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Qualitative assessment of crisis
services among persons using injection
drugs in the city of Saskatoon
Katherine Langa, Anas El-Aneeda, Shawna Berenbauma, Colleen
Anne Dellb, Judith Wrightc & Zoe Teed McKayd
a College of Pharmacy and Nutrition, University of Saskatchewan,
Saskatoon, SK, Canada
b Department of Sociology & School of Public Health, University of
Saskatchewan, Saskatoon, SK, Canada
c Public Health Services, Saskatoon Health Region, Saskatoon, SK,
Canada
d Mental Health & Addictions Services, Saskatoon Health Region,
Saskatoon, SK, Canada
Published online: 15 May 2015.
To cite this article: Katherine Lang, Anas El-Aneed, Shawna Berenbaum, Colleen Anne Dell, Judith
Wright & Zoe Teed McKay (2013) Qualitative assessment of crisis services among persons using
injection drugs in the city of Saskatoon, Journal of Substance Use, 18:1, 3-11
To link to this article: http://dx.doi.org/10.3109/14659891.2011.606350
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Journal of Substance Use, 2013; 18(1): 3–11
ORIGINAL ARTICLE
Qualitative assessment of crisis services among persons
using injection drugs in the city of Saskatoon
KATHERINE LANG1, ANAS EL-ANEED1, SHAWNA BERENBAUM1,
COLLEEN ANNE DELL2, JUDITH WRIGHT3, & ZOE TEED MCKAY4
1College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, SK, Canada,
2Department of Sociology & School of Public Health, University of Saskatchewan, Saskatoon, SK,
Canada, 3Public Health Services, Saskatoon Health Region, Saskatoon, SK, Canada, 4Mental
Health & Addictions Services, Saskatoon Health Region, Saskatoon, SK, Canada
Abstract
Objectives: Injection drug users (IDUs) are a population that exhibit poor utilization of health services,
despite having a greater need for health care than people who do not use drugs. Although several stud-
ies have reported reasons for poor utilization, these investigations are usually carried out in large urban
centres or outside of Canada. The purpose of this investigation is to examine barriers to accessing care
for IDUs in the small urban centre of Saskatoon, Canada.
Methods: Data were collected through group discussions and interviews with IDUs in Saskatoon.
Two group discussions were held with a total of 13 adults, and 12 youth IDUs were individually
interviewed. Qualitative content analysis was performed to determine major themes.
Results: Five barriers to care were identified by participants: poor communication with health ser-
vices; lack of system resources and restrictive policies; insufficient financial resources; discrimination
and stigmatization; and social support. Conversely, there were many services that participants found
helpful during times of crisis.
Conclusion: Many barriers to service access were identified by IDUs. In order to achieve a more
complete understanding of access to services in Saskatoon, views of health service providers will be
examined in the future.
Keywords: Injection drug use, needs assessment, barriers, qualitative
Introduction
Between 11 and 21 million people inject illicit substances worldwide, causing significant
morbidity and mortality (United Nations Office on Drugs and Crime [UNODC], 2009).
Canada is no exception, where illicit substance use has proven to be detrimental at both the
individual and societal levels (Wall et al., 2000; Rehm et al., 2007). Injection drug users
Correspondence: Anas El-Aneed, College of Pharmacy and Nutrition, University of Saskatchewan, 110 Science Place, Saskatoon,
SK S7N 5C9, Canada. Tel: +306 966 2013. Fax: +306 966 6377. E-mail: anas.el-aneed@usask.ca
ISSN 1465-9891 print/ISSN 1475-9942 online C
2013 Informa UK Ltd.
DOI: 10.3109/14659891.2011.606350
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4K. Lang et al.
(IDUs) and their families account for an increasing number of new blood-borne infec-
tions including HIV and Hepatitis C (Saskatoon Health Region Public Health Services,
2007). To limit disease transmission, and improve health and social outcomes for IDUs
and their families, it is important for health services to provide appropriate, equitable and
compassionate care. Although IDUs generally have a greater need for health services than
those who do not use drugs, their utilization of services is limited (Morrison et al., 1997;
Chitwood et al., 1999; Heinzerling et al., 2006). Previous studies have examined this issue
and uncovered that reasons for poor access to care can range from system resource deficien-
cies to discrimination (Drumm et al., 2003). The majority of these studies have been con-
ducted outside of Canada (Appel et al., 2004; Lally et al., 2008) or in large Canadian urban
centres (Wood et al., 2002). The purpose of this exploratory study was to assess the expe-
riences of IDUs while seeking help during a crisis in the small urban centre of Saskatoon,
Canada.
BRIDGE Saskatoon
BRIDGE (Building Relationships around Injection Drug Use for Greater Engagement)
Saskatoon is a community collective which facilitates cooperation among service providers,
researchers, policymakers and community activists with an interest in injection drug use ser-
vices (Saskatoon Health Region Public Health Services, 2007). Its mandate includes health
promotion and prevention of injection drug use, harm reduction, law enforcement and
treatment and recovery. This research was undertaken by members of BRIDGE Saskatoon,
in collaboration with the University of Saskatchewan and the Saskatoon Health Region, in
order to provide information to guide future actions.
Methods
Research framework
This research was conducted in Saskatoon, Canada, which has a population of 224,300
(“Population estimate & projection”, 2011). As the purpose of this investigation was pri-
marily exploratory, a qualitative method of data collection and synthesis was deemed most
appropriate. It was determined that group discussion was the most suitable method for col-
lecting data for several reasons. First, group discussions provide a friendly environment
where participants are able to identify important themes, rather than allowing them to
be predetermined by the research team (Morgan, 1998). In addition, group discussions
are superior to surveys when attempting to bridge the gap between two different groups
(in this case IDUs and researchers/service providers) (Morgan, 1998). Lastly, group dis-
cussions can provide an excellent medium for the collection of sensitive data (such as
information regarding illicit substance abuse) (Morgan, 1998). In our study, group dis-
cussion methodology was successfully employed among adult participants. However, after
unsuccessful recruitment of youth participants for group discussions, a community service
provider recommended holding personal, semi-structured interviews with this vulnerable
study population. As a result, 12 youths were successfully recruited and interviewed.
A letter of ethics exemption was provided by the University of Saskatchewan Behavioural
Research Ethics Board on the basis of the research being service oriented under the category
of needs assessment.
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Crisis services among persons using injection drugs 5
Study population
Twenty-five IDUs were recruited for this study with the assistance of two community-based
agencies. These agencies volunteered to assist with recruitment as some of their employees
are members of BRIDGE Saskatoon, and they frequently provide services to IDUs in the
city. To be included in this investigation, a participant should have injected drugs within
the past year. For privacy reasons, and to encourage participation, the only personal infor-
mation collected from participants was whether the participant’s age was within the adult
or youth criteria. Other demographic information such as gender or racial background was
not collected. AIDS Saskatoon recruited adults aged 19 years and older, and Communities
for Children identified youth participants between the ages of 15 and 24 years (as per the
United Nations definition of youth, in “Frequently asked questions”, 2011).
Data collection and instruments
Data were collected between January and July of 2009. Thirteen adult IDUs partici-
pated in two group discussions (each approximately an hour in duration). The participants
were divided into one group of six members and one group of seven members based
on convenience. Both groups were facilitated by community outreach workers, and after
obtaining verbal consent, the groups were audiotaped. For youth participants, personal,
semi-structured interviews were conducted. Twelve youth participated in the interviews
and only two gave permission to be audiotaped. In response, detailed notes were docu-
mented. Interviews with youth participants were facilitated by previous IDUs employed by
Communities for Children who were trained by the principal investigator. Each adult and
youth participant was provided a $20 honorarium.
The interview/group discussion guide was developed by members of BRIDGE Saskatoon
(service providers and researchers); two 1-hour meetings were held to develop the research
instrument. Many front-line health providers, such as drug counsellors, who engage on
daily interactions with IDUs, formulated the discussion guide; as such, validation was not
critical. In fact, other published work (Copeland, 1997; Drumm et al., 2003; Lee et al.,
2006) did not report piloting their study instrument, nor did they use literature to develop
the discussion guide. Four questions were eventually adopted:
•What was your experience when trying to get help during a “crisis”?
•Did you ever try to navigate services (the system) and what was the outcome?
•Do people treat you differently when you are trying to access services because of your
injection drug use?
•What are some of the resources that were helpful during times of crisis?
Data analysis
All audio tapes were transcribed verbatim by a research team member. An inductive
approach based on the framework method (as described by Ritchie & Spencer (2002))
was used. The analyst read the transcripts and notes several times to become familiar with
the data collected. During this stage, concepts were identified, and from these concepts, a
thematic framework was established. Using the defined themes, the analyst read the tran-
scripts again and coded each participant quotation according to the appropriate theme.
As comments from the group discussions and interviews were similar, and the age criteria
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6K. Lang et al.
for the two collection tools overlapped, data were integrated for analysis. The analysis was
externally verified by an independent auditor.
Findings
Participants identified different types of crises, such as homelessness, physical trauma and
drug-related problems, such as overdose and exhausting their drug supply. The data sug-
gested that there are many factors which may determine the way that IDUs experience care
during crisis situations. Five major themes were identified: poor communication with health
services; lack of system resources and restrictive policies; insufficient financial resources;
discrimination and stigmatization; and social support. Participants agreed that despite
problems in the current system, there are many successful aspects of service provision in
Saskatoon.
Poor communication with health services
Participants indicated that there are problems with integration between services, explaining
that service providers do not know where to send their clients for various service needs.
Another cause for concern among IDUs was communication between services and clients.
A participant shared that “people [IDUs] don’t know where to look [for help] or what’s
available”and that once the service is accessed, maintaining contact with service providers
is difficult.
Many participants stated that a viable source for accessing information was other IDUs
on the street. This was evident within the group discussions, as a significant portion
of the conversation centred on participants exchanging information about available ser-
vices. Nevertheless, participants explained that information transfer on the street alone is
inefficient:
That . . . program that we didn’t know about until we heard from somebody else. And
then we had to . . . through about three or four other people just to get that number.
Lack of system resources and restrictive policies
Deficiencies in system resources were discussed at length. Participants discussed the need
for shorter waiting lists and more availability (evenings and weekends). One woman
illustrated how insufficient system resources affected her life in a time of need:
I was getting abused, one time. When I phoned there [transient housing] they told me to
call back . .. And they’re saying “phone me back in a couple weeks and we might have an
opening.”
Some restrictive aspects of policy were noted, such as being “cut off” methadone due to
ongoing drug use or expelled from detoxification for swearing. The participants felt that
such policies were unfair, as they felt these behaviours should be tolerated. Additionally,
participants were reluctant to access services that required identification, such as needle
exchange.
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Crisis services among persons using injection drugs 7
Insufficient financial resources
Participants described the stress of “being broke” in an already stressful lifestyle. They
spoke at length about poor transient housing, homelessness and crowded living conditions.
Participants indicated that lack of money, transportation and a phone made finding care
difficult:
We didn’t have a phone at the time so we arranged with public health . . . to slide a note
under your door, let you know that you have an appointment . . . I go [to the service] to
go get uh, syringes . . . and one of the nurses [says] “did you go to your appointment?”
“What appointment?” “Oh, you missed it last week” . . . that happened three different
times.
Discrimination and stigmatization
Participants identified discrimination from service providers as a barrier to accessing care.
As service providers in Saskatoon were not consulted on this matter, it is unclear whether
they are actually discriminatory towards IDUs or the participants simply perceive discrim-
ination. However, stigma and discrimination among some service providers while dealing
with IDUs is well documented in the literature (Carroll, 1993; Chan & Reidpath, 2007).
Participants speculated that they were treated poorly by health-care professionals, public
agencies and law enforcement because of their appearance, race or drug using status. Some
felt they were treated differently than non-using clients and described rough treatment,
mistrust and a general lack of compassion:
They [hospital doctors] obviously thought I was a junkie, or you know, out, a piece of
shit . . . like, what did I do wrong, I’m a human being . . . His job is to take care of
people. Regardless of anything.
In addition, several people experienced poor treatment from the general public, saying
that injection drug use is “not acceptable out there”. Some participants also described
discrimination from family and friends:
Even my own family . . . they all know I’m, I’m a junkie, like I don’t hide the fact . . .
they’re all afraid that I’m gonna rip them off or steal their money.
Social support
Participants discussed how social networks were not always helpful. Many IDUs felt helpless
when their families stopped speaking to them and described how fear of family members
discovering their drug use prevented them from seeking care. One participant explained the
challenges of stopping drug use when her friends and family were still using drugs:
I came back from treatment and my old man is still using. So, that’s a trigger.
Although many IDUs explained how friends and family can have a negative impact on care,
some participants explained how friends and family have influenced them in a positive way.
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8K. Lang et al.
For them, social contacts provided assistance with physical needs such as housing, clean
needles and help during an overdose, as well as emotional support.
Success in the system
For every service with which participants had concerns, strengths were also recognized.
Participants noted that service providers working in the area of addictions were gener-
ally less discriminatory than other practitioners; indeed, the most preferred services in all
groups were those that specifically cater to the drug using population. Many participants
had positive experiences with health-care services, Aboriginal and religious programmes
and drug-related programmes:
What made it really easy was knowing that the [needle exchange] van would be there
every night.
Participants also commented about the way in which services were delivered. Although
participants expressed concerns with discrimination in many care settings, they did report
positive interactions with service providers. IDUs explained that their experience was gen-
erally better when staff members are lenient, friendly and knowledgeable. IDUs in previous
studies also found these characteristics to be desirable (Neale & Kennedy, 2002; Drumm
et al., 2003).
In one of the group discussions, participants offered solutions to some of the problems
that IDUs face, such as using pharmacists to aid with communication between agencies
and clients or opening a safe injection site. They also expressed some desire to be part
of prevention programming to stop community youth from injecting drugs. All of these
suggestions were put forward without prompting from the moderator.
Discussion
The findings of this investigation indicate that IDUs encounter multiple barriers when
attempting to access care during a crisis, although they acknowledge that there are currently
many useful services available. Challenges that IDUs face are a result of system deficiencies
(system resources and poor communication), service provider perception (discrimination)
and social issues (family support and insufficient financial resources). Our findings are con-
sistent with previous studies (Wood et al., 2002; Drumm et al., 2003; Appel et al., 2004;
Gustafson et al., 2008; Lally et al., 2008; Neale et al., 2008); however, there are themes
found in the literature that were not mentioned in this investigation. Personal factors for
avoiding care such as prioritization of drugs, incorrect belief that personal drug use prac-
tices are low risk and depressive symptoms have been discussed in previous studies, yet
were not discussed by the study participants (Drumm et al., 2003; Gustafson et al., 2008;
Lally et al., 2008). Additionally, the literature suggests that IDUs avoid care because they
believe service providers lack knowledge and experience to care for them (Drumm et al.,
2003), which was minimally mentioned in this investigation. This could be due to the small
sample size or because the questions posed were not suitable to stimulate conversation on
such themes.
There are limitations to this study. Typically, group discussions (or focus groups) and
interviews are held until no new information arises (i.e. saturation of data). Limited sample
size prevented saturation from being achieved. However, our emerged themes are consistent
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Crisis services among persons using injection drugs 9
with the literature (Wood et al., 2002; Drumm et al., 2003; Appel et al., 2004; Gustafson
et al., 2008; Lally et al., 2008; Neale et al., 2008). In addition, a large proportion of youth
participants did not want to be audiotaped, which may have caused crucial data to be omit-
ted or misinterpreted. The question guide was not pre-tested in the injection drug using
population; however, service providers involved in the care of IDUs did formulate the ques-
tions. Furthermore, the age criteria for the youth and adult groups overlapped slightly, and
the exact age of group discussion participants was unknown, which made determination
of age-based trends impractical. We opted for collecting limited demographic information
to encourage participation by AIDS Saskatoon clients. There also may be disparities in the
data that emerged between adult and youth participants as different data collection methods
were used (although question guide was the same).
Novel programmes described in the literature may present opportunities to resolve some
of the barriers discussed in this study. Peer leadership programmes, for example, train IDUs
to disseminate information, condoms and needles to their peers (Latkin, 1998; Friedman
et al., 2004; Davey-Rothwell & Latkin, 2007). This type of programme is ideal for smaller
urban centres where social networks may be closer than in a larger city. Findings of this
study indicate that this could be a successful programme in Saskatoon, as participants have
demonstrated the desire to be part of the solution. Additionally, such a programme would
take advantage of the fact that IDUs in Saskatoon receive a large proportion of drug use
safety information from their peers.
As discrimination was a dominant theme in this investigation, it is important to address
this issue, regardless of whether the discrimination is real or perceived. Further research
(as outlined below) may help to determine the opinions of Saskatoon service providers
regarding this matter. In addition, members of BRIDGE Saskatoon are currently developing
a workshop for health service providers to address stigma and discrimination issues. Central
to this programme is that the voice of IDUs leads the discussion.
As this investigation was primarily exploratory, demographic factors such as race and sex
were not examined. In Saskatoon, 80% of the IDUs using street services are Aboriginal, and
the majority of younger IDUs are female (Saskatoon Health Region Public Health Services,
2007). The literature has shown that the drug use experiences of these people may be
different than those of other demographic groups (Copeland, 1997; Wood et al., 2008), so
it may be worthwhile to conduct further research regarding women and Aboriginals who
inject drugs.
Engaging service providers in recognizing and addressing problems of stigmatization and
communication is an important step towards improving services. New initiatives are needed
to improve education and communication between service providers. We are undertaking a
second phase of this study, in which service providers will be asked questions complemen-
tary to the research presented here. Group discussions with service providers could provide
useful insight regarding the state of current services and also produce the information
necessary to implement new or improve programming in Saskatoon.
Acknowledgements
Financial support was provided by the University of Saskatchewan Summer Student
Employment Program (USTEP); the office of the Research Chair in Substance Abuse,
University of Saskatchewan, funded by a grant from the Ministry of Health; College
of Pharmacy and Nutrition; and Saskatoon Health Region. Assistance was provided by
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10 K. Lang et al.
AIDS Saskatoon, Indian & Metis Friendship Centre, Communities for Children, White
Buffalo Youth Lodge, as well as BRIDGE Saskatoon members: Meaghan Friesen, Kathy
Pruden-Nansel, Simrata Ritter, Grace Barr, Sherri Doell and Sue Delanoy.
Declaration of interest
The authors report no conflict of interest. The authors alone are responsible for the content
and writing of the paper.
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