What factors impact the engagement of people who inject drugs in primary care?

Primary care is important to maintaining health through the prevention of illness and the management of ongoing health conditions. A primary care provider is a key access point for individuals engaging in routine healthcare and a source of referrals to more specialized care when needed. This article summarizes a systematic review on the barriers and facilitators to engaging in primary care among people who inject drugs.¹

Primary care use and people who inject drugs

People who inject drugs are impacted by a range of health conditions. These can include infections associated with injecting drugs, such as HIV, hepatitis C and skin and soft tissue infections. They can also include other health issues, such as diabetes, depression, hypertension and chronic pain.² People who inject drugs also have a greater frequency of emergency department visits to address health issues.³

Primary care visits provide important opportunities to prevent illness and to address comorbidities experienced by people who inject drugs. Providing primary care is also a way to reduce the use of emergency department visits to address health concerns.^3,4 However, people who use drugs often avoid healthcare for a number of reasons, such as previous experiences of stigma and discrimination from healthcare providers.^{5, 6} Understanding the factors that impact the engagement of people who inject drugs in primary care can help service providers reduce barriers to care.

What kind of research did the systematic review include?  

The systematic review included 23 articles published from 2001 to 2020. A study was included if it reported on:

• people in the United States who were actively injecting drugs, characterized as injecting drugs within the past 12 months and
• primary care engagement outcomes. Primary care engagement was defined as any interaction with primary care. Engagement outcomes fell into three categories:
  1. healthcare provider visits for disease management or diagnosis
  2. receipt of or adherence to medication or health services, such as the use of antiretroviral drugs for HIV
  3. control of a diagnosed health condition, such as blood pressure management or treatment to cure hepatitis C

What factors impact the primary care engagement of people who inject drugs?

The review identified a number of factors that impact the engagement of people who inject drugs in primary care. The authors grouped these factors into four areas taken from the Behavioural Model for Vulnerable Populations.

1. Predisposing characteristics

Predisposing characteristics are defined as an individual’s existing personal characteristics that are not directly responsible for their engagement in primary care but are associated with it. The review found different studies that showed an association between a person’s sex or gender, race and ethnicity, education, and age and how they engaged with primary care. However, the authors were unable to draw conclusions about how these characteristics impacted engagement in care overall because of the quality of the evidence and the limited number of studies that reported on these factors.

2. Enabling conditions

Enabling conditions are defined as organizational and financial factors outside of a person’s control that act as barriers or facilitators to primary care engagement. The review found an association between how people engaged in care and the following factors: health insurance and financial barriers, service location, patient–provider relationship and substance use stigma, housing, and peer norms. Of these factors, a positive patient–provider relationship appeared to be strongly associated with engagement in care. The co-location of primary care with other services accessed by people who inject drugs, access to peer support, stable housing and access to health insurance were also identified as facilitators to primary care engagement.

3. Need conditions

Need conditions are defined as the needs an individual perceives that they have for engaging in healthcare, as well as the needs evaluated by a healthcare provider such as a diagnosed condition. The review confirmed that people who inject drugs experience multiple health issues that contribute to a need for care, but they face many barriers to engaging in accessible primary care to address these needs.

4. Health behaviours

Health behaviours are defined as actions taken by individuals that impact their ability to engage in healthcare. The review found an association between actively injecting drugs and accessing harm reduction supplies and engagement in primary care. Actively injecting drugs was identified as a barrier to primary care engagement. In one study, accessing more harm reduction supplies was identified as a facilitator to care engagement.

What are the implications of the review for service providers?

The review identified factors that impact the engagement of people who inject drugs in primary care. While evidence to support some factors was limited, several key factors can be highlighted as areas of focus for supporting greater engagement in care.

• The patient–provider relationship was an important factor in engagement in primary care. A positive relationship with a healthcare provider was associated with greater engagement in care and a negative relationship was associated with lower engagement in care. Every interaction with a person who injects drugs is an opportunity for service providers to build the positive relationship essential to supporting their engagement in primary care. Improving patient–provider relationships can include addressing stigma and discrimination toward people who inject drugs within healthcare delivery. It can also include having open and non-judgmental conversations about substance use and harm reduction with clients.
• Actively injecting drugs, defined in the review as injecting drugs within the past year, was identified as a barrier to engaging in primary care. Owing to multiple factors, including criminalization, people who inject drugs can experience instability and competing priorities in their lives that may prevent them from engaging in healthcare.^6,7 Services that address social determinants of health (e.g., housing) can help create more stable environments for people who inject drugs and address some of the competing priorities they may be facing.
• Co-location of primary care with other health services accessed by people who inject drugs (e.g., supervised consumption sites, harm reduction supplies, opioid agonist therapy) was also identified as a facilitator to primary care.

When considering this review, it is important to remember that:

• The review identified a number of factors impacting the primary care engagement of people who inject drugs, but many factors were addressed in only one or two studies. More research will help us better understand the type of impact these factors have on engagement in care including their role as barriers or facilitators to care.
• The review was limited to studies of people who inject drugs in the United States. Differences in the delivery of healthcare in Canada may impact the applicability of the review to people who inject drugs in Canada. Examining Canadian studies will also provide additional context on the engagement in primary care of people who inject drugs in Canada.
• The review aimed to encompass engagement in primary care for a range of healthcare needs, but more than half of the included studies looked at care among people with HIV. Looking at studies addressing other healthcare needs will help broaden our understanding of barriers and facilitators to primary care engagement for people who inject drugs.

What is a systematic review?

Systematic reviews are important tools for informing evidence-based programming. A systematic review is a critical summary of the available evidence on a specific topic. It uses a rigorous process to identify all the studies related to a specific research question. Relevant studies can then be assessed for quality and their results summarized to identify and present key findings and limitations. If studies within a systematic review contain numerical data, these data can be combined in strategic ways to calculate summary (“pooled”) estimates. Combining data to produce pooled estimates can provide a better overall picture of the topic being studied. The process of pooling estimates from different studies is referred to as a meta-analysis. 

References

1. Heidari O, Tormohlen K, Dangerfield DT et al. Barriers and facilitators to primary care engagement for people who inject drugs: a systematic review. Journal of Nursing Scholarship. 2023 May;55(3):605-22.
2. Lim J, Pavalagantharajah S, Verschoor CP et al. Infectious diseases, comorbidities and outcomes in hospitalized people who inject drugs (PWID) infections in persons who inject drugs. PLOS ONE. 2022 Apr 20;17(4):e0266663. Available from: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0266663
3. Kendall CE, Boucher LM, Mark AE et al. A cohort study examining emergency department visits and hospital admissions among people who use drugs in Ottawa, Canada. Harm Reduction Journal. 2017 May 12;14(1):16. Available from: https://harmreductionjournal.biomedcentral.com/articles/10.1186/s12954-017-0143-4
4. Mandel E, E Kendall C, Mason K et al. Impact of comprehensive care on health care use among a cohort of marginalized people living with hepatitis C in Toronto. Canadian Liver Journal. 2020;3(2):203-11. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9202786/
5. Chan Carusone S, Guta A, Robinson S et al. “Maybe if I stop the drugs, then maybe they’d care?”—hospital care experiences of people who use drugs. Harm Reduction Journal. 2019 Feb 13;16(1):16. Available from: https://harmreductionjournal.biomedcentral.com/articles/10.1186/s12954-019-0285-7
6. Motavalli D, Taylor JL, Childs E et al. “Health is on the back burner:” multilevel barriers and facilitators to primary care among people who inject drugs. Journal of General Internal Medicine. 2021 Jan;36(1):129-37. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7858998/
7. Scher BD, Neufeld SD, Butler A et al. “Criminalization causes the stigma”: perspectives from people who use drugs. Contemporary Drug Problems. 2023 Sep 1;50(3):402-25. Available from: https://journals.sagepub.com/doi/full/10.1177/00914509231179226

About the author(s)

Erica Lee is CATIE’s manager of website content and evaluation. Since earning her master of information studies, Erica has worked in the health library field, supporting the information needs of frontline service providers and service users. Before joining CATIE, Erica worked as the Librarian at the AIDS Committee of Toronto (ACT).