Weaving community-based participatory research and co-design to improve opioid use treatments and services for youth, caregivers, and service providers.

Integrating the voices of service users and providers in the design and delivery of health services increases the acceptability, relevance, and effectiveness of services. Such efforts are particularly important for youth opioid use treatments and services, which have failed to consider the unique needs of youth and families. Applying community-based participatory research (CBPR) and co-design can facilitate this process by contextualizing service user experiences at individual and community levels and supporting the collaborative design of innovative solutions for improving care. However, few studies demonstrate how to effectively integrate these methods and engage underserved populations in co-design. As such, this manuscript describes how our team wove CBPR and co-design methods to develop solutions for improving youth opioid use treatments and services in Canada. As per CBPR methods, national, provincial, and community partnerships were established to inform and support the project's activities. These partnerships were integral for recruiting service users (i.e., youth and caregivers) and service providers to co-design prototypes and support local testing and implementation. Co-design methods enabled understanding of the needs and experiences of youth, caregivers, and service providers, resulting in meaningful community-specific innovations. We used several engagement methods during the co-design process, including regular working group meetings, small group discussions, individual interviews and consultations, and feedback grids. Challenges involved the time commitment and resources needed for co-design, which were exacerbated by the COVID-19 pandemic and limited our ability to engage a diverse sample of youth and caregivers in the process. Strengths of the study included youth and caregiver involvement in the co-design process, which centered around their lived experiences; the therapeutic aspect of the process for participants; and the development of innovations that were accepted by design partners.

"A peer support worker can really be there supporting the youth throughout the whole process": a qualitative study exploring the role of peer support in providing substance use services to youth.

BACKGROUND: Youth (ages 12-24) rarely access services and supports to address substance use concerns. Peer support can facilitate service engagement and has been associated with positive substance use recovery outcomes in adults, yet few studies have examined this role among youth specifically. As such, this qualitative study explored the role of peer support in providing substance use services to youth in British Columbia and how best to support them in their role. METHODS: Participatory action research methods were used by partnering with youth who had lived/living experience of substance use, including peer support workers, to co-design the research protocol and materials. An initial focus group and subsequent interviews were held with 18 peer support workers who provide services to youth (ages 12-24) based on their own lived experience with mental health and/or substance use. The discussions were audio-recorded, transcribed verbatim, and analysed thematically using an inductive approach. RESULTS: Peer support workers' core experiences providing substance use services to youth centred around supporting youth throughout the whole process. This was accomplished by meeting youth where they are at, providing individualized care, and bridging the gap between other services and supports. However, participants experienced multiple organizational barriers hindering their ability to support youth and stressed the importance of having an employer who understands the work you are doing. This involved having someone advocating for the peer support role to promote collaboration, empowering peers to set boundaries and define their own role, and providing adequate training and mentorship. Finally, peer support workers described how their lived experience bridges connection and de-stigmatization at the individual, organizational, and community level, which was unique to their role. CONCLUSIONS: Peer support plays a unique role in youths' substance use journeys, given their own lived experience and flexibility within their role. However, their position is often misunderstood by employers and other service providers, leaving peers with inadequate support, training, and mentorship to do their job. The findings from this study call for improved integration of peer support into service environments, as well as standardized training that is in-depth and continuous.

"The system always undermined what I was trying to do as an individual": identifying opportunities to improve the delivery of opioid use services for youth from the perspective of service providers in four communities across British Columbia, Canada.

BACKGROUND: Substance use among youth is a longstanding global health concern that has dramatically risen in the era of highly toxic and unregulated drugs, including opioids. It is crucial to ensure that youth using unregulated opioids have access to evidence-based interventions, and yet, youth encounter critical gaps in the quality of such interventions. This study aims to address these gaps by identifying opportunities to improve the quality of opioid use services from the perspective of service providers, a perspective that has received scant attention. METHODS: This community-based participatory study was conducted in four communities in British Columbia (Canada), a province that declared a public health overdose emergency in 2016. Human-centered co-design workshops were held to understand service providers' (n = 41) experiences, needs, and ideas for improving the quality of youth opioid use services/treatments in their community. Multi-site qualitative analysis was used to develop overarching experiences and needs themes that were further contextualized in each local community. A blended deductive and inductive thematic analysis was used to analyze the ideas data. RESULTS: Three overarching themes were identified, reflecting service providers' goals to respond to youth in a timely and developmentally appropriate manner. However, this was significantly limited by organizational and systems-level barriers, revealing service providers' priorities for intra- and inter-organizational support and collaboration and systems-level innovation. Across communities, service providers identified 209 individual ideas to address these prioritized needs and improve the quality of youth opioid use services/treatments. CONCLUSION: These themes demonstrate a multi-level tension between macro-level systems and the meso-level organization of youth opioid use services, which undermine the quality of individual-level care service providers can deliver. These findings underscore the need for a coordinated multi-level response, such as developing youth-specific standards (macro-level), increasing inter-organizational activities and collaboration (meso-level), and creating programs that are specific to youths' needs (micro-level).

A qualitative study exploring how young people perceive and experience substance use services in British Columbia, Canada.

BACKGROUND: Substance use among youth (ages 12-24) is troublesome given the increasing risk of harms associated. Even more so, substance use services are largely underutilized among youth, most only accessing support when in crisis. Few studies have explored young people's help-seeking behaviours to address substance use concerns. To address this gap, this study explored how youth perceive and experience substance use services in British Columbia (BC), Canada. METHODS: Participatory action research methods were used by partnering with BC youth (under the age of 30) from across the province who have lived and/or living experience of substance use to co-design the research protocol and materials. An initial focus group and interviews were held with 30 youth (ages 12-24) with lived and/or living experience of substance use, including alcohol, cannabis, and illicit substances. The discussions were audio-recorded, transcribed verbatim, and analyzed thematically using a data-driven approach. RESULTS: Three main themes were identified and separated by phase of service interaction, starting with: Prevention/Early intervention, where youth described feeling unworthy of support; Service accessibility, where youth encountered many barriers finding relevant substance use services and information; and Service delivery, where youth highlighted the importance of meeting them where they are at, including supporting those who have milder treatment needs and/or do not meet the diagnosis criteria of a substance use disorder. CONCLUSIONS: Our results suggest a clear need to prioritize substance use prevention and early interventions specifically targeting youth and young adults. Youth and peers with lived and/or living experience should be involved in co-designing and co-delivering such programs to ensure their relevance and credibility among youth. The current disease model of care leaves many of the needs of this population unmet, calling for a more integrated youth-centred approach to address the multifarious concerns linked to young people's substance use and service outcomes and experiences.

Becoming our young people's case managers: caregivers' experiences, needs, and ideas for improving opioid use treatments for young people using opioids.

BACKGROUND: Evidence continues to show that young people, ages 15-24, remain at significant risk of harms from non-medical opioid use and opioid use disorder (OUD), with experts calling for widespread implementation of developmentally-appropriate interventions. These recommendations include the involvement of caregivers in the prevention, early intervention, and treatment of young people using opioids. However, little research has investigated caregivers' experiences supporting young people, leaving critical gaps in understanding this role. The aim of this study is to explore caregivers' experiences accessing opioid use treatments with young people and their needs and ideas for improving such treatments. METHODS: This study reports qualitative findings from Phase 1 of the Improving Treatment Together project, a multi-phase, multi-site community-based participatory study broadly aimed at co-designing opioid use treatments to improve the experiences and outcomes of young people using non-medical opioids. During Phase 1, a total of 27 caregivers (parents, guardians) participated in full-day workshops that were conducted in three communities in British Columbia, Canada. Following human-centred co-design methods, caregivers engaged in small and large group discussions of their experiences, needs, and ideas for improving opioid use treatments for young people. Discussions were audio-recorded, transcribed verbatim, and thematically analysed. RESULTS: Across communities, caregivers' main experiences were defined as 'becoming our young people's case managers' and 'enduring a never-ending rollercoaster'. To improve these experiences, two needs themes were identified - expanding organizational and system-level capacity and wider-spread understanding of opioid use as a health issue. Caregivers brainstormed a total of 378 individual ideas to meet these needs, several of which spanned multiple needs themes. CONCLUSIONS: Caregivers' experiences, needs, and ideas reveal critical opportunities for improving the quality of interventions for opioid use among young people. This study represents a substantial contribution to the design and implementation of developmentally-appropriate and family-centred interventions for young people using opioids.

"We need to build a better bridge": findings from a multi-site qualitative analysis of opportunities for improving opioid treatment services for youth.

BACKGROUND: Adolescence and young adulthood is an important period for substance use initiation and related harms. In the context of the ongoing opioid crisis, the risks for youth (ages 16-29) who use opioids are particularly heightened. Despite recommendations to adopt a developmentally appropriate and comprehensive approach to reduce opioid-related harms among youth, data continue to show that youth are not adequately engaged in opioid treatments and encounter many barriers. The aim of this study is to identify youth-centered opportunities for improving opioid treatment services. METHODS: This paper reports multi-site qualitative findings from youth participating in the 'Improving Treatment Together' project, a community-based participatory project being conducted in British Columbia and Alberta, two western Canadian provinces that have been dramatically impacted by the opioid crisis. Qualitative data were collected during three workshops with youth who used opioids and accessed opioid treatment services in the prior 12 months. These workshops were conducted in three communities following the core elements of human-centered co-design. A multi-site qualitative analysis was conducted to identify within- and between-site themes surrounding youths' needs for improving opioid treatment service experiences and outcomes. RESULTS: Three overarching needs themes were identified from across the communities. The first reflected youths' difficulties finding and staying connected to opioid treatment services, with the overarching need theme suggesting opportunities to reduce organizational and systems-related barriers to care, such as waiting times and wider information about service availability. The second area of need was rooted in youths' feelings of judgment when accessing services. Consequently, opportunities to increase respectful and empathic interactions were the overarching need. The final theme was more nuanced across communities and reflected opportunities for an individualized approach to opioid treatment services that consider youths' unique basic safety, social, and health needs. CONCLUSIONS: This study identifies fundamental directions for the operationalization and implementation of youth-centered opioid treatment services. These directions are contextualized in youths' lived experiences accessing services in their local communities, with overarching themes from across sites strengthening their transferability to other settings.

On the path to reclaiming Indigenous midwifery: Co-creating the Maternal Infant Support Worker pilot program.

OBJECTIVE: The aim of the Maternal Infant Support Worker (MiSW) pilot program was to implement a virtual training program for lay maternal-infant health providers in remote First Nations communities in Northwestern Ontario, Canada. METHODS: The MiSW pilot program was administered jointly by a community college and a university and consisted of a 20-week virtual course followed by a 9-month mentored work placement in the community. RESULTS: The MiSW pilot program was delivered successfully; 11 of 13 participants received a certificate from a community college. MiSWs provided culturally and linguistically appropriate care to women, infants, and families in their respective communities. MiSWs provided doula support in their communities-a first for our region since the policy of forced evacuation for birth was implemented. MiSWs developed a community of practice for ongoing education, as well as to support each other in their work. CONCLUSION: The MiSW pilot program demonstrated that it is possible to provide a virtual training program and then provide continued virtual mentorship as the participants work in their First Nations communities. By prioritizing Indigenous voices above those of the research team, we were able to gain the trust of the MiSWs and maintain engagement with communities.

Improving Treatment Together: a protocol for a multi-phase, community-based participatory, and co-design project to improve youth opioid treatment service experiences in British Columbia.

BACKGROUND: Opioid use is one of the most critical public health issues as highly potent opioids contribute to rising rates of accidental opioid-related toxicity deaths. This crisis has affected people from all age groups, including youth (ages 15-24) who are in a critical developmental period where the stakes of opioid use are especially high. Efforts to reduce the significant harms of opioid use have focused on the expansion of evidence-based treatments, including medications for opioid use disorder (e.g. buprenorphine). While these treatments are unequivocally life saving, recent evidence suggests that they may not align with youths' needs. Accordingly, the 'Improving Treatment Together' (ITT) project has been designed with the aim to improve youths' opioid treatment service experiences and outcomes by co-developing, implementing, and measuring youth-centred opioid use treatment service innovations. This manuscript describes the protocol for this multi-phase project. METHODS: The ITT project follows community-based participatory research (CBPR) and strategically integrates co-design processes throughout its four phases. Upon establishing a project partnership between national, provincial and community-based organizations, Phase 1 follows four core elements of human-centred co-design (empathy, needs identification, ideation, prototyping) in nine separate workshops. These workshops will be held in four diverse communities with youth, caregivers and service providers who have accessed or delivered opioid treatment services. Phase 1 will culminate in the co-production of opioid treatment service innovations to be considered by the project's partners for further co-development, pilot testing, and wider implementation during the remaining phases of the project. Throughout each phase, the project will collect and analyse both qualitative and quantitative research and evaluation data to determine the project's impact. DISCUSSION: This protocol provides a detailed description of the ITT project, with an emphasis on the project's application of co-design and CBPR processes, the planned research and implementation procedures, and the establishment of a unique partnership. To our knowledge, this is one of the first projects to integrate these participatory processes to the design, implementation and measurement of youth-centred opioid treatment services. Embedding these processes throughout each phase of the project will strengthen the relevance and feasibility of the project's service delivery innovations.

Assessing the relationship between multimorbidity and depression in older men and women: the International Mobility in Aging Study (IMIAS).

Objectives: Our study aims to assess whether multimorbidity is an independent risk factor for the development of depression in older adults living in Canada, Brazil, Colombia, and Albania and examines differences in incidence of depression regarding social and psychosocial characteristics.Methods: The longitudinal International Mobility Aging Study (IMIAS) collected information from adults between 65-74 years old. Depression was defined by a 16 or higher score assessed by the Centre for Epidemiological Studies Depression (CES-D) Scale. Multimorbidity was defined as having two or more chronic conditions, which were self-reported by participants using a list of eight physical chronic conditions. Poisson regression was performed to estimate the relative risk of depression in older adults with multimorbidity compared to those living with 0-1 chronic conditions, adjusting for sex, age, education, number of doctor visits, degree of assistance needed, social support, and smoking status. The analysis was stratified by study region (Canada; Latin America; Albania).Results: Crude and adjusted models showed no statistically significant associations between multimorbidity and the incidence of depression in any of the study regions, confirmed by sensitivity analyses. However, the incidence of depression varied across study region, confirmed by the intra-class correlation coefficient which indicated that 13% of variations in depression incidence were due to geographic differences.Conclusion: Multimorbidity does not appear to increase the risk of developing depression in older adults between 65-74. Higher rates of depression in Latin America and Albania (compared to Canada) may be attributed to lifecourse exposures to social and economic adversity in these regions.

Differences in hospital length of stay between neonates exposed to buprenorphine versus methadone in utero: A retrospective chart review.

INTRODUCTION: Neonatal abstinence syndrome is a growing concern in neonatal intensive care units in rural and remote settings. METHODS: A retrospective chart review was conducted of 180 mother-infant dyads born with in utero exposure to buprenorphine (n=60), methadone (n=60) or to other opioids (n=60) to determine neonatal length of stay in hospital, number of days on morphine, day of life of initiation of morphine and the need for phenobarbital. RESULTS: The length of stay in hospital for neonates was 5.8 days shorter (95% confidence interval [CI] 6.1 to 8.5 days) for buprenorphine exposure in utero compared to methadone (P=0.001). For neonates requiring treatment for Neonatal abstinence syndrome, those with in utero exposure to buprenorphine required 6.1 fewer days (95% CI 2.5 to 9.7) of treatment with morphine then those exposed to methadone (P<0.0005). There were no statistically significant differences in day of life of initiation of morphine therapy for each of the study groups. The proportion of neonates requiring adjuvant therapy with phenobarbital was statistically significantly higher in neonates exposed to methadone in utero than either buprenorphine or illicit opioids (P<0.0005). CONCLUSIONS: Retrospective data suggest that neonates with in utero exposure to buprenorphine experience a shorter length of stay in hospital, fewer days of treatment with morphine for neonatal abstinence syndrome, and less use of phenobarbital than neonates exposed in utero to methadone. This suggests that Ontario provincial guidelines should be updated to recommend buprenorphine as first line for replacement therapy in pregnancy.