grounded theory methodology and purposefully sampled participants involved in any capacity with the BETTER Trial. Two physicians and one coordinator in each of two cities (Toronto, Ontario and Edmonton, Alberta) conducted eight individual semi-structured interviews and seven focus groups. We used an interview guide and documented research activities through an audit trail, journals, field notes and memos. We analyzed the data using the constant comparative method throughout open coding followed by theoretical coding. RESULTS: A framework and process involving external and internal practice facilitation using the new role of PP was thought to impact CDPS. The PP facilitated CDPS through on-going relationships with patients and practice team members. Key components included: 1) approaching CDPS in a comprehensive manner, 2) an individualized and personalized approach at multiple levels, 3) integrated continuity that included linking the patients and practices to CPDS resources, and 4) adaptability to different practices and settings. CONCLUSIONS: The BETTER framework and key components are described as impacting CDPS through a process that involved a new role, the PP. The introduction of a novel role of a clinician within the primary care practice with skills in CDPS could appropriately address gaps in prevention and screening.

Perspectives of patients who inject drugs on a needle and syringe program at a large acute care hospital.

BACKGROUND: People who inject drugs in North America often continue to inject while hospitalized, and are at increased risk of premature hospital discharge, unplanned readmission, and death. In-hospital access to sterile injection supplies may reduce some harms associated with ongoing injection drug use. However, access to needle and syringe programs in acute care settings is limited. We explored the implementation of a needle and syringe program integrated into a large urban tertiary hospital in Western Canada. The needle and syringe program was administered by an addiction medicine consult team that offers patients access to specialized clinical care and connection to community services. METHODS: We utilized a focused ethnographic design and semi-structured interviews to elicit experiences and potential improvements from 25 hospitalized people who inject drugs who were offered supplies from the needle and syringe program. RESULTS: Participants were motivated to accept supplies to prevent injection-related harms and access to supplies was facilitated by trust in consult team staff. However, fears of negative repercussions from non-consult team staff, including premature discharge or undesired changes to medication regimes, caused some participants to hesitate or refuse to accept supplies. Participants described modifications to hospital policies regarding inpatient drug use or access to an inpatient supervised consumption service as potential ways to mitigate patients' fears. CONCLUSIONS: Acute care needle and syringe programs may aid hospital providers in reducing harms and improving hospital outcomes for people who inject drugs. However, modifications to hospital policies and settings may be necessary.

Guidelines and recommendations about virtual mental health services from high-income countries: a rapid review.

OBJECTIVES: This study reviewed existing recommendations for virtual mental healthcare services through the quadruple aim framework to create a set of recommendations on virtual healthcare delivery to guide the development of Canadian policies on virtual mental health services. DESIGN: We conducted a systematic rapid review with qualitative content analysis of data from included manuscripts. The quadruple aim framework, consisting of improving patient experience and provider satisfaction, reducing costs and enhancing population health, was used to analyse and organise findings. METHODS: Searches were conducted using seven databases from 1 January 2010 to 22 July 2022. We used qualitative content analysis to generate themes. RESULTS: The search yielded 40 articles. Most articles (85%) discussed enhancing patient experiences, 55% addressed provider experiences and population health, and 25% focused on cost reduction. Identified themes included: screen patients for appropriateness of virtual care; obtain emergency contact details; communicate transparently with patients; improve marginalised patients' access to care; support health equity for all patients; determine the cost-effectiveness of virtual care; inform patients of insurance coverage for virtual care services; increase provider training for virtual care and set professional boundaries between providers and patients. CONCLUSIONS: This rapid review identified important considerations that can be used to advance virtual care policy to support people living with mental health conditions in a high-income country.

Enhancing screening, brief intervention, and referral to treatment among socioeconomically disadvantaged patients: study protocol for a knowledge exchange intervention involving patients and physicians.

BACKGROUND: Screening, Brief Intervention, and Referral for Treatment (SBIRT) is an effective approach for managing alcohol and other drug misuse in primary care; however, uptake into routine care has been limited. Uptake of SBIRT by healthcare providers may be particularly problematic for disadvantaged populations exhibiting alcohol and other drug problems, and requires creative approaches to enhance patient engagement. This knowledge translation project developed and evaluated a group of patient and health care provider resources designed to enhance the capacity of health care providers to use SBIRT and improve patient engagement with health care. METHODS/DESIGN: A nonrandomized, two-group, pre-post, quasi-experimental intervention design was used, with baseline, 6-, and 12-month follow-ups. Low income patients using alcohol and other drugs and who sought care in family medicine and emergency medicine settings in Edmonton, Canada, along with physicians providing care in these settings, were recruited. Patients and physicians were allocated to the intervention or control condition by geographic location of care. Intervention patients received a health care navigation booklet developed by inner city community members and also had access to an experienced community member for consultation on health service navigation. Intervention physicians had access to online educational modules, accompanying presentations, point of care resources, addiction medicine champions, and orientations to the inner city. Resource development was informed by a literature review, needs assessment, and iterative consultation with an advisory board and other content experts. Participants completed baseline and follow-up questionnaires (6 months for patients, 6 and 12 months for physicians) and administrative health service data were also retrieved for consenting patients. Control participants were provided access to all resources after follow-up data collection was completed. The primary outcome measure was patient satisfaction with care; secondary outcome measures included alcohol and drug use, health care and addiction treatment use, uptake of SBIRT strategies, and physician attitudes about addiction. DISCUSSION: Effective knowledge translation requires careful consideration of the intended knowledge recipient's context and needs. Knowledge translation in disadvantaged settings may be optimized by using a community-based participatory approach to resource development that takes into account relevant patient engagement issues. TRIAL REGISTRATION: Northern Alberta Clinical Trials and Research Centre #30094.

Flawed reports can harm: the case of supervised consumption services in Alberta.

Supervised consumption services have been scaled up within Canada and internationally as an ethical imperative in the context of a public health emergency. A large body of peer-reviewed evidence demonstrates that these services prevent poisoning deaths, reduce infectious disease transmission risk behaviour, and facilitate clients' connections to other health and social services. In 2019, the Alberta government commissioned a review of the socioeconomic impacts of seven supervised consumption services in the province. The report is formatted to appear as an objective, scientifically credible evaluation of these services; however, it is fundamentally methodologically flawed, with a high risk of biases that critically undermine its authors' assessment of the scientific evidence. The report's findings have been used to justify decisions that jeopardize the health and well-being of people who use drugs both in Canada and internationally. Governments must ensure that future assessments of supervised consumption services and other public health measures to address drug poisoning deaths are scientifically sound and methodologically rigorous. Health policy must be based on the best available evidence, protect the right of structurally vulnerable populations to access healthcare, and not be contingent on favourable public opinion or prevailing political ideology.

RéSUMé: Les services de consommation supervisée ont été établis au Canada et à l'étranger en tant qu'impératif éthique dans le contexte d'une urgence de santé publique. Un grand nombre d'études rigoureuses démontrent que ces services préviennent les décès par empoisonnement, réduisent les comportements à risque de transmission de maladies infectieuses, et facilitent les liens avec d'autres services sociaux et de santé. En 2019, le gouvernement de l'Alberta a commandé un examen des impacts socioéconomiques de sept services de consommation supervisée dans la province. La présentation du rapport donne l'impression que l'évaluation de ces services est objective et scientifiquement crédible; cependant, il présente des faiblesses importantes au plan méthodologique, notamment en raison de la présence de biais qui compromet l'évaluation des preuves scientifiques. Ses conclusions ont été utilisées pour justifier des décisions qui mettent en péril la santé et le bien-être des personnes qui consomment des drogues, tant au Canada qu'à l'étranger. Les gouvernements doivent s'assurer que les futures évaluations des services de consommation supervisée et d'autres mesures de santé publique pour lutter contre les décès par empoisonnement dû aux drogues sont scientifiquement fondées. Les politiques en matière de santé doivent être basées sur les meilleures données disponibles, protéger les droits des populations structurellement vulnérables à accéder aux soins de santé, et ne pas dépendre de l'opinion publique ou d'une idéologie politique dominante.

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.

Policy actor views on structural vulnerability in harm reduction and policymaking for illegal drugs: A qualitative study.

BACKGROUND: Health risks associated with drug use are concentrated amongst structurally vulnerable people who use illegal drugs (PWUD). We described how Canadian policy actors view structural vulnerability in relation to harm reduction and policymaking for illegal drugs, and what solutions they suggest to reduce structural vulnerability for PWUD. METHODS: The Canadian Harm Reduction Policy Project is a mixed-method, multiple case study. The qualitative component included 73 semi-structured interviews conducted with harm reduction policy actors across Canada's 13 provinces and territories between November 2016 and December 2017. Interviews explored perspectives on harm reduction and illegal drug policies and the conditions that facilitate or constrain policy change. Our sub-analysis utilized a two-step inductive analytic process. First, we identified transcript segments that discussed structural vulnerability or analogous terms. Second, we conducted latent content analysis on the identified excerpts to generate main findings. RESULTS: The central role of structural vulnerability (including poverty, unstable/lack of housing, racialization) in driving harm for PWUD was acknowledged by participants in all provinces and territories. Criminalization, in particular, was seen as a major contributor to structural vulnerability by justifying formal and informal sanctions against drug use and, by extension, PWUD. Many participants expressed that their personal understanding of harm reduction included addressing the structural conditions facing PWUD, yet identified that formal government harm reduction policies focused solely on drug use rather than structural factors. Participants identified several potential policy solutions to intervene on structural vulnerability including decriminalization, safer supply, and enacting policies encompassing all health and social sectors. CONCLUSIONS: Structural vulnerability is salient within Canadian policy actors' discourses; however, formal government policies are seen as falling short of addressing the structural conditions of PWUD. Decriminalization and safer supply have the potential to mitigate immediate structural vulnerability of PWUD while policies evolve to advance social, economic, and cultural equity.