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BACKGROUNDAlcohol Minimum Unit Pricing (MUP) was introduced in Scotland in May 2018. Existing evidence suggests MUP can reduce alcohol consumption in the general population, but there is little research about its impact on vulnerable groups. This qualitative study aimed to explore experiences of MUP among people with experience of homelessness.METHODSWe conducted qualitative semi-structured interviews with a purposive sample of 46 people with current or recent experience of homelessness who were current drinkers when MUP was introduced. Participants (30 men and 16 women) were aged 21 to 73 years. Interviews focused on views and experiences of MUP. Data were analysed using thematic analysis.RESULTSPeople with experience of homelessness were aware of MUP but it was accorded low priority in their hierarchy of concerns. Reported impacts varied. Some participants reduced their drinking, or moved away from drinking strong white cider in line with policy intentions. Others were unaffected because the cost of their preferred drink (usually wine, vodka or beer) did not change substantially. A minority reported increased involvement in begging. Wider personal, relational and social factors also played an important role in participant responses to MUP.CONCLUSIONOur findings suggest that MUP worked as intended for some people with experience of homelessness, while a minority reported negative consequences. Our findings highlight the importance of considering the impact of population level health policies on marginalised groups. Policymakers in Scotland, and elsewhere, need to consider wider contextual factors that affect responses to MUP in people with experience of homelessness. It is important to invest further in secure housing and appropriate support services for people with experience of homelessness who consume alcohol, and implement and evaluate harm reduction initiatives such as managed alcohol programmes.

Although there has been significant research on the relationship between alcohol consumption and demographic and psychological influences, this does not consider the effect of social influence among older drinkers and if these effects differ between men and women. One aspect of social influence is social capital. The aim of this paper is to examine whether relational and cognitive social capital are associated with higher or lower risk of alcohol use among adults aged 50 years or older and to assess the extent to which this relationship differs between men and women. To investigate this, data were collected from a cross-sectional questionnaire survey of adults over the age of 50 in the United Kingdom who were recruited from general practitioners. The sample consisted of 9,984 individuals whose mean age was 63.87 years. From these data, we developed proxy measures of social capital and associate these with the respondent's level of alcohol consumption as measured on the Alcohol Use Disorders Identification Test (AUDIT-10) scale. In the sample, just over 20 per cent reported an increasing risk or dependency on alcohol. Using two expressions of social capital – relational (social relationships) and cognitive (knowledge acquisition and understanding) – we found that greater levels of both are associated with a reduced risk of higher drinking risk. Being female had no significant effect when combined with relational capital but did have a significant effect when combined with cognitive capital. It is argued that interventions to enhance social relations among older people and education to help understand alcohol risks would be helpful to protect older people from the damaging effects of excessive alcohol consumption.

Background: The traditional focus of adolescent sexual health research is on risk and adverse outcomes and on first vaginal intercourse as a portent of risk. This preoccupation with first sex limits research on social processes of sexual development and is out of step with the contemporary reality of young people’s early sexual experiences in which vaginal sex (if it happens at all) often follows a wide range of intimate and sexual experiences. Aim: With an innovative approach combining latent class analysis and social network analysis, we assessed how sexual knowledge, positive norm adherence, confidence and sexual activity are patterned across school-year social networks and explored the extent to which individualist and social influence theories could explain these patterns. Methods: We analysed cross-sectional survey data from 10 school year-group (students age 14-16) from the STis And Sexual Health (STASH) feasibility study. Students completed measures on sexual health knowledge, norms, confidence and behaviours, and named up to six friends in their year group. We used Latent Class Analysis to categorise patterns of sexual behaviour, and Exponential Random Graph Models to assess how sexual behaviour, knowledge, norms and confidence related to friendship ties.Results: Of 1,446 students 21% (n=309) did not report any sexual experience (inactive), 42% (602) reported some sexual experience but not oral or vaginal sex, and 22% (323) had oral and/or vaginal sex. Friendship ties were more likely between students who had similar levels of competencies (knowledge, norms and confidence). Friendships were also more likely between students who were sexually inactive (OR 1.73 95% CI 1.54, 1.95), and between students who reported oral/vaginal sex (OR 1.77 95% CI 1.46, 2.15). Active but not oral/vaginal sex students were slightly less likely (OR 0.86 95% CI 0.75, 0.99) to have friendship ties with each other.Interpretation: Our findings suggest that peer influence operating on sexual health competencies may occur independently of current sexual behaviour and there may not be strong naturally occurring social influence process to initiate pre-intercourse sexual behaviours. Our findings suggest that sexual health interventions acting on network influences are justified and that the focus of such interventions should shift from first intercourse to patterning of developing sexual repertoires.

Minimum unit pricing (MUP) may reduce harmful drinking in the general population, but there is little evidence regarding its impact on marginalised groups. Our study is the first to explore the perceptions of MUP among stakeholders working with people experiencing homelessness following its introduction in Scotland in May 2018.Qualitative semi-structured interviews were conducted with 41 professional stakeholders from statutory and third sector organisations across Scotland. We explored their views on MUP and its impact on people experiencing homelessness, service provision and implications for policy. Data were analysed using thematic analysis.Participants suggested that the introduction of MUP in Scotland had negligible if any discernible impact on people experiencing homelessness and services that support them. Most service providers felt insufficiently informed about MUP prior to its implementation. Participants reported that where consequences for these populations were evident, they were primarily anticipated although some groups were negatively affected. People experiencing homelessness have complex needs in addition to alcohol addiction, and changes in the way services work need to be considered in future MUP-related discussions.This study suggests that despite initial concerns about potential unintended consequences of MUP, many of these did not materialise to the levels anticipated. As a population-level health policy, MUP is likely to have little beneficial impact on people experiencing homelessness without the provision of support to address their alcohol use and complex needs. The additional needs of certain groups (e.g., people with no recourse to public funds) need to be considered.

PurposeNo studies have evaluated the relationship between cognitive impairment and alcohol treatment outcomes amongst older drinkers. This study aims to explore the extent of cognitive impairment amongst older adults seeking alcohol treatment and examine the relationship between cognitive impairment, treatment retention and alcohol use following treatment.Design/methodology/approachThe study used data from the Drink Wise Age Well programme; an alcohol intervention service for older adults (aged 50+). The Montreal Cognitive Assessment was used to screen for cognitive impairment; alcohol use was assessed using the alcohol use disorders identification test.FindingsIn total, 531 participants completed the assessment at treatment entry. Over half the sample were male (57%), with a mean age of 60 years (Standard deviation: 7.09). Almost half (48.4%) had cognitive impairment at the entry to treatment: 51.6% had a normal cognitive function, 41.4% had mild cognitive impairment, 5.8% had moderate cognitive impairment and 1.1% had severe cognitive impairment. Cognitive impairment was not associated with increased treatment drop-out and was not predictive of alcohol use following treatment. Alcohol treatment was associated with a significant improvement in cognitive functioning.Originality/valueThis study suggests there may be a significant amount of unidentified cognitive impairment amongst older adults attending alcohol treatment. Assessment and routine screening for cognitive impairment in drug and alcohol services may help in care planning and setting treatment goals; in the absence of routine screening opportunities for treatment planning and intervention may be missed.

BackgroundThe ease of contemporary hepatitis C virus (HCV) therapy has prompted a global drive towards simplified and decentralised treatment pathways. In some countries, primary care has become an integral component of community-based HCV treatment provision. In the UK, however, the role of primary care providers remains largely focused on testing and diagnosis alone.AimTo develop a primary care-initiated HCV treatment pathway for people who use drugs, and recommend theory-informed interventions to help embed that pathway into practice.Design and settingA qualitative study informed by behaviour change theory. Semi-structured interviews were undertaken with key stakeholders (n = 38) primarily from two large conurbations in Scotland.MethodAnalysis was three-stage. First, a broad pathway structure was outlined and then sequential pathway steps were specified; second, thematic data were aligned to pathway steps, and significant barriers and enablers were identified; and, third, the Theoretical Domains Framework and Behaviour Change Wheel were employed to systematically develop ideas to enhance pathway implementation, which stakeholders then appraised.ResultsThe proposed pathway structure spans broad, overarching challenges to primary care-initiated HCV treatment. The theory-informed recommendations align with influences on different behaviours at key pathway steps, and focus on relationship building, routinisation, education, combating stigmas, publicising the pathway, and treatment protocol development.ConclusionThis study provides the first practicable pathway for primary care-initiated HCV treatment in Scotland, and provides recommendations for wider implementation in the UK. It positions primary care providers as an integral part of community-based HCV treatment, providing workable solutions to ingrained barriers to care.

Background The impact of parental drug use on children is a major public health problem. However, opioid-dependent fathers have been largely ignored in parenting research. Objective To implement and test the feasibility and acceptability of the Parents under Pressure programme (PuP4Dads) for opioid-dependent fathers and their families, and to determine whether or not a full-scale evaluation could be conducted. Design A mixed-methods feasibility study. Setting Two non-NHS family support services for parents who use drugs in Scotland. Participants Fathers prescribed opioid substitution therapy (n = 25), their partners (n = 17) and children, as well as practitioners, supervisors, service managers and referrers. Intervention A home-visiting programme, including an integrated theoretical framework, case formulation, collaborative goal-setting and modules designed to improve parenting, the caregiving environment and child welfare. The programme was delivered flexibly over 6 months by accredited practitioners. Main outcome measures Feasibility progression criteria included the recruitment target (n = 24 fathers), acceptability of PuP4Dads, father engagement in the study (including a minimum of 66% of fathers completing PuP and a minimum of 10 fathers completing baseline and post-treatment research interviews), engagement in qualitative interviews (including a minimum of 10 fathers and 90% practitioner uptake and 80% manager uptake), focus groups (with a minimum of 80% referrer uptake), adequate fidelity and no adverse events. Data sources The following researcher-administered validated questionnaires were used: the Brief Child Abuse Potential Inventory, the Parenting Sense of Competence Scale, the Difficulties in Emotion Regulation Scale, the Paternal Antenatal Attachment Scale, the Maternal Antenatal Attachment Scale, the Emotional Availability Scale, the Brief Infant Toddler Social and Emotional Assessment, the Strengths and Difficulties Questionnaire, the Conflict Tactics Scale, Treatment Outcome Profile and the EuroQol-5 Dimensions, five-level version. Other sources included parent-completed service use (an economic measure), social work child protection data, NHS opioid substitution therapy prescription data and practitioner-reported attendance data. We also conducted interviews with fathers (n = 23), mothers (n = 14), practitioners (n = 8), supervisors (n = 2) and service managers (n = 7); conducted focus groups with referrers (n = 28); and held an ‘expert event’ with stakeholders (n = 39). Results The PuP4Dads was successfully delivered within non-NHS settings and was considered acceptable and suitable for the study population. Referrals (n = 44) resulted in 38 (86%) eligible fathers, of whom 25 (66%) fathers and 17 partners/mothers consented to participate. Most fathers reported no previous parenting support. A total of 248 sessions was delivered to the 20 fathers and 14 mothers who started the intervention. Fourteen fathers (and 10 mothers) completed ≥ 6 sessions and six fathers (and four mothers) completed ≤ 5 sessions. Father and mother attendance rates were equal (mean 71%). Median length of engagement for fathers was 26 weeks and for mothers it was 30 weeks. Twenty-three fathers completed interviews at baseline, 16 fathers completed interviews at follow-up 1 and 13 fathers completed interviews at follow-up 2. Outcome measures were well tolerated; however, the suitability of some measures was dependent on family circumstances. The researcher-administered questionnaires had few missing data. The perceived benefits of PuP4Dads reported by parents, practitioners and managers included the following: the therapeutic focus on fathers improved parental emotion regulation, there was improved understanding and responding to child’s needs, there was better multiagency working and the programme was a good fit with practice ‘ethos’ and policy agenda. Learning highlighted the importance of service-wide adoption and implementation support, strategies to improve recruitment and retention of fathers, managing complex needs of both parents concurrently, understanding contextual factors affecting programme delivery and variables affecting intervention engagement and outcomes. Limitations Lack of emotional availability and economic (service use) data. Conclusions A larger evaluation of PuP4Dads is feasible. Future work Further work is required to demonstrate the effectiveness of PuP4Dads and the cost implications. A better understanding is needed of how the intervention works, for whom, under what circumstances and why. Trial registration Current Controlled Trials ISRCTN43209618. Funding This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 10, No. 3. See the NIHR Journals Library website for further project information.

People who identify as LGBTQ+ are more likely to drink excessively compared to heterosexual and cisgender people. Perceived barriers to accessing alcohol services may further increase the potential for alcohol related harm for LGBTQ+ people. This qualitative study explores the experiences of LGBTQ+ people who have used alcohol services, including peer support groups, in Scotland and their suggestions for how alcohol services could be improved.Participants were recruited using social media adverts, dating websites, organisations that work with LGBTQ+ clients and snowball sampling. Participants' (n = 14) experiences of alcohol services and peer support groups were explored through semi-structured interviews. Data were analysed using the Framework Approach and thematic analysis.Many participants thought their drinking was closely associated with their LGBTQ+ identity, as a response to shame, stigma, or family rejection. Some service users had positive experiences of alcohol services. However, participants were rarely asked about their sexuality / gender identity and some reported a lack of discussion about how identity might impact drinking. There were common views across the sample that barriers experienced by others in the LGBTQ+ community were amplified for trans people. Service users recommended that services need to signal LGBTQ+ inclusivity and provide a safe space to discuss multiple issues (e.g., alcohol use, mental health, gender identity). Participants highlighted the importance of alcohol-free spaces in the LGBTQ+ communities.The study has clear practice and policy implications. Alcohol services should provide a safe space for LGBTQ+ people and clearly indicate that. Service providers should be trained to discuss potential connections between LGBTQ+ identity and substance use. At a broader level, alcohol-free social spaces would help reduce alcohol-related harm in LGBTQ+ communities.

Background Effective sex education is the key to good sexual health. Peer-led approaches can augment teacher-delivered sex education, but many fail to capitalise on mechanisms of social influence. We assessed the feasibility of a novel intervention (STASH) in which students (aged 14–16) nominated as influential by their peers were recruited and trained as Peer Supporters (PS). Over a 5–10-week period, they spread positive sexual health messages to friends in their year group, both in-person and via social media, and were supported to do so via weekly trainer-facilitated meetings. The aims of the study were to assess the feasibility of STASH (acceptability, fidelity and reach), to test and refine the programme theory and to establish whether the study met pre-set progression criteria for continuation to larger-scale evaluation. Methods The overall design was a non-randomised feasibility study of the STASH intervention in 6 schools in Scotland. Baseline (n=680) and follow-up questionnaires (approx. 6 months later; n=603) were administered to the intervention year group. The control group (students in year above) completed the follow-up questionnaire only (n=696), 1 year before the intervention group. The PS (n=88) completed a brief web survey about their experience of the role; researchers interviewed participants in key roles (PS (n=20); PS friends (n=22); teachers (n=8); trainers (n=3)) and observed 20 intervention activities. Activity evaluation forms and project monitoring data also contributed information. We performed descriptive quantitative analysis and thematic qualitative analysis. Results The PS role was acceptable; on average across schools >50% of students nominated as influential by their friends, signed up and were trained (n=104). This equated to 13% of the year group. Trained PS rarely dropped out (97% completion rate) and 85% said they liked the role. Fidelity was good (all bar one trainer-led activity carried out; PS were active). The intervention had good reach; PS were reasonably well connected and perceived as ‘a good mix’ and 58% of students reported exposure to STASH. Hypothesised pre-conditions, contextual influences and mechanisms of change for the intervention were largely confirmed. All bar one of the progression criteria was met. Conclusion The weight of evidence supports continuation to full-scale evaluation. Trial registration Current controlled trials ISRCTN97369178

There is growing interest in social network-based programmes to improve health, but rigorous methods using Social Network research to evaluate the process of these interventions is less well developed. Using data from the “STis And Sexual Health” (STASH) feasibility trial of a school-based, peer-led intervention on sexual health prevention, we illustrate how network data analysis results can address key components of process evaluations for complex interventions—implementation, mechanisms of impacts, and context. STASH trained students as Peer Supporters (PS) to diffuse sexual health messages though face-to-face interactions and online Facebook (FB) groups. We applied a Multilevel Exponential Random Graph modelling approach to analyse the interdependence between offline friendship relationships and online FB ties and how these different relationships align. Our results suggest that the creation of online FB communities mirrored offline adolescent groups, demonstrating fidelity of intervention delivery. Data on informal friendship networks related to student’s individual characteristics (i.e., demographics, sexual health knowledge and adherence to norms, which were included for STASH), contributed to an understanding of the social relational ‘building’ mechanisms that sustain tie-formation. This knowledge could assist the selection of opinion leaders, improving identification of influential peers situated in optimal network positions. This work provides a novel contribution to understanding how to integrate network research with the process evaluation of a network intervention.

Sexually transmitted infections, HIV, and unplanned pregnancy challenge the health of Scottish teens. We conducted focus groups with teens (ages 16-19 years) recruited from an urban youth cafe in Edinburgh and assessed sexual risk-taking and protective behaviors. A trained facilitator, using a semi-structured interview guide, led the groups. We taped and transcribed data verbatim for coding and theming. The teens revealed similar concerns despite differences in gender and/or sexual histories. Despite school-based sex education, sex was rarely discussed with peers or adults outside classrooms; the ability to practice communication and negotiation skills was minimal. Much risky behavior occurred in public spaces and was often linked to drug or alcohol intake. There was a glaring lack of teen planning for, or contemplating, future adult lives. Findings highlight the challenges these teens faced in practicing safer sex and limited opportunities to tailor intervention strategies to address the cultural realities of their lives.

BackgroundNeonatal Abstinence Syndrome (NAS) is an anticipated effect of maternal drug use during pregnancy. Yet it remains a contested area of policy and practice. In this paper, we contribute to ongoing debates about the way NAS is understood and responded to, through different treatment regimes, or logics of care. Our analysis examines the role of risk and recovery discourses, and the way in which the bodies of women and babies are conceptualised within these.MethodsQualitative interviews with 16 parents (9 mothers, 7 fathers) and four focus groups with 27 health and social care professionals based in Scotland. All the mothers were prescribed opioid replacement therapy and parents were interviewed after their baby was born. Data collection explored understandings about the causes and consequences of NAS and experiences of preparing for, and caring for, a baby with NAS. Data were analysed using a narrative and discursive approach.ResultsParent and professional accounts simultaneously upheld and subverted logics of care which govern maternal drug use and the assessment and care of mother and baby. Despite acknowledging the unpredictability of NAS symptoms and the inability of the women who are opioid-dependent to prevent NAS, logics of care centred on ‘proving’ risk and recovery. Strategies appealed to the need for caution, intervening and control, and obscured alternative logics of care that focus on improving support for mother-infant dyads and the family as a whole.ConclusionDiffering notions of risk and recovery that govern maternal drug use, child welfare and family life both compel and trouble all logics of care. The contentious nature of NAS reflects wider socio-political and moral agendas that ultimately have little to do with meeting the needs of mothers and babies. Fundamental changes in the principles, quality and delivery of care could improve outcomes for families affected by NAS.

Introduction Gender and sexual minority populations are more likely to drink excessively compared to heterosexual and cisgender people. Existing reviews of alcohol interventions focus on specific subgroups within the lesbian, gay, bisexual, trans*, queer, questioning or otherwise gender or sexuality diverse (LGBTQ+) population and neither identify their theoretical basis nor examine how interventions are tailored to meet the needs of specific subgroups. Methods This systematic review includes published studies reporting the effectiveness of interventions to reduce alcohol use in LGBTQ+ people. The review followed PRISMA guidelines. Quality was assessed using the Effective Public Health Practice Project (EPHPP) Quality Assessment Tool. Results The review includes 25 studies, with the earliest published in 2005. The majority (n = 20) focused on men who have sex with men; only two included sexual minority women and three included trans* people. Most studies were conducted in the USA (n = 21) and used a randomised design (n = 15). Five studies were assessed to be of strong quality, seven moderate and 13 weak. Interventions were mainly delivered face-to-face (n = 21). The most common approaches used to inform interventions were Motivational Interviewing (n = 8) and Cognitive Behavioural Therapy (n = 8). Nineteen studies reported a significant reduction in alcohol consumption. Discussion and conclusions This review suggests that for interventions to be effective in reducing alcohol consumption in LGBTQ+ people, they need to be informed by theory and adapted for the target population. Alcohol interventions that focus on sexual minority women, trans* people and people with other gender identities are needed. The findings have implications for professionals who need to identify when gender and/or sexuality are peripheral or central to alcohol use.

Objectives:\ud The COVID-19 global pandemic resulted in major changes to the provision of alcohol treatment in the UK, these changes coincided with increases in the use of alcohol. This study sought to understand the impact of the pandemic on older adults in alcohol treatment, and to explore how changes in the provision of alcohol treatment were experienced.\ud \ud Method:\ud Semi-structured interviews were completed with older adults (aged 55+) in alcohol treatment, as well as alcohol practitioners providing support to older adults. Data were analysed using thematic analysis. Alcohol use was assessed using the Alcohol Use Disorders Identification Test – Consumption (AUDIT-C).\ud \ud Results:\ud Thirty older adults in alcohol treatment and fifteen alcohol practitioners were recruited. The COVID-19 pandemic was found to result in both increases and decreases in alcohol use; changes in alcohol use depended on a number of factors, such as living arrangements, family support, physical and mental health. Many alcohol treatment services moved to a model of remote support during the pandemic. However, face-to-face service provision was considered to be essential by both older adults in alcohol treatment and alcohol practitioners. Engagement with online support was low, with older adults facing barriers in using online technology.\ud \ud Conclusion:\ud The study highlights the importance of face-to-face treatment and intervention for older adults in alcohol treatment. Addiction services may see increased demand for treatment as a result of the pandemic; it is important that services consider the needs of older adults, many of whom may be marginalised by a remote model of service provision.

The ease of direct‐acting antiviral (DAA) medications for hepatitis C virus (HCV) has provided an opportunity to decentralize HCV treatment into community settings. However, the role of non‐specialist clinicians in community‐based pathways has received scant attention to date. This study examined barriers and enablers to expanding the role of general practitioners (GPs) in HCV treatment provision, using simple behaviour change theory as a conceptual framework. A maximum variation sample of 22 HCV treatment providers, GPs and HCV support workers participated in semi‐structured interviews. Data were inductively coded, and the resulting codes deductively mapped into three principal components of behaviour change: capability, opportunity and motivation (COM‐B). By this process, a number of provider‐ and systemic‐level barriers and enablers were identified. Key barriers included the pre‐treatment assessment of liver fibrosis, GP capacity and the ‘speciality’ of HCV care. Enablers included the simplicity of the drugs, existing GP/patient relationships and the provision of holistic care. In addition to these specific factors, the data also exposed an overarching provider understanding of ‘HCV treatment’ as triumvirate in nature, incorporating the assessment of liver fibrosis, the provision of holistic support and the treatment of disease. This understanding imposes a further fundamental barrier to GP‐led treatment as each of these three components needs to be individually addressed. To enable sustainable models of HCV treatment provision by GPs, a pragmatic re‐examination of the ‘HCV treatment triumvirate’ is required, and a paradigm shift from the ‘refer and treat’ status quo.

Objectives: Existing qualitative studies focussed predominantly on exploring immigrants’ stress, distress and coping aimed at reducing stress. Little attention has been paid to immigrants’ psychological growth or positive life changes. In the present study the impact of post-migration experiences on well-being among economic immigrants has been explored. Design: Semi-structured interviews were conducted with a sample of 17 immigrants. Transcripts were analysed by a deductive and inductive thematic analysis. Results: All immigrants reported positive life changes as a result of migration. Experiences related to migration helped immigrants rebuild their sense of self-worth and find ‘mental peace’ after living a demanding and burdensome life in Poland. Immigrants’ accounts also suggested that their thinking and behaviour patterns may be shaped by their cultural values and socio-economic background. Conclusion: Overall, the study indicates that migration is not merely a stressful life event but can have a positive impact on many aspects of immigrants’ lives and may provide opportunities for personal growth

The use of alcohol and other drugs during pregnancy is understood to be an important public health problem. One way in which this problem is expressed and responded to is via the identification and treatment of neonatal abstinence syndrome (NAS). In this article, we demonstrate how the processes of anticipating, identifying and responding to NAS are characterised by significant uncertainty among parents and health and social care practitioners. We draw on interviews with 16 parents who had recently had a baby at risk of NAS, and multidisciplinary focus groups with 27 health and social care professionals, held in Scotland, UK. NAS, and drug use in pregnancy, is a fraught and complex arena. Parents in the UK who use opioids risk losing custody of children, and must navigate a high degree of surveillance, governance and marginalisation. We suggest that considering NAS as a social diagnosis, further informed by Mol's political ontology of ‘multiple’ bodies/diseases, may help to produce clinical and social responses to uncertainty which avoid, rather than promote, further marginalisation of parents who use drugs. One such response is to develop a culture of relationship‐based care which empowers both service providers and service users to challenge existing practice and decision‐making.

Cognitive Impairment (CI) screening is recommended for those engaged in harmful levels of alcohol use. However, there is a lack of evidence on implementation. This paper explores the barriers and facilitators to CI screening experienced across a service specifically for older drinkers. The findings draw on data gathered as part of an evaluation of a multilevel programme to reduce alcohol-related harm in adults aged 50 and over in five demonstration areas across the United Kingdom. It is based on qualitative interviews and focus groups with 14 service providers and 22 service users. Findings are presented thematically under the section headings: acceptability of screening, interpretation and making sense of screening and treatment options. It is suggested that engagement with CI screening is most likely when its fit with agency culture and its purpose is clear; where service providers have the technical skills to administer and discuss the results of screening with service users; and where those undertaking screening have had the opportunity to reflect on their own experience of being screened. Engagement with CI screening is also most likely where specific intervention pathways and engagement practices can be accessed to respond to assessed need.

BACKGROUND: International 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.METHODS: Data 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 was interrogated using a thematic analysis, underpinned by social phenomenological theory.RESULTS: Three 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 amongst 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.CONCLUSION: This 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.

IntroductionHepatitis C virus (HCV) is the second largest contributor to liver disease in the UK, with injecting drug use as the main risk factor among the estimated 200 000 people currently infected. Despite effective prevention interventions, chronic HCV prevalence remains around 40% among people who inject drugs (PWID). New direct-acting antiviral (DAA) HCV therapies combine high cure rates (>90%) and short treatment duration (8 to 12 weeks). Theoretical mathematical modelling evidence suggests HCV treatment scale-up can prevent transmission and substantially reduce HCV prevalence/incidence among PWID. Our primary aim is to generate empirical evidence on the effectiveness of HCV ‘Treatment as Prevention’ (TasP) in PWID.Methods and analysisWe plan to establish a natural experiment with Tayside, Scotland, as a single intervention site where HCV care pathways are being expanded (including specialist drug treatment clinics, needle and syringe programmes (NSPs), pharmacies and prison) and HCV treatment for PWID is being rapidly scaled-up. Other sites in Scotland and England will act as potential controls. Over 2 years from 2017/2018, at least 500 PWID will be treated in Tayside, which simulation studies project will reduce chronic HCV prevalence among PWID by 62% (from 26% to 10%) and HCV incidence will fall by approximately 2/3 (from 4.2 per 100 person-years (p100py) to 1.4 p100py). Treatment response and re-infection rates will be monitored. We will conduct focus groups and interviews with service providers and patients that accept and decline treatment to identify barriers and facilitators in implementing TasP. We will conduct longitudinal interviews with up to 40 PWID to assess whether successful HCV treatment alters their perspectives on and engagement with drug treatment and recovery. Trained peer researchers will be involved in data collection and dissemination. The primary outcome – chronic HCV prevalence in PWID – is measured using information from the Needle Exchange Surveillance Initiative survey in Scotland and the Unlinked Anonymous Monitoring Programme in England, conducted at least four times before and three times during and after the intervention. We will adapt Bayesian synthetic control methods (specifically the Causal Impact Method) to generate the cumulative impact of the intervention on chronic HCV prevalence and incidence. We will use a dynamic HCV transmission and economic model to evaluate the cost-effectiveness of the HCV TasP intervention, and to estimate the contribution of the scale-up in HCV treatment to observe changes in HCV prevalence. Through the qualitative data we will systematically explore key mechanisms of TasP real world implementation from provider and patient perspectives to develop a manual for scaling up HCV treatment in other settings. We will compare qualitative accounts of drug treatment and recovery with a ‘virtual cohort’ of PWID linking information on HCV treatment with Scottish Drug treatment databases to test whether DAA treatment improves drug treatment outcomes.Ethics and disseminationExtending HCV community care pathways is covered by ethics (ERADICATE C,ISRCTN27564683, Super DOT C Trial clinicaltrials.gov:NCT02706223). Ethical approval for extra data collection from patients including health utilities and qualitative interviews has been granted (REC ref: 18/ES/0128) and ISCRCTN registration has been completed (ISRCTN72038467). Our findings will have direct National Health Service and patient relevance; informing prioritisation given to early HCV treatment for PWID. We will present findings to practitioners and policymakers, and support design of an evaluation of HCV TasP in England.

Background:\ud Surveys of young people under-represent those in alternative education settings (AES), potentially disguising health inequalities. We present the first quantitative UK evidence of health inequalities between AES and mainstream education school (MES) pupils, assessing whether observed inequalities are attributable to socioeconomic, familial, educational and peer factors.\ud \ud Methods:\ud Cross-sectional, self-reported data on individual- and poly-substance use (PSU: combined tobacco, alcohol and cannabis use) and sexual risk-taking from 219 pupils in AES (mean age 15.9 years) were compared with data from 4024 pupils in MES (mean age 15.5 years). Data were collected from 2008 to 2009 as part of the quasi-experimental evaluation of Healthy Respect 2 (HR2).\ud \ud Results:\ud AES pupils reported higher levels of substance use, including tobacco use, weekly drunkenness, using cannabis at least once a week and engaging in PSU at least once a week. AES pupils also reported higher levels of sexual health risk behaviours than their MES counterparts, including: earlier sexual activity; less protection against sexually transmitted infections (STIs); and having 3+ lifetime sexual partners. In multivariate analyses, inequalities in sexual risk-taking were fully explained after adjusting for higher deprivation, lower parental monitoring, lower parent-child connectedness, school disengagement and heightened intentions towards early parenthood among AES vs MES pupils. However, an increased risk (OR = 1.73, 95% CI 1.15, 2.60) of weekly PSU was found for AES vs MES pupils after adjusting for these factors and the influence of peer behaviours.\ud \ud Conclusion:\ud AES pupils are more likely to engage in health risk behaviours, including PSU and sexual risk-taking, compared with MES pupils. AES pupils are a vulnerable group who may not be easily targeted by conventional population-level public health programmes. Health promotion interventions need to be tailored and contextualised for AES pupils, in particular for sexual health and PSU. These could be included within interventions designed to promote broader outcomes such as mental wellbeing, educational engagement, raise future aspirations and promote resilience.

Background Evidence suggests that the use of alcohol among older adults (defined as those aged 50+) has increased in recent years, with people aged 55–64 now more likely to exceed the recommended weekly guidelines than any other age group. Methods/ design This is a quasi-experimental study with a before-after design. A postal questionnaire will be sent to 76,000 people aged 50 and over registered with a general practice in five different ‘demonstration’ (intervention) and control areas in the UK. Multiple interventions will then be delivered in demonstration areas across the UK. At the end of the programme, a postal questionnaire will be sent to the same individuals who completed it pre-programme to establish if there has been a reduction in alcohol use, at-risk drinking and alcohol related problems. Qualitative interviews with clients and staff will explore how the interventions were experienced; how they may work to bring about change and to identify areas for practice improvements. Discussion This study protocol describes a multi-level, multi-intervention prevention-to-treatment programme which aims to reduce alcohol-related harm in people aged 50 and over.

Background There is a strong interest in the use of social media to spread positive sexual health messages through social networks of young people. However, research suggests that this potential may be limited by a reluctance to be visibly associated with sexual health content on the web or social media and by the lack of trust in the veracity of peer sources. Objective The aim of this study was to investigate opportunities and challenges of using social media to facilitate peer-to-peer sharing of sexual health messages within the context of STASH (Sexually Transmitted Infections and Sexual Health), a secondary school-based and peer-led sexual health intervention. Methods Following training, and as a part of their role, student-nominated peer supporters (aged 14-16 years) invited school friends to trainer-monitored, private Facebook groups. Peer supporters posted curated educational sex and relationship content within these groups. Data came from a feasibility study of the STASH intervention in 6 UK schools. To understand student experiences of the social media component, we used data from 11 semistructured paired and group interviews with peer supporters and their friends (collectively termed students; n=42, aged 14-16 years), a web-based postintervention questionnaire administered to peer supporters (n=88), and baseline and follow-up questionnaires administered to students in the intervention year group (n=680 and n=603, respectively). We carried out a thematic analysis of qualitative data and a descriptive analysis of quantitative data. Results Message sharing by peer supporters was hindered by variable engagement with Facebook. The trainer-monitored and private Facebook groups were acceptable to student members (peer supporters and their friends) and reassuring to peer supporters but led to engagement that ran parallel to—rather than embedded in—their routine social media use. The offline context of a school-based intervention helped legitimate and augment Facebook posts; however, even where friends were receptive to STASH messages, they did not necessarily engage visibly on social media. Preferences for content design varied; however, humor, color, and text brevity were important. Preferences for social media versus offline message sharing varied. Conclusions Invitation-only social media groups formed around peer supporters’ existing friendship networks hold potential for diffusing messages in peer-based sexual health interventions. Ideally, interactive opportunities should not be limited to single social media platforms and should run alongside offline conversations. There are tensions between offering young people autonomy to engage flexibly and authentically and the need for adult oversight of activities for information accuracy and safeguarding.

Background There is an ongoing HIV outbreak amongst people who inject drugs (PWID) in Glasgow, Scotland, and one response which has not yet been widely implemented is the provision of Pre-exposure prophylaxis (PrEP). PrEP is the use of HIV anti-retrovirals prior to HIV infection to provide a barrier to infection. This has been shown to be effective amongst various at-risk populations in preventing HIV spread. The present study aimed to explore views of PWID who might benefit from PrEP provision and Service Providers working with PWID to understand will to use PrEP and literacy of PrEP, contributing to the development of a PrEP service. Methods A qualitative approach was taken, with semi structured interviews conducted in Glasgow at two third sector service sites. 11 Service Providers and 21 PWID participated in the study. Data was analysed thematically. Results Participants, both PWID and Service Providers, were keen to engage with PrEP and perceived substantial potential benefits of PrEP for this population. Potential barriers to engagement were identified as a lack of health literacy, motivation, and self-ascribed risk, as well as the overwhelming unpredictability of substance use. Participants wanted PrEP to be provided within already existing structures, particularly community pharmacies, and for promotion and provision to involve peers. Conclusion This sample reported willingness to engage with PrEP, and suggested there is a specific need amongst PWID for PrEP. However, PWID have specific lived experienced contexts and needs, and are burdened by social and economic marginalisation and inequality at every level. This contrasts them from other populations currently being provided with PrEP, and must be considered in the development of provision.

Background The Social and Emotional Education and Development programme (SEED) aims to improve the social and emotional wellbeing (SEW) of primary school pupils. It is based on a cycle of collecting school specific data on pupil and staff SEW, providing benchmarked feedback and facilitating the adoption of evidence-based initiatives to address need. A stratified randomised controlled trial (RCT) involved 37 schools across three local authority districts in Scotland between 2013 and 2017. Complementing the RCT was a detailed process evaluation, which enabled interpretation of the trial outcomes and answered secondary questions on implementation, mechanisms and context. We present the first stage of the process evaluation, an assessment of the likely effectiveness of the intervention prior to knowing the quantitative outcomes of the trial, focusing on case study schools. Methods The process evaluation design was guided by the UK Medical Research Council framework for the evaluation of complex interventions. Mixed methods included semi-structured interviews with head/depute head teachers and educational psychologists, ethnographic notes from reflexive discussion sessions, focus groups with pupils and staff, pupil and parent questionnaires. The preliminary analysis was carried out on ten case study schools. Results SEED was delivered largely as intended, the main exception being fewer reflexive discussion and action cycles than intended. Participants cited restrictions on time and resources and a lack of embeddedness in local authority structures as barriers to implementation. There was evidence that SEED was valued for providing time and structure to reflect on SEW and foster a collective commitment to tackle and prevent problems, although actions often reinforced existing priorities rather than encouraged the adoption of innovative initiatives. There was limited evidence of an improvement in pupils’ SEW but there was evidence that SEED improved relationships between staff. The school’s pre-existing climate, strength of leadership and readiness for change appeared important in determining engagement with SEED. Conclusion Based on this preliminary case study analysis we were not confident that enough schools implemented the intervention in sufficient depth to demonstrate an effect on pupils’ Strengths and Difficulties Questionnaire scores (primary outcome). However, the RCT subsequently found a significant improvement in pupil SEW across the life of the trial, particularly for older pupils. Ongoing process evaluation analyses aim to explain this and revisit key questions of implementation and mechanisms for change. These analyses will be available by September 2018.

Economic migration has increased dramatically over the past decades, yet, still little is known about the well-being of economic migrants. Most studies focus on the poor mental health of migrants. The few studies that examine well-being do not include a comprehensive range of predictors. They focus mostly on socio-economic factors and a limited number of cognitive-behavioural factors. Furthermore, most research is not theoretically based. The present study aims to (1) examine a comprehensive range of determinants of well-being (i.e. circumstantial, cognitive-behavioural and personality) among economic migrants; (2) establish the extent to which the findings are supported by an integrative theory of well-being—the Sustainable Happiness Model (SHM). A total of 188 Polish immigrants living in Scotland took part in the study. Participants completed a survey on well-being and potential predictors: circumstantial factors (e.g. socio-demographics), cognitive-behavioural factors (e.g. coping strategies) and personality. The data were analysed by descriptive statistics, multiple and hierarchical regression. The results indicated that cognitive-behavioural factors account for most variance in well-being and personality explains the least variance. This contradicts the SHM which posits that well-being is mostly accounted for by the set-point. It was argued that the SHM, largely based on studies conducted on non-migrant populations in developed countries, may not be applicable in its current form to economic migrant populations or non-western cultures. A modified model is proposed to explain well-being of migrant populations and non-western, more collectivistic societies. The study highlights the importance of addressing migrants’ adverse circumstances to help maintain well-being.

BackgroundThere is limited evidence on the health needs and service access among children and young people who are looked after by the state. The aim of this study was to compare dental treatment needs and access to dental services (as an exemplar of wider health and well-being concerns) among children and young people who are looked after with the general child population.MethodsPopulation data linkage study utilising national datasets of social work referrals for ‘looked after’ placements, the Scottish census of children in local authority schools, and national health service’s dental health and service datasets.Results633 204 children in publicly funded schools in Scotland during the academic year 2011/2012, of whom 10 927 (1.7%) were known to be looked after during that or a previous year (from 2007–2008). The children in the looked after children (LAC) group were more likely to have urgent dental treatment need at 5 years of age: 23%vs10% (n=209/16533), adjusted (for age, sex and area socioeconomic deprivation) OR 2.65 (95% CI 2.30 to 3.05); were less likely to attend a dentist regularly: 51%vs63% (n=5519/388934), 0.55 (0.53 to 0.58) and more likely to have teeth extracted under general anaesthesia: 9%vs5% (n=967/30253), 1.91 (1.78 to 2.04).ConclusionsLAC are more likely to have dental treatment needs and less likely to access dental services even when accounting for sociodemographic factors. Greater efforts are required to integrate child social and healthcare for LAC and to develop preventive care pathways on entering and throughout their time in the care system.

Background and objectives: \ud \ud Children in state care (‘looked after children’) have poorer health than children who are not looked after. Recent developments in Scotland and elsewhere have aimed to improve services and outcomes for looked after children. Routine monitoring of the health outcomes of looked after children compared to those of their non-looked after peers is currently lacking. Developing capacity for comparative monitoring of population-based outcomes based on linkage of routinely collected administrative data has been identified as a priority. To our knowledge there are no existing population-based data linkage studies providing data on the health of looked after and non-looked after children at national level. Smaller scale studies that are available generally provide very limited information on linkage methods and hence do not allow scrutiny of bias that may be introduced through the linkage process.\ud \ud Study design and methods: \ud \ud National demonstration project testing the feasibility of linking routinely collected looked after children, education and health data.\ud \ud Participants: \ud \ud All children in publicly funded school in Scotland in 2011/12.\ud \ud Results: \ud \ud Linkage between looked after children data and the national pupil census classified 10,009 (1.5%) and 1757 (0.3%) of 670,952 children as, respectively, currently and previously looked after. Recording of the unique pupil identifier (Scottish Candidate Number, SCN) on looked after children returns is incomplete, with 66% of looked after records for 2011/12 for children of possible school age containing a valid SCN. This will have resulted in some under-ascertainment of currently and, particularly, previously looked after children within the general pupil population. Further linkage of the pupil census to the National Health Service Scotland master patient index demonstrated that a safe link to the child's unique health service (Community Health Index) number could be obtained for a very high proportion of children in each group (94%, 95% and 95% of children classified as currently, previously, and non-looked after, respectively). In general, linkage rates were higher for older children and those living in more affluent areas. Within the looked after group, linkage rates were highest for children with the fewest placements and for those in permanent fostering.\ud \ud Conclusions: \ud \ud This novel data linkage demonstrates the feasibility of monitoring population-based health outcomes of school-aged looked after and non-looked after children using linked routine administrative data. Improved recording of the unique pupil identifier number on looked after data returns would be beneficial. Extending the range of personal identifiers on looked after children returns would enable linkage to health data for looked after children who are not in publicly funded schooling (i.e. those who are preschool or postschool, home schooled or in independent schooling).

Aims and Objectives: To explore the experience of adults living with hepatitis C in a new era of interferon-free treatment.Background: Hepatitis C is a leading cause of morbidity and mortality worldwide, posing a significant challenge to global public health. Historically, the treatment of hepatitis C was poorly efficacious and highly demanding, however, more effective and tolerable therapies have become available in high-income nations in recent years. This is the first study to explore how these significant developments in the treatment of hepatitis C may have influenced the experience of those living with the virus, and their understanding of the disease.Design: A qualitative study underpinned by social phenomenological theory.Methods: Data were generated through semi-structured interviews with a purposive sample of 20 hepatitis C positive adults living in a large city in Scotland. Results: Thematic analysis identified three over-riding themes. ‘Positioning hepatitis C’ illustrated how the disease was understood within wider sociocultural, medical and politico-economic contexts. ‘Beyond a physical burden’ emphasised the emotional aspect of infection, and ‘a new uncertainty’ revealed participants’ cautious response to the advances in hepatitis C therapy.Conclusions: Inter-thematic discourse portrayed the new era of hepatitis C treatment as holding little sway over constructions of the illness, as narratives resonated with previous studies. Such unmoving ‘lay’ understandings of hepatitis C may pose potential barriers to the new therapeutic era from reaching its full potential.Relevance to clinical practice: How people living with the virus perceive and understand hepatitis C can have an adverse impact on their engagement with care and treatment. Whilst global medical discourse eulogises the arrival of a new era of therapy, there remain significant challenges for nurses engaging those with hepatitis C in therapeutic pathways.

ObjectivesChildren that are ‘looked after’ include those that are accommodated in foster, kinship and residential care placements, as well as those at home on compulsory supervision. They have poorer physical and mental health than their peers and there are concerns about the relatively high levels of untreated morbidity. Oral health and access to dental services among Looked After Children (LAC) has received limited attention to date. The objective of this study was to compare the oral health and access to dental services of children who are looked after by the state, with comparable children in the general population. ApproachSchool and Social Work datasets were able to be linked using the Scottish Exchange of Data (ScotXed) Unit. This in turn was linked with health data making use of the Scottish national record-linkage system provided by the NHS eDRIS team for the FARR Institute Scotland. All of the following datasets used in this study are complete national datasets for the time periods noted. School Pupil Census 2012: a census of children in local authority primary and secondary schools that provides each child’s age, sex and socioeconomic status as measured by the Scottish Index of Multiple Deprivation (SIMD). The other datasets cover the period 2008-2012: LAC- all children with social work referrals for various types of placement; registration with dentists; hospital discharge data for all episodes of tooth extraction; National Dental Inspection Programme (NDIP) data from Primary 1 and Primary 7 school years (dental decay). The LAC group were compared to their peers by logistic regression adjusted by SIMD, using remote access to the National Safe Haven. ResultsThere were 633204 subjects in the study group (10927 LAC, 622280 nonLAC). Ages ranged from four to 17 years (mean 12 LAC and 10 nonLAC); with 53% male for LAC and 51% nonLAC; and 42% in the most deprived SIMD level for LAC and 21% for non-LAC. The subjects in the LAC group were more likely to have dental decay at Primary 1, odds-ratio (OR) 2.93 (2.55, 3.38), and Primary 7, OR 1.81 (1.68, 1.94). LAC subjects were less likely to be registered with a dentist, OR 0.50 (0.43, 0.59), and more likely to have teeth extracted, OR 1.50 (1.40, 1.60). All tests p

BackgroundMen who have sex with men (MSM) experience significant inequalities in health and well-being. They are the group in the UK at the highest risk of acquiring a human immunodeficiency virus (HIV) infection. Guidance relating to both HIV infection prevention, in general, and individual-level behaviour change interventions, in particular, is very limited.ObjectivesTo conduct an evidence synthesis of the clinical effectiveness of behaviour change interventions to reduce risky sexual behaviour among MSM after a negative HIV infection test. To identify effective components within interventions in reducing HIV risk-related behaviours and develop a candidate intervention. To host expert events addressing the implementation and optimisation of a candidate intervention.Data sourcesAll major electronic databases (British Education Index, BioMed Central, Cumulative Index to Nursing and Allied Health Literature, EMBASE, Educational Resource Index and Abstracts, Health and Medical Complete, MEDLINE, PsycARTICLES, PsycINFO, PubMed and Social Science Citation Index) were searched between January 2000 and December 2014.Review methodsA systematic review of the clinical effectiveness of individual behaviour change interventions was conducted. Interventions were examined using the behaviour change technique (BCT) taxonomy, theory coding assessment, mode of delivery and proximity to HIV infection testing. Data were summarised in narrative review and, when appropriate, meta-analysis was carried out. Supplemental analyses for the development of the candidate intervention focused on post hoc realist review method, the assessment of the sequential delivery and content of intervention components, and the social and historical context of primary studies. Expert panels reviewed the candidate intervention for issues of implementation and optimisation.ResultsOverall, trials included in this review (n = 10) demonstrated that individual-level behaviour change interventions are effective in reducing key HIV infection risk-related behaviours. However, there was considerable clinical and methodological heterogeneity among the trials. Exploratory meta-analysis showed a statistically significant reduction in behaviours associated with high risk of HIV transmission (risk ratio 0.75, 95% confidence interval 0.62 to 0.91). Additional stratified analyses suggested that effectiveness may be enhanced through face-to-face contact immediately after testing, and that theory-based content and BCTs drawn from ‘goals and planning’ and ‘identity’ groups are important. All evidence collated in the review was synthesised to develop a candidate intervention. Experts highlighted overall acceptability of the intervention and outlined key ways that the candidate intervention could be optimised to enhance UK implementation.LimitationsThere was a limited number of primary studies. All were from outside the UK and were subject to considerable clinical, methodological and statistical heterogeneity. The findings of the meta-analysis must therefore be treated with caution. The lack of detailed intervention manuals limited the assessment of intervention content, delivery and fidelity.ConclusionsEvidence regarding the effectiveness of behaviour change interventions suggests that they are effective in changing behaviour associated with HIV transmission. Exploratory stratified meta-analyses suggested that interventions should be delivered face to face and immediately after testing. There are uncertainties around the generalisability of these findings to the UK setting. However, UK experts found the intervention acceptable and provided ways of optimising the candidate intervention.Future workThere is a need for well-designed, UK-based trials of individual behaviour change interventions that clearly articulate intervention content and demonstrate intervention fidelity.Study registrationThe study is registered as PROSPERO CRD42014009500.FundingThe National Institute for Health Research Health Technology Assessment programme.

Previous reviews have highlighted parent-child connectedness and communication as important protective factors against adolescent substance use. However, these reviews focus on single substances such as alcohol. An integrative review of the literature was conducted to examine which elements of parent-child connectedness and substance-use specific communication are effective across adolescent alcohol, tobacco and drug use. Forty-two English language, peer reviewed articles were reviewed. Open communication occurs within the context of high connectedness between parents and their children. Conversations about health risks are associated with lower levels of substance use while more frequent conversations, those about parents’ own use, permissive messages and consequences of use are associated with higher levels of use. There are disparities regarding conversations about use of each substance: alcohol and tobacco are easier topics of conversation while drug use is rarely discussed. Parental alcohol and tobacco use can influence the credibility of their communication with their child. Parents should be encouraged to have open, constructive, credible, two-sided conversations with their adolescents about substance use. Interventions to improve parents’ communication skills around substance use, particularly drug use, should include the types of approaches and messages highlighted in this review, and, where possible, these interventions should include all family members.

Despite encouragement from policy and research for drug services to involve family members in drug users’ treatment and support families and carers in their own right, family members’ involvement with services remains limited. Research to date offers limited insights into why barriers and tensions are perceived the way they are and reveals little about values and perspectives that underpin relationships between family members and drug services. This qualitative study aimed to generate a fuller understanding of the relationships that carers have with adult drug services and how this might affect involvement. The findings suggest that by reinforcing stereotypes, perpetuating stigma and fuelling self-fulfilling prophecies, the dominant narrative of ‘family as part of the problem’ frames and constrains family members’ involvement with drug services. Recommendations for policy and practice need to focus on strengthening the narrative that family members’ involvement with drug services is achievable, necessary and worthwhile.

ObjectivesTo explore how personal and institutional factors promote or limit caregivers promoting sexual health and relationships (SHR) among looked-after children (LAC). In so doing, develop existing research dominated by atheoretical accounts of the facilitators and barriers of SHR promotion in care settings.DesignQualitative semistructured interview study.SettingUK social services, residential children’s homes and foster care.Participants22 caregivers of LAC, including 9 foster carers, 8 residential carers and 5 social workers; half of whom had received SHR training.MethodsIn-depth interviews explored barriers/facilitators to SHR discussions, and how these shaped caregivers’ experiences of discussing SHR with LAC. Data were systematically analysed using predetermined research questions and themes identified from reading transcripts. Role theory was used to explore caregivers’ understanding of their role.ResultsSHR policies clarified role expectations and increased acceptability of discussing SHR. Training increased knowledge and confidence, and supported caregivers to reflect on how personally held values impacted practice. Identified training gaps were how to: (1) Discuss SHR with LAC demonstrating problematic sexual behaviours. (2) Record the SHR discussions that had occurred in LAC’s health plans. Contrary to previous findings, caregivers regularly discussed SHR with LAC. Competing demands on time resulted in prioritisation of discussions for sexually active LAC and those ‘at risk’ of sexual exploitation/harm. Interagency working addressed gaps in SHR provision. SHR discussions placed emotional burdens on caregivers. Caregivers worried about allegations being made against them by LAC. Managerial/pastoral support and ‘safe care’ procedures minimised these harms.ConclusionsWhile acknowledging the existing level of SHR promotion for LAC there is scope to more firmly embed this into the role of caregivers. Care needs to be taken to avoid role ambiguity and tension when doing so. Providing SHR policies and training, promoting interagency working and providing pastoral support are important steps towards achieving this.

The relationship between history of childhood sexual abuse and psychopathology in adult life is well established. However, understanding of the mechanisms by which abuse exerts its effects is limited. To our knowledge, this is the first study which investigates the relationship between a wide range of sexual abuse characteristics (i.e. age at onset, frequency of assaults, number of perpetrators and their relationship to the victim) and the severity of psychopathological disorders in a large sample of adult child sexual abuse (CSA) survivors who attended a specialist Psychotherapy Service for CSA survivors. CSA survivors in our study experienced severe sexual assault(s) in their early years and presented with severe pathology which could suggest a strong causal link. However, none of the examined trauma characteristics significantly predicted severity of psychopathology. This may suggest that for severely disordered, treatment-seeking CSA survivors post-abuse psychopathology could be caused by other factors. The study adds to the growing body of evidence suggesting that CSA effects may be dependent on factors which are not necessarily related to the nature of sexual abuse. The study findings will help improve clinicians' insight into the determinants of psychopathology.

To establish the extent to which professional role identity shapes community nurses' reactions before the implementation of a policy that sought to introduce a generic role. BACKGROUND: Many countries seek to alter community nurse roles to address changes in population health and health workforce. We know little about the influences that might shape nurses' reaction to these policies before their implementation and our theoretical understanding is poorly developed at this point in the policy-making cycle. METHOD: Self completed cross-sectional survey of 703 community nurses before the introduction of a generic Community Health Nurse role in Scotland. RESULT: The minority (33%) supported the new role. The professional role identity of those who were supportive differed significantly from those who did not support the policy or were uncertain of it. CONCLUSION: It is possible that the new policy acted to increase the value of the professional role identity of those who were supportive and conversely devalued the professional role identity of those who were unsupportive or uncertain of it. IMPLICATIONS: Professional role identity should be considered by policy makers in any country seeking to introduce policies that aim to radically change the role of community nurses and that this is acknowledged at an early stage in the policy-making cycle.

Objectives Successful partnership working has theoretically been linked to improvements in service delivery and is dependent on the strength of the partnership, trust, communication, professional roles and resource sharing. Empirical evidence to confirm the relationships between these factors and improved service provision, however, is lacking. Our aim was to assess the views of staff as to the conditions required for partnership working. Methods This study was a cross-sectional survey of 687 staff offering sexual health education, information or support to young people in the Healthy Respect intervention area in Scotland. Views of each variable were scored and structural equation modelling was used to assess the theoretical model. Results Responses were received from 284 (41%) staff. Greater strength of partnership was directly associated with increasing the number of referrals. Establishing professional roles between organizations was also associated with increasing the number of referrals. Strength of partnership was indirectly associated with working more effectively with young people and this relationship depended on clear communication, trust, established professional roles and shared resources. Effective partnership working depends on a number of interdependent relationships between organizations, which act synergistically to improve organizational outcomes. Conclusions Effective partnership working leads to improved service delivery though there is a need for better controlled studies which demonstrate the effect on health outcomes.

Introduction Women with a raised BMI are more likely to gain excessive weight in pregnancy compared to women with a BMI in the normal range. Recent behaviour change interventions have had moderate to no influence on GWG, and no effect on other perinatal outcomes. Evidence is required regarding the social and cultural contexts of weight and pregnancy. No studies to date have included the views of partners Aims: 1. To explore the experiences, attitudes and health-related behaviours of pregnant women with a BMI >40 kg/m2; and to identify the factors and considerations which shape their beliefs, experiences and behaviours, and how these may change during and after pregnancy.2. To determine the impact, if any, of the beliefs and attitudes of significant members of the women's families and social networks upon the women's experiences, attitudes and health-related behaviours in relation to weight and pregnancy. Methods: This was a prospective serial interview study. Semi-structured interviews were conducted with 11 pregnant women with a BMI >40 kg/m2, during pregnancy and after birth, and once with 7 partners (all male) of women. Interview questions were designed to be appropriately but flexibly framed, in order to explore and gather data on participants' everyday life, lifestyles, views, experiences, relationships and behaviours, focussing more specifically on beliefs about health, pregnancy, weight and diet. Thematic content analysis was used to formally analyse and unearth patterns in the data. Findings: The findings can be grouped into six interrelated themes: the complexities of weight histories and relationships with food; resisting risk together; resisting stigma together; pregnancy as a 'pause';receiving dietary advice; postnatal intentions. These themes are interrelated due to the 'spoiled identity' (Goffman 1963) that the large body represents in western culture and related stigma. Conclusion and implications: This study provides evidence that there exist deeply ingrained social and cultural beliefs among women and in particular their partners, regarding pregnancy diet and weight gain. Further, this study provides evidence that male partners may resist stigmatised risk on behalf of a pregnant partner. All women (and several men) expressed an intention to adopt healthy behaviours and lose weight once their baby was born. Further evidence is required regarding the means by which women who experience stigmatised risk during pregnancy, and their partners, might be engaged and receptive to health advice. Models which draw on ideals of relationship-centred care, and selfefficacy via open discussion with women and families, engaging women and partners by providing them with an opportunity to talk about their beliefs and concerns, could be explored to inform future research and practice.

Objective To explore how older patients self-manage their coronary heart disease (CHD) after undergoing elective percutaneous transluminal coronary angioplasty (PTCA). Methods This mixed methods study used a sequential, explanatory design and recruited a convenience sample of patients (n = 93) approximately three months after elective PTCA. The study was conducted in two phases. Quantitative data collected in Phase 1 by means of a self-administered survey were subject to univariate and bivariate analysis. Phase 1 findings informed the purposive sampling for Phase 2 where ten participants were selected from the original sample for an in-depth interview. Qualitative data were analysed using thematic analysis. This paper will primarily report the findings from a sub-group of older participants (n = 47) classified as 65 years of age or older. Results 78.7% (n = 37) of participants indicated that they would manage recurring angina symptoms by taking glyceryl trinitrate and 34% (n = 16) thought that resting would help. Regardless of the duration or severity of the symptoms 40.5% (n = 19) would call their general practitioner or an emergency ambulance for assistance during any recurrence of angina symptoms. Older participants weighed less (P = 0.02) and smoked less (P = 0.01) than their younger counterparts in the study. Age did not seem to affect PTCA patients' likelihood of altering dietary factors such as fruit, vegetable and saturated fat consumption (P = 0.237). Conclusions The findings suggest that older people in the study were less likely to know how to correctly manage any recurring angina symptoms than their younger counterparts but they had fewer risk factors for CHD. Age was not a factor that influenced participants' likelihood to alter lifestyle factors.