Chapter 28
Providing Health Services to Marginalized Urban Populations
Anita Palepu and Mark W. Tyndall
1.0. INTRODUCTION
Part I of this book highlighted the diversity of urban populations. We learned that the residents of an urban core often differ widely in terms of income, age, educa- tion, chronic health conditions, physical ability and mental capacity. They can range from homeless people to ethnic minorities to the upper classes and the eld- erly, and each subgroup has its own set of unique health challenges. To add fur- ther complexity to this, the methods of deliver y of health ser vices in urban centers vary with respect to their funding structures; publicly funded services are often rationed by wait-lists, whereas private services are rationed by the user’s abil- ity to pay (Alter, et al., 1999; Detsky and Naylor, 2003; Iglehart, 2000). General principles of delivering quality health care (Chassin and Galvin, 1998) suggest that the provision of services must be tailored to address the predominant health concerns and social environment of the target subpopulation being ser ved (Vlahov and Galea, 2002). Good examples of this are the numerous interventions that address child health issues in urban settings, such as immunizations, nutri- tion and asthma (Lara, et al., 1999; McCormick, et al., 1997; Tallon and Sandman, 1998; D. Wood, et al., 1994). These approaches consider the complex life situa- tions that many urban children and families face. Another group who are chal- lenging to provide comprehensive health ser vices to in the urban setting are persons who are homeless and persons with severe and persistent mental illness.
They face barriers to accessing conventional health care and adhering to treat- ment plans thus requiring a modified deliver y approach (Barkin, et al., 2003;
Hwang and Bugeja, 2000; Hwang, et al., 2001; Kushel, et al., 2001; Prevention of Homelessness, 1998).
The tailoring of health services in an urban context is often related to the social and physical environment in which people live. (Vlahov and Galea, 2002). Even within an urban center, the social and physical environments can be varied and often reflect the income and education of the persons residing in these
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neighborhoods. One important aspect of urban health includes the health issues faced by persons of lower socioeconomic status and visible minority groups, particu- larly in the U.S. where they are over-represented and experience numerous barriers to quality health care (Vlahov and Galea, 2002). We recognize that there are many advantaged urban populations who have access to some of the best health care serv- ices in the world, however, we will describe a model of health services delivery to dis- advantaged urban populations.
In this chapter, we focus on one of the marginalized urban sub-populations, namely drug users, since many of the challenges faced by this group are issues that are relevant to other disadvantaged populations in urban areas. Drug users face particular complexities that can provide a helpful model in considering the issues of health service provision to other marginalized urban populations. This will be highlighted by the challenges of providing comprehensive health ser vices to these persons who have numerous medical and mental health complications of their drug use. We recognize the funding of health care in other settings differ from the universal, publicly funded health care in Canada, however, we offer a description of providing a spectrum of health ser vices to marginalized persons including illicit drug users drawing from the setting and ser vices in Vancouver, British Columbia as a practical example of service delivery to this population. By studying these challenges and methods employed to meet their needs, we hope to provide a useful model that can be applied to other marginalized populations in our cities.
2.0. HEALTH NEEDS OF DRUG USERS
The health status of drug users is typically poor, as described in more detail in an earlier chapter. As a direct consequence of their drug use, individuals may suffer from symptoms of withdrawal, intoxication and overdose. The most worrying conse- quence, however, is that drug users are at great risk of contracting HIV and Hepatitis C. In 1997, the incidence of HIV infection among injection drug users reached 18%, which was the highest rate in the Western world (Strathdee, et al., 1997). The prevalence of HIV and Hepatitis C among injection drug users is 30%
and 90%, respectively (Tyndall, et al., 2001).
In addition to these serious viral infections and their associated complica- tions, injection drug users are susceptible to a range of bacterial infections due to unhygienic injection practices and the lack of clean water (Kerr and Palepu, 2001). These include soft-tissue infections (cellulitis and abscess) bacterial pneu- monia, endocarditis, septic arthritis and osteomyelitis (Ebright and Pieper, 2002;
Kak and Chandrasekar, 2002; O’Connor, et al., 1994; Palepu, et al., 2001). Adding further complexity to the medical needs of drug users is the high prevalence of concurrent psychiatric diagnoses, such as mood disorders, personality disorders, post-traumatic stress disorders and psychosis (O’Connor, et al., 1994; Palepu, et al., 2001; Stein, 1999).
The myriad and severity of physical and mental health issues faced by injection drug users highlights the complexity of health care they require. It is important to note that there is a substantial overlap between the health needs of drug users and the issues facing homeless people and those living with severe and persistent mental illness. Clearly, these groups share a common need for innovative approaches to health services delivery.
3.0. DETERMINING THE OBSTACLES TO HEALTH CARE ACCESS
The list of obstacles to health care access for disadvantaged urban groups is long (Freudenberg, 2000). Perhaps the most significant barrier in most countries is the lack of health care insurance for marginalized populations (Newacheck, et al., 1998). Without the ability to pay for the services they simply go without. But even in Canada, a society where universal health care is a fundamental tenet, drug users and homeless persons still face a variety of additional barriers when it comes to accessing these services (Cheung and Hwang, 2004).
Again, it is important to note that many of the obstacles described in the follow- ing sections also apply to other disadvantaged urban subpopulations, such as home- less people and those with severe and persistent mental illness. In addition, minority groups are often over-represented in urban centers and require special considera- tion. Aboriginal people in some Canadian cities and black people in cities through- out the U.S. are consistently found to have substantially worse health outcomes when compared to white residents (Craib, et al., 2003). Ethno-cultural practices and beliefs must be taken into consideration when developing programs for these groups (Benoit, et al., 2003).
3.1. Social Obstacles
Perhaps the most troubling obstacle for drug users seeking treatment is that, histori- cally, the response to drug addiction in North America has been one of law enforce- ment. Addiction is seen as a criminal issue rather than a health issue. Accordingly, drug users may be reluctant to seek medical services because they fear criminal repercus- sions to their actions and there is evidence that police presence may reduce the will- ingness of drug users to access available health services (Wood, et al., 2003). Viewing the issue of addiction through the lens of health rather than enforcement permits a broader approach to providing health services to this vulnerable population.
Along with fears of criminal prosecution, drug users also face the social stigma that accompanies addiction. They may feel discriminated against for their habits and lifestyle and therefore not seek the help they need. In some cases, the potential for discrimination is enough to keep individuals away from public health support, but in others cases the social isolation resulting from addiction is a very real and psy- chologically debilitating obstacle.
Individuals in this marginalized population often suffer from extremely low self- esteem. They are commonly embarrassed by their health issues and their poverty and do not seek help for fear of further injuring their self-worth. In addition, health care workers who are under-trained and lack addiction experience can sometimes act antagonistically towards drug users, which contribute further to their low self- esteem. By judging them instead of welcoming them, inexperienced health care providers can increase the chance that an addicted individual will avoid public serv- ices in the future.
Another significant reason for health care avoidance is the low level of awareness within the drug-using community about the medical issues associated with injection drug-use (Metzger and Navaline, 2003). Without access to education programs, individuals may not recognize the severity of their situations until they have reached a crisis-point. Awareness of the importance of detecting the early warning signs of various complications may increase their willingness to seek health care when these symptoms arise.
Finally, the transience of many marginalized groups limits their ability to access proper medical care and follow-up. Without proper housing opportunities, they are unable to settle in one place, adding a further handicap to their uptake of health care services (Lewis, et al., 2003).
3.2. Institutional Obstacles
Many health care services for drug users are “high-threshold” services (Appel, et al., 2004). This means they are programs that are based on abstinence and require indi- viduals to stop using the drugs they are addicted to. These programs are problem- atic, however, and they symbolize a common misconception about drug addiction therapy. Many abstinence programs do not recognize the long-term, comprehen- sive process by which an injection drug user successfully gains control over their addiction. A large part of a successful treatment plan involves “preparing” the indi- vidual to quit (i.e., through education, motivation, raising self-esteem, etc.) and may be conducted while the individual is still using drugs. Unfortunately, the majority of drug users who enter abstinence programs do not have this background. They are not properly prepared to quit, and so they often drop out.
3.3. Continuity-of-Care
Continuity-of-care is also a challenging problem (Chan, et al., 2002). For many, the hospital emergency room is their first and only point of contact with the medical sys- tem. It is also clear that many of the people who frequent emergency rooms also make frequent visits to primary care (Byrne, et al., 2003). The transition between acute hospital care and community follow-up is sub-optimal because primary care clinics are not readily accessible, and those that do exist are unable to provide the requisite level of diagnostic testing and treatment. This is not sufficient for chronic illnesses such as drug addiction and HIV infection, both of which require long- term, consistent care. The result is a pattern of “crisis-based” medical interventions without a focus on early-detection, prevention or follow-up.
The traditional model for medical service requires patients to make appoint- ments and arrive on time. However, for many active drug users, the chaotic nature of their lifestyle makes it difficult for them to adhere to specific meeting times.
Therefore, the inflexibility of scheduled appointments limits the level of uptake of health services by these individuals. In addition, drug addicted people are unlikely to persevere through the typically long wait times in emergency rooms. They often leave the hospital without being seen because they do not want to wait, which results in frustration for both the addicted individuals and the health care providers.
4.0. MODELS OF HEALTH SERVICE DELIVERY
Now that we have determined the obstacles that drug users and other marginalized groups face with respect to health care access, we can discuss some of the ways in which those obstacles can be overcome. The most important point to recognize is that traditional methods to medical service are probably not going to be effective with these groups. We need flexible, innovative programs if we want to reach these people. The facilities used to administer health care must be flexible and welcom- ing to those who are being served. In the case of people using illicit drugs and other
marginalized groups, this may be very different than traditional models of care. The location of the office, expected waiting times, hours of operation, and the ancillary services offered are critical considerations in this setting. In addition, many people on society’s margins do not actively pursue health care when faced with the immedi- ate concerns of obtaining illicit drugs, and securing housing, food and money.
Given that addiction is the underlying health problem in these cases, health services must always consider the addiction when addressing the attendant medical conditions. As we stated earlier, medical programs for drug-dependent people can be categorized as high-, medium- or low-threshold. “Threshold” refers to the eligi- bility criteria for participation (i.e., the ability of individuals to meet program demands) and the amount of organizational structure involved. The higher the threshold, the more demands and long-term expectations are placed on the partici- pant. As threshold decreases, the treatment environment becomes less rigid and the focus shifts to short-term goals and contracts.
Low threshold programs can be a major point of contact for drug dependent individuals. Accordingly, a significant percentage of the medical community’s efforts in Vancouver are directed towards these innovative initiatives. In recognition of the complex life situations of many drug users, the programs are multidiscipli- nary in their approach. They combine the expertise of people from a variety of fields such as education, psychology and social work within the context of medical service in order to help participants overcome the long list of obstacles they face.
The key to these programs is well-trained, highly skilled staff. They must be able to de-escalate tense situations, set realistic expectations and boundaries and show empathy and respect towards the participants. These skill sets are critical given the nature of addiction as a chronic relapsing illness and are necessary attributes for low-threshold health services to succeed.
We advocate multi-disciplinary public health and clinical programs that help people manage social issues as well as health concerns (Galea and Vlahov, 2002).
There are alternate models of care that can successfully engage marginalized indi- viduals in a process that will see substantial improvements in their social and health situation. Below, we provide examples of health care delivery models that can attract, sustain, and benefit urban populations who are not engaged in care.
4.1. Community Drop-In Centers
Community drop in centers offer a range of social services in addition to health care. The scope of the services varies, but access to experienced social and health professionals in a casual setting is a prerequisite. These facilities are often managed by community members and encourage the participation of peer workers and volunteers. They often have extended hours of operation to accommodate those who have difficulty attending during regular daytime appointments and services are provided on a drop-in basis. Contact and trust is developed over time and health interventions are introduced slowly. Community-based facilities such as these can be the only viable entry point for many individuals. These initiatives are based on a long-term vision for their community that involves a commitment to low-threshold programs, and it is vital that they resist becoming institutionalized.
4.2. Food Programs
Food programs offer an excellent point of contact and can attract people who may not otherwise attend health clinics. Along with a nutritional meal, participants have
the opportunity to connect with health care professionals in a casual setting. Many meal programs have participants who attend on a regular basis. This provides an opportunity to develop trusting relationships between participants and health work- ers. For the regular attendees there is an opportunity to dispense medications.
In Vancouver, a successful food program exists that provides antiretroviral therapies on a daily basis for those who are not able to take their medications on a consistent basis.
4.3. Needle Exchange Programs (NEPs)
NEPs are very effective as points of contact for marginalized individuals who are using injection drugs. Although most NEPs are designed to be hassle-free and pro- vide a quick exchange, they can also serve to direct participants to health care professionals. Some NEPs are affiliated with health care facilities that can provide rapid access to care if the staff are able to identify clients in need of attention as well as offer important interventions (Stein, et al., 2002; Stein, et al., 2002a; Strathdee, et al., 1999). The NEPs are also an important venue to distribute educational materi- als and promote vaccines and other health interventions. They provide a way to rap- idly disseminate information about changes in drug purity, drug contamination and other suspicious observations regarding street drugs.
4.4. Opiate Replacement Therapy
Opiate replacement therapy with methadone and buprenorphine has been shown to reduce the adverse health impacts associated with opiate addiction and to improve health outcomes (Barnett, et al., 2001; Zaric, Barnett, and Brandeau, 2000). The daily dispensing of methadone provides an opportunity for ongoing contact and relationship building and can be linked to ongoing medical care and monitoring. The dispensing of antiretroviral medications along with daily methadone is convenient and acceptable to many HIV seropositive individuals (Conway, et al., 2004).
4.5. Outreach Nursing
Outreach nursing has become an important health delivery model in many urban settings. Community-based nurses are able to provide critical health interventions to highly marginalized groups in locations far from traditional clinics. Visits to apartments, hotels, shelters, recovery houses and street-based contacts require a flexible team of nursing professionals equipped with a range of skills and equip- ment. Educational messages, vaccination programs, STD screening and medication delivery are examples of initiatives that can be conducted through outreach nurs- ing. Some of these services can be delivered out of mobile health vans that can be used as small clinics where minor procedures can be performed, such as dressing changes for abscesses and foot care.
4.6. Peer Involvement
Peer involvement is an important and under-explored concept in health service delivery to marginalized populations. Many hard-to-reach individuals may only respond to peer contacts who have an intimate understanding of the obstacles to
accessing health care. Successful collaboration with outreach teams has been devel- oped in Vancouver, with a street-nurse program that includes past and present drug users. Similar outreach teams have also been used to attract and support a wide range of other marginalized urban subpopulations (Broadhead, et al., 2002).
North America’s first Supervised Injection Site (SIS) was opened in Vancouver in September 2003 (Wood, et al., 2004). Although the primary impetus to open the facility was the issue of drug-dependent people injecting in public spaces, there is an excellent opportunity to link the SIS with health and counseling services. There are already nurses on the premises to deal with injection-related complications as well as a counselor to provide on-site addiction counseling. Links to public health inter- ventions and detoxification programs are also in place.
5.0. STAFF SAFETY AND SECURITY
In order to connect with marginalized people and have the opportunity to improve health in urban environments, an emphasis has been placed on accessibility to health care programs and acceptance by the health care team. A major barrier to working in this environment is personal safety concerns on the part of the staff. This must be addressed in all low-threshold programs. The establishment of clear rules of conduct for the clients, including appropriate sanctions on those who are not willing to comply with these expectations, not only improve the working environ- ment for the staff but are supported by the vast majority of clients, who also value a respectful and safe environment.
6.0. INTEGRATION OF CLINICAL SERVICES
There is no substitute for establishing relationships between health care providers and their clients. Multi-disciplinary models offer the best chance for success as they can provide a range of services and can include members who are not commonly involved with health care delivery. Traditional physician-based models of care are less successful as they are often clinic based and do not provide the services that are required.
Screening, diagnostic testing, and medical treatment is at the core of health care provision, and well-equipped facilities must be available within the communi- ties. People are unlikely to travel long distances to receive care, and transportation is an obstacle faced by many. The provision of comprehensive primary care can pre- vent some of the more catastrophic illness that requires hospital care and preempt
“crisis-based” care.
Substance misuse contributes to poor health in many ways and is the major determinant of low uptake of health services. Therefore, addiction counseling and treatment programs must be readily available and of high quality. Addiction coun- selors have an important role to play in attracting people to medical care and in encouraging their persistence. The integration of substance abuse treatment, detoxification and harm reduction services with primary care can improve access to primary medical care and adherence to recommended interventions (Broadhead, et al., 2002; Heller, et al.,2004; Samet et al., 2003; Sweeney, et al., 2004).
A pharmacy is another important component to health care delivery. A health facility with a pharmacy on-site is ideal as the medicine can be provided directly to
the patient. In addition, pharmacists can explain the expected effects of the med- ications and answer any questions the individual might have. In some cases, medica- tions can be dispensed from the pharmacy on a daily basis in order to enhance adherence and identify adverse events.
A one-stop approach to receiving medical assistance is optimal but not always possible. The size of the facility and the resources that are available will ultimately determine what each site can offer. If resources permit, financial services can also be an important addition to any health-related facility since finances are often a major concern for many marginalized people. The amount of social assistance available is related to health status, and if an individual is unable to fill out the appropriate forms they may not receive the level of help they need. Housing assistance is also a valuable service and can be an important determinant of health. Unstable housing situations can make it difficult to attend follow-up appointments, take regular medications, and eat properly (Hwang, 2001; Hwang and Bugeja, 2000; Hwang, et al., 2003).
7.0. GOALS AND MEASURABLE OUTCOMES
Program evaluation is a critical component of any health intervention. Many inno- vative and successful programs aimed at marginalized populations have gone unno- ticed and un-replicated because they have not been adequately evaluated. Likewise, resources continue to be invested in programs that are not effective because they have not been critically assessed.
Due to the “hidden” nature of the urban, drug-dependent population, a major obstacle to evaluating the impact of an intervention is determining the number of people who are in need of medical services. In this case there is a tendency for a rel- atively small proportion of the population to be responsible for a large percentage of the health service uptake, while the majority of individuals do not participate.
These kinds of artifacts in the data must be kept in mind when dealing with specific subpopulations.
There are several methods of data collection that allow us to evaluate the cur- rent situation as well as the success of specific programs over time.
7.1. Databases at Health Care Facilities
Databases at health care facilities provide a crude measure of health care uptake and are probably the best resources available. Databases have been used to assess STD prevalence, HIV prevalence and infective endocarditis. However, simply counting the number of individuals who present with a particular illness tends to under- estimate the true scope of the problem. Of course, these types of observations are needed in order to launch more rigorous investigations. As existing electronic data- bases are improved and new ones are implemented, these records become more use- ful in determining individual and community health service uptake. For example, the province of British Columbia established a centralized database that records all antiretroviral prescriptions. These data have proved invaluable in determining who is accessing therapy for HIV as well as response to treatment (Hogg, et al., 2001).
7.2. Sentinel Disease Surveillance
Sentinel disease surveillance gives an indication of the burden of disease within the population. Examples of this include standardized surveillance programs for STDs,
HIV, tuberculosis and overdose deaths. This type of analysis can show trends of dis- ease burden over time. Therefore, correlations can be made between these trends and specific health care interventions to determine their impact. This type of data collection can be limited by a failure to access some of the higher risk groups.
7.3. Rapid Assessment Surveys
Rapid Assessment Surveys target specific health outcomes and can be implemented to determine the needs within a community (Fitch, et al., 2004). These surveys are best conducted by persons who are familiar with the community and can gain access to hard-to-reach places and people. For example, housing surveys can be per- formed within specific neighborhoods and health outcomes that are associated with homelessness can be determined (Hwang, et al., 2003).
7.4. Prospective Cohort Studies
Prospective studies in which a representative sample of people are monitored to track health concerns and diagnostic testing, is also a good way to measure out- comes. These cohort studies are expensive to initiate and sustain but they can con- tribute important information over time. In Vancouver, the Vancouver Injection Drug Users Study (VIDUS) was instrumental in identifying a major outbreak of HIV and continues to influence policy by providing important information on the course of the HIV epidemic (Strathdee, et al., 1997).
There are also a number of measurable health outcomes that can be moni- tored to assess needs, evaluate progress and determine the impact of health inter- ventions in urban settings. In the case of illicit drug users, we can examine HIV testing statistics to determine the proportion of individuals that have been tested in the past six months. For those who test HIV positive, the CD4 and viral load meas- ures can also be monitored every three months. We can also look at the uptake of antiretroviral therapy among injection drug users as another good measure of health care coverage (in many urban centers the uptake is sub-optimal due to inadequate services and support). We can analyze the number of annual Pap smears to deter- mine the level of screening in women, and we can examine the number of influenza and pneumococcal vaccinations within specific groups to provide additional meas- ures of primary care uptake.
Finally, we can also look at adverse outcome statistics (i.e., emergency room visits, drug overdoses, injection-related infections, etc.) to determine the health of the commu- nity. One important adverse outcome that is sometimes overlooked is the level of public disorder within the community. Public order and safety are intimately linked to individual health and well-being. Communities that are able to improve the health status of their residents invariably see improvements in order and safety.
8.0. CONCLUSION
In this chapter, we have provided an overview of providing health services to a mar- ginalized group who live in an urban setting. It is clear that the context that the tar- get population is living in must be considered in designing and implementing health care services. Understanding the health needs and barriers to care are cru- cial in planning and implementing health services to various urban populations.
In many North American cities the approach to health care among marginal- ized groups in urban centers has been paradoxical. While there is intense public and political scrutiny of poverty and poor health outcomes in inner cities, there is also a severe lack of resources to improve services and reach those in need.
Although each community requires unique approaches to confront the challenges of poor health outcomes, inadequate housing, entrenched poverty and substance misuse are consistent features of inner city environments.
There are a number of general lessons that can be learned from the observa- tions and research to date. First, there are no “quick-fixes” for many of the people who are out of care and living in urban centers. Realistic goals must be set and each situation requires an innovative approach to improve health. Second, the genera- tional cycle of poverty and poor health needs to be broken. A renewed focus on youth, young mothers and minority groups should be promoted in any program.
Third, multidisciplinary teams are required to address the needs of the community.
Success will come when these teams begin to operate outside of the traditional mod- els of health care delivery. Fourth, the community itself must be involved in pro- gramming to ensure that the interventions are needed and appropriate and to promote buy-in from those that are expected to benefit from the program. Finally, a system of evaluation is required so that the outcomes can be measured and success- ful interventions can be expanded and replicated.
Designing health services for marginalized urban subpopulations requires ingenuity, persistence and compassion. It is a holistic approach – one that considers the specific health concerns and barriers facing individuals within these groups – that is most likely to yield a positive, practical and sustainable health service envi- ronment in our cities.
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