Suboptimal Nonmedical Qualities of Primary Care Linked With Care Avoidance Among People Who Use Drugs in a Canadian Setting Amid an Integrated Health Care Reform

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Moallef, S., Dale, L., Homayra, F., Zonneveld, C., Milloy, M.-J., Nosyk, B., & Hayashi, K. (2022). Suboptimal nonmedical qualities of primary care linked with care avoidance among people who use drugs in a Canadian setting amid an integrated health care reform. Journal of Substance Abuse Treatment, 108784.

Date created: 
DOI: 10.1016/j.jsat.2022.108784
Health care avoidance
Health care delivery
Health system responsiveness
Drug use
Primary care

Background:  People who use unregulated drugs (PWUD) often face significant barriers to—and thereby avoid seeking—health care. In Vancouver, Canada, a neighborhood-wide health care system reform began in 2016 to improve health care delivery and quality. In the wake of this reform, we sought to determine the prevalence of health care avoidance and its association with emergency department use among PWUD in this setting and examine patient-reported nonmedical qualities of health care (“responsiveness”).   Methods:  The study derived data 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). The study used Pearson chi-squared test to examine differences in responsiveness between those who did and did not avoid care. The study team used multivariable logistic regression 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 health care, 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 health care decision-making (27.9% vs. 12.7%) (all p < 0.05). In multivariable analyses, avoidance of health care 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 health care due to past mistreatment, and all seven measured domains of responsiveness were suboptimal and linked with avoidance. Individuals who reported avoidance of health care were significantly more likely to report emergency department use. Multi-level interventions are needed to remedy the suboptimal qualities of health care and thereby reduce care avoidance.


The full text of this paper will be available in April, 2023 due to the embargo policies of Journal of Substance Abuse Treatment for works funded by Canadian Institutes of Health Research (CIHR). Contact to enquire if the full text of the accepted manuscript can be made available to you.

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Canadian Institutes of Health Research (CIHR)
National Institutes of Health (NIH)