“Like being put on an ice floe and shoved away”: A qualitative study of the impacts of opioid-related policy changes on people who take opioids

AimsTo characterize the impacts of policies intended to improve opioid prescribing and prevent opioid-related overdose and death on individuals who take opioids.MethodsWe conducted a qualitative study using focus groups with 48 adults aged 18 years and over who had experience taking opioids. Participants were recruited from across Ontario, Canada, and separate focus groups were held for individuals taking opioids for chronic pain and individuals taking opioids for other reasons. We drew upon stigma theory to interpret participants’ accounts.ResultsFollowing analysis and interpretation, we generated three themes describing the impacts of recently implemented opioid-related policies and harm reduction interventions on people who take opioids: ‘propagating stigma: addict as dominant status’, ‘loss of autonomy’ and ‘producing/reproducing structural vulnerabilities’. Specifically, participants characterize an environment in which ‘addict’ has become the dominant social identity ascribed to people who take opioids, and where relationships with providers have become strained as participants perceive themselves to be powerless when decisions regarding opioid use and pain management are made. These shifts in identity and relationships had negative repercussions when help-seeking and exposed larger vulnerabilities related to poverty and criminalization.ConclusionsThe introduction of opioid-related policies had unintended consequences for people who take opioids. Potential measures for mitigating these consequences include ensuring that people who take opioids are involved in all facets of policy development and implementation, integrating peer workers into the care of these individuals, and respecting patient agency when decisions about pain management and opioid use are made.     

A systematic review of behaviour change techniques within interventions to prevent return to smoking postpartum

IntroductionThere is no routine support to prevent postpartum smoking relapse, due to lack of effective interventions. Previous reviews have identified behaviour change techniques (BCTs) within pregnancy cessation trials to specify which components might be incorporated into more effective interventions, but no reviews have identified BCTs for prevention of smoking relapse postpartum. We reviewed BCTs and potential delivery modes, to inform future interventions.MethodsWe searched Medline and EMBASE from January 2015–May 2017; and identified trials published before 2015 by handsearching systematic reviews. We included RCTs where: i) ≥1 intervention component aimed to maintain smoking abstinence versus a less intensive intervention; ii) participants included pregnant or postpartum smoking quitters; iii) smoking status was reported in the postpartum period. We extracted trial characteristics and used the Behaviour Change Technique Taxonomy v1 to extract BCTs. We aimed to identify ‘promising’ BCTs i.e. those frequently occurring and present in ≥2 trials that demonstrated long-term effectiveness (≥6 months postpartum). Data synthesis was narrative.ResultsWe included 32 trials, six of which demonstrated long-term effectiveness. These six trials used self-help, mainly in conjunction with counselling, and were largely delivered remotely. We identified six BCTs as promising: ‘problem solving’, ‘information about health consequences’, ‘information about social and environmental consequences’, ‘social support’, ‘reduce negative emotions’ and ‘instruction on how to perform a behaviour’.ConclusionsFuture interventions to prevent postpartum smoking relapse might include these six BCTs to maximise effectiveness. Tailored self-help approaches, with/without counselling, may be favourable modes of delivery of BCTs.Registration: PROSPERO CRD42018075677.     

The Government's alcohol strategy: A commentary from Adfam

This article explores the complex relationships that exist between the consumption of alcohol, the terminology used to describe consumption patterns and their effects, and the various frames of meaning through which these inherently related activities are perceived and understood. A particular focus is on the cultural meaning ascribed to terms and expressions commonly associated with alcohol consumption in different national contexts, something that has implications for an increasingly integrated EU survey approach. Data were collected by way of 12 focus group discussions conducted in four European countries (Estonia, Hungary, Poland and the UK) during the course of the Standardising Measurement of Alcohol Related Troubles (SMART) project. The focus groups produced a rich data set of qualitative material and provided insights into the variable interpretations of many concepts and terms and the difficulty sometimes encountered when seeking ‘equivalent’ translations. Discussion of the main findings to emerge from the research is centred around four main themes: how participants interpret and perceive the concept/activity of ‘drinking’; what/how much is ‘a drink’; the perceived relationship between ‘heavy drinking’ and alcoholism; and how the concept of ‘drunkenness’ is understood. Analysis of the different narratives that emerged from the focus groups points towards significant variation in the usage and meaning associated with these terms within and across the participating countries. Contrasts and commonalities are explored across the data set and the views of participants are considered in relation to the existing literature.     

Biased Perception of Mean Emotion in Abstinent Heroin Abusers

Abstract

Although evidence suggests that drug abusers exhibit biases when coding individual emotional facial expressions, little is known about how they process multiple expressions simultaneously. The present study evaluated the mean emotions perceived by abstinent heroin abusers. Male abstinent heroin abusers (AHs) and healthy controls (HCs) were randomly assigned into three emotional conditions (happy, sad, or angry), viewed sets of four faces (Experiment 1) or individual faces (Experiment 2) that varied in emotionality (neutral to happy/sad/angry), and judged whether a test face presented later was more/less emotional than the preceding stimuli. Average points of subjective equality were calculated to reflect participants’ biases in perceiving emotions of sets or single faces. Relative to HCs, AHs overestimated mean emotions for sad and angry faces in Experiment 1; however, no such biases were found in Experiment 2. This suggests biased ensemble coding towards negative emotional facial expressions in AHs. Furthermore, when controlling for depression and anxiety, AHs’ enhanced perception of mean emotion for angry or sad faces in Experiment 1 decreased, indicating a possible mediating effect of these psychopathological variables in the relationship between drug addiction history and abnormal ensemble processing for sets of emotional expressions.     

Men's views of antidepressant treatment for depression,and their implications for community pharmacy practice

BackgroundMen with depression can express and navigate their condition differently to women. Understanding this population's needs, and experiences, can help healthcare professionals better support these patients. There is a lack of knowledge in this area, and no studies have explored men's depression in the context of community pharmacy.ObjectivesExplore views of men around their medication for the treatment of depression and the role of community pharmacy in their treatment.SettingUnited Kingdom (UK) primary care.MethodSemi-structured in-depth interviews were conducted. Eligible participants were male, aged 18–65 years, and treating depression with antidepressants. Participants were recruited through 5 UK pharmacies (via the pharmacist or poster recruitment) and a UK University (poster recruitment). A thematic approach was used for analysis.Results14 men aged 26–61 years, predominantly of white ethnicity were interviewed. Key themes were found. The theme ‘Antidepressant's attributions to benefits' highlighted all men noticed benefits when taking antidepressants, but held uncertainty on what extent their antidepressants caused this. The themes ‘Views of pharmacist's role influences engagement’, and ‘Influence of cognitive state upon healthcare interactions’ demonstrated men were not inclined to discuss concerns with the community pharmacist. These men didn't see this as the pharmacist's role, nor had these men given cognitive space to evaluate their treatment beliefs or information needs. Yet the theme ‘Reflection of support and information needs’ shows men did have unmet information and support needs. This also links into the ‘Hegemonic Masculinity and taking antidepressants’ theme, where taking antidepressants could challenge ones masculinity.ConclusionCommunity pharmacists should create opportunities for men to engage in conversations around their antidepressants and wider support. Men, as a requisite for engagement, will need to see such interactions as within the community pharmacists’ remit, and as part of a collaborative healthcare system.     

Peer to peer communication about hepatitis C treatment amongst people who inject drugs: A longitudinal qualitative study

BackgroundLittle is known about how information on direct-acting antiviral treatment for hepatitis C circulates through peer networks of people who inject drugs. In this study we aimed to explore what and how treatment-related information is shared between people undergoing treatment and their peers.MethodsParticipants were recruited from two general practice clinics and the community-based hepatitis C Treatment and Prevention Study. Semi-structured interviews were conducted with each participant (N = 20) before, during and following treatment. Interviews explored hepatitis C treatment experiences, key sources of DAA information and the impact of receiving and sharing knowledge. Inductive thematic analysis was conducted. Time sequential matrices were generated to understand thematic change over time.ResultsFifty-four interviews were conducted with 20 participants across seven field-sites in Melbourne, Australia. Key themes were: ‘peers as a source treatment information’, ‘do it together’ and ‘becoming a treatment advocate’. Peers were a crucial trusted source of information. Positive treatment anecdotes were important for building confidence in and motivation to initiate treatment. Many participants adopted a ‘treatment advocate’ role in their close peer networks, which was described as empowering. Some participants described benefits of undertaking treatment alongside members of their close network.ConclusionFindings illustrate the importance of close peers in shaping treatment perceptions and engagement. This will be important in designing health promotion messaging and interventions to increase treatment uptake.     

A qualitative study of a publicly funded pharmacy-dispensed naloxone program

AimsTo characterize the experiences of individuals accessing pharmacy-based naloxone and relate these experiences to the risk environments and discourses in which they are embedded.MethodsWe conducted a qualitative study using in-depth interviews of 37 adults aged 18 years and over who had accessed pharmacy-dispensed naloxone. Participants were recruited from across Ontario, Canada, and comprised individuals taking opioids for chronic pain, those taking opioids for reasons other than chronic pain, and individuals acquiring naloxone to act as bystanders in an opioid overdose setting. We drew upon risk environment theory to interpret participants’ accounts.ResultsFollowing analysis and interpretation, we generated five theoretically-informed themes characterizing the experiences of individuals accessing pharmacy-dispensed naloxone: ‘intersection of naloxone narrative with pharmacy environment’, ‘individual risk environment and pharmacy-dispensed naloxone uptake’, ‘safe spaces: creating an enabling environment for pharmacy-dispensed naloxone’, ‘individuation: becoming a first responder’ and 'beyond naloxone: the macro risk environment’. Specifically, participants described how judgement and stereotyping associated with the broader naloxone narrative can be amplified in the space of the pharmacy, leading to fears of reprisals and strategies to mitigate social risk. In addition, the social construction of naloxone as a drug for ‘problematic’ opioid use and a lack of pharmacist awareness regarding the risk environments in which opioid use occurs was perceived to limit opportunities for optimizing naloxone distribution and training. Finally, participants described approaches that could create enabling environments in the space of the pharmacy while remaining cognizant of the structural changes required in the macro risk environments of people who take opioids.ConclusionsDespite increasing the availability of naloxone, participants characterized several social and environmental factors that could limit the accessibility of the drug from pharmacies. Strategies to address these factors could create enabling environments within pharmacies that optimize the reach and impact of pharmacy-dispensed naloxone.     

Exploring community pharmacists’ use of health literacy interventions in their everyday practice

BackgroundLimited health literacy often results in people inadequately understanding medicines-related information and subsequently not taking medicines as prescribed. Using health literacy interventions is important for community pharmacists, as they are increasingly managing long-term conditions. However, there appear to be no previous studies of community pharmacists’ everyday use of health literacy interventions in the UK.ObjectivesTo explore UK community pharmacists’ perspectives on the usability of health literacy interventions in their everyday practice.MethodsSemi-structured interviews were conducted with participants, following attendance at health literacy training that included practicing the use of four health literacy interventions (Teach-Back, Chunk and Check, Simple Language and visual aids) and two months experience of attempting to use them in their everyday practice. Participants were pharmacists from community pharmacies in Staffordshire, England who were invited to participate by an email sent to the pharmacy. Interviews were audio-recorded, transcribed verbatim and analysed using the Framework Analysis technique.ResultsFour themes emerged from 11 interviews undertaken: intervention appeal, limitations, adaptations and continued use. Participants reported using all four health literacy interventions in their everyday practice but Teach-Back appeared to be favoured most. Most participants talked about practicing Teach-Back before using it with patients but described it as useable with patients of all ages, without being prohibitively time consuming. Chunk and Check seemed to be viewed as a type of Teach-Back, whilst visual aids were reported as being used in conjunction with Teach Back rather than as a standalone intervention. Participants reported that Simple Language was an easy concept but easily ‘slipped back’ into medical jargon and were challenged to use simple enough words. All participants said they would continue to use all four health literacy interventions.ConclusionsThe findings suggest that with training, community pharmacists can successfully incorporate these four health literacy interventions into their everyday practice.     

The lived experience of interferon-free treatments for hepatitis C: A thematic analysis

BackgroundInternational discourse concerning the evolution in hepatitis C virus (HCV) therapy has tended to focus on improving outcomes, shortened treatment length and reduced side-effects of interferon-free regimens. How these treatments are being understood and experienced by the people receiving them has so far been overlooked. This study therefore aimed to explore the lived experience of individuals taking interferon-free HCV therapies.MethodsData were generated through 16 semi-structured interviews with a purposive sample of eight participants, recruited from a university hospital in Scotland. The interviews took place between June 2015 and March 2016, before and after a period of interferon-free HCV treatment. The data were interrogated using a thematic analysis, underpinned by social phenomenological theory.ResultsThree overriding themes were identified. ‘Expectations and realisations’ characterised the influence that interferon continued to cast over interferon-free treatment, contrasting the practicalities of taking interferon-free therapy with preconceived notions. ‘An honour and a pleasure’ portrayed a positive experience of an undemanding therapy, yet among those with a history of drug use, was also positioned as a privilege, associated with feelings of luck and guilt. ‘Treatment needs’ illustrated the strategies participants used to search for treatment efficacy, and the value those with a significant history of drug use placed on support. One nonconforming case is then discussed to enhance rigour and trustworthiness.ConclusionThis is the first qualitative exploration of the experience of interferon-free HCV treatment reported globally. The results from this study suggest a cultural lag exists between the pharmacological developments which have been witnessed, and societal understandings of them. This has implications for the way services meet the needs of, and offer therapy to, HCV positive individuals.     

Reasons for missed appointments with a hepatitis C outreach clinic: A qualitative study

BackgroundNon-attendance in drug service hepatitis C outreach clinics means clients miss the opportunity of being given lifestyle advice and referral to hospital for assessment and treatment. A similar problem is experienced in other services throughout the UK. A qualitative study was undertaken to investigate the problem.MethodsClients with a history of not attending the outreach clinic were invited to participate during a routine drug clinic appointment. A contact details sheet with a preferred telephone number was completed by those agreeing to take part. Verbal consent was taken and a telephone interview took place. The participants were remunerated for taking part with a five pounds high street voucher. The ‘framework method’ was used to analyse the data with key themes identified.ResultsTwenty-eight telephone interviews were undertaken from April to June 2012. All the clients gave ‘prima-facie’ reasons for non-attendance including ‘not a priority’ and ‘forgot’. However, the study indicates these are insufficient to explain the various experiences and influences. Underlying reasons that impacted upon attendance were identified. These reasons relate to (i) client characteristics e.g. ‘priority’ to score drugs and the ‘cost of travel’ and (ii) clinic service e.g. ‘difficult journey’ to the clinic and timing of the ‘appointment’. The reasons operated within a complex context where other factors had an impact including addiction, welfare policy, stigma and the nature of hepatitis C itself.ConclusionThe study revealed that beneath apparently simple explanations for non-attendance, such as clients’ chaotic lifestyle resulting in them forgetting or not being bothered to attend, there were far more complex and varied underlying reasons. This has important implications for drug policy including the need to better incorporate clients’ perspectives. Policy that is based only on the simple, surface reasons is unlikely to be effective.     

Re-configured pleasures: How young people feel good through abstaining or moderating their drinking

BackgroundAlcohol use has strong associations with the pursuit of pleasure, yet trends in young people's drinking have been declining in Australia for more than 15 years. Therefore, it is important to examine how the increasing number of young people who drink lightly or abstain think about pleasure and alcohol, and how this might reflect changing practices around drinking for pleasure.MethodsSemi-structured interviews were conducted with 50 young people aged 16–19 from Melbourne who abstained from alcohol or drank within Australian guidelines for risky drinking. Participants reflected on how they socialised whilst drinking lightly or without drinking at all, and how they experienced pleasure in this context. These responses were analysed thematically.ResultsFour key themes emerged; authenticity, intimacy, control, and vicarious pleasure. Some participants felt that by not drinking, they were enacting authentic or better versions of themselves, whilst developing a stronger sense of intimacy with their sober friends. Others described the displeasure of potentially losing control of their emotions and bodies in social situations and were able to instead experience enjoyment vicariously through their friends’ drinking.ConclusionDrinking has long been regarded as a way to build a connection with others, relax and feel a sense of pleasure. However, it is important to recognise that avoiding drinking and drunkenness provides an alternative means by which some young people pursue feelings of pleasure and enjoyment. In a time of declining drinking rates, participants here drew on notions of authenticity, intimacy, self-control, and vicarious enjoyment to construct light or non-drinking as a pleasurable pursuit, and a positive part of selfhood.     

Being serious about quitting: a qualitative analysis of Australian ex-smokers’ explanations of their quitting success

BackgroundThe process of successful quitting, and the personal and social conditions required to support it, remain poorly understood.MethodsThis qualitative grounded theory study used in-depth interviews with 37 Australian adult ex-smokers (24–68 years; 15 men and 22 women) who quit in the past 6–24 months to explore how ex-smokers explain their quitting success.FindingsThis analysis provides a framework for understanding the personal, social and structural factors critical to successful quitting. The key analytic finding was the core concept ‘being serious’. Three factors contributed to ‘being serious’: (1) prior experiences of quitting; (2) an identity (or existential) threat; and (3) timing and circumstances. The analysis indicated that the concept ‘being serious’ rather than the oft-cited psychological constructs motivation and willpower more accurately captures how participants talked about and explained their quitting success, how they accounted for their success when previous apparently similar attempts had failed, and the advice they would offer would-be quitters about achieving quitting success. An explanation is provided for why some participants battled with quitting for years, while others quit unexpectedly, even effortlessly. The social and structural factors that made the state of ‘being serious’ easier or harder for the participant to attain are also discussed.Conclusion‘Being serious’ was a term that resonated with participants. Participants’ accounts of quitting indicate that quitting is a complex and gradual process and that social and structural influences have a key role in determining how easy or difficult it was to become serious about quitting.     

Experiences of medical dominance in pharmacist-doctor interactions - An elephant in the room?

BackgroundThe development of new roles by pharmacists supports the delivery of healthcare services but potentially also encroaches into other healthcare professions’ domains of practice. Some novel pharmacy services are only reluctantly accepted by the medical profession and are surrounded by a discourse which expresses medical dominance, with pharmacists facing resistance to their closer involvement in patient care.ObjectiveTo investigate whether and how pharmacists may experience medical dominance in their practice.MethodsFor this qualitative study, pharmacists working in primary care settings were introduced to concepts of sociology in healthcare and medical dominance, then asked to reflect on personal experiences of potential medical dominance, and their emotional and behavioural response. The reflective texts were thematically analysed using a framework based on theories of medical dominance, self-regulation and the influence of emotions on cognition to interpret themes.ResultsTwenty-five pharmacists provided detailed reflective accounts. Most worked in a community pharmacy when they experienced medical dominance in interactions with doctors. They described how doctors demarcated territory, evaded scrutiny or disparaged pharmacists’ professional expertise. Pharmacists perceived limited options in negotiating these experiences and often employed patients in resolving issues which were left unaddressed. They felt frustrated, undervalued and angry after their experiences and described apprehensiveness in future interactions with doctors.ConclusionAlthough experiences of medical dominance by pharmacists working in primary care seem to be an infrequent though regular occurrence pharmacists do not seem to be well prepared to counter or negotiate around it. Perceived and actual dominance in interprofessional interactions with doctors are stressors which may affect pharmacists’ ability to problem-solve, their role effectiveness and satisfaction.     

Conceptualising hepatitis C stigma: A thematic synthesis of qualitative research

BackgroundStigma is an important element in the experience of living with chronic viral hepatitis B (HBV) and C (HCV), impacting healthcare access and uptake as well as health outcomes. Conceptualisations of stigma in research are, however, often assumed and implicit. This study aimed to synthesise and critically engage with the qualitative literature to provide an overarching conceptualisation of stigma as it pertains to viral hepatitis.MethodsWe critically reviewed qualitative literature that mobilised concepts or theories of stigma in relation to viral hepatitis. We searched seven electronic databases for peer-reviewed literature from 2000 to 2019. Given a dearth of conceptual literature on HBV stigma, we conducted a thematic analysis of concepts deployed to theorise stigma in relation to HCV.ResultsWe found 13 studies that conceptualised stigma in relation to HCV, yet none for HBV. We synthesise the analytical findings of these studies and explore how HCV is theorised in relation to four themes: ‘identity’, ‘embodiment’, ‘institutionalisation’, and ‘structuration’. Taken together, these themes illustrate the way in which HCV stigma manifests as the confluence of normative assumptions of socially unacceptable practices relating to HCV, such as injecting drug use and sexual behaviours; attitudes towards socially excluded populations; and fears of contracting a contagious and chronic illness. As such, operating within political, social, and economic systems, HCV stigma can act to silence the needs of those with HCV through misrecognising the multifaceted identities of individuals with HCV and structural determinants of health. Stigma, which is built and perpetuated by institutional arrangements, as well as in social processes and policies, shapes deservedness to, as well as engagements with, health and social care.ConclusionWhile commonly employed as a framing concept, much research lacks explicit theoretical or critical engagement on how stigma is conceptualised. There is a tendency for qualitative, empirical research to focus on risk factors shaping individual behaviour change, rather than on risk contexts and socio-structural change. Approaches to address stigma in relation to HCV must consider how stigma operates throughout social processes and is embedded in systems of power and normalised in institutional operating systems.     

Alcohol control policies in Indigenous communities: A qualitative study of the perceptions of their effectiveness among service providers,stakeholders and community leaders in Queensland (Australia)

BackgroundFavourable impacts are reported from complex alcohol control strategies, known as ‘Alcohol Management Plans’ (AMPs) implemented 14 years ago in 19 Aboriginal and Torres Strait Islander (Indigenous) communities in Queensland (Australia). However, it is not clear that all communities benefited and that positive impacts were sustained. Service providers, key stakeholders and community leaders provided insights about issues and impacts.MethodsParticipants (N = 382) were recruited from knowledgeable and experienced persons using agency lists and by recommendation across sectors which have a mandate for managing alcohol-related issues and consequences of AMP policies in communities. In semi-structured interviews, participants (51% Indigenous, 55% male and comprised of at least one-third local community residents) were asked whether they believed alcohol controls had been effective and to describe any favourable and unfavourable outcomes experienced or perceived. Inductive techniques were used for thematic analysis of the content of transcribed recorded interviews. Comments reflecting themes were assessed across service sectors, by gender, Indigenous status and remoteness.ResultsParticipants attributed reduced violence and improved community amenity to AMPs, particularly for ‘very remote’ communities. Participants’ information suggests that these important achievements happened abruptly but may have become undermined over time by: the availability of illicit alcohol and an urgency to consume it; migration to larger centres to seek alcohol; criminalization; substitution of illicit drugs for alcohol; changed drinking behaviours and discrimination. Most issues were more frequently linked with ‘very remote’ communities.ConclusionAlcohol restrictions in Queensland's Indigenous communities may have brought favourable changes, a significant achievement after a long period of poorly regulated alcohol availability from the 1980s up to 2002. Subsequently, over the past decade, an urgency to access and consume illicit alcohol appears to have emerged. It is not clear that relaxing restrictions would reverse the harmful impacts of AMPs without significant demand reduction, treatment and diversion efforts.     

Understanding women's feelings about safety and hazards of street drinking in London through interpretative phenomenological analysis

AimsDrinking alcohol in outdoor public places (e.g. streets and parks) and outside of formally organised events is perceived and reported as antisocial behaviour and may be indicative of a problematic relationship with alcohol, and other clinical needs. This paper aims to address a lack of qualitative research on street drinking in the United Kingdom and develop a textured understanding of the lived-experience of how some women engage in street drinking, in the context of one London borough.MethodThe authors collected semi-structured interviews as part of a larger mixed methods study on street drinking from April to August 2018. A sub-set of interviews (n = 3) with women who were accessing local drug and alcohol services and had a history of street drinking behaviour were selected as a case series for triangulating analysis with a smaller, homogenous sample. These data were analysed using Interpretative Phenomenological Analysis with a reflexive, feminist, social constructionist approach.ResultsThe authors developed and named a superordinate theme, Constellations of Safety and Hazards for Women Drinking in Public and Private. Within this, four themes were defined and illustrated from the data: Drinking outdoors to be away from hazards at home; Women's awareness of geo-temporal factors to moderate risk; Women identifying risks of accepting drinks from strangers; and Threats of untreated trauma within histories of heavy drinking. Definitions and illustrations from participants aid explanations of how the texts add detail or disruption to dominant discourses.ConclusionThe case studies illustrating how these women have experienced alcohol misuse and behaviour change provide reflexive accounts of exercising agency in managing embodied and affective states of vulnerability. This was demonstrated by asserting choice around environmental spaces and friendships, even when still in positions deemed as ‘risky’. These three women's decisions around drinking in public, outdoor spaces were shaped by complex interactions of interpersonal, intrapersonal, socio-economic, and cultural structures. Understanding behaviours is improved with data that situates people in contexts where they experience and make sense of their lives.