Capabilities and quality of life in Dutch psycho-geriatric nursing homes: an exploratory study using a proxy version of the ICECAP-O

Purpose

To validate the ICECAP-O capability measure in psycho-geriatric elderly in nursing homes, we compared the capability scores of restrained and unrestrained clients. Both nursing staff and family were used as proxies for assessing clients?? capabilities.

Method

For 122 psycho-geriatric elderly, a total of 96 nursing professionals and 68 family members completed a proxy questionnaire. We investigated the convergent and discriminant validity of the ICECAP-O and measures of care dependency, health-related quality of life, and overall quality of life. We also directly compared ICECAP-O scores of the 56 clients for whom both nursing staff and family members had completed the questionnaire.

Results

Convergent validity between ICECAP-O and care dependency, health-related, and overall quality of life measures could be established, as well as discriminant validity for the restrained and unrestrained groups. Nursing and family proxy ICECAP-O tariffs were not significantly correlated.

Discussion

ICECAP-O measures a more general concept than health-related quality of life and can differentiate between restrained and non-restrained psycho-geriatric clients. Since nurses seem to be able to assess the current quality of life of clients using the ICECAP-O more precisely than the family proxies, for now the use of nursing proxies is recommended in a nursing home setting.     

Domestic violence management in Malaysia: A survey on the primary health care providers

Aim

To assess the knowledge, attitudes and practices of primary health care providers regarding the identification and management of domestic violence in a hospital based primary health care setting.

Method

A survey of all clinicians and nursing staff of the outpatient, casualty and antenatal clinics in University Malaya Medical Centre using a self-administered questionnaire.

Results

Hundred and eight out of 188 available staff participated. Sixty-two percent of the clinicians and 66.9% of the nursing staff perceived the prevalence of domestic violence within their patients to be very rare or rare. Majority of the clinicians (68.9%) reported asking their patients regarding domestic violence 'at times' but 26.2% had never asked at all. Time factor, concern about offending the patient and unsure of how to ask were reported as barriers in asking for domestic violence by 66%, 52.5% and 32.8% of the clinicians respectively. Clinicians have different practices and levels of confidence within the management of domestic violence. Victim-blaming attitude exists in 28% of the clinicians and 51.1% of the nursing staff. Less than a third of the participants reported knowing of any written protocol for domestic violence management. Only 20% of the clinicians and 6.8% of the nursing staff had ever attended any educational program related to domestic violence.

Conclusion

Lack of positive attitude and positive practices among the staff towards domestic violence identification and management might be related to inadequate knowledge and inappropriate personal values regarding domestic violence.     

Evaluation of lifestyle interventions to treat elevated cardiometabolic risk in primary care (E-LITE): a randomized controlled trial

Background

Physicians in small to moderate primary care practices in the United States (U.S.) (<25 physicians) face unique challenges in implementing quality improvement (QI) initiatives, including limited resources, small staffs, and inadequate information technology systems 23,36. This qualitative study sought to identify and understand the characteristics and organizational cultures of physicians working in smaller practices who are actively engaged in measurement and quality improvement initiatives.

Methods

We undertook a qualitative study, based on semi-structured, open-ended interviews conducted with practices (N = 39) that used performance data to drive quality improvement activities.

Results

Physicians indicated that benefits to performing measurement and QI included greater practice efficiency, patient and staff retention, and higher staff and clinician satisfaction with practice. Internal facilitators included the designation of a practice champion, cooperation of other physicians and staff, and the involvement of practice leaders. Time constraints, cost of activities, problems with information management and or technology, lack of motivated staff, and a lack of financial incentives were commonly reported as barriers.

Conclusion

These findings shed light on how physicians engage in quality improvement activities, and may help raise awareness of and aid in the implementation of future initiatives in small practices more generally.     

Scientists and clinicians have to be on the qui VIVE: benefit, outcome, value and utility in health care as a challenge

Aim

Health care is no longer a national topic as the results of health care research as well as health care services are shared across countries and continents. The common feature in almost any of these countries is the perceived limitation of health care resources and the discussions about health care expenditures which strongly depend on the definition of health care values.

Hygienization of terms

Identical terms should be used with the same commonly accepted meanings.

Different perspectives–different values

Health care values from a US, UK and German perspective are compared and the influence of the perspectives on practical health care decisions are discussed.

The sequence of value information validity evidence (VIVE)

Seven steps are presented which can capture the value of health care from the perspectives of different players.

Conclusion

Two reciprocal perspectives explain the differences. The individual perspective, which is used by patients and doctors, considers consequences per costs, while a general perspective, which is used by economists and politicians, considers costs per consequences. The conclusions derived from these two perspectives are different and depend on values, not directly on evidence. Nevertheless, evidence is essential to coin our values. Therefore, it is essential first to define the problem which has to be solved, and subsequently to select the methods that help to find and to appraise the found evidence. The appraised evidence will coin our values which finally are the basis for solving the problems.     

A successful chronic care program in Al Ain-United Arab Emirates

Background

The cost effective provision of quality care for chronic diseases is a major challenge for health care systems. We describe a project to improve the care of patients with the highly prevalent disorders of diabetes and hypertension, conducted in one of the major cities of the United Arab Emirates.

Settings and Methods

The project, using the principles of quality assurance cycles, was conducted in 4 stages. The assessment stage consisted of a community survey and an audit of the health care system, with particular emphasis on chronic disease care. The information gleaned from this stage provided feedback to the staff of participating health centers. In the second stage, deficiencies in health care were identified and interventions were developed for improvements, including topics for continuing professional development. In the third stage, these strategies were piloted in a single health centre for one year and the outcomes evaluated. In the still ongoing fourth stage, the project was rolled out to all the health centers in the area, with continuing evaluation. The intervention consisted of changes to establish a structured care model based on the predicted needs of this group of patients utilizing dedicated chronic disease clinics inside the existing primary health care system. These clinics incorporated decision-making tools, including evidence-based guidelines, patient education and ongoing professional education.

Results

The intervention was successfully implemented in all the health centers. The health care quality indicators that showed the greatest improvement were the documentation of patient history (e.g. smoking status and physical activity); improvement in recording physical signs (e.g. body mass index (BMI)); and an improvement in the requesting of appropriate investigations, such as HbA1c and microalbuminurea. There was also improvement in those parameters reflecting outcomes of care, which included HbA1c, blood pressure and lipid profiles. Indicators related to lifestyle changes, such as smoking cessation and BMI, failed to improve.

Conclusion

Chronic disease care is a joint commitment by health care providers and patients. This combined approach proved successful in most areas of the project, but the area of patient self management requires further improvement.     

Predictors of health related quality of life in older people with non-communicable diseases attending three primary care clinics in Malaysia

Objectives

To determine the health related quality of life and its predictive factors among older people with non-communicable diseases attending primary care clinics.

Design

Cross-sectional study.

Setting

Three public primary care clinics in a district in Selangor, Malaysia.

Participants

Registered patients aged 55 years and above.

Measurements

A face-to-face interview was conducted using a validated questionnaire of Medical Outcome Study 36-item short form health survey (SF-36). The outcome measure was the health related quality of life (HRQoL) and other factors measured were socio demography, physical activity, social support (Duke-UNC Functional Social Support Questionnaire), and presence of non-communicable diseases.

Results

A total of 347 participants had non-communicable diseases which included hypertension (41.8%), type 2 diabetes (33.7%), asthma (4.8%), hyperlipidaemia (1.7%), coronary heart disease (1.2%), and osteoarthritis (0.2%). Age ?? 65 years old (OR =2.23; 95%CI=1.42, 3.50), single (OR=1.75; 95%CI=1.06,2.90), presence of co-morbid condition (OR=1.66; 95%CI=1.06, 2.61), and poorer social support (OR=2.11; 95%CI=1.27, 3.51; p=0.002) were significant predictors of poorer physical component of HRQoL. In predicting lower mental health component of HRQoL, the significant predictors were women (OR=2.28; 95%CI=1.44, 3.62), Indian ethnicity (OR=1.86; 95%CI=1.08, 3.21) and poorer social support (OR=2.71; 95%CI=1.63, 4.51). No interactions existed between these predictors.

Conclusion

Older people with non-communicable diseases were susceptible to lower health related quality of life. Increasing age, single, presence of co-morbid conditions, and poorer social support were predictors of lower physical health component of HRQoL. While the older women, Indian ethnicity and poorer social support reported lower mental health component of HRQoL.     

Knowledge and performance of the Ethiopian health extension workers on antenatal and delivery care: a cross-sectional study

Background

This paper describes the task-shifting taking place in health centres and district hospitals in Mozambique and Zambia. The objectives of this study were to identify the perceived causes and factors facilitating or impeding task-shifting, and to determine both the positive and negative consequences of task-shifting for the service users, for the services and for health workers.

Methods

Data collection involved individual and group interviews and focus group discussions with health workers from the civil service.

Results

In both the Republic of Mozambique and the Republic of Zambia, health workers have to practice beyond the traditional scope of their professional practice to cope with their daily tasks. They do so to ensure that their patients receive the level of care that they, the health workers, deem due to them, even in the absence of written instructions. The “out of professional scope” activities consume a significant amount of working time. On occasions, health workers are given on-the-job training to assume new roles, but job titles and rewards do not change, and career progression is unheard of. Ancillary staff and nurses are the two cadres assuming a greater diversity of functions as a result of improvised task-shifting.

Conclusions

Our observations show that the consequences of staff deficits and poor conditions of work include heavier workloads for those on duty, the closure of some services, the inability to release staff for continuing education, loss of quality, conflicts with patients, risks for patients, unsatisfied staff (with the exception of ancillary staff) and hazards for health workers and managers. Task-shifting is openly acknowledged and widespread, informal and carries risks for patients, staff and management.     

From parallel practice to integrative health care: a conceptual framework

Background

"Integrative health care" has become a common term to describe teams of health care providers working together to provide patient care. However this term has not been well-defined and likely means many different things to different people. The purpose of this paper is to develop a conceptual framework for describing, comparing and evaluating different forms of team-oriented health care practices that have evolved in Western health care systems.

Discussion

Seven different models of team-oriented health care practice are illustrated in this paper: parallel, consultative, collaborative, coordinated, multidisciplinary, interdisciplinary and integrative. Each of these models occupies a position along the proposed continuum from the non-integrative to fully integrative approach they take to patient care. The framework is developed around four key components of integrative health care practice: philosophy/values; structure, process and outcomes.

Summary

This framework can be used by patients and health care practitioners to determine what styles of practice meet their needs and by policy makers, healthcare managers and researchers to document the evolution of team practices over time. This framework may also facilitate exploration of the relationship between different practice models and health outcomes.     

Health technology assessment of utilization,practice and ethical issues of self-pay services in the German ambulatory health care setting

Objectives

The provision of self-pay medical services is common across health care systems, but understudied. According to the German Medical Association, such services should be medically necessary, recommended or at least justifiable, and requested by the patient. We investigated the empirical evidence regarding frequency and practice of self-pay services as well as related ethical, social, and legal issues (ELSI).

Methods

A systematic literature search in electronic databases and a structured internet search on stakeholder websites with qualitative and quantitative information synthesis.

Results

Of 1,345 references, we included 64 articles. Between 19 and 53 % of insured persons received self-pay service offers from their physician; 16–19 % actively requested such services. Intraocular pressure measurement was the most common service, followed by ultrasound investigations. There is a major discussion about ELSI in the context of individual health services.

Conclusions

Self-pay services are common medical procedures in Germany. However, the empirical evidence is limited in quality and extent, even for the most frequently provided services. Transparency of their provision should be increased and independent evidence-based patient information should be supplied.     

Trends in health resource disparities in primary health care institutions in Liaoning Province in Northeast China

Background

The allocation of health resources in primary health care institutions (PHCI) is crucial to health reform. China has recently implemented many reform measures emphasizing the provision of primary health care services, with equity as one of the major goals. The aim of this study was to analyze the quantity, quality, and distribution of health resources in Liaoning Province from 2005 to 2017.

Methods

Data were drawn from the annual financial report from 2005 to 2017 and information from the Liaoning Province Department of Statistics. Numbers of beds and physicians were used as indicators of health resources. Capital assets per bed, value of medical equipment per bed, operational space per bed, and number of physicians with different educational levels were used as indicators of quality of health resources. Concentration indices (CI) and Gini coefficients were calculated.

Results

There was a steady rise in health resources in PHCI. From 2005 to 2017, the quality of health resources improved. The CI of beds showed an overall downward trend, indicating an improvement in the disparity among PHCI. There was a similar trend in the CI of fixed assets per bed. The Gini coefficients of physicians overall and physicians with different educational levels were almost always <?0.3, showing preferred equity status. There was a decreasing trend in the Gini coefficients of PHCI physicians with bachelor’s degrees or higher and physicians with associate’s degrees. The proportion of health resource of PHCI in health system increased from 2005 to 2009, before decreasing from 2009 to 2017 and the percentage of physicians overall and physicians with bachelor’s degrees or higher in PHCI declined after 2011.

Conclusions

There was an improvement in the quantity and quality of health resources in PHCI from 2005 to 2017. The distribution of health resource allocation in PHCI also improved. The findings revealed that the measures for the improvement of PHCI physicians’ educational level has been successful and the measures taken by the government in health reform to strengthen the primary health care system have not been successful.

     

Determinants of out-of-pocket health expenditure in China

Background

Within total health expenditure, the share of out-of-pocket health expenditure by individuals has increased in the past 25 years in China, from 20% in 1980 to 49% in 2006, with a peak of 59% in 2000. Medical issues have become a larger concern than any other issue for households.

Objective

To estimate the determinants of individual out-of-pocket health expenditure in China.

Methods

We used a subsample of 9860 adults aged ≥18 years from the 2004 China Health and Nutrition Survey. To control for potential sample selection bias, the Heckman selection model was used to analyse individuals’ health expenditure decisions, which is based on a sample that excludes individuals who do not report paying for healthcare.

Results

Of the sampled population, 24.6% reported recent illness, 80.6% of whom sought care; 82.3% of those who sought care reported the amount of health spending. The average out-of-pocket health expenditure was Chinese Yuan (Y) 502 (Y100 = $US12.2 in 2004). Illness perceived as ‘quite serious’ and self-reported poor health status had the highest coefficients (2.012 [p < 0.01] and 3.351 [p < 0.01], respectively). People spent more on healthcare with increasing age, especially over the age of 65 years, with a coefficient of 1.171 (p < 0.01). Those who had chronic disease, earned higher incomes, resided in urban areas, lived in the middle or eastern region, or lived in a household with a head having a middle school or higher education paid more for healthcare. In the model examining disaggregated effects of insurance programmes, the coefficients were positive, except for commercial insurance, and the coefficient for labour insurance was significant.

Conclusion

Perceived severity of illness and self-reported health status are the most important factors when determining out-of-pocket health expenditure. The effect of aging is substantial. China should develop appropriate medical relief policies for the elderly to help them gain access to necessary healthcare services. Certain types of insurance programmes tend to increase out-of-pocket health expenditures, which highlights the need to continuously monitor and rigorously evaluate the impact of ongoing health insurance reform in China.     

Die Leitlinie „Brustkrebs-Früherkennung in Deutschland“

Background

Guidelines aim to improve the quality of health care by providing scientific knowledge for physicians and patients regarding specific options for everyday healthcare practice. Their purpose is to describe current knowledge, based on scientific evidence and practice experience for specific problems of health care; to evaluate methodological and clinical aspects; to clarify conflicting points of view; and to weigh benefits and risks in order to make recommendations for the optimum procedures and actions.

Methods

The question was raised on how to update the stage 3 guideline for early detection of breast cancer in Germany in view of the difficulties of this complex chain of health care, the high methodological requirements, and the limited time and finances for the development of guidelines. It was assumed that, besides incorporating advances in scientific knowledge, such updating requires a check of the present applications of the guideline in clinical practice, including its dissemination, implementation, and consequences on healthcare services and outcomes.

Results

The concept of quality management for the stage 3 guideline of the Association of the Scientific Medical Societies in Germany (AWMF) was expanded for continous updating under systematically defined conditions.

Conclusions

The stepwise concept proved to be practical. The update was realized successfully with clearly lower expenditures compared with development of the first guideline for early detection of breast cancer in Germany.     

Providing surgical care in Somalia: A model of task shifting

Background

Somalia is one of the most political unstable countries in the world. Ongoing insecurity has forced an inconsistent medical response by the international community, with little data collection. This paper describes the "remote" model of surgical care by Medecins Sans Frontieres, in Guri-El, Somalia. The challenges of providing the necessary prerequisites for safe surgery are discussed as well as the successes and limitations of task shifting in this resource-limited context.

Methods

In January 2006, MSF opened a project in Guri-El located between Mogadishu and Galcayo. The objectives were to reduce mortality due to complications of pregnancy and childbirth and from violent and non-violent trauma. At the start of the program, expatriate surgeons and anesthesiologists established safe surgical practices and performed surgical procedures. After January 2008, expatriates were evacuated due to insecurity and surgical care has been provided by local Somalian doctors and nurses with periodic supervisory visits from expatriate staff.

Results

Between October 2006 and December 2009, 2086 operations were performed on 1602 patients. The majority (1049, 65%) were male and the median age was 22 (interquartile range, 17-30). 1460 (70%) of interventions were emergent. Trauma accounted for 76% (1585) of all surgical pathology; gunshot wounds accounted for 89% (584) of violent injuries. Operative mortality (0.5% of all surgical interventions) was not higher when Somalian staff provided care compared to when expatriate surgeons and anesthesiologists.

Conclusions

The delivery of surgical care in any conflict-settings is difficult, but in situations where international support is limited, the challenges are more extreme. In this model, task shifting, or the provision of services by less trained cadres, was utilized and peri-operative mortality remained low demonstrating that safe surgical practices can be accomplished even without the presence of fully trained surgeon and anesthesiologists. If security improves in Somalia, on-site training by expatriate surgeons and anesthesiologists will be re-established. Until then, the best way MSF has found to support surgical care in Somalia is continue to support in a "remote" manner.     

Sources of evidence in HIV/AIDS care: pilot study comparing family physicians and AIDS service organization staff

Background

The improvement of the quality of the evidence used in treatment decision-making is especially important in the case of patients with complicated disease processes such as HIV/AIDS for which multiple treatment strategies exist with conflicting reports of efficacy. Little is known about the perceptions of distinct groups of health care workers regarding various sources of evidence and how these influence the clinical decision-making process. Our objective was to investigate how two groups of treatment information providers for people living with HIV/AIDS perceive the importance of various sources of treatment information.

Methods

Surveys were distributed to staff at two local AIDS service organizations and to family physicians at three community health centres treating people living with HIV/AIDS. Participants were asked to rate the importance of 10 different sources of evidence for HIV/AIDS treatment information on a 5-point Likert-type scale. Mean rating scores and relative rankings were compared.

Results

Findings suggest that a discordance exists between the two health information provider groups in terms of their perceptions of the various sources of evidence. Furthermore, AIDS service organization staff ranked health care professionals as the most important source of information whereas physicians deemed AIDS service organizations to be relatively unimportant. The two groups appear to share a common mistrust for information from pharmaceutical industries.

Conclusions

Discordance exists between medical "experts" from different backgrounds relating to their perceptions of evidence. Further investigation is warranted in order to reveal any effects on the quality of treatment information and implications in the decision-making process. Possible effects on collaboration and working relationships also warrant further exploration.     

Study protocol: national research partnership to improve primary health care performance and outcomes for Indigenous peoples

Background

Strengthening primary health care is critical to reducing health inequity between Indigenous and non-Indigenous Australians. The Audit and Best practice for Chronic Disease Extension (ABCDE) project has facilitated the implementation of modern Continuous Quality Improvement (CQI) approaches in Indigenous community health care centres across Australia. The project demonstrated improvements in health centre systems, delivery of primary care services and in patient intermediate outcomes. It has also highlighted substantial variation in quality of care. Through a partnership between academic researchers, service providers and policy makers, we are now implementing a study which aims to 1) explore the factors associated with variation in clinical performance; 2) examine specific strategies that have been effective in improving primary care clinical performance; and 3) work with health service staff, management and policy makers to enhance the effective implementation of successful strategies.

Methods/Design

The study will be conducted in Indigenous community health centres from at least six States/Territories (Northern Territory, Western Australia, New South Wales, South Australia, Queensland and Victoria) over a five year period. A research hub will be established in each region to support collection and reporting of quantitative and qualitative clinical and health centre system performance data, to investigate factors affecting variation in quality of care and to facilitate effective translation of research evidence into policy and practice. The project is supported by a web-based information system, providing automated analysis and reporting of clinical care performance to health centre staff and management.

Discussion

By linking researchers directly to users of research (service providers, managers and policy makers), the partnership is well placed to generate new knowledge on effective strategies for improving the quality of primary health care and fostering effective and efficient exchange and use of data and information among service providers and policy makers to achieve evidence-based resource allocation, service planning, system development, and improvements of service delivery and Indigenous health outcomes.     

A systematic review of integrated working between care homes and health care services

Background

In the UK there are almost three times as many beds in care homes as in National Health Service (NHS) hospitals. Care homes rely on primary health care for access to medical care and specialist services. Repeated policy documents and government reviews register concern about how health care works with independent providers, and the need to increase the equity, continuity and quality of medical care for care homes. Despite multiple initiatives, it is not known if some approaches to service delivery are more effective in promoting integrated working between the NHS and care homes. This study aims to evaluate the different integrated approaches to health care services supporting older people in care homes, and identify barriers and facilitators to integrated working.

Methods

A systematic review was conducted using Medline (PubMed), CINAHL, BNI, EMBASE, PsycInfo, DH Data, Kings Fund, Web of Science (WoS incl. SCI, SSCI, HCI) and the Cochrane Library incl. DARE. Studies were included if they evaluated the effectiveness of integrated working between primary health care professionals and care homes, or identified barriers and facilitators to integrated working. Studies were quality assessed; data was extracted on health, service use, cost and process related outcomes. A modified narrative synthesis approach was used to compare and contrast integration using the principles of framework analysis.

Results

Seventeen studies were included; 10 quantitative studies, two process evaluations, one mixed methods study and four qualitative. The majority were carried out in nursing homes. They were characterised by heterogeneity of topic, interventions, methodology and outcomes. Most quantitative studies reported limited effects of the intervention; there was insufficient information to evaluate cost. Facilitators to integrated working included care home managers' support and protected time for staff training. Studies with the potential for integrated working were longer in duration.

Conclusions

Despite evidence about what inhibits and facilitates integrated working there was limited evidence about what the outcomes of different approaches to integrated care between health service and care homes might be. The majority of studies only achieved integrated working at the patient level of care and the focus on health service defined problems and outcome measures did not incorporate the priorities of residents or acknowledge the skills of care home staff. There is a need for more research to understand how integrated working is achieved and to test the effect of different approaches on cost, staff satisfaction and resident outcomes.

     

Measurement and analysis of inequality of opportunity in access of maternal and child health care in Togo

Background

Access to maternal and child health care in low- and middle-income countries such as Togo is characterized by significant inequalities. Most studies in the Togolese context have examined the total inequality of health and the determinants of individuals’ health. Few empirical studies in Togo have focused on inequalities of opportunity in maternal and child health. To fill this gap, we estimated changes in inequality of opportunity in access to maternal and child health services between 1998 and 2013 using data from Togo Demographic and Health Surveys (DHS).

Method

We computed the Human Opportunity Index (HOI)—a measure of how individual, household, and geographic characteristics like sex and place of residence can affect individuals’ access to services or goods that should be universal—using five indicators of access to healthcare and one composite indicator of access to adequate care for children. The five indicators of access were: birth in a public or private health facility; whether the child had received any vaccinations; access to prenatal care; prenatal care given by qualified staff; and having at least four antenatal visits. We then examined differences across the two years.

Results

Between 1998 and 2013, inequality of opportunities decreased for four out of six indicators. However, inequalities increased in access to antenatal care provided by qualified staff (5.9% to 12.5%) and access to adequate care (27.7% to 28.6%).

Conclusions

Although inequality of opportunities reduced between 1998 and 2013 for some of the key maternal and child health indicators, the average coverage and access rates underscore the need for sustained efforts to ensure equitable access to primary health care for mothers and children.

     

Harm reduction, methadone maintenance treatment and the root causes of health and social inequities: An intersectional lens in the Canadian context

Background

Using our research findings, we explore Harm Reduction and Methadone Maintenance Treatment (MMT) using an intersectional lens to provide a more complex understanding of Harm Reduction and MMT, particularly how Harm Reduction and MMT are experienced differently by people dependent on how they are positioned. Using the lens of intersectionality, we refine the notion of Harm Reduction by specifying the conditions in which both harm and benefit arise and how experiences of harm are continuous with wider experiences of domination and oppression;

Methods

A qualitative design that uses ethnographic methods of in-depth individual and focus group interviews and naturalistic observation was conducted in a large city in Canada. Participants included Aboriginal clients accessing mainstream mental health and addictions care and primary health care settings and healthcare providers;

Results

All client-participants had profound histories of abuse and violence, most often connected to the legacy of colonialism (e.g., residential schooling) and ongoing colonial practices (e.g., stigma &; everyday racism). Participants lived with co-occurring illness (e.g., HIV/AIDS, Hepatitis C, PTSD, depression, diabetes and substance use) and most lived in poverty. Many participants expressed mistrust with the healthcare system due to everyday experiences both within and outside the system that further marginalize them. In this paper, we focus on three intersecting issues that impact access to MMT: stigma and prejudice, social and structural constraints influencing enactment of peoples' agency, and homelessness;

Conclusions

Harm reduction must move beyond a narrow concern with the harms directly related to drugs and drug use practices to address the harms associated with the determinants of drug use and drug and health policy. An intersectional lens elucidates the need for harm reduction approaches that reflect an understanding of and commitment to addressing the historical, socio-cultural and political forces that shape responses to mental illness/health, addictions, including harm reduction and methadone maintenance treatment.