Mitigating structural vulnerability for people who use drugs at the clinical- and policy-level

  • Author / Creator
    Gehring, Nicole Dawn
  • People who use illegal drugs (PWUD) often face adverse socio-political contexts (e.g., poverty, homelessness, racialization, criminalization) that make them structurally vulnerable. Structurally vulnerable PWUD experience elevated exposure to stigmatization, discrimination, and cultural oppression which increases their risk of drug-related harm. These groups of PWUD often have health and social care needs that go unmet. Service providers and policies typically do not sufficiently address the underlying structural factors that lead to substance-related harm. A critical link to mitigating structural vulnerability lies in understanding the perspectives of clinicians and policy actors who inform decisions that govern the lives of PWUD. Therefore, the overarching goal of this thesis was to explore structural vulnerability at the clinical- and policy-level through the perspectives of social care providers and policy actors.

    Two qualitative studies addressed this goal. Study 1 focused on the clinical-level and analyzed 18 semi-structured interviews conducted with social care providers caring for PWUD at a large, urban acute care hospital in Western Canada. Study 2 focused on the policy-level and analyzed 73 semi-structured interviews conducted as part of the Canadian Harm Reduction Policy Project. Participants included policy actors from all 13 Canadian provinces and territories who were involved in harm reduction and drug policy within their respective jurisdictions. Latent content analyses were conducted for both studies, informed by critical realism.

    At the clinical-level, there were contradictions in how different Study 1 participants discussed patient-level barriers to providing social care. Some blamed poor outcomes on patient deficits in motivation, while others emphasized structural factors that impede patients’ ability to secure income, housing, and other social supports. Within the hospital, some participants felt that acute care was not the appropriate setting to address social needs, but most felt that hospital visits afford a rare opportunity to address health inequities and reach structurally vulnerable patients who use drugs who otherwise have limited access to effective care in the community. Participants described gaps in community services, particularly in housing and financial supports, which limited successful social care provision. Finally, several potential policy solutions were identified, including establishing better transitional and permanent housing supports that comprehensively address medical, income, and substance use needs.

    At the policy-level, participants in Study 2 acknowledged the central role of structural vulnerability (e.g., poverty, homelessness, racialization) in drug use and related harm across the provinces and territories. Criminalization, in particular, was seen as a major contributor to structural vulnerability by justifying a litany of formal and informal sanctions against drug use, and by extension PWUD. Many participants expressed that their personal understanding of harm reduction included addressing the structural conditions facing PWUD, but stated that formal government policies often ignore or downplay the centrality of addressing structural conditions for improving the wellbeing of PWUD. Participants identified several potential policy solutions to intervene on structural vulnerability, including decriminalization, safer supply, and enacting policies encompassing all health and social sectors.

    This thesis offers unique insight on structural vulnerability and substance use from the perspectives of social care providers and policy actors which have been lacking from the broader literature on structural vulnerability. Taken together, findings from this thesis reinforce structural vulnerability as a main contributor to drug-related harm for PWUD and highlight services and policies that could better address the structural conditions in which PWUD live. Overall, it is apparent that more comprehensive efforts are needed to develop and implement both services and policies aimed at mitigating structural factors for PWUD.

  • Subjects / Keywords
  • Graduation date
    Fall 2021
  • Type of Item
  • Degree
    Master of Science
  • DOI
  • License
    This thesis is made available by the University of Alberta Libraries with permission of the copyright owner solely for non-commercial purposes. This thesis, or any portion thereof, may not otherwise be copied or reproduced without the written consent of the copyright owner, except to the extent permitted by Canadian copyright law.