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Background In Canada, several community-based, multi-service programs aimed at reaching vulnerable pregnant or parenting women with substance use and complex issues have emerged. These programs offer basic needs and social supports along with perinatal, primary, and mental health care, as well as substance use services. Evaluations of these ‘one-stop’ programs have demonstrated positive outcomes; nevertheless, few published studies have focused on how these programs are structured, on their cross-sectoral partnerships, and on clients’ perceptions of their services. Methods The Co-Creating Evidence (CCE) project was a three-year evaluation of eight multi-service programs located in six Canadian jurisdictions. The study used a mixed-methods design involving semi-structured interviews, questionnaires, output data, and de-identified client data. This article focuses on qualitative interviews undertaken with 125 clients during the first round of site visits, supplemented by interview data with program staff and service partners. Results Each of the programs in the CCE study employs a multi-service model that both reflects a wrap-around approach to care and is intentionally geared to removing barriers to accessing services. The programs are either operated by a health authority (n = 4) or by a community-based agency (n = 4). The programs’ focus on the social determinants of health, and their provision of primary, prenatal, perinatal and mental health care services is essential; similarly, on-site substance use and trauma/violence related services is pivotal. Further, programs’ support in relation to women’s child welfare issues promotes collaboration, common understanding of expectations, and helps to prevent child/infant removals. Conclusions The programs involved in the Co-Creating Evidence study have impressively blended social and primary care and prenatal care. Their success in respectfully and flexibly responding to women’s diverse needs, interests and readiness, within a community-based, wraparound service delivery model paves the way for others offering pre- and postnatal programming.

Background Individuals experiencing homelessness in Canada face high morbidity and mortality due to intersecting toxic drug and housing crises. These risks are profoundly gendered; women experiencing homelessness have a median age of death of just 36 years, significantly lower than women in the general population (85 years), and face heightened overdose risk. Despite these inequities, gender-disaggregated analyses across homelessness, shelter systems, and mortality remain limited. This study integrates multiple publicly available datasets to examine how gender and age shape patterns of homelessness, service access, and overdose mortality in Toronto, Ontario. Methods We drew on publicly available datasets to examine gendered patterns of homelessness, shelter service use and operations, and mortality in Toronto. Data extracted included: demographics, shelter visits, shelter capacity, service availability, and mortality by cause and location. When possible, data were aggregated by quarter and disaggregated by age and gender. Chi-square tests were performed when possible to assess differences by gender. Results Men comprised most people experiencing homelessness (57%), shelter users (58%), and individuals living outdoors (68%). However, women and gender-diverse individuals accounted for a larger share of outdoor deaths occurring at younger ages (< 40 years) compared with men. Although men accounted for most deaths in shelters (78%), there was no significant gender difference in the age of in-shelter mortality ( p  = 0.19). Shelter capacity was structurally gender-imbalanced: there were more men-only beds (37%) than women-only beds (18%). Harm reduction availability was limited across all shelter types and was lowest in women-only shelters (26%). Overdose was leading among women (76% of all deaths) and gender-diverse individuals (80%), compared to 46% of deaths among men. In addition, overdose deaths among women and gender-diverse individuals were significantly more concentrated in younger age groups (< 40 years), compared to men ( p  = 0.024). Conclusions While men represent the largest share of the homeless population, women and gender-diverse individuals account for a disproportionate share of overdose and premature deaths, often at younger ages. Limited women-only shelter capacity, scarcity of gender-responsive harm reduction services, and safety concerns in mixed-gender shelters may contribute to women and gender-diverse individuals relying on hidden homelessness or unsheltered settings, where harms are more likely to occur. Addressing these inequities requires expanding women-only and gender-affirming shelter spaces, strengthening trauma-informed and gender-responsive harm reduction, and ensuring staff are trained to provide safe, non-stigmatizing care.

Objectives Fentanyl has contributed to a sharp rise in the toxicity of the unregulated drug supply and fatal overdoses in Canada. It has also changed injection practices. Injection frequency has increased as a result and so has equipment sharing and health-related risks. The aim of this analysis was to explore the impact of safer supply programs on injection practices from the perspective of clients and providers in Ontario, Canada. Methods The data set included qualitative interviews with 52 clients and 21 providers that were conducted between February and October 2021 across four safer supply programs. Interview excerpts discussing injection practices were extracted, screened, coded and then grouped into themes. Results We identified three themes, each theme corresponding to a change in injection practices. The first change was a decrease in the amount of fentanyl used and a decrease in injection frequency. The second change involved switching to injecting hydromorphone tablets instead of fentanyl. Finally, the third change was stopping injecting altogether and taking safer supply medications orally. Conclusion Safer supply programs can contribute to reducing injection-related health risks in addition to overdose risks. More specifically, they have the potential to address disease prevention and health promotion gaps that stand-alone downstream harm reduction interventions cannot address, by working upstream and providing a safer alternative to fentanyl.

Background Since 2016, over 50,928 people have died of an opioid-related overdose in Canada. The unregulated supply of drugs is increasingly toxic and volatile, and fentanyl from unregulated, street-based markets is driving this epidemic. Concerns that existing overdose prevention approaches were insufficient to address the rising number of overdoses led to the implementation of safer supply programs (SSPs) in Canada. SSPs provide prescribed medications to people who use drugs and are designed for individuals at high risk of overdose for whom existing care options have been ineffective or inappropriate. Evidence of SSP impact is growing but implementation processes, including admissions, are not well understood nor well-described in practice guidelines. Our purpose was to describe how the admission processes of four Ontario SSPs evolved and how these changes influenced program reach and perceived effectiveness. Methods During 2021, we conducted short demographic and semi-structured interviews with healthcare providers (n = 21) from four SSPs in Ontario about implementation processes, challenges, and impacts. Thematic analysis of data concerning admission processes was conducted in MAXQDA and descriptive statistics in SPSSv28. Results Although the desire was for SSPs to have a broad reach, programs quickly realized they needed to develop strategies to manage the high demand for their programs. To manage this demand, strategies were implemented like waitlists, which were later replaced by points-based admission criteria. These admission criteria evolved over time, leading to a client population with high medical and social needs. The combination of high-acuity clients, limited capacity, and funding constraints, exacerbated by COVID-19, caused significant distress and burnout among service providers, prompting further changes to the SSPs. Discussion The implementation of SSPs in Ontario highlights the challenges of addressing intersecting public health emergencies in a resource-constrained healthcare system. SSPs, were adaptive and evolved in real time; while these adaptations addressed significant equity gaps, they also underscored the limitations of operating within an under-funded primary care model. The narrowing of admission criteria, necessitated by overwhelming demand and limited resources, ultimately constrained their reach and potential population-level impact.

Introduction Despite advances in HIV and hepatitis C virus (HCV) treatment, people who use drugs (PWUD) face significant barriers along prevention and treatment cascades. Safer supply programmes (SSPs) providing prescribed pharmaceutical alternatives to the unregulated drug supply may create opportunities for enhanced healthcare engagement and person‐centred care. Methods We conducted a qualitative study examining four SSPs in Ontario, Canada between February and October 2021. Semi‐structured interviews were conducted with 52 patients and 21 providers (including physicians, registered nurse practitioners, nurses and allied health professionals). Interviews explored experiences with safer supply and HIV/HCV care. Analysis used thematic techniques guided by the Consolidated Framework for Implementation Research. Results SSPs supported HIV/HCV care by first addressing patients’ substance use needs, which created subsequent opportunities for building trust for broader health engagement. Providers identified the safer supply model as giving PWUD something they wanted, which then opened opportunities to discuss HIV, HCV, and other sexually transmitted and blood‐borne infections. SSPs provided opportunities to support patients with HIV and HCV testing and treatment initiation, and safer supply medications were bundled with HIV and HCV medications to support adherence. Non‐punitive approaches helped overcome previous negative healthcare experiences by prioritizing patient autonomy. Implementation challenges included balancing flexible, patient‐directed care with programme requirements and coordinating comprehensive services around individual needs. Conclusions SSPs may improve HIV/HCV care delivery for PWUD by building services around their priorities and lived realities. The integration of safer supply with HIV/HCV care through daily dispensing and wraparound services showed promise for engaging people previously disconnected from care. While findings suggested improved treatment outcomes, limitations included data collection during COVID‐19, limited representation of some populations and a focus on opioid‐only programmes. Research examining long‐term outcomes and programme sustainability is needed as SSPs face growing scrutiny and closure in Canada.

Background As a teratogen, alcohol exposure during pregnancy can impact fetal development and result in adverse birth outcomes. Despite the clinical and social importance of prenatal alcohol use, limited routinely collected information or epidemiological data exists in Canada. The aim of this study was to pool data from multiple Canadian cohort studies to identify sociodemographic characteristics before and during pregnancy that were associated with alcohol consumption during pregnancy and to assess the impact of different patterns of alcohol use on birth outcomes. Methods We harmonized information collected (e.g., pregnant women’s alcohol intake, infants' gestational age and birth weight) from five Canadian pregnancy cohort studies to consolidate a large sample ( n  = 11,448). Risk factors for any alcohol use during pregnancy, including any alcohol use prior to pregnancy recognition, and binge drinking, were estimated using binomial regressions including fixed effects of pregnancy cohort membership and multiple maternal risk factors. Impacts of alcohol use during pregnancy on birth outcomes (preterm birth and low birth weight for gestational) were also estimated using binomial regression models. Results In analyses adjusting for multiple risk factors, women’s alcohol use during pregnancy, both any use and any binge drinking, was associated with drinking prior to pregnancy, smoking during pregnancy, and white ethnicity. Higher income level was associated with any drinking during pregnancy. Neither drinking during pregnancy nor binge drinking during pregnancy was significantly associated with preterm delivery or low birth weight for gestational age in our sample. Conclusions Pooling data across pregnancy cohort studies allowed us to create a large sample of Canadian women and investigate the risk factors for alcohol consumption during pregnancy. We suggest that future pregnancy and birth cohorts should always include questions related to the frequency and amount of alcohol consumed before and during pregnancy that are prospectively harmonized to support data reusability and collaborative research.

Effective prevention of risky alcohol use in pregnancy involves much more than providing information about the risk of potential birth defects and developmental disabilities in children. To categorize the breadth of possible initiatives, Canadian experts have identified a four-part framework for fetal alcohol spectrum disorder (FASD) prevention: Level 1, public awareness and broad health promotion; Level 2, conversations about alcohol with women of childbearing age and their partners; Level 3, specialized support for pregnant women; and Level 4, postpartum support for new mothers. In order to describe the level of services across Canada, 50 Canadian service providers, civil servants, and researchers working in the area of FASD prevention were involved in an online Delphi survey process to create a snapshot of current FASD prevention efforts, identify gaps, and provide ideas on how to close these gaps to improve FASD prevention. Promising Canadian practices and key areas for future action are described. Overall, Canadian FASD prevention programming reflects evidence-based practices; however, there are many opportunities to improve scope and availability of these initiatives.

Setting The crisis of unregulated fentanyl-related overdose deaths presents a significant public health challenge. This article describes the implementation and evaluation of four Safer Opioid Supply programs (SSPs) in Ontario, one in London and three in Toronto. Intervention and implementation SSPs aim to curtail overdose fatalities while connecting individuals using drugs to healthcare services. The programs involve a daily dispensed prescription of immediate-release hydromorphone tablets for take-home dosing alongside an observed dose of long-acting opioids like slow-release oral morphine. Implemented within a multidisciplinary primary care framework, these programs emphasize patient-centred approaches and comprehensive health and social support. Outcomes In our study conducted in 2020/2021, clients and service providers reported that receiving pharmaceutical opioids through these programs improved the clients’ health and well-being. The regulated supply was reported to lead to decreases in overdose incidents, use of unregulated substances, and criminalized activities. Increased engagement with healthcare and harm reduction services and improvements in social determinants of health, such as food security, were also reported. Despite these positive outcomes, some implementation challenges, including capacity issues and provider burnout, were described by service providers. Implications Our findings suggest that the combination of safer supply, wrap-around support, and harm reduction within primary care settings can lead to increased healthcare engagement, HIV/HCV prevention, testing, and treatment uptake, reducing the burden of infectious diseases and overdose risk. SSPs have the potential to meaningfully reduce overdose rates, address the ongoing overdose crisis, and if scaled up, influence population-level outcomes.

Prenatal alcohol exposure is a leading cause of disability, and a major public health concern in Canada. There are well-documented barriers for women and for service providers related to asking about alcohol use in pregnancy. Confidential research is important for learning about alcohol use before, during and after pregnancy, in order to inform fetal alcohol spectrum disorder (FASD) prevention strategies. The Research Advancement through Cohort Cataloguing and Harmonization (ReACH) initiative provides a unique opportunity to leverage the integration of the Canadian pregnancy and birth cohort information regarding women’s drinking during pregnancy. In this paper, we identify: The data that can be collected using formal validated alcohol screening tools; the data currently collected through Canadian provincial/territorial perinatal surveillance efforts; and the data currently collected in the research context from 12 pregnancy cohorts in the ReACH Catalogue. We use these findings to make recommendations for data collection about women’s alcohol use by future pregnancy cohorts, related to the frequency and quantity of alcohol consumed, the number of drinks consumed on an occasion, any alcohol consumption before pregnancy, changes in use since pregnancy recognition, and the quit date. Leveraging the development of a Canadian standard to measure alcohol consumption is essential to facilitate harmonization and co-analysis of data across cohorts, to obtain more accurate data on women’s alcohol use and also to inform FASD prevention strategies.