ArticlePDF Available

Qualitative Assessment of Crisis Services among Persons Using Injection Drugs in the City of Saskatoon



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 studies 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 services; 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.
This article was downloaded by: [University of Saskatchewan Library]
On: 24 July 2015, At: 08:18
Publisher: Taylor & Francis
Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered
office: 5 Howick Place, London, SW1P 1WG
Journal of Substance Use
Publication details, including instructions for authors and
subscription information:
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,
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:
Taylor & Francis makes every effort to ensure the accuracy of all the information (the
“Content”) contained in the publications on our platform. However, Taylor & Francis,
our agents, and our licensors make no representations or warranties whatsoever as to
the accuracy, completeness, or suitability for any purpose of the Content. Any opinions
and views expressed in this publication are the opinions and views of the authors,
and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content
should not be relied upon and should be independently verified with primary sources
of information. Taylor and Francis shall not be liable for any losses, actions, claims,
proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or
howsoever caused arising directly or indirectly in connection with, in relation to or arising
out of the use of the Content.
This article may be used for research, teaching, and private study purposes. Any
substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing,
systematic supply, or distribution in any form to anyone is expressly forbidden. Terms &
Conditions of access and use can be found at
Downloaded by [University of Saskatchewan Library] at 08:18 24 July 2015
Journal of Substance Use, 2013; 18(1): 3–11
Qualitative assessment of crisis services among persons
using injection drugs in the city of Saskatoon
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
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
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:
ISSN 1465-9891 print/ISSN 1475-9942 online C
2013 Informa UK Ltd.
DOI: 10.3109/14659891.2011.606350
Downloaded by [University of Saskatchewan Library] at 08:18 24 July 2015
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,
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.
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.
Downloaded by [University of Saskatchewan Library] at 08:18 24 July 2015
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
Downloaded by [University of Saskatchewan Library] at 08:18 24 July 2015
6K. Lang et al.
for the two collection tools overlapped, data were integrated for analysis. The analysis was
externally verified by an independent auditor.
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
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
availableand 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
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
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
Downloaded by [University of Saskatchewan Library] at 08:18 24 July 2015
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
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
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.
Downloaded by [University of Saskatchewan Library] at 08:18 24 July 2015
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.
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
Downloaded by [University of Saskatchewan Library] at 08:18 24 July 2015
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.
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
Downloaded by [University of Saskatchewan Library] at 08:18 24 July 2015
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.
Appel, P. W., Ellison, A. A., Jansky, H. K., & Oldak, R. (2004). Barriers to enrollment in drug abuse treatment and
suggestions for reducing them: Opinions of drug injecting street outreach clients and other system stakeholders.
American Journal of Dr ug and Alcohol Abuse, 30(1), 129–153.
Carroll, J. (1993). Attitudes of professionals to drug abusers. British Journal of Nursing, 2(14), 705–711.
Chan, K. Y., & Reidpath, D. D. (2007). Stigmatization of patients with AIDS: Understanding the interrelationships
between Thai nurses’ attitudes toward HIV/AIDS, drug use, and commercial sex. AIDS Patient Care and STDs,
21(10), 763–775.
Chitwood, D. D., McBride, D. C., French, M. T., & Comerford, M. (1999). Health care need and utilization: A
preliminary comparison of injection drug users, other illicit drug users, and nonusers. Substance Use & Misuse,
34(4–5), 727–746.
Copeland, J. (1997). A qualitative study of barriers to formal treatment among women who self-managed change
in addictive behaviours. Journal of Substance Abuse Treatment, 14(2), 183–190.
Davey-Rothwell, M. A., & Latkin, C. A. (2007). HIV-related communication and perceived norms: An analysis of
the connection among injection drug users. AIDS Education & Prevention, 19(4), 298–309.
Drumm, R. D., McBride, D. C., Metsch, L., Page, J. B., Dickerson, K., & Jones, B. (2003). The rock always comes
first: Drug users’ accounts about using formal health care. Jour nal of Psychoactive Drugs, 35(4), 461–469.
Frequently Asked Questions. (2011). Retrieved from website:
Friedman, S. R., Maslow, C., Bolyard, M., Sandoval, M., Mateu-Gelabert, P., & Neaigus, A. (2004). Urging
others to be healthy: “Intravention” by injection drug users as a community prevention goal. AIDS Education
& Prevention, 16(3), 250–263.
Gustafson, D. L., Goodyear, L., & Keough, F. (2008). When the dragon’s awake: A needs assessment of people
injecting drugs in a small urban centre. International Jour nal of Drug Policy, 19(3), 189–194.
Heinzerling, K. G., Kral, A. H., Flynn, N. M., Anderson, R. L., Scott, A., Gilbert, M. L., Asch, S. M., & Bluthen-
thal, R. N. (2006). Unmet need for recommended preventive health services among clients of California syringe
exchange programs: Implications for quality improvement. Drug and Alcohol Dependence, 81(2), 167–178.
Lally, M. A., Montstream-Quas, S. A., Tanaka, S., Tedeschi, S. K., & Morrow, K. M. (2008). A qualitative study
among injection drug using women in Rhode Island: Attitudes toward testing, treatment, and vaccination for
hepatitis and HIV. AIDS Patient Care and STDs, 22(1), 53–63.
Latkin, C. A. (1998). Outreach in natural settings: The use of peer leaders for HIV prevention among injecting
drug users’ networks. Public Health Reports, 113(Suppl. 1), 151–159.
Lee, T. S., Fu, L., & Fleming, P. (2006). Using focus groups to investigate the educational needs of female injecting
heroin users in Taiwan in relation to HIV/AIDS prevention. Health Education Research, 21(1), 55–65.
Morgan, D. L. (1998). The focus group guidebook. Thousand Oaks, CA: Sage Publications.
Morrison, A., Elliott, L., & Gruer, L. (1997). Injecting-related harm and treatment-seeking behaviour among
injecting drug users. Addiction, 92(10), 1349–1352.
Neale, J., & Kennedy, C. (2002). Good practice towards homeless drug users: Research evidence from Scotland.
Health & Social Care in the Community, 10(3), 196–205.
Neale, J., Tompkins, C., & Sheard, L. (2008). Barriers to accessing generic health and social care services: A
qualitative study of injecting drug users. Health and Social Care in the Community, 16(2), 147–154.
Population Estimate & Projection. (2011). Retrieved from website:
Rehm, J., Gnam, W., Popova, S., Baliunas, D., Brochu, S., Fischer, B., Patra, J., Sarnocinska-Hart, A., & Taylor,
B. (2007). The costs of alcohol, illegal drugs, and tobacco in Canada, 2002. Journal of Studies on Alcohol and
Drugs, 68(6), 886–895.
Ritchie, J., & Spencer, L. (2002). Qualitative data analysis for applied policy research. In A. M. Huberman & M.
B. Miles (Eds.), The qualitative researcher’s companion (pp. 305–330). Thousand Oaks, CA: Sage Publications.
Downloaded by [University of Saskatchewan Library] at 08:18 24 July 2015
Crisis services among persons using injection drugs 11
Saskatoon Health Region Public Health Services. (2007). Building partnerships for health: A strategic planning
framework for injection drug use in Saskatoon. Saskatoon, SK: Saskatoon Health Region.
[UNODC] United Nations Office on Drugs and Crime. (2009). World drug report 2009. New York, NY: United
Nations Publications.
Wall, R., Rehm, J., Fischer, B., Brands, B., Gliksman, L., Stewart, J., Medved, W., & Blake, J. (2000). Social costs
of untreated opioid dependence. Journal of Urban Health, 77(4), 688–722.
Wood, E., Montaner, J. S. G., Li, K., Zhang, R., Barney, L., Strathdee, S. A., Tyndall, M. W., & Kerr, T. (2008).
Burden of HIV infection among Aboriginal injection drug users in Vancouver, British Columbia. American
Journal of Public Health, 98(3), 515–519.
Wood, E., Tyndall, M. W., Spittal, P. M., Li, K., Hogg, R. S., O’Shaughnessy, M. V., & Schechter, M. T. (2002).
Needle exchange and difficulty with needle access during an ongoing HIV epidemic. International Journal of
Drug Policy, 13(2), 95–102.
Downloaded by [University of Saskatchewan Library] at 08:18 24 July 2015
... [46,48] Moreover, the stigmatizing attitudes of health care providers appear to manifest in perceived treatment inequities [45,46]; for example, PWUD have reported receiving inadequate analgesia due to perceived drug-seeking assumptions [49] or as a result of intentionally underreporting pain to mitigate anticipated stigma from health care professionals. [46] Similar to HIV-related stigma, stigma and discrimination associated with drug use has also been associated with poorer physical [50,51] and mental health, [50][51][52] decreased treatment adherence, [53] and a reluctance to seek care for clinical indications, [46,49,54,55] which may ultimately exacerbate the poorer health outcomes commonly seen in this population. [56] PLWH who use drugs may be especially vulnerable to the negative health outcomes associated with mistreatment in health care settings. ...
... Optimal adherence was defined as greater than 95%, as this threshold has previously been shown to be associated with non-detectable VL and survival. [54] For HIV VL, we used the median of all observations in the previous 180 days. If none, we used the most recent observation. ...
Full-text available
People living with HIV (PLWH) often experience stigma and discrimination by health care professionals. We investigated the prevalence of perceived mistreatment in health care settings and its associations with HIV clinical outcomes and health care-seeking behaviour using data from a long-running prospective cohort of PLWH who use drugs. Of the 857 participants included, 19% reported at least one instance of perceived mistreatment during the study period. In adjusted longitudinal analyses, perceived mistreatment was positively associated with not being on ART in the same follow-up period, and participants who reported perceived mistreatment were less likely to report seeing a physician in the subsequent follow-up period. Daily use of injection drugs was positively associated with reporting perceived mistreatment. These findings demonstrate the implications of negative health care interactions in a population that must consistently engage with the health care system, and the need for stigma-reducing educational interventions for health care professionals.
... Current drug policy strategies in Saskatoon are inept at reducing the co-morbidity cases among the disadvantaged Indigenous group. A recent study conducted in Saskatoon demonstrated that PWID encounter multiple barriers when attempting to access harm reduction services which include but not limited to system deficiencies, poor communication, discrimination by healthcare providers and police and insufficient financial resources (42)(43)(44). Consequently, the health authority needs to take a paradigm shift toward more effective harm reduction programs in addition to the services that are being already provided. We suggest that harm reduction services in Saskatoon should include SIF as part of healthcare delivery to this vulnerable population. ...
... Recent qualitative studies conducted in Saskatoon suggests that the city could benefit from experimenting with smaller scale harm reduction approaches that rely on peer drug users to disseminate information and skills to the most marginalized PWID (42,43). Accordingly, the study suggests that this type of "program is ideal for smaller urban centers where social networks may be closer than in a larger city …. ...
Full-text available
Research predicting the public health and fiscal impact of Supervised Injection Facilities (SIFs), across different cities in Canada, has reported positive results on the reduction of HIV cases among People Who Inject Drugs (PWID). Most of the existing studies have focused on the outcomes of Insite, located in the Vancouver Downtown Eastside (DTES). Previous attention has not been afforded to other affected areas of Canada. The current study seeks to address this deficiency by assessing the cost-effectiveness of opening a SIF in Saskatoon, Saskatchewan. We used two different mathematical models commonly used in the literature, including sensitivity analyses, to estimate the number of HIV infections averted due to the establishment of a SIF in the city of Saskatoon, Saskatchewan. Based on cumulative cost-effectiveness results, SIF establishment is cost-effective. The benefit to cost ratio was conservatively estimated to be 1.35 for the first two potential facilities. The study relied on 34% and 14% needle sharing rates for sensitivity analyses. The result for both sensitivity analyses and the base line estimates indicated positive prospects for the establishment of a SIF in Saskatoon. The opening of a SIF in Saskatoon, Saskatchewan is financially prudent in the reduction of tax payers' expenses and averting HIV infection rates among PWID. © 2015 by Kerman University of Medical Sciences.
... As a result, PWUD who are not interested in receiving buprenorphine, and especially those in methadone programs, may be excluded from peer communications about The Spot van. Previous research has documented the importance of peer-to-peer information sharing among PWUD, however, which has been linked to healthcare utilization within populations of PWUD [103][104][105]. In addition to sharing flyers or pamphlets with other service organizations for PWUD and having greater information dissemination by the SSP staff, awareness of The Spot and its services could be aided through the use of formalized peer dissemination and recruitment strategies that ensure diverse messages about The Spot services [106][107][108]. ...
Full-text available
Introduction People who use drugs (PWUD) face a multitude of barriers to accessing healthcare and other services. Mobile health clinics (MHC) are an innovative, cost-effective health care delivery approach that increases healthcare access to vulnerable populations and medically underserved areas. There is limited understanding, however, of how PWUD perceive and experience MHCs. Methods Semi-structured interviews were conducted with 31 PWUD – 16 who had received care (clients) on an MHC (The Spot) and 15 who had not (non-clients) – to explore their perceptions and utilization of an MHC partnered with a mobile syringe services program in Baltimore, Maryland. Data analysis of the text was conducted using an iterative thematic constant comparison process informed by grounded theory. Results Clients and non-clients, once aware of the MHC, had positive perceptions of The Spot and its benefits for their individual health as well as for the wellbeing of their community. These sentiments among clients were largely driven by access to low-barrier buprenorphine and service delivery without stigma around drug use. However, lack of general awareness of the spot and specific service offering were barriers to its use among non-clients. Discussion MHCs provide an important opportunity to engage PWUD in healthcare and to expand buprenorphine use; however, even with accessibility near where PWUD access injection equipment, barriers to its use remain. Peer dissemination may be able to facilitate program information sharing and recruitment. • KEY MESSAGES • People who use drugs perceive a mobile health clinic in their neighbourhood as a benefit to their communities and themselves by improving access to healthcare services, providing access to low-threshold buprenorphine dispensation, and offering services without drug use stigma. • People who use drugs learned about a mobile health clinic in their neighbourhood largely through word-of-mouth. As a result, people received limited information about the mobile health clinic services creating a barrier to its use.
... The present study extends our knowledge about access barriers and support needs of PWLE, and lls an important gap in current research by providing PWLE perspectives on substance use treatment and service issues. Speci cally, our results con rm particular barriers to accessing treatment among PWLE, such as lack of information about available services, lack of motivation to seek support, discrimination and stigmatization, accessibility issues (including geographic and transportation), cost of treatment, service capacity and wait lists, among other structural barriers [48][49][50][51][52][53][54][55]. ...
Full-text available
Introduction: Substance use is a complex issue, with rates of illicit and licit substances varying across Canada, and in Ontario, specifically. Services and treatment options for problematic substance use remain vital. Recent initiatives to increase the effectiveness of services have been implemented, however, a disconnect remains between the availability and accessibility of these programs and the real-world experiences and needs of people with lived experience (PWLE). There is a lack of knowledge regarding barriers to accessing services and service needs, yet PWLE are best suited to identify these factors. As such, this study critically examined these issues among a cohort of PWLE in Ontario, Canada. Methods: Semi-structured, one-on-one interviews with n=50 adult PWLE participants were conducted. Participants were recruited from substance use services across Ontario, based on ConnexOntario’s directory of all provincial addiction services, as well as by word-of-mouth. Questions focused on participants’ experiences and perspectives on substance use services. All data were transcribed and underwent an inductive thematic analysis based on key themes that emerged. Results: Beneficial services identified varied based on participant experiences and needs. A variety of barriers to service access were acknowledged, primarily related to system-level issues such as an overall lack of services, a lack of service capacity, and a severe lack of service coordination and gaps in service delivery. Recommendations revolved around the need for low-barrier, affordable, seamless services run by non-judgemental staff, including fellow PWLE. Conclusions: This study identified needs and barriers to substance use care among PWLE in Ontario, and highlighted important areas for policy change and program planning and implementation. Concrete recommendations include the development of a government-funded, low-barrier, comprehensive and integrated model of substance use services that includes PWLE as collaborators and program facilitators to ensure that services are as successful and meaningful as possible. Results from this study will work towards the improvement of substance use treatment and service provision across the province.
... Indeed, studies have shown that rates of emergency department use and inpatient hospitalization are elevated in this population O'Brien et al., 2015;Thakarar, Morgan, Gaeta, Hohl, & Drainoni, 2015). From the perspective of PWID, the causes for primary care underutilization are numerous and range from system deficiencies, such as physical inaccessibility or lack of resources and restrictive policies, to personal factors, such as insufficient financial resources, having other daily priorities (including illicit drug use), or normalization of injection complications (Appel, Ellison, Jansky, & Oldak, 2004;Lally, Montstream-Quas, Tanaka, Tedeschi, & Morrow, 2008;McCoy, Metsch, Chitwood, & Miles, 2001;Lang et al., 2013;Wood et al., 2002). Stigma and discrimination towards PWID by health care providers are other important barriers that PWID report as reasons for their underutilization of services (Ahern, Stuber, & Galea, 2007). ...
Childhood traumatic experiences can disrupt attachment, influence personality development, and precipitate chronic disease. Although the repercussions of these experiences may also pose a barrier to healthcare, few studies have examined the association between childhood trauma and access to healthcare. Therefore, we sought to investigate whether a history of childhood trauma is associated with self-reported inability to access hospital care among persons who inject drugs (PWID). Data were derived from two prospective cohorts of PWID in Vancouver, Canada. We used multivariable generalized estimating equations to examine associations between five types of childhood trauma and self-reported inability to access hospital care, both overall and specifically due to perceived mistreatment by hospital staff. In total, 300 participants (18.3%) reported having tried but being unable to access hospital care in the previous 6 months at some point during the study period; the primary reason was perceived mistreatment by hospital staff (32.1%). In multivariable analyses, childhood emotional abuse was independently associated with self-reported inability to access hospital care, adjusted odds ratio (AOR) = 1.51, 95% CI [1.03, 2.20]. Childhood physical neglect was also independently associated with inability to access care due to perceived mistreatment by hospital staff, AOR = 1.80, 95% CI [1.11, 2.93]. This suggests potentially damaging consequences of early trauma in adult PWID populations. Further, this study emphasizes the need for trauma-informed models of care as well as the need to improve therapeutic alliances with survivors of childhood trauma in the PWID population.
... Stigma has received increasing attention as a health risk factor and an obstacle to service utilization among people with HIV [9][10][11][12][13] and people who inject drugs [14][15][16][17]. Stigma refers to a personal trait or mark that serves as the basis for social devaluation and discrediting [18]. ...
Full-text available
Marked overlap between the HIV and injection drug use epidemics in St. Petersburg, Russia, puts many people in need of health services at risk for stigmatization based on both characteristics simultaneously. The current study examined the independent and interactive effects of internalized HIV and drug stigmas on health status and health service utilization among 383 people with HIV who inject drugs in St. Petersburg. Participants self-reported internalized HIV stigma, internalized drug stigma, health status (subjective rating and symptom count), health service utilization (HIV care and drug treatment), sociodemographic characteristics, and health/behavioral history. For both forms of internalized stigma, greater stigma was correlated with poorer health and lower likelihood of service utilization. HIV and drug stigmas interacted to predict symptom count, HIV care, and drug treatment such that individuals internalizing high levels of both stigmas were at elevated risk for experiencing poor health and less likely to access health services.
Although oral direct acting agents (DAA) therapies have the potential to reduce the burden of hepatitis C virus (HCV) infection, treatment uptake remains low, particularly among people who inject drugs (PWID). This study examined the feasibility of an innovative peer‐based recruitment strategy to engage PWID in HCV testing and treatment. We interviewed an initial set of HCV antibody positive PWID as “primary indexes” to gather demographic, drug use, health information, and drug network characteristics. Primary indexes were then briefly educated on HCV and its treatment and encouraged to recruit their injection drug “network members” for HCV testing and linkage to care. Eligible network members were enrolled as “secondary indexes” and completed the same index study procedures. In sum, 17 of 36 primary indexes initiated the recruitment of 64 network members who were HCV antibody positive and eligible to become indexes. In multivariable analysis, successful recruitment of at least one network member was positively associated with prior HCV treatment (OR 2.80; CI [1.01, 7.72]), daily or more injection drug use (OR 2.38; CI [1.04, 5.47]), and a higher number of injection drug network members (OR 1.20; CI [1.01, 1.42]). Among the 69 participants with chronic HCV not previously linked to HCV care at enrollment, 91% (n=63) completed a linkage to HCV care appointment, 45% (n=31) scheduled an appointment with an HCV provider, and 20% (n=14) initiated HCV therapy. These findings suggest a potential benefit for peer‐driven, network‐based interventions focused on HCV treatment experienced PWID as a mechanism to increase HCV linkage to care.
Full-text available
Saskatoon has nearly half of the diagnoses of HIV in Saskatchewan, Canada, with an incidence rate among Indigenous populations within inner-city contexts that is 3 times higher than national rates. Previous research does not adequately explore the relations between HIV vulnerabilities within these contexts and the experiences of illness disclosure that are informed by identity transformations, experiences of stigma, and social support. From an intersectionality framework and a constructivist grounded theory approach, this research involved in-depth, semistructured interviews with 21 Indigenous people living with HIV and/or AIDS in Saskatoon, both male and female. In this article, we present the key themes that emerged from the interviews relating to experiences of HIV disclosure, including experiences of and barriers to the disclosure process. In the end, we highlight the important identity transformation and role of being and becoming a “helper” in the community and how it can be seen as a potential support for effective community health interventions.
Background: Frequent emergency department (ED) visits often suggest inappropriate use for low acuity needs and multiple comorbidities, including substance use disorders. Objective: This study examines associations of individuals and their social networks with high frequency ED use among persons reporting substance use. Methods: Information was obtained from interview responses from the first 6-month follow-up visit of a longitudinal. Prevalence ratios for the outcome of high frequency ED visits (≥2 in 6 months) were determined with a generalized linear model, log link, Poisson distribution and robust standard errors. Results: Of 653 participants, 131 (20%) had ≥2 ED visits. In multivariable analysis, greater likelihood of high frequency ED visits over 6 months was associated with being homeless (PR: 1.58; 95% CI: 1.19, 2.10), taking ≥3 medications (PR: 1.58; 95% CI: 1.19, 2.10) and having had a hospitalization over the same period (PR: 4.33; 95% CI: 3.26, 7.56). Among social network factors, lower likelihood of high frequency visits was associated with each increasing year of mean alter age (PR: 0.98; 95% CI: 0.6, 0.99) and greater likelihood with having received health-related informational support from ≥2 alters (PR: 1.62; 95% CI: 1.04, 2.53). Conclusions/Importance: Social network factors may play an important role in ED use. Interventions to promote health behaviors through social influence may be helpful in reducing high frequency ED visits.
The role of primary care physicians (PCP) in hepatitis C virus (HCV) prevention is increasingly emphasized. Yet, little is known about the patterns of contacts with PCP among persons who inject drugs (PWID). We sought to assess the 6-month prevalence of PCP visiting among PWID at risk of HCV infection and to explore the associated factors. Baseline data were collected from HCV-seronegative PWID recruited in HEPCO, an observational Hepatitis Cohort study (2004-2011) in Montreal, Canada. An interviewer-administered questionnaire elicited information on socio-demographic factors, drug use patterns and healthcare services utilization. Blood samples were tested for HCV antibodies. Using the Gelberg-Andersen Behavioral Model, hierarchical logistic regression analyses were conducted to identify predisposing, need and enabling factors associated with PCP visiting. Of the 349 participants (mean age = 34; 80.8% male), 32.1% reported visiting a PCP. In the multivariate model, among predisposing factors, male gender [adjusted odds ratio (AOR) = 0.45 (0.25-0.83)], chronic homelessness [AOR = 0.08 (0.01-0.67)], cocaine injection [AOR = 0.46 (0.28-0.76)] and reporting greater illegal or semi-legal income [AOR = 0.48 (0.27-0.85)] were negatively associated with PCP visits. Markers of need were not associated with the outcome. Among enabling factors, contact with street nurses [AOR = 3.86 (1.49-9.90)] and food banks [AOR = 2.01 (1.20-3.37)] was positively associated with PCP visiting. Only one third of participating PWID reported a recent visit to a PCP. While a host of predisposing factors seems to hamper timely contacts with PCP among high-risk PWID, community-based support services may play an important role in initiating dialogue with primary healthcare services in this population. © 2015 John Wiley & Sons Ltd.
Full-text available
Guided by a social influence and empowerment framework, peer leaders in the injecting drug user (IDU) community were trained to promote human immunodeficiency virus (HIV) prevention among their contacts within and beyond their sex and drug networks. From 1994 to 1995 in Baltimore, Maryland, 36 peer leaders who participated in the 10-session training program were administered pretest and posttest surveys. Evaluation included leaders' self-reported HIV-related behaviors and outreach activities. Survey data also were collected from 78 of the leaders' risk network members. Peer leaders reported a significant increase in condom use and in cleaning used needles with bleach. The leaders' risk network members, compared with controls, were significantly more likely to report greater needle hygiene. In an assessment of diffusion of information, the majority of risk network members who were current injectors reported receiving needle-cleaning materials from the leaders, and the majority of risk network members were able to correctly identify the HIV prevention slogans that had been taught to the leaders. The leaders documented 2165 HIV prevention interactions, of which 84% were with active drug users. The results from this study suggest that, in the IDU community, training peer leaders as HIV educators may promote HIV prevention among the leaders' risk network members and others at risk of acquiring and transmitting HIV. This training also may provide the leaders with effective prosocial roles.
Full-text available
Using cost-of-illness methodology applied to a comprehensive survey of 114 daily opiate users not currently in or seeking treatment for their addiction, we estimated the 1996 social costs of untreated opioid dependence in Toronto (Ontario, Canada). The survey collected data on social and demographic characteristics, drug use history, physical and mental health status, the use of health care and substance treatment services, drug use modality and sex-related risks of infectious diseases, sources of income, as well as criminality and involvement with the law enforcement system. The annual social cost generated by this sample, calculated at Canadian $5.086 million, is explained mostly by crime victimization (44.6%) and law enforcement (42.4%), followed by productivity losses (7.0%) and the utilization of health care (6.1%). Applying the $13,100 cost to the estimated 8,000 to 13,000 users and 2.456 million residents living in Toronto yields a range of social cost between $43 and $69 per capita.
Providing a general introduction to focus group research, Morgan includes the appropriate reasons for using focus groups and what you can expect to accomplish with them. He provides a brief history of focus groups, a discussion of when to use focus groups and why, and several brief case studies illustrating different uses of focus groups. The author covers the timeline and costs associated with focus groups, including a discussion of the ethical issues involved in focus group research. Thoroughly covering all the information to help you start your focus group project, this guidebook is appropriate for anybody beginning a focus group, as well as managers or clients who will be using focus groups.
During the mid to late 1990s, Vancouver, Canada experienced a rapid injection drug use-related HIV epidemic, despite the presence of a well-established, high-volume, needle exchange program (NEP). The NEP presently exchanges needles through several fixed sites, the largest of which operates in the city's Downtown Eastside where injection drug users (IDU) are concentrated, and through mobile exchange vans which exchange needles throughout neighboring areas. The program's inability to prevent the epidemic has led to persistent questions about the efficacy of needle exchange as a public health intervention. We recently sought possible explanations for persistent needle sharing through an evaluation of the Vancouver Injection Drug Users Study (VIDUS), an ongoing cohort study of IDU that began in 1996. In these analyses, the strongest predictor of needle sharing was difficulty accessing needles; those who reported difficulty accessing needles were 3.5 times more likely to report sharing than those who did not have difficulty with access. In the present study, we sought to identify reasons why IDU continued to have difficulty accessing needles despite the efforts of the NEP. Overall, 761 active injectors were interviewed during the period June 2000–May 2001. Of these 172 (22.6%) reported having difficulty accessing sterile needles. In a multivariate analysis, frequent cocaine injection and bingeing were associated with difficulty accessing needles, whereas residing in the Downtown Eastside was negatively associated with difficulty. When we evaluated IDU's reasons for difficulty with access, the most common reasons given were the operating hours of the NEP, difficulty meeting the needle exchange van, being away from the area where needles are exchanged, and being refused sterile needles at pharmacies. These findings suggest that programmatic deficiencies related to the operation of the needle exchange and refusal of pharmacists to sell needles may be primary factors related to difficulty accessing needles.
Aims: This study aims to identify the physical harm associated with injecting drug use and examine the treatment-seeking behaviour of injecting drug users (IDUs). Specific attention is given to the factors associated with presentation and non-presentation of injecting-related problems. Design: Participants were interviewed by research staff using a semi-structured questionnaire, then physically examined by a medical team. Setting: Needles exchanges in Glasgow. Participants: One hundred and twelve injecting drug users. Findings: Respondents' accounts of their current injecting-related problems were found to be consistent with the clinician's findings, suggesting that IDUs are able to self-diagnose injecting-related harm. However, almost three-quarters had not sought help for these problems. Qualitative data suggest the main reasons for non-presentation, or delayed presentation, of injecting-related problems are normalization of injecting-related harm and a reluctance to attend available services. Almost half of those seeking treatment for injecting-related problems did so during an emergency or crisis. Conclusions: Low threshold services, such as needle exchanges, may have to take a more proactive stance to encourage injectors to present with injecting-related problems. This may help reduce injecting-related harms, especially the resulting medical complications, which would in turn relieve the pressure on other services such as hospital Accident and Emergency Departments.
Drug abusers are generally regarded as a demanding client group by health care professionals. The occupational background of health care professionals and their familiarity with drug users is likely to affect their emotional responses and attitudes. Professional carers who are more familiar with drug users, e.g. addiction counsellors and psychiatric nurses, tend to have a more positive attitude. Awareness of HIV infection may increase the fears and anxieties of professionals, resulting in a more negative attitude to drug users. Little research has been carried out into the attitudes of professional carers, particularly nurses, towards drug users. Attitudes of professional carers are very important in determining standards of care delivery and more research is needed into the effects of attitudes on the delivery of health care.
Alcohol and drug abuse and dependence are common disorders in our society, and the vast majority of those who recover do so without formal treatment. Although this phenomenon appears to be more common among women than men there has been no gender-sensitive research. This qualitative study explored the barriers to formal treatment seeking among women who self-managed change in their alcohol and other drug dependence. The principal barriers identified included social stigma and labelling; lack of awareness of the range of treatment options, concerns about childcare, the perceived economic and time costs of residential treatment, concerns about the confrontational models used by some treatment services, and stereotypical views of clients of treatment services. A number of recommendations were made regarding program reach and content.
This paper investigates the relationship between chronic drug use and the health care system. Data from 536 African-American, Hispanic, and non-Hispanic White men and women were analyzed to determine independent risk factors for three outcome variables: 1) Need for health care treatment, 2) Utilization of health care treatment, and 3) Failure to receive needed treatment. Nine independent demographic, health, and drug-use history variables were assessed in logistic regression models. Chronic drug users were more likely in the past year to need health care treatment, were as likely to receive some health care treatment, and were more likely not to receive needed treatment than were nonusers.