Abstract
Objective To examine the prevalence and correlation of self-reported inability to access community primary care clinics among people who inject drugs (PWID).
Design Self-report questionnaire data.
Setting Vancouver, BC.
Participants Data were derived from 3 prospective cohort studies of PWID between 2013 and 2016.
Main outcome measures Multivariable generalized estimating equations were used to determine prevalence of and reasons for self-reported inability to access primary care, as well as factors associated with inability to access care.
Results Of 1396 eligible participants, including 525 (37.6%) women, 209 (15.0%) persons were unable to access a primary care clinic at some point during the study period. In the multivariable analysis, factors independently associated with inability to access clinics included ever being diagnosed with a mental health disorder (adjusted odds ratio [AOR] = 1.63, 95% CI 1.14 to 2.35), dealing drugs (AOR = 1.60, 95% CI 1.15 to 2.22), using emergency services (AOR = 1.51, 95% CI 1.13 to 2.02), being female (AOR = 1.49, 95% CI 1.08 to 2.08), and testing positive for HIV (AOR = 0.47, 95% CI 0.30 to 0.72) (for all factors, P < .05).
Conclusion Specific exposures were linked to challenges in accessing primary care among the sample of PWID, even in a publicly funded health care setting. Notably, models designed for care of people with HIV appear to increase access to primary care among PWID. Further research is needed to determine how to effectively treat accompanying mental illness, how to provide women-centred services, and how to connect people with primary care who would likely otherwise go to the emergency department.
People who inject drugs (PWID) face an elevated risk of living with an array of complex medical conditions that can have serious long-term consequences, such as HIV and hepatitis C virus (HCV).1 People who inject drugs often face difficulties when trying to access care.2 Consequently, they typically present later to care, have more severe disease, and develop more long-term consequences.3
Some primary care clinic models meant to increase accessibility for PWID have been pilot tested in the United States and Europe, and have increased access to primary care and have decreased emergency department use.4,5 However, location, staff turnover, acceptance of harm reduction, and cost have been shown to be persistent barriers in clinics seeking to serve PWID.4,5 Also, it is unclear whether previous research findings apply to settings where harm-reduction programs are endorsed and where a publicly funded health care system provides primary care (not including dental care or some medications) with virtually no immediate out-of-pocket expenses.
Vancouver, BC, has a publicly funded health care system and a well-established primary care clinic network that supports harm-reduction programming. These clinics often have multidisciplinary teams, addiction treatment, and harm-reduction services (including distribution of naloxone and sterile supplies for illicit drug use). Therefore, we sought to identify the prevalence and correlation of self-reported inability to access community primary care clinics among PWID in Vancouver.
METHODS
Study procedures
The VIDUS (Vancouver Injection Drug Users Study),6 ACCESS (AIDS Care Cohort to Evaluate Exposure to Survival Services),7 and ARYS (At-Risk Youth Study)8 are ongoing, open prospective cohort studies of those who use drugs and are recruited through self-referral and street outreach in Vancouver. Sampling and recruitment procedures for these cohorts have been described elsewhere.9 The VIDUS enrolled HIV-negative adults (≥ 18 years of age) who reported injecting an illicit drug at least once in the month preceding enrollment; the ACCESS study enrolled HIV-positive adults who reported using an illicit drug other than or in addition to cannabis in the previous month; and the ARYS enrolled street-involved youth aged 14 to 26 years who had used illicit drugs other than or in addition to cannabis in the month before enrollment. For all cohorts, other eligibility criteria included residing in the greater Vancouver region, understanding English, and providing written informed consent.
Study instruments and all other follow-up procedures for each study were harmonized to allow for combined analyses. At baseline and semi annually thereafter, participants completed the same interviewer- and nurse-administered questionnaires that elicited sociodemographic data as well as information pertaining to drug use patterns, risky behaviour, and health care use.
Nurses collected blood samples to detect HIV and performed a serology test to detect HCV, provided basic medical care, and arranged referrals to appropriate health care services if required. An example of a common referral is to nearby community health clinics for wound care. Participants received a $ 30 honorarium for each study visit. The University of British Columbia in Vancouver and the Providence Health Care Research Ethics Board provided ethical approval for all studies.
Study sample and primary outcome measure
This analysis included participants who completed study visits between December 1, 2013, and May 31, 2016, because a question about the primary outcome measure was asked consecutively during this period. Only observations that included reports of injection drug use in the preceding 6 months were eligible for our analysis.
The primary outcome of interest was self-reported inability to access primary care clinics in the previous 6 months. This was defined as responding yes to the question: “In the past 6 months, have you tried to access a health care clinic but were unable to?” Participants were also asked about reasons this occurred. Response options included wait list too long, turned away, “I don’t have HIV,” clinic too busy, no identification, regular doctor on vacation or no longer there, and another open-ended answers. Participants were able to select multiple responses on the questionnaire.
Variables associated with primary care access
Several explanatory variables that researchers have associated with an inability to access primary care clinics were selected and were asked about in the questionnaire.3,4,10 Sociodemographic data included age (in 10-year blocks); sex (female vs male); education (high school completion or higher vs less than high school); White ancestry (yes vs no); drug dealing (yes vs no); homelessness (yes vs no); involvement in sex work (yes vs no); employment (yes vs no); and residency in the Downtown Eastside neighbourhood of Vancouver (yes vs no). The Downtown Eastside has many people who use illicit drugs and has a concentration of low-barrier health services.11 All behavioural variables referred to the previous 6 months unless otherwise specified.
Variables that examined access to other types of health care in the previous 6 months were asked (yes vs no) and included receiving opioid agonist therapy, receiving other drug and alcohol treatment (ie, excluding methadone, and buprenorphine-naloxone), receiving outreach health services, and accessing emergency services. Measures related to health status or outcomes in the previous 6 months included ever being diagnosed with a mental health disorder, having suicidal thoughts, having HIV seropositivity, having HCV seropositivity, and having drug overdose.
Drug use patterns in the previous 6 months were asked (yes vs no) and included daily injection of cocaine, daily injection of heroin, daily injection of crystal methamphetamine, daily injection of nonmedical prescription opioids, daily crack smoking, and binge drug use defined as use that is greater than one’s normal pattern in a short time.
Analyses
Given that analyses of factors potentially associated with inability to access primary care clinics included serial measures for each participant, we used generalized estimating equations with logit links, which provided standard errors adjusted by multiple observations per person using an exchangeable correlation structure. We used an a priori–defined backward model selection procedure to fit a multivariable model. We first included all explanatory variables that were associated with the outcome at the level of P < .10 in bivariate analyses in a full model. After examining the likelihood under the independence model criterion statistic of the model, we removed the variable with the largest P value and built a reduced model. We continued this iterative process and selected the multivariable model with the lowest independence model criterion statistic value. All statistical analyses were performed using the statistical software package R, version 3.5.0. All P values were 2-sided, and the α level was set at .05.
RESULTS
A total of 1396 eligible participants contributed 5312 observations to this analysis. Among the 1396 participants, 525 (37.6%) were female, 814 (58.3%) reported they were White, and the median age was 43.3 years (interquartile range = 30.7 to 51.5). In total, 209 (15.0%) persons contributed a total of 281 reports that indicated reasons for inability to access primary care clinics in the previous 6 months. Baseline characteristics are presented in Table 1.
Baseline characteristics (N = 1396)
Results of the bivariate and multivariable generalized estimating equation analyses are shown in Table 2. In the multivariable analysis, factors that were independently associated with inability to access primary care clinics included having ever been diagnosed with a mental health disorder (adjusted odds ratio [AOR] = 1.63, 95% CI 1.14 to 2.35), dealing drugs (AOR = 1.60, 95% CI 1.15 to 2.22), having used emergency services (AOR = 1.51, 95% CI 1.13 to 2.02), being female (AOR = 1.49, 95% CI 1.08 to 2.08), and being HIV positive (AOR = 0.47, 95% CI 0.30 to 0.72).
Bivariate and multivariable GEE analyses of factors associated with inability to access addiction treatment among PWID (N = 1396)
As shown in Table 3, the most common reasons for inability to access primary care clinics included being turned down by clinic (32.7%), clinic too busy (14.6%), and presence of waiting list (12.8%).
Reasons for inability to access health care clinic and number of reports for each reason (N = 281), among PWID
DISCUSSION
Despite Canada’s publicly funded health care system and our local clinic network supporting harm-reduction programming, we found persistent barriers to accessing primary care clinics for PWID, such as being turned down by clinics and clinics being too busy. In contrast to previous studies that were conducted in settings without a publicly funded health care system,4 financial barriers were among the least common barriers in our study. However, other previously identified barriers (including a lack of physician skills to treat PWID and perceived discrimination4) could persist in our setting and require further exploration.
People who had difficulty accessing primary care clinics had a greater likelihood of using emergency services. Research has demonstrated that people who experience barriers to primary care often use emergency services when their medical condition worsens.12 This leads to a pattern of accessing emergency services instead of primary care, which is more costly to the health care system.13 Alternatively, the greater likelihood of using emergency services could also reflect greater complexity of comorbid illnesses requiring the use of emergency over primary care. Regardless, this finding calls for supporting strong linkages between emergency services and primary care in communities.
Local research has shown use of emergency services is often secondary to soft tissue infections among our study population.14 While some community-based antibiotic care models exist locally,15 innovative strategies to improve access to intravenous antibiotics are needed. For example, the San Francisco Antibiotics Clinic provides low-barrier access to intravenous antibiotics and has reduced visits to emergency departments by 33.7% in 1 year.16 Low-barrier care can be defined as easily accessible, user-friendly care attempting to minimize demands on patients (including shorter wait times and fewer eligibility criteria).
We found people who suffered from mental illness were more likely to report inability to access primary care clinics. This has been documented previously; reported barriers among this population include distance from clinic, socioeconomic status, and physician expertise.13,17,18 Addressing barriers involves various levels of intervention: having outreach workers can increase access for individuals; ensuring clinics are multidisciplinary and staff have a good understanding of mental illness can increase local access; and addressing social determinants of health (including poverty) can increase structural flexibility.17,18
In our study, women were more likely than men to report inability to access primary care clinics. Factors such as marginalization from sex work, sex-based violence, and income insecurity limited access to health care among female PWID.19 In this context, women-centred clinics (such as Oak Tree Clinic in Vancouver, which serves women with HIV) have reduced barriers to accessing care. They provide child care, transportation subsidy (among other social services), and have female care providers.20 While more research is needed to examine barriers specific to female PWID in our setting, extending these types of services to HIV-negative women could help improve access.
In contrast to previous literature,11,21,22 we found that people living with HIV were less likely to report inability to access clinics. This could be explained by several strategies that have been employed to improve care for people with HIV in our setting,23 including the community-wide seek, test, treat, and retain initiative. This initiative has outreach services with social workers, nurses, and peers who help people get to appointments, find housing, and overcome barriers to social and medical services.24 Previous research has documented improvements in care with this initiative, including increased prevalence of undetectable HIV plasma viral load.25
Limitations
This study has limitations. Self-reported data have potential reporting bias. Also, non-random sampling limits the generalizability of our findings to other populations of PWID. Furthermore, as with any observational research, the presence of residual confounding between the outcome and explanatory variables is possible. Our outcome measure has an additional limitation because it does not measure the frequency of occurrence.
Conclusion
In our sample, 15.0% of PWID reported they were unable to access a primary care clinic over a 3-year study period. Engaging with people who visit the emergency department, decreasing barriers for those with mental illness, and ensuring services specifically meet the needs of women could improve access to primary care and decrease overall health care costs.
Acknowledgment
We thank the study participants for their contribution to the research, as well as current and past researchers and staff. The study was supported by the US National Institutes of Health. This research was undertaken, in part, because of funding from the Canada Research Chairs program through a Tier 1 Canada Research Chair in Inner City Medicine that supports Dr Evan Wood, a Canadian Institutes of Health Research (CIHR) grant, and the CIHR Canadian Research Initiative on Substance Misuse. Dr Kanna Hayashi is supported by a CIHR New Investigator Award, a Michael Smith Foundation for Health Research (MSFHR) Scholar Award, and the St Paul’s Foundation. Dr M-J Milloy is supported by a CIHR New Investigator Award, a MSFHR Scholar Award, and the US National Institutes of Health; his institution has received an unstructured gift from National Green Biomed Ltd to support him. Dr Kora DeBeck is supported by a MSFHR–St Paul’s Hospital Foundation—Providence Health Care Career Scholar Award and a CIHR New Investigator Award. Dr Seonaid Nolan is supported by a MSFHR award.
Notes
Editor’s key points
▸ Even within a publicly funded health care system and clinics supporting harm-reduction programming, people who inject drugs face persistent barriers to accessing primary care. Reasons for this include busy clinics, being turned down by clinics, and presence of a waiting list.
▸ Factors independently associated with inability to access primary care clinics include suffering from mental illness, dealing drugs, using emergency services, being female, and testing positive for HIV.
▸ Strategies are needed to improve primary care access for those who present to the emergency department, those with mental illness, and women. Doing so could decrease overall health care costs.
▸ Notably, those who test positive for HIV are less likely to report inability to access primary care clinics, possibly owing to the presence of many HIV initiatives.
Points de repère du rédacteur
▸ Même dans un système de santé financé par le secteur public et des cliniques offrant des programmes de réduction des risques, les utilisateurs de drogues par injection se heurtent à des obstacles persistants à l’accès aux soins primaires. La situation s’explique, entre autres, par la forte fréquentation des cliniques, le refus des cliniques d’accepter ces personnes et l’existence de listes d’attente.
▸ Parmi les facteurs indépendamment associés à l’incapacité d’accéder aux soins primaires figurent la maladie mentale, le trafic de drogues, le recours aux services des urgences, le fait d’être une femme et des résultats positifs au dépistage du VIH.
▸ Des stratégies s’imposent pour améliorer l’accès aux soins primaires par les personnes qui se présentent aux services des urgences, les personnes qui souffrent de maladies mentales et les femmes. Ce faisant, il serait possible de réduire les coûts globaux des soins de santé.
▸ Fait à signaler, les personnes dont les résultats sont positifs au VIH sont moins enclines à signaler des difficultés d’accès aux cliniques de soins primaires, possiblement en raison de l’existence de nombreuses initiatives liées au VIH.
Footnotes
Contributors
All authors contributed to the concept and design of the study; data gathering, analysis, and interpretation; and preparing the manuscript for submission.
Competing interests
None declared
This article has been peer reviewed.
Cet article a fait l’objet d’une révision par des pairs.
- Copyright © 2021 the College of Family Physicians of Canada
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