Impact of Health System Engagement on the Health and Well-Being of People Who Use Drugs: A Realist Review

Context People who use drugs (PWUD) choose to partner with the health system in improving care delivery for a variety of reasons. When done meaningfully, health system engagement provides mutual benefit to both communities and care teams. There may also be individual-level benefits, but also paradoxical experiences of harm; this is especially relevant for historically oppressed and equity-seeking groups.

Objective To examine how health system engagement (e.g., health service planning and delivery, scholarly activities, collaborative advocacy) influences the health and well-being of PWUD.

Study Design and Analysis Realist review, using the following steps: (i) clarifying scope, (ii) searching for evidence, (iii) appraising the studies and extracting data, (iv) synthesizing evidence and drawing conclusions, and (v) disseminating, implementing, and evaluating recommendations.

Setting / Dataset A Western Canadian team of lived experience co-researchers, clinicians, and academic experts participated in defining the explanatory model describing the content, mechanism, and outcomes at play during PWUD-partnered activities. An Indigenous knowledge broker joined the team for the latter stages of the review at PWUD co-researchers’ recommendation based on emerging program theory. Data sources also include formal theories and 85 empiric publications selected via a librarian-facilitated search. The review scope included:

Population Studied PWUD, involving any unsanctioned use of opioids/stimulants/illegal substances;

Intervention Activities related to health system engagement in the form of planning, delivery, or research, whether as an internal (e.g. front line outreach work) or external (e.g. patient advisor) actor; and

Outcome Measures Individual physical, emotional, social, or spiritual health and well-being.

Results Healthy partnership depends on social and structural support, clear role definition, cultural safety, and an anti-oppressive space that fosters personal development. Several recommendations were generated to guide partnership best practices, including fair compensation, clear role descriptions, psychological and cultural support, continuous learning, and meaningful input into key decisions.

Conclusions Multiple macro-meso-micro level conditions can create either healthy or harmful engagement experiences for PWUD. Health system actors should develop and action health-promoting policies when partnering with PWUD.