UBC Faculty Research and Publications

Suboptimal non-medical qualities of primary care linked with care avoidance among people who use drugs in a Canadian setting amidst an integrated healthcare reform Moallef, Soroush; Dale, Laura; Homayra, Fahmida; Zonneveld, Cristy; Milloy, M-J; Nosyk, Bohdan; Hayashi, Kanna; Vancouver Area Network of Drug Users


Background: People who use unregulated drugs (PWUD) often face significant barriers to – and thereby avoid seeking – healthcare. In Vancouver, Canada, a neighborhood-wide healthcare system reform began implementation in 2016 to improve healthcare delivery and quality. In the wake of this reform, we sought to determine the prevalence of healthcare avoidance and its association with emergency department use among PWUD in this setting and examine patient-reported non-medical qualities of healthcare (“responsiveness”). Methods: Data were derived from two prospective cohort studies of community-recruited PWUD in Vancouver in 2017-18. Responsiveness was ascertained by the World Health Organizations’ standardized measurements and we evaluated seven domains of responsiveness (dignity, autonomy, communication, confidentiality, prompt attention, choice of provider, and quality of basic amenities). Pearson chi-squared test was used to examine differences in responsiveness between those who did and did not avoid care. Multivariable logistic regression was used to determine the relationship between care avoidance due to past mistreatment and emergency department use, adjusting for potential confounders. Results: Among 889 participants, 520 (58.5%) were male, 204 (22.9%) reported avoiding healthcare, most commonly for chronic pain (47.4%). Overall, 6.6% to 36.2% reported suboptimal levels (i.e., not always meeting the expected quality) across all seven measured domain of responsiveness. Proportions reporting suboptimal qualities were significantly higher among those who avoided care than those who did not across all domains, including: care as soon as wanted (51.0% vs. 31.8%), listened to carefully (44.1% vs. 20.4%), and involved in healthcare decision making (27.9% vs. 12.7%) (all p<0.05). In multivariable analyses, avoidance of healthcare was independently associated with self-reported emergency department use (adjusted odds ratio=1.49; 95% confidence interval:1.01–2.19). Conclusion: We found that almost a quarter of our sample of PWUD avoided seeking healthcare due to past mistreatment, and all seven measured domains of responsiveness were suboptimal and linked with avoidance. Individuals who reported avoidance of healthcare were significantly more likely to report emergency department use. Multi-level interventions are needed to remedy the suboptimal qualities of healthcare and thereby reduce care avoidance.

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