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Background Exclusionary care policy contributes to the growing number of older adults experiencing homelessness and complex health challenges including substance misuse. The aim of this study was to examine how harm reduction policy and practices are experienced and enacted for older adults with homeless histories and care staff in congregate supportive housing. Methods Drawing on harm reduction (HR) principles, Rhodes’ risk environment framework, and 15 semi-structured interviews (six residents, nine staff) at a 70-bed supportive housing facility in Western Canada, this qualitative constructivist grounded theory study aimed to determine: How is harm reduction experienced and enacted from the perspectives of older adults and their care staff? Results HR policy and practices helped residents to feel respected and a sense of belonging, due largely to staff’s understanding of structural vulnerability related to homelessness and their efforts to earn and maintain residents’ trust. Physical and program structures in the facility combined with the social environment to mitigate harms due to substance- and nonsubstance-related risk behaviours. Conclusion HR policy and practices in supportive living empower care providers and older adults to work together to improve housing and health stability. Wider adoption of HR approaches is needed to meet the needs of a growing number of older people experiencing homelessness and substance use challenges.

Background Few studies have systematically examined the barriers and facilitators to buprenorphine uptake, despite increasing opioid-related harms and guideline recommendations for use. The aim of the study was to use behaviour change frameworks to investigate barriers and facilitators to buprenorphine access and use from diverse perspectives in Ontario, Canada. Methods We conducted semi-structured face-to-face or telephone interviews with Ontarians including: people with living/lived expertise of opioid use (including family members), healthcare professionals, and organizational and system-level representatives. We used purposive sampling via existing professional networks to recruit participants with diverse experiences. The Theoretical Domains Framework (TDF) guided the data collection tool and analysis. Interviews were recorded, transcribed, coded, and underwent thematic analysis involving three study team members. Results We interviewed 28 participants between September 2019 and January 2020. Three predominant TDF domains were identified across all 4 levels: (1) environmental context/resources; (2) beliefs about consequences; (3) social influences. Key cross-cutting themes included access to comprehensive care, medication and treatment characteristics, confidence and experiences with buprenorphine, as well as supportive relationships and stigma/discrimination. Conclusions Multi-level barriers to optimal buprenorphine implementation continue in the face of the drug toxicity crisis. To counter the identified barriers and enhance facilitators, there is need for mentorship models of support for prescribing, flexibility in buprenorphine treatment requirements, better recognition of mental health and the social determinants of health in buprenorphine treatment, and comprehensive and integrated systems of care.

Background Opiate agonist therapy (OAT) prescribing rates by family physicians are low in the context of community-based, comprehensive primary care. Understanding the factors that support and/or inhibit OAT prescribing within primary care is needed. Our study objectives are to identify and synthesize documented barriers to, and facilitators of, primary care opioid agonist prescribing, and effective strategies to inform intervention planning and support increased primary care OAT prescribing. Methods/design We will systematically search EMBASE, CINAHL, PsycINFO, Cochrane Central Register of Controlled Trials, MEDLINE, and gray literature in three domains: primary care providers, opioid agonist therapy, and opioid abuse. We will retain and assess primary studies reporting documented participation, or self-reported willingness to participate, in OAT prescribing; and/or at least one determinant of OAT prescribing; and/or strategies to address determinants of OAT prescribing from the perspective of primary care providers in comprehensive, community-based practice settings. There will be no restrictions on study design or publication date. Studies limited to specialty clinics with specialist prescribers, lacking extractable data, or in languages other than English or French will be excluded. Two reviewers will perform abstract review and data extraction independently. We will assess the quality of included studies using the Joanna Briggs Institute Critical Appraisal Tool. We will use a framework method of analysis to deductively code barriers and facilitators and to characterize effective strategies to support prescribing using a combined, modified a priori framework comprising the Theoretical Domains Framework and the Consolidated Framework for Implementation Research. Discussion To date, no synthesis has been undertaken of the barriers and facilitators or effective interventions promoting OAT prescribing by primary care clinicians in community-based comprehensive care settings. Enacting change in physician behaviors, community-based programming, and health services is complex and best informed by using theoretical frameworks that allow the analysis of the available data to assist in designing and implementing interventions. In light of the current opioid crisis, increasing the capacity of primary care clinicians to provide OAT is an important strategy to curb morbidity and mortality from opioid use disorder. Systematic review registration PROSPERO CRD86835

Background Inner city patients have a higher illness burden and need for care, but experience more unmet care needs. Hospital Addiction Medicine Consult Teams (AMCTs) are a promising emerging intervention. The objective of this study was to assess the impact of a Canadian AMCT-like intervention for inner city patients on reduction in high emergency department (ED) use, hospital admission, and inpatient length of stay. Methods Using a community-engaged, two-arm, pre-post, longitudinal quasi-experimental study design, 572 patients reporting active substance use, unstable housing, unstable income, or a combination thereof (302 at intervention site, 270 at control sites) were enrolled. Survey and administrative health service data were collected at baseline, six months post-enrolment, and 12 months post-enrolment. Multivariable regression models tested the intervention effect, adjusting for clinically important covariables (inpatient status at enrolment, medical complexity, age, gender, Indigenous identity, shelter use, opioid use). Results Initial bivariable analyses demonstrated an intervention effect on reduction in admissions and length of stay, however, this effect was no longer significant after adjusting for covariables. There was no evidence of reduction in high ED use on either bivariable or subsequent multivariable analysis. Conclusions After adjusting for covariables, no AMCT intervention effect was detected for reduction in high ED use, inpatient admission, or hospital length of stay. Further research is recommended to assess other patient-oriented intervention outcomes.

Background Although community-level benefits of health system engagement (i.e., health service planning, delivery, and quality improvement, engaged research and evaluation, and collaborative advocacy) are well established, individual-level impacts on the health and well-being of community members are less explored, in particular for people who use or have used illegal drugs (PWUD). Capacity building, personal growth, reduced/safer drug use, and other positive outcomes may or may not be experienced by PWUD involved in engagement activities. Indeed, PWUD may also encounter stigma and harm when interacting with healthcare and academic structures. Our objective is to uncover why, how, and under what circumstances positive and negative health outcomes occur during health system engagement by PWUD. Methods We propose a realist review approach due to its explanatory lens. Through preliminary exploration of literature, lived experience input, and consideration of formal theories, an explanatory model was drafted. The model describes contexts, mechanisms, and health outcomes (e.g., mental health, stable/safer drug use) involved in health system engagement. The explanatory model will be tested against the literature and iteratively refined against formal theories. A participatory lens will also be used, wherein PWUD with lived experience of health system engagement will contribute throughout all stages of the review. Discussion We believe this is the first realist review to explore the contextual factors and underlying mechanisms of health outcomes for PWUD who participate in health system engagement. A thorough understanding of the relevant literature and theoretical underpinnings of this process will offer insights and recommendations to improve the engagement processes of PWUD.

IntroductionHumanism has been identified as an important contributor to patient care and physician wellness; however, what humanism means in the context of medicine has been limited by opinion and a focus on personal characteristics. Our aim was to describe attitudes and behaviours that enable clinicians to integrate humanism within the clinical setting.MethodsWe conducted semi-structured individual interviews with ten clinical faculty to explore how they enact and experience humanism in patient care and clinical teaching. Interpretive description was used to analyze the data qualitatively.ResultsHumanism in medicine was described through five themes representing core attitudes and behaviours: whole person care, valuing, perspective-taking, recognizing universality, and relational focus. Whole person care involved recognizing the multiple dimensions of personhood and sensitivity to others’ needs; valuing involved respecting and appreciating others; perspective-taking consisted of considering others’ perspectives, suspending judgment, and listening; recognizing universality involved acknowledging the shared human condition, finding common ground, transcending roles, and humility; and relational focus was described through multiple relationships between patients, families, clinicians and learners, becoming part of another’s story, reciprocal influence, and accompaniment.ConclusionsWhereas previous descriptions of humanism have focused on clinicians’ personal qualities, our research describes a number of attitudinal and behavioural foundations of humanistic care and teaching, grounded in the experiences of clinical faculty. In drawing attention to the holistic and relational elements of humanism, our work highlights how these foundational elements can be more explicitly integrated into patient care, workplace culture, and clinical education.