"We can't change that while they're in the hospital": Unveiling the manifestations of infrastructural violence and wound care for people who inject drugs

Healthcare avoidance or delays for wounds and related skin- and soft-tissue infections are often attributed to negative interactions with medical providers. An infrastructural violence framework posits that healthcare infrastructure serves as a material channel for structural violence, maintaining inequities in healthcare experiences and outcomes. Infrastructural violence ensues when infrastructure is designed for some members or groups within a society while perpetuating violence among others. This study draws on the concept to understand how healthcare infrastructure creates and perpetuates inequities within the healthcare system for people who inject drugs for their wound care-related needs. Between January and September 2023, semi-structured interviews were conducted with 12 medical providers in Maryland. An abductive thematic analysis approach was followed. Healthcare infrastructure mediated the relationship between structural factors, such as policies on prescribing privileges of medications for opioid use disorder and subsequent individual health experiences. Medical providers also described how their access to training, protocols, and other resources was insufficient to meet the needs of people who inject drugs presenting to healthcare settings for wound care. A new conceptual grounding provides recommendations on extending beyond medical provider behavior change interventions in healthcare settings to create supportive infrastructure, which includes readily available and accessible policies, protocols, and resources to care for this patient population.