Structural competency in the post-prison period for people who inject drugs: A qualitative case study.

Introduction: Access to services is key to successful community (re-)integration following release from prison. But many people experience disengagement from services, including people who inject drugs (PWID). We use a case study approach and the notion of structural competency to examine influences on access to services among a group of PWID recently released from prison.

Methods: This qualitative study recruited participants from SuperMIX, (a longitudinal cohort study in Victoria, Australia).

Inclusion Criteria: aged 18+; lifetime history of injecting drug use; incarcerated for > three months and released from custody < 12 months previously. From 48 participants, five case studies were selected as emblematic of the complex and intersecting factors occurring at the time participants missed an appointment at a service.

Results: Numerous, concurrent, and interdependent structural influences in participants' lives coincided with their difficulty accessing and maintaining contact with services and resulted in missed appointments. The key factors involved in the cases presented here include policies around opioid agonist treatment, inadequate, unsuitable and unsafe housing, the management of mental health and side effects of treatment, the lack of social support or estrangement from family, and economic hardship. The support available from service workers to navigate these structural issues was inconsistent. One dissenting case is examined in which missing appointments is anticipated and accommodated.

Conclusions: A case study approach enabled a holistic and in-depth examination of upstream structural elements that intersect with limited social and economic resources to exacerbate the challenges of community re-entry. These results highlight structural issues that have a disproportionate impact on the choices and opportunities for PWID. The incorporation of a structural competency framework in design of services and in staff training could support person-centred and coordinated service provision that take into account PWID's experiences post-release to overcome structural barriers to service engagement.