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There are particular complexities faced by people attempting to tell their stories in the context of social stigma, such as the hostility which often surrounds injecting drug use. In this article, we identify some of the distinct advantages of taking a narrative approach to understanding these complexities by exploring a single case study, across two life-history interviews, with "Jimmy," a young man with a history of social disadvantage, incarceration, and heroin dependence. Drawing on Miranda Fricker's notion of "hermeneutical injustice," we consider the effects of stigmatization on the sociocultural practice of storytelling. We note the way Jimmy appears both constrained and released by his story-how he conforms to but also resists the master narrative of the "drug user." Narrative analysis, we conclude, honors the complex challenges of the accounting work evident in interviews such as Jimmy's, providing a valuable counterpoint to other forms of qualitative inquiry in the addictions field.

Background: The 2017 National Comprehensive Cancer Network Clinical Practice Guidelines recommend surgical resection or definitive radiation therapy for early-stage oral cavity malignancies, and surgical resection or multimodality clinical trials for late-stage disease. Few studies have been conducted to identify predictors of choice of treatment modality for oral cavity malignancies., Methods: All patients in the National Cancer Data Base (NCDB) diagnosed with oral cavity squamous cell carcinoma (OCSCC) between 1998 and 2011 were identified. Chi-square and binary logistic regression were used to identify factors predictive of surgical or nonsurgical treatment; multiple imputation was used for missing data. Cox proportional hazards models were generated to identify associations between treatment modality and overall survival (OS)., Results: Of 23,459 patients, 4139 (17.6%) underwent primary nonsurgical treatment. Among NCDB-registered facilities, there has been a decrease in use of nonsurgical treatment for OCSCC (OR 0.97, p<0.001). Older age, non-white race, Medicaid insurance, low income, low education, and later-stage disease were associated with nonsurgical therapy, while patients at academic/research programs were more likely to undergo surgery (OR 0.38, p<0.001). Nonsurgical treatment was associated with decreased OS (HR=2.02, p<0.001); this was upheld on subgroup analysis of early- and late-stage disease., Conclusions: Use of primary nonsurgical treatment for OCSCC has decreased over time among NCDB-registered facilities and is associated with factors related to access to care. Surgical resection for the primary treatment of oral cavity cancer may be associated with improved OS, though conclusions regarding survival are limited by the non-randomized nature of the data., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Background: overweight and obesity in the pregnant population is increasing and this is a public health concern. Many women have difficulty in following the recommendation to maintain a healthy diet and to keep active, indeed some identify pregnancy as the start of their concern with being overweight., Objective: to assess the feasibility and acceptability of the 'Eat Well Keep Active' intervention programme designed to promote healthy eating and physical activity in pregnant women. This brief midwife led intervention was based upon the Self Determination Theory (SDT) framework and utilised Motivational Interviewing and individualised goal setting., Design: this was a prospective qualitative study to explore women's views on the acceptability and perceived efficacy of the 'Eat Well Keep Active' programme obtained through one-to-one interviews 6 weeks after the delivery of the intervention. Data were also analysed to assess fidelity of the intervention to the psychological constructs of SDT; autonomy, competence and relatedness., Setting: Wales, UK., Participants: pregnant women suitable for Midwife Led Care and therefore deemed to be 'low risk' were recruited from a large maternity unit in South Wales (n=20)., Findings: the results indicated that the 'Eat Well Keep Active' intervention programme was well received by participants who reported that it positively influenced their health behaviours. There was clear evidence of the intervention supporting the three SDT psychological needs., Key Conclusions: The Eat Well Keep Active intervention was designed to be incorporated into existing antenatal provision and findings from this study have demonstrated its acceptability. The brief midwife led intervention based on SDT was found to be acceptable by the participants who embraced the opportunity to discuss and explore their lifestyle behaviours with a midwife., Implications for Practice: theoretically designed interventions that can facilitate women to pursue a healthy lifestyle during pregnancy are lacking and the 'Eat Well Keep Active' programme has the potential to address this. Further research is needed in order to assess the acceptability of the intervention to midwives and other groups of pregnant women prior to assessing its efficacy in changing and maintaining healthful behaviours., (Crown Copyright © 2016. Published by Elsevier Ltd. All rights reserved.)

Public health research treats intimate partnerships as sites of risk management, including in the management of HIV and hepatitis C transmission. This risk-infused biomedical approach tends to undermine appreciation of the emotional and socially situated meanings of care in intimate partnerships. In this article we explore qualitative interview accounts of the care enacted in partnerships between people who inject drugs, drawing on a 2014 study of 34 couples and 12 individuals living in two locations of Australia. A thematic analysis highlights 'best friend relationships', 'doing everything together', 'co-dependency', and 'doing normalcy' as core to narratives of care. As we will argue, the accounts position the care undertaken by couples as at once shaped by day-to-day practices of drug use and by social situation, with the partnership enacting care as a form of social protection, including protection from stigma and other environmental hostilities. The intimacy of doing everything together offers insulation against stigma, yet also reproduces its isolating effects. While the care produced in drug-using partnerships is presented as double-edged, we note how interview accounts are used to deflect the charge that these relationships represent harmful co-dependency. Taken together, the interview accounts negotiate a 'counter-care' in relation to normalcy, presenting the intimate partnership between people who use drugs as a legitimate embodiment of care., (Copyright © 2017. Published by Elsevier Ltd.)

Background: While the health-related benefits of intimate partnership are well documented, little attention has been paid to couples exposed to high levels of social stigma and exclusion. In this project we investigated an important site of stigma for partnerships by collecting accounts of changing hepatitis C (HCV) status ("sero-change") among couples that inject drugs. We explored what these accounts reveal about the meaning of HCV for these couples, and how this understanding contributes to our collective efforts at prevention and care., Methods: Drawing from a large dataset of qualitative interviews with couples, we focussed on those containing reports of sero-change. By adopting a methodology that positioned partnerships rather than individuals as the primary unit of analysis, we addressed the commonplace tendency to either overlook or discount as dysfunctional, the sexual relationships of people who inject drugs., Results: While some couples sought greater biomedical understanding as a means of coming to terms with sero-change, others drew on alternative logics or "rationalities" that sat firmly outside conventional biomedical discourse (privileging notions of kinship, for example). Regardless of which explanatory framework they drew on, participants ultimately prioritised the security of their relationship over the dangers of viral infection., Conclusions: Effectively engaging couples in HCV prevention and care requires acknowledging and working with the competing priorities and complex realities of such partnerships beyond simply the identification of viral risk. The "new era" of direct acting antiviral treatments will provide ongoing opportunities to learn to integrate biomedical information within more socially sophisticated, relationally aware approaches., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Objectives: Venous thromboembolism (VTE, including deep vein thrombosis [DVT] and pulmonary embolism [PE]) is a serious, potentially traumatic, life-threatening condition and a major cause of mortality and morbidity. The aim of this study was to explore the patients' experiences of VTE and its psychosocial impact., Methods: Audio-recorded semistructured interviews with a purposive sample of 12 participants who had experienced a first-time DVT or PE within the previous 6 months. Interviews were transcribed and thematically analysed., Results: Four key themes with 10 subthemes were identified. The major themes were as follows: VTE as life-changing and traumatic, living with uncertainty and fear of reoccurrence, feeling let down by health services, and positive changes and outcomes. The content of themes varied according to age at the time of VTE and participants' experiences of diagnosis and treatment., Conclusions: The data demonstrate the psychosocial impact of VTE as life-changing, encompassing a dynamic duality of trauma and growth. The findings highlight a potential role for health care professionals in identifying and supporting individuals at risk of post-traumatic stress, and targeted interventions to enhance psychological well-being and recovery and reduce distress. Statement of contribution What is already known on this subject? Venous thromboembolism (VTE) is often characterized by sudden onset and may carry a significant threat to life, particularly in the form of pulmonary embolism. Early studies suggest that health-related quality of life is negatively affected by VTE and there is likely to be a high prevalence of trauma. What does this study add? This study explores for the first time the experience of, and reactions to, VTE in the 6 months following its occurrence. It explores the role that psychological well-being can play in recovery after VTE. This study highlights that improvements are needed to support VTE patients to cope with the emotional impact of VTE. A dual process of trauma and post-traumatic growth after VTE is reported for the first time., (© 2016 The British Psychological Society.)

Introduction: Cancer is a growing health, social and economic problem. 1 in 3 people in the UK will develop cancer in their lifetime. With survival rates rising to over 50%, the long-term needs of cancer survivors are of growing importance. Cancer rehabilitation is tailored to address the physical or psychosocial decline in ability to engage in daily activities. Its use is supported by high-quality international, multicentre research. Incorporating strategies for self-management behaviour development into rehabilitation can prepare individuals for cancer survivorship. However, healthcare professionals will need to adjust their therapeutic interactions accordingly. Research is yet to clarify the impact of the therapeutic relationship on rehabilitation outcomes in cancer. This study aims to explore the impact of therapeutic relationships on self-management behaviours after cancer., Methods and Analysis: This qualitative study aims to understand cancer rehabilitation participants' beliefs regarding the importance of therapeutic relationships in developing self-management behaviours. A sample representative of a local cancer rehabilitation cohort will be asked to complete a semistructured interview to identify their perspectives on the importance of therapeutic relationships in cancer rehabilitation. Data obtained from the interviews will be analysed, coded and entered into a Delphi questionnaire for circulation to a local cancer rehabilitation population to determine if the views expressed by the interviewees are supported by group consensus., Ethics and Dissemination: This study was approved by Wales Research Ethics Committee 6 (15/WA/0331) in April 2016. Findings will be disseminated through the first author's doctoral thesis; peer-reviewed journals; local, national and international conference presentations; and public events involving research participants and the general public., Competing Interests: This study will be carried out as part of the principal investigator's candidature for a professional practice doctorate, and will make a significant contribution to the thesis for this award. The study runs parallel to the principal investigator's employment in a cancer rehabilitation service. It is sponsored by the Research and Development Team in Abertawe Bro Morgannwg University Health Board. The authors declare that they have no conflict of interest., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Aims: Despite injecting-equipment sharing between sexual partners leaving them at increased risk of hepatitis C (HCV), there is scant literature available to guide harm reduction workers in their encounters with couples who inject drugs. This article explored workers' understandings of such couples and their accounts of working with them in relation to HCV prevention., Method: Semi-structured interviews were conducted with 22 staff of harm reduction services located in Sydney and Melbourne, Australia., Results: Overall, staff represented couples as either absent from the service or as presenting with needs indiscernible from those of individual clients. Responses to questions about HCV and couples were framed primarily in terms of risk. Staff participants questioned 'genuineness' of clients' intimate relationships, instead characterising them as inauthentic and drug-driven. Working with couples was seen to present a number of organisational and clinical challenges. The benefits of recognising and working with such partnerships received scant acknowledgement. Rather, staff tended to perceive couples as being 'impenetrable' to health promotion messaging., Discussion: The framing and delivery of harm reduction in Australia remains an individualising enterprise with little capacity to recognise the intimate partnerships, including addressing the HCV risks specific to them. More effective harm reduction strategies may be achieved by transitioning to a practice framework that addresses the social context of injecting, including the experience of couples. This would require direct involvement of couples who inject drugs., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Background: Adolescents face many barriers to physical activity, demonstrated by the decline in physical activity levels in teenage populations. This study aimed to assess the feasibility of overcoming such barriers via the implementation of an activity-promoting voucher scheme to teenagers in deprived areas., Methods: All Year 9 pupils (n = 115; 13.3 ± 0.48 years; 51 % boys) from one secondary school in Wales (UK) participated. Participants received £25 of activity vouchers every month for six months for physical activity or sporting equipment. Focus groups (n = 7), with 43 pupils, and qualitative interviews with teachers (n = 2) were conducted to assess feasibility, in addition to a process evaluation utilising the RE-AIM framework. Quantitative outcomes at baseline, five months (during intervention) and twelve months (follow-up) included: physical activity (accelerometer), aerobic fitness (12 min Cooper run) and self-reported activity (PAQ-A). Motivation to exercise (BREQ-2) was measured three months post-baseline and at follow-up., Results: Qualitative findings showed that vouchers encouraged friends to socialise through activity, provided opportunities to access local activities that pupils normally could not afford, and engaged both those interested and disinterested in physical education. Improvements in weekend moderate-to-vigorous physical activity and reductions in sedentary behaviour were observed in both sexes. Boys' fitness significantly improved during the voucher scheme. 'Non-active' pupils (those not meeting recommended guidelines of 60 mins∙day(-1)) and those with higher motivation to exercise had higher voucher use., Conclusions: Adolescents, teachers and activity providers supported the voucher scheme and felt the vouchers enabled deprived adolescents to access more physical activity opportunities. Voucher usage was associated with improved attitudes to physical activity, increased socialisation with friends and improved fitness and physical activity; presenting interesting avenues for further exploration in a larger intervention trial.

Aims: To examine the relationship between specific reasons for stopping breastfeeding and depressive symptoms in the postnatal period., Background: Difficulty breastfeeding has been connected to postnatal depression although it is unclear whether difficulty breastfeeding precedes or succeeds a diagnosis. However, the concept of 'breastfeeding difficulty' is wide and includes biological, psychological and social factors., Design: A cross-sectional self-report survey., Methods: Data were collected between December 2012 and February 2013. 217 women with an infant aged 0-6 months who had started breastfeeding at birth but had stopped before 6 months old completed a questionnaire examining breastfeeding duration and reasons for stopping breastfeeding. They further completed a copy of the Edinburgh Postnatal Depression Scale., Results: A short breastfeeding duration and multiple reasons for stopping breastfeeding were associated with higher depression score. However, in a regression analysis only the specific reasons of stopping breastfeeding for physical difficulty and pain remained predictive of depression score., Conclusions: Understanding women's specific reasons for stopping breastfeeding rather than breastfeeding duration is critical in understanding women's breastfeeding experience and providing women with emotional support. Issues with pain and physical breastfeeding were most indicative of postnatal depression in comparison to psychosocial reasons highlighting the importance of spending time with new mothers to help them with issues such as latch., (© 2015 The Authors. Journal of Advanced Nursing published by John Wiley & Sons Ltd.)

Objectives: To explore the lived experiences of implantable cardioverter defibrillator (ICD) recipients., Background: Previous research suggests ICD recipients experience significant psychological distress with a focus on shock anxiety. In response, avoidant behaviors are often used which can lead to reduced quality of life, cardiac fitness and increased risk of arrhythmia., Methods: A qualitative study using semi-structured interviews with a purposive sample of 18 recipients who had either received or not received an ICD shock was conducted. Data were analyzed using a thematic approach., Results: Three themes with sub-themes were defined: (i) physical consequences; (ii) emotional consequences (feeling vulnerable and uncertain; anxiety and depression); and (iii) coping with the ICD (avoidance/restrictive behaviors; acceptance; concealment)., Conclusion: ICD recipients might be helped by a psycho-social intervention that corrects false beliefs about exercise and offers some simple stress management techniques. Additional elements might include helping recipients to re-evaluate goals and find a valued sense of self which this study found aided ICD acceptance., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Aims: Interest in health-care related trust is growing with the recognition that trust is essential for effective therapeutic encounters. While most trust-related research has been conducted with general patient groups, the experiences of people who inject drugs cannot be understood without acknowledging the critical role social stigma plays in shaping (mis)trust, both generally and in regards to health services specifically. This study examined the experiences of trust among clients and staff of Needle and Syringe Programs (NSPs) in one area of Sydney, Australia., Method: In-depth interviews with 12 NSP staff and 31 NSP clients were conducted. Analysis was informed by a five component model of trust, with particular emphasis on the notion of "global trust" as encompassing experiences of stigma and other negative social processes related to injecting drug use. Participant experiences of trust in NSPs were compared with those within other drug-related health services. Particular attention was paid to understanding the relationship between 'identity' (as a drug user) and 'legitimacy' (as a service user) and the centrality of this relationship to the experience of global trust for PWID., Results: Notions of identity and legitimacy were inextricably bound up with the stigmatisation of drug use, shaping participants' experiences and accounts of trust in NSPs and drug treatment services. Client participants reported high levels of trust in NSPs, especially when compared with drug treatment services, describing being treated like "any other person" even when negotiating 'sensitive' issues. NSP staff participants described the establishment of trust as not only underpinning their work with clients but as something that required ongoing renewal and demonstration., Conclusion: "Global trust" assists us to better understand the complex experiences shaping PWID decisions to engage with and trust health services. The high levels of trust reported between client and NSP need to be recognised as a valuable resource for the delivery of effective health care for people who inject drugs, including encouraging behaviours to support the prevention of blood-borne viruses., (Copyright © 2015 Elsevier B.V. All rights reserved.)

Aim: Peer support services have been shown to be beneficial in increasing uptake and adherence to treatment in other areas but few examples of these services exist in hepatitis C (HCV) care. This study examined the performance of two community-controlled peer support services operating within a larger study aimed at increasing access to HCV care and treatment for opiate substitution treatment (OST) clients, ETHOS., Methods: Semi-structured interviews were conducted in two clinics with three groups of participants: clients (n=31), staff (n=8) and peer workers (n=3) and examined the operation of the service in relation to process, outputs and impacts., Results: There was a very strong positive response to the peer worker services reported by staff and clients who had and had not interacted with a peer worker. A number of changes were reported that were not explicit goals of the service including providing access to additional services for clients and staff, peer workers acting as mediators between clients and staff and a less tangible notion of a changing "feel" of the clinic to a more positive and client-friendly social and physical space. Explicit goals of the service were also reported in peer workers supporting clients to consider and prepare for treatment (via blood tests and other assessments) as well as provide information and support about treatment., Conclusions: The peer support service was acceptable to clients and clinic staff. All groups of participants noted that the service met its goals of engaging clients, building trusting relationships and providing instrumental support for clients to access HCV treatment. Peer workers may also contribute to more effective deployment of health resources by preparing clients for clinical engagement with HCV health workers., (Copyright © 2015 Elsevier B.V. All rights reserved.)

Background: Schools play an important role in promoting the health of children. However, little consideration is often given to the influence that headteachers' and school staff's prior beliefs have on the implementation of public health interventions. This study examined primary school headteachers' and school health co-ordinators' views regarding child health in order to provide greater insights on the school's perspective for those designing future school-based health interventions., Methods: A qualitative study was conducted using 19 semi-structured interviews with headteachers, deputy headteachers and school health co-ordinators in the primary school setting. All transcripts were analysed using thematic analysis., Results: Whilst many participants in this study believed good health was vital for learning, wide variance was evident regarding the perceived health of school pupils and the magnitude of responsibility schools should take in addressing child health behaviours. Although staff in this study acknowledged the importance of their role, many believed the responsibility placed upon schools for health promotion was becoming too much; suggesting health interventions need to better integrate school, parental and societal components. With mental health highlighted as an increasing priority in many schools, incorporating wellbeing outcomes into future school based health interventions is advocated to ensure a more holistic understanding of child health is gained., Conclusion: Understanding the health beliefs of school staff when designing interventions is crucial as there appears to be a greater likelihood of interventions being successfully adopted if staff perceive a health issue as important among their pupils. An increased dependability on schools for addressing health was expressed by headteachers in this study, highlighting a need for better understanding of parental, child and key stakeholder perspectives on responsibility for child health. Without this understanding, there is potential for certain child health issues to be ignored.

Background: Schools are repeatedly utilised as a key setting for health interventions. However, the translation of effective research findings to the school setting can be problematic. In order to improve effective translation of future interventions, it is imperative key challenges and facilitators of implementing health interventions be understood from a school's perspective., Methods: Nineteen semi-structured interviews were conducted in primary schools (headteachers n = 16, deputy headteacher n = 1, healthy school co-ordinator n = 2). Interviews were transcribed verbatim and analysed using thematic analysis., Results: The main challenges for schools in implementing health interventions were; government-led academic priorities, initiative overload, low autonomy for schools, lack of staff support, lack of facilities and resources, litigation risk and parental engagement. Recommendations to increase the application of interventions into the school setting included; better planning and organisation, greater collaboration with schools and external partners and elements addressing sustainability. Child-centred and cross-curricular approaches, inclusive whole school approaches and assurances to be supportive of the school ethos were also favoured for consideration., Conclusions: This work explores schools' perspectives regarding the implementation of health interventions and utilises these thoughts to create guidelines for developing future school-based interventions. Recommendations include the need to account for variability between school environments, staff and pupils. Interventions with an element of adaptability were preferred over the delivery of blanket fixed interventions. Involving schools in the developmental stage would add useful insights to ensure the interventions can be tailored to best suit each individual schools' needs and improve implementation.

Background: While there is growing recognition of the benefits of user involvement within drug treatment there is scant literature documenting the actual implementation of such initiatives. Nonetheless, the extant research is remarkably consistent in identifying poor relationships between service users and staff as a principal barrier to the successful implementation of consumer participation. Focussing on participants' accounts of change within the 'therapeutic alliance', this paper investigates a consumer participation initiative introduced within three Australian drug treatment services., Methods: In 2012, the New South Wales Users and AIDS Association (NUAA), a state-based drug user organisation, introduced a consumer participation initiative within three treatment facilities across the state. This paper draws on 57 semi-structured interviews with staff and service-user project participants. Approximately ten participants from each site were recruited and interviewed at baseline and six months later at evaluation., Results: The enhanced opportunities for interaction enabled by the consumer participation initiative fostered a sense of service users and staff coming to know one another beyond the usual constraints and limitations of their relationship. Both sets of participants described a diminution of adversarial relations: an unsettling of the 'them and us' treatment divide. The routine separation of users and staff was challenged by the emergence of a more collaborative ethos of 'working together'. Participants noted 'seeing' one another--the other--differently; as people rather than simply an identity category., Conclusion: For service users, the opportunity to have 'a voice' began to disrupt the routine objectification or dehumanisation that consistently, if unintentionally, characterises the treatment experience. Having a voice, it seemed, was synonymous with being human, with having ones' 'humanness' recognised. We contend that not only did the introduction of consumer participation appear to empower service users and enhance the therapeutic alliance, it may have also improved service quality and health outcomes., (Copyright © 2014 Elsevier B.V. All rights reserved.)

Objective: breast feeding is affected by numerous psycho-social factors. Antenatal concerns such as embarrassment regarding public feeding and the impact of breast feeding upon breast shape are known to lead to artificial milk use. However, although work has explored the relationship between maternal weight and infant feeding, wider body image concerns have not been examined. The aim of the current study was to explore the association between maternal body image concerns during pregnancy upon intended and actual breast feeding duration., Design: a two stage self report questionnaire completed during pregnancy and at six months post partum., Setting: mothers were recruited from local mother and infant groups, nurseries and online mother and infant forums., Participants: 128 pregnant women completed both stages., Measures: phase one: completion of a questionnaire exploring body image during pregnancy (concerns about stretch marks, weight gain and appearance) and planned breast feeding duration during the second/third trimester of pregnancy (body image, weight, intended duration) followed by a second questionnaire measuring actual breast feeding duration and breast feeding experiences., Findings: factor analysis revealed three primary body image concerns: pregnancy body image, prospective postnatal body image and dieting during pregnancy. Higher concerns on all three factors were associated with both intended and actual shorter breast feeding duration. Amongst mothers who stopped breast feeding before six months, those with higher body image concerns were more likely to report stopping due to embarrassment or the perceived impact upon their breast shape. The relationship was not explained by maternal weight, although a higher residual weight gain at six months was associated with a shorter breast feeding duration., Conclusions and Implications for Practice: mothers who are affected negatively by changes to their body during pregnancy may be less likely to plan to or initiate breast feeding potentially due to underlying issues such as embarrassment or perceived impact of feeding upon their appearance. The findings are important to those working with women during pregnancy and the postpartum period in understanding the impact of body image upon intention and ability to initiate and continue breast feeding., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Background: Given the increasing burden of hepatitis C (HCV) related liver disease, innovative health care models are required to extend the reach of HCV care and treatment. Opioid substitution treatment (OST) clinics are places of high HCV prevalence. The OST clinic is a complex environment, quite distinct to other health care settings, with punitive regulations and practices, and a client population likely to be mistrustful of systems of authority. Nonetheless, trust is widely documented as essential to effective therapeutic encounters. This paper examines what is required to develop a trustworthy service in a place, the OST clinic, described by some critics as a site of "social control"., Methods: In-depth interviews were conducted with 57 clients and 19 staff from four NSW pilot clinics participating in the Australian ETHOS study., Results: Interview data were examined using Hall's framework of trust, involving five principle domains: fidelity, competence, honest, confidentiality and global trust. 'Honesty' was found to be key to participants' establishing trust in the co-located service and its staff. However, the clinic site was also found to be a place of rationed trust, in which the themes of OST as "ruling peoples' lives" and the fear of repercussions resulting from perceived transgressions against clinic rules, threatened to over-ride or undermine the development of trust in HCV services. Client participants described trusting health workers "to a point". They expressed concerns about the fidelity of co-located HCV and OST services and described fears of "institutionalised lies" and breaches of confidentiality. Anxieties around the latter revealed a sense of "us and them" held by some clients, one in which health workers were perceived to "stick together" by putting their own interests before those of the clients., Discussion: Although the co-location of HCV and opioid treatments makes intuitive policy sense, HCV health workers in the OST space may be seen as representatives of a deeply mistrusted system. For the effective development of a trustworthy HCV care service, policy and practice activities are required to engender trust through clearly articulated explanations of service boundaries and the promotion of "success stories" through trusted peer networks., (Copyright © 2014 Elsevier B.V. All rights reserved.)

Provision of hepatitis C virus (HCV) assessment and treatment via opioid substitution treatment (OST) clinics has been posed as an effective means of engaging populations with high HCV prevalence. This study explores OST client and health professional reports concerning barriers and facilitators affecting the delivery and uptake of HCV care and treatment within OST settings. In-depth interviews were conducted with 57 clients, 16 staff from four NSW clinics participating in the Australian ETHOS study and three peer workers. Client participants included those who had not had HCV assessment; those who had HCV assessment only; and those who were awaiting or undertaking HCV treatment. A clear difference in decisions about HCV treatment emerged between participant groups. For those who have not been assessed, barriers to engaging with HCV care included the perception that they were physically well, were not experiencing HCV symptoms, had other life priorities and were concerned about the side effects and tolerability of treatment. Those who had engaged with care expressed motivations stemming from seeing friends becoming unwell, wanting to live longer and hearing positive stories of treatment. For those interested in HCV treatment, issues related to both provider and setting were important, such as presence of an engaged clinician, an accessible treatment pathway and availability of support. In this integrated care model, some barriers to HCV care and treatment (particularly those relating to health provider and the system) are minimized. In this setting, HCV treatment remained an unattractive option for a significant number of clients. Providing ways for those without HCV symptoms to be assessed for liver damage may be important to open up alternative conversations about HCV care. Further, the importance of a changing discourse of treatment is apparent from these data and could be enhanced by peer communication that provides information about successful treatment experiences., (© 2013 John Wiley & Sons Ltd.)

Aims: To explore identity transformation among service users attending opiate substitution therapy (OST) clinics following the introduction of hepatitis C (HCV) care and treatment., Design: An interview-based substudy of the Australian ETHOS (Enhancing Treatment for Hepatitis C in Opiate Substitution Settings) project., Setting: Three OST clinics and one community health centre (operating a public OST) in New South Wales, Australia. Participants were interviewed at the recruitment sites., Participants: The sample consisted of 57 OST service users concurrently living with HCV, 16 staff, including specialist HCV clinicians, and three peer-support workers, employed on the ETHOS project., Measurements: Semi-structured interviews., Findings: Service-user participants largely welcomed the introduction of HCV treatment as a practical, clinical intervention that also intimated a more comprehensive, holistic form of care. Negative stereotypes characteristic of OST settings-of limited, routinized clinical exchanges and minimal social-care interaction-were unsettled, opening up the possibility of new relations between staff and service users. The shift in the dynamic of the clinical encounter to address health in addition to dependence appeared to catalyse transformative possibilities not only for the therapeutic alliance but also for service-user understandings of self and identity., Conclusion: Trial introduction of HCV care and treatment in selected Australian opiate substitution therapy (OST) clinics may have facilitated alternative, 'non-addict' identities to emerge from a clinical setting where the stigmatizing figure of 'the drug user' has traditionally prevailed.

Background: Internationally, there are ongoing efforts to increase access to hepatitis C (HCV) assessment and treatment to counter a generally low uptake of treatment among people with a history of injecting drug use. The aim of this qualitative study was to examine client and staff attitudes towards and experience of co-location of HCV and opioid substitution treatment (OST) services., Methods: In-depth interviews were conducted with 57 clients and 19 staff from four NSW clinics participating in the Australian ETHOS study., Results: Client and staff participants typically welcomed integrated treatment, citing issues of convenience, reduced travel time and costs, persistent cues to engagement and immediacy of access to care. Positive attitudes towards the initiative were expressed even by clients who had not engaged with HCV care. Providing co-located care largely avoided the negative, stigmatising or discriminatory experiences that participants reported encountering in settings less familiar with people who use drugs. A minority of client participants expressed concerns about the lack of privacy and/or confidentiality available in the co-located model, preferring to seek HCV care elsewhere., Conclusions: The co-location of HCV care in OST clinics was welcomed by the large majority of participants in this study. Besides issues of convenience, the appeal of the co-located service centred on the familiarity of existing relationships between clients and staff in the OST setting. While some clients remained distrustful of OST and chose not to take up HCV care in this setting, the co-located treatment model was overwhelmingly successful amongst both client and staff participants., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

A large body of literature emphasizes the relationship between stigma and adverse health outcomes and health access measures. For people living with hepatitis C virus (HCV), stigma is a defining feature given the association of HCV with the socially demonized practice of injection drug use. However, there is little literature that specifically examines stigma as a barrier to HCV care and treatment. This review argues that the relationship between the person living with HCV and their health worker can work to ameliorate the effects of stigma. We draw on an emerging literature that examines the positive association between a patient's "trust" in their health worker and outcomes such as increased healthcare utilization and reduced risk behaviors. We investigate a growing body of health services research that acknowledges the importance of stigma and demonstrates ways to build positive, enabling relationships between patient, health worker, and health setting.

Background: Eating a diet that is high in fat and sugar and having a sedentary lifestyle during pregnancy is understood to increase the risk of excessive gestational weight gain and obesity following the birth of the baby. However, there are no clinical guidelines in the UK on what is considered to be appropriate gestational weight gain. Indeed, clinical recommendations discourage the routine re-weighing of pregnant women, stating instead that women should be advised regarding their diet and activity levels, in order to prevent excessive weight gain. Pregnancy is seen as a time when many women may have an increased motivation to improve their lifestyle behaviours for the benefit of the fetus. However, it is evident that many women have difficulty in both maintaining a healthy balanced diet and remaining active through pregnancy. It would seem that midwives may be ideally placed to assist women to make and maintain healthier lifestyle choices during pregnancy., Methods/design: This study will look at the feasibility and acceptability of a newly devised intervention programme called 'Eat Well Keep Active'. Participants will complete a questionnaire prior to the programme to obtain baseline data on food frequency, physical activity and to gauge their perception of personal ability to improve/maintain healthy lifestyle. The programme comprises client centred techniques; motivational interviewing and goal setting delivered early in pregnancy (12-16 weeks) with the aim of supporting a healthy well balanced diet and either continuing or commencing appropriate levels of physical activity. Participants will then be followed up six weeks following the intervention with a one-to-one interview, and a further brief questionnaire. The interview will provide preliminary data regarding perceived effectiveness and acceptability of the 'Eat Well Keep Active' programme whilst the questionnaire will provide data regarding changes in the confidence of participants to lead a healthy lifestyle., Discussion: There is an identified need for effective interventions that assist pregnant women in managing their diet and activity levels. Results from this study will demonstrate whether women find this programme of intervention, designed to elicit healthy behaviours in pregnancy, acceptable and whether they perceive it to be effective.

Despite advances in understanding the structural contexts in which drug use occurs and shifts beyond the individual-level focus of adult education theory, peer education models remain wedded to questions of individual behaviour. Our analysis examines the structural context of peer education and its implications for peer training. People who inject drugs (PWID) were invited to participate in a series of three focus group discussions in order to develop peer education messages and strategies. These were then trialled by participants within their networks and their experiences discussed in subsequent focus groups. The influence of structural factors (such as the policing of public space) on participants' peer education attempts were identified and discussed. We propose that despite the damaging impact of structural factors on the lives of PWID, they can in turn be used by peer educators to develop innovative interventions designed to increase resilience and reduce internalized stigma. Peer education programmes need sufficient flexibility and resources to allow for the negotiation of participants' immediate needs and for collaborative learning between PWID and peer educators. This would require an informed and responsive funder-a challenge to the current orthodoxy wherein peer education is increasingly delivered in formats predetermined by the funder.

The hepatitis C virus (HCV) epidemic is a significant public health challenge in Australia. Current initiatives to expand access to HCV treatment focus on opiate substitution therapy (OST) settings where the prevalence of hepatitis C among clients is high. In Australia, the provision of OST for many clients is via large clinics, with an estimated median of 150 clients per service. Conceptually informed by the work of Michel Foucault, our analysis of the proposed integrated treatment model focuses on the critical but overlooked question of organisational culture and power operating within OST. We argue that the specific context of OST not merely reflects but actively participates in the political economy of social exclusion via which the socio-spatial segregation and stigmatisation of the service user as 'drug user' is enacted. This paper analyses data collected from two samples during 2008/9: OST clients living in New South Wales, Australia and a range of OST health professionals working in Australian settings. In total, 27 interviews were conducted with current OST clients; 19 by phone and 8 face-to-face. One focus group and 16 telephone interviews were conducted with OST health professionals. Our analysis of key themes emerging from the interview data suggests that the successful introduction of HCV treatment within the OST clinic is not a given. We are concerned that particular areas of tension, if not explicit contradiction, have been overlooked in current research and debates informing the proposed combination treatment model. We question the appropriateness of co-locating a notoriously arduous, exacting treatment (HCV) within the highly surveillant and regulatory environment of OST. While applauding the intention to improve access to HCV care and treatment for people who inject drugs we caution against a treatment model that risks further entrenching (socio-spatial) stigmatisation amongst those already experiencing significant marginalisation., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

In this study, we systematically compare two vector design strategies for recombinant monoclonal antibody (Mab) synthesis by Chinese hamster ovary (CHO) cells; a dual open reading frame (ORF) expression vector utilizing separate cytomegalovirus (CMV) promoters to drive heavy chain (HC) and light chain (LC) expression independently, and a single ORF vector design employing a single CMV promoter to drive HC and LC polypeptide expression joined by a foot and mouth disease virus F2A polypeptide self-cleaving linker sequence. Initial analysis of stable transfectants showed that transfectants utilizing the single ORF vector designs exhibited significantly reduced Mab production. We employed an empirical modeling strategy to quantitatively describe the cellular constraints on recombinant Mab synthesis in all stable transfectants. In all transfectants, an intracellular molar excess of LC polypeptide over HC polypeptide was observed. For CHO cells transfected with the single ORF vectors, model-predicted, and empirical intracellular intermediate levels could only be reconciled by inclusion of nascent HC polypeptide degradation. Whilst a local sensitivity analysis showed that qMab of all transfectants was primarily constrained by recombinant mRNA translation rate, our data indicated that all single ORF transfectants exhibited a reduced level of recombinant gene transcription and that Mab folding and assembly reactions generically exerted greater control over qMab. We infer that the productivity of single ORF transfectants is limited by ER processing/degradation "capacity" which sets a limit on transcriptional input. We conclude that gene vector design for oligomeric recombinant proteins should be based on an understanding of protein-specific synthetic kinetics rather than polypeptide stoichiometry., (Copyright © 2011 American Institute of Chemical Engineers (AIChE).)

Background: Debates surrounding the use of conventional approaches in public health and the existence of perceived barriers to using the results of economic evaluations have led to questions posed as to how to establish priorities within public health schemes. The aims of this study were therefore to explore the feasibility and validity of economic evaluation techniques in developing priorities within public health programmes and consider the extent to which different presentational approaches are likely to be incorporated into decision-making, from perspectives of relevant stakeholders., Methods: An advisory board, representative of potential users of economic evaluations, was set up to identify preferences for how findings from economic evaluations might be presented to decision makers and to test the impact of different approaches, different outputs and different presentational styles. The board was divided into two groups, each of which was given three hypothetical 'scenarios' to consider. The scenarios comprised descriptions of methods and outputs, with costs, effects, target population and context of intervention constant across all scenarios., Results: The perceived validity of estimates of effectiveness was vitally important, along with sufficient information to gauge whether designs were appropriate and to assess implementation practicalities. Cost-benefit analysis and cost-utility analysis were the preferred approaches despite their complexity, although participants required benchmarks to place net-benefit estimates from cost-benefit analyses into context., Conclusion: Further research is required to substantiate and build on these preliminary findings and collaborations between economists and policy makers are needed to develop clear, rigorous and standard guidance relating to economic evaluation, recognizing the diversity of public health strategies.

This project evaluated consumer participation projects in five drug user treatment services in metropolitan and regional areas in three Australian states. Qualitative interviews were conducted with staff and consumers at two time points between 2008 from 2010 (n = 108). At baseline staff and some consumers focused on the stability of consumers to undertake representative roles. At postimplementation, the focus was on the stability of the organization, as frequent staffing changes and lack of adequate handover affected the progress of the projects. These issues combined with the perceived "noncore" status of consumer participation resulted in none of the projects achieving all of their agreed goals.

Uptake of treatment for hepatitis C virus (HCV) infection is very low particularly among people who have injected drugs. Opiate substitution treatment (OST) programs, with a high prevalence of people living with HCV, have been a site of growing interest in the delivery of hepatitis C treatment. There has been no exploration of OST clients' and health professionals' perceptions of the barriers and facilitators to uptake and delivery of HCV treatment in OST clinics from personal and organizational perspectives. This qualitative study involved interviews with 27 OST clients in New South Wales and a focus group and interviews with 22 Australian OST health professionals. Clients and health professionals viewed hepatitis C treatment in OST as a 'one-stop-shop' model which could increase access to and uptake of treatment and build on existing relationships of trust between OST client and health professional. Elements of the organizational culture were also noted as barriers to HCV treatment delivery including concerns about confidentiality, lack of discussion of HCV treatment and that HCV treatment was not perceived by clinicians as a legitimate activity of OST clinics. OST client participants also reported a number of personal barriers to engaging with HCV treatment including family responsibilities (and concerns about treatment side effects), unstable housing, comorbidities and perceptions of the unsatisfactory level of treatment efficacy. These findings emphasize the need for future research and delivery of services which addresses the complexity of care and treatment for people in marginalized social circumstances., (© 2010 Blackwell Publishing Ltd.)

Background: In the United Kingdom, mental health nurses (MHNs) can independently prescribe medication once they have completed a training course. This study investigated attitudes to mental health nurse prescribing held by psychiatrists and nurses., Method: 119 MHNs and 82 psychiatrists working in South-East England were randomly sampled. Participants completed a newly created questionnaire. This included individual item statements with 6-point likert scales to test levels of agreement which were summated into 7 subscales., Results: Psychiatrists had significantly less favourable, albeit generally positive attitudes than MHNs regarding general beliefs (63% vs. 70%, p<0.001), impact (62% vs. 70%, p<0.001), uses (60% vs. 71%, p<0.001), clinical responsibility (69% vs. 62%, p<0.001) and legal responsibility (71% vs. 64%, p<0.001). More MHNs than psychiatrists believed that nurse prescribing would be useful in emergency situations for rapid tranquilisation (82% vs. 37%, p<0.001), and that the consultant psychiatrist should have ultimate clinical responsibility for prescribing by an MHN (42% vs. 28%, p<0.001). Approximately half of all participants agreed nurse prescribing would create conflict in clinical teams., Conclusions: The majority of both groups were in favour of mental health nurse prescribing, although significantly more psychiatrists expressed concerns. This may be explained by a perceived change in power balance.

Background: An evaluation of NHS Direct Wales (NHSDW), a national telephone-based healthcare advice and information service, was undertaken. A key objective was to describe the actions of callers and assess the appropriateness of advice and healthcare contacts made following calls, results of which are reported here., Methods: Postal questionnaires were sent to consecutive callers to NHSDW in May 2002 and February 2004 to determine 1) callers' actions following calls and 2) their views about the appropriateness of: advice given; and when to seek further care. An independent clinical panel agreed and applied a set of rules about healthcare sites where examinations, investigations, treatments and referrals could be obtained. The rules were then applied to the subsequent contacts to healthcare services reported by respondents and actions were classified in terms of whether they had been necessary and sufficient for the care received., Results: Response rates were similar in each survey: 1033/1897 (54.5%); 606/1204 (50.3%), with 75% reporting contacting NHSDW. In both surveys, nearly half of all callers reported making no further healthcare contact after their call to NHSDW. The most frequent subsequent contacts made were with GPs.More than four fifths of callers rated the advice given - concerning any further care needed and when to seek it - as appropriate (further care needed: survey 1: 673/729, 82.3%; survey 2: 389/421, 92.4%; when to seek further care - survey 1: 462/555, 83.2%; survey 2: n = 295/346, 85.3%). A similar proportion of cases was also rated through the rule set and backed up by the clinical panel as having taken necessary and sufficient actions following their calls to NHSDW (survey 1: 624/729, 80.6%; survey 2: 362/421, 84.4%), with more unnecessary than insufficient actions identified at each survey (survey 1: unnecessary 132/729, 17.1% versus insufficient 11/729, 1.4%; survey 2: unnecessary 47/421, 11.0% versus insufficient 14/421, 3.3%)., Conclusion: Based on NHSDW caller surveys responses and applying a transparent rule set to caller actions a large majority of subsequent actions were assessed as appropriate, with insufficient contacts particularly infrequent. The challenge for NHSDW is to reduce the number of unnecessary contacts made following calls to the service, whilst maintaining safety.

Optimization of gene coding-sequence, including preferred codon usage and removal of cryptic splice sites and mRNA-destabilizing motifs, has been shown to improve recombinant protein production of different proteins. Here, we present data to show that gene optimization can also be used to improve the production of a complex macromolecule, namely an antibody. When applied to the heavy and light chain genes of our model antibody, we found that greater numbers of high-producing transfectants as well as increased levels of protein production were observed (approximately 1.5-fold). In this test model, production was improved even though the antibody has previously been demonstrated to give high expression in stably transfected cells (up to 5 g/L in bioreactors). Because the parental heavy chain sequence contained introns, and the process of gene optimization is most efficiently performed on sequences without introns, we demonstrated that removal of introns in the coding sequence had no effect on the quantity of antibody produced. All constructs were evaluated using Lonza's glutamine synthetase gene expression vectors in Chinese hamster ovary cells. Our findings suggest that significant improvements in product yields can be achieved by gene optimization, which may facilitate the processing and translation of gene transcripts.

Background: Primary prevention of type 2 diabetes is now possible with lifestyle or pharmacological interventions in people who are at risk. Primary care would seem to be the legitimate setting for this to take place., Aim: To explore the views of general practitioners and practice nurses about the detection and management of people at risk of developing type 2 diabetes., Design of Study: Qualitative study., Setting: One local health board area in Wales., Method: General practitioners and practice nurses participated in multi-professional focus groups, and opinions of participants were analysed into themes and sub-themes according to focus group content analysis methodology to search for 'markers of text'., Results: Participants from 21 practices were involved. Participants' opinions on the detection and management of individuals at risk of developing type 2 diabetes were polarised into those who considered these activities inappropriate for primary care and those who were already engaged in the detection, management and follow-up of these individuals. For the former, existing workload, the questionable role of primary care as a 'screening service', lack of resources, and conflict and concern about increasing specialisation were given as justification. Those already engaged in these activities emphasised their importance but were also concerned with the lack of available resources. Other concerns were the perceived low motivation of patients to modify their lifestyle and the unnecessary medicalisation of the precursor conditions of impaired glucose tolerance and impaired fasting glycaemia. The prevention of type 2 diabetes was seen as largely the responsibility of other agencies such as health promotion and education., Conclusion: The often strongly held views about this topic are at least partly influenced by current pressures on primary care. To make the primary prevention of type 2 diabetes a reality, either practitioners need to be motivated and resourced to carry out preventive strategies or alternative methods must be identified.

Factor XIII is activated by thrombin, and this reaction is enhanced by the presence of fibrin(ogen). Using a substrate-based screening assay for factor XIII activity complemented by kinetic analysis of activation peptide cleavage, we show by using thrombin mutants of surface-exposed residues that Arg-178, Arg-180, Asp-183, Glu-229, Arg-233, and Trp-50 of thrombin are necessary for direct activation of factor XIII. These residues define a low specificity site known to be important also for both protein C activation and for inhibition of thrombin by antithrombin. The enhancing effect of fibrinogen occurs as a consequence of its conversion to fibrin and subsequent polymerization. Surface residues of thrombin further involved in high specificity fibrin-enhanced factor XIII activation were identified as His-66, Tyr-71, and Asn-74. These residues represent a distinct interaction site on thrombin (within exosite I) also employed by thrombomodulin in its cofactor-enhanced activation of protein C. In competition experiments, thrombomodulin inhibited fibrin-enhanced factor XIII activation. Based upon these and prior published results, we propose that the polymerization process forms a fibrin cofactor that acts to approximate thrombin and factor XIII bound to separate and complementary domains of fibrinogen. This enables enhanced factor XIII activation to be localized around the fibrin clot. We also conclude that proximity to and competition for cofactor interaction sites primarily directs the fate of thrombin.

Background: Erectile dysfunction (ED) is one complication of diabetes for which the treatment is rationed. Despite considerable public debate there has been no formal assessment of the views of patients and sufferers of the priority of treating ED., Aims: To determine the perceptions of diabetic patients of the relative priority of treating ED in comparison with treatments for other diabetic complications and common medical conditions., Methods: Psychological measures were used to assess subjects' perceptions of the relative importance of ED in comparison with eight other common problems (blindness, foot ulcers, high blood pressure, impotence, kidney disease, high cholesterol, migraine, mild indigestion and sleeping difficulties). The concept of willingness to pay was used to assess the amount per month participants would be prepared to pay for treatment for ED and other conditions. Four groups (controls, healthy diabetic men, impotent diabetic men and impotent diabetic men not in a sexual relationship) were studied., Results: Significant differences were found between the four groups with regard to the ranking of the importance of ED compared with other health problems. Impotent diabetic male patients were prepared to pay more for treatment for their condition than all other conditions except blindness and renal failure., Conclusions: Men with diabetes, in particular ED sufferers, believe ED has a major impact on quality of life and is as important to treat as many other conditions associated with diabetes.

Cluster headache and manic depressive illness share in common similarities like: periodic symptomatology, accessibility to lithium therapy, abnormalities in circadian rhythm of cortisol. Though, in contrast to periodic depression, D.S.T. was found normal in 9 patients with cluster headache.