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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. [ABSTRACT FROM AUTHOR]

Aims: Prevention education has had limited success in reducing transmission of blood borne virus among people who inject drugs. Innovative approaches to prevention education are required. Method: This study used video recordings of injecting episodes and interviews with participants reviewing their video recordings to explore the concept of mindlessness as a new tool for prevention education. Findings: The data demonstrate elements of mindlessness in participants’ injecting practice. Participants were unable to provide detailed description of their practice, could not recall the origin of their practices, described limited sensitivity to the environment around them and described learned behaviours ‘dropping out of mind’. Conclusions: Although potentially useful as a prevention tool, prevention messages using mindlessness concepts should be developed in collaboration with injecting drug users to avoid judgmental or alienating messages. Finally, the use of these video recordings themselves can be a powerful education tool given the very hidden and stigmatized nature of injecting drug use. [ABSTRACT FROM AUTHOR]

Abstracts: Several candidate vaccines for hepatitis C are currently in preclinical development or the early stages of clinical trials. Implementing trials of these vaccines among people who inject drugs will be challenging. Previous research, particularly willingness to participate studies in relation to HIV vaccines in marginalised groups, has focused on the modifiable characteristics of individual participants. This qualitative research with people who inject drugs, health staff and clinicians focuses on social, organisational and structural elements of vaccine trial designs which may exclude or reduce the participation of people who inject drugs. [Copyright &y& Elsevier]

Background: Little is known about the factors that influence injecting drug users’ (IDUs) choice of outlet, and in particular why some IDUs might prefer to use pharmacies. Greater understanding of the influences on this choice will contribute to more sophisticated policy and programme responses for blood-borne virus prevention and for health and wellbeing programmes for people who inject drugs. Method: In-depth interviews were conducted with 15 IDUs about their experiences of accessing injecting equipment from pharmacies that participated in the government-sponsored pharmacy needle and syringe scheme. Results: A range of factors influenced participants’ decisions about equipment access. The advantages of the pharmacy scheme access included convenience, relative anonymity, increased positive feelings of self-worth when accessing equipment from pharmacies where they had a good relationship with staff, less police surveillance and access to a greater range of equipment than available in publicly funded Needle and Syringe Programmes. The disadvantages of pharmacy access included the cost of equipment and complications related to methadone dosing and equipment access. Conclusion: Pharmacy access to injecting equipment is highly valued by IDUs. The results of this study direct attention to several elements of programme and policy in the area that would increase access to equipment from pharmacies relating to cost, need for exchange, police surveillance practices, out-of-hours access and anonymity. [ABSTRACT FROM AUTHOR]

Hepatitis C virus infection is a stigmatized condition because of its close association with injecting drug use. There is a need to explore how people who inject drugs (IDUs) perceive hepatitis C, including in relation to treatment experience. We undertook a review, using a qualitative synthesis approach, of English-language qualitative research focusing on the lived experience of hepatitis C among IDUs. The review included 25 published articles representing 20 unique studies. A synthesis of this literature generated three interplaying themes: social stigma, biographical adaptation, and medical and treatment encounters. Interactions with health systems can reproduce stigma linked to drug injecting and hepatitis C, as well as trivialize the lived experience of diagnosis and illness. Hepatitis C can be biographically reinforcing of socially accommodated risk and spoiled identity, as well as disruptive to everyday life. We hypothesize hepatitis C as a liminal illness experience, oscillating between trivial and serious, normalized and stigmatized, public and personal. We conclude by emphasizing the disconnects between the lived experience of hepatitis C among IDUs and Western health care system responses. [ABSTRACT FROM AUTHOR]

Issues. In an effort to increase the number of people undergoing hepatitis C treatment, a range of initiatives are planned or underway to provide treatment in non-specialist services, such as opioid pharmacotherapy treatment (OPT) clinics. Approach. This commentary considers the implications of this new approach to treatment delivery, taking account of individual-level issues generally discussed in the literature, such as knowledge of treatment and concerns about side effects. In addition, because less visible organisational and structural factors would equally influence the successful implementation of hepatitis C treatment in OPT services, these are also explored. Key Findings. Provision of hepatitis C treatment in OPT services raises a broad range of pressing questions, from individual knowledge and concern about treatment, to workforce issues, such as discrimination, and tensions between the need for supportive care during hepatitis C treatment and the surveillant, regulatory nature of OPT clinic operations. Implications. A thorough critical examination of the structure and delivery of all services involved is necessary. Social research can play a unique role in this assessment because of its ability to generate detailed insights into lived experience and make use of social theories that allow previously invisible operations of power to become visible. Conclusion. The success of hepatitis C treatment in new sectors, such as OPT clinics, is not a given. Close attention needs to be paid to the context and culture in which OPT is delivered. In turn, this needs to be considered alongside the context and culture necessary for successful hepatitis C treatment delivery.[Treloar CJ, Fraser SM. Hepatitis C treatment in pharmacotherapy services: Increasing treatment uptake needs a critical view. Drug Alcohol Rev 2009;28:436–440] [ABSTRACT FROM AUTHOR]

Aims: Although mental-health problems are common among drug-treatment consumers, little is known about how mental health is discussed by service providers or understood by clients within treatment settings. We analysed how co-occurring drug and mental-health problems are discussed in Australian drug-treatment settings, particularly clinical terminology such as 'comorbidity' or 'dual diagnosis'. Method: 77 drug-treatment clients with common psychological problems (anxiety or depression) and 18 service providers were interviewed about barriers and incentives to treatment for co-occurring drug and mental-health problems. Findings: Consumers had low levels of understanding of clinical terminology for co-occurring drug and mental-health problems, except for those who had accessed literature or participated in programs developed by drug-user organizations. Service providers recognized low levels of consumer mental-health literacy, and advocated a client-centred approach that avoided the use of clinical terminology. Conclusions: Providers should encourage consumers to discuss mental-health problems, and should not avoid using clinical terminology as this may undermine the development of mental-health literacy among consumers. Treatment services may benefit from working with drug-user organizations to develop resources aimed at improving awareness and understanding of mental-health problems among drug-treatment consumers. [ABSTRACT FROM AUTHOR]

Background Intervention impact on reductions in hepatitis C virus (HCV) incidence among injecting drug users (IDUs) are modest. There is a need to explore how drug injectors' interpret HCV risk. Aims To review English-language qualitative empirical studies of HCV risk among IDUs. Methods Qualitative synthesis using a meta-ethnographic approach. Searching of eight electronic databases and reference lists identified manually papers in peer-reviewed journals since 2000. Only studies investigating IDU perspectives on HCV risk were included. Themes across studies were identified systematically and compared, leading to a synthesis of second- and third-order constructs. Findings We included 31 papers, representing 24 studies among over 1000 IDUs. Seven themes were generated: risk ubiquity; relative viral risk; knowledge uncertainty; hygiene and the body; trust and intimacy; risk environment; and the individualization of risk responsibility. Evidence supports a perception of HCV as a risk accepted rather than avoided. HCV was perceived largely as socially accommodated and expected, and in relative terms to human immunodeficiency virus (HIV) as the ‘master status’ of viral dangers. Symbolic knowledge systems, rather than biomedical risk calculus, and especially narratives of hygiene and trust, played a primary role in shaping interpretations of HCV risk. Critical factors in the risk environment included policing, homelessness and gendered risk. Conclusions Appealing to risk calculus alone is insufficient. Interventions should build upon the salience of hygiene and trust narratives in HCV risk rationality, and foster community changes towards the perceived preventability of HCV. Structural interventions in harm reduction should target policing, homelessness and gendered risk. [ABSTRACT FROM AUTHOR]

Introduction: Access to services is key to successful community (re-)integration following release from prison. But many people experience disengagement from services, including people who inject drugs (PWID). We use a case study approach and the notion of structural competency to examine influences on access to services among a group of PWID recently released from prison.Methods: This qualitative study recruited participants from SuperMIX, (a longitudinal cohort study in Victoria, Australia).Inclusion Criteria: aged 18+; lifetime history of injecting drug use; incarcerated for > three months and released from custody < 12 months previously. From 48 participants, five case studies were selected as emblematic of the complex and intersecting factors occurring at the time participants missed an appointment at a service.Results: Numerous, concurrent, and interdependent structural influences in participants' lives coincided with their difficulty accessing and maintaining contact with services and resulted in missed appointments. The key factors involved in the cases presented here include policies around opioid agonist treatment, inadequate, unsuitable and unsafe housing, the management of mental health and side effects of treatment, the lack of social support or estrangement from family, and economic hardship. The support available from service workers to navigate these structural issues was inconsistent. One dissenting case is examined in which missing appointments is anticipated and accommodated.Conclusions: A case study approach enabled a holistic and in-depth examination of upstream structural elements that intersect with limited social and economic resources to exacerbate the challenges of community re-entry. These results highlight structural issues that have a disproportionate impact on the choices and opportunities for PWID. The incorporation of a structural competency framework in design of services and in staff training could support person-centred and coordinated service provision that take into account PWID's experiences post-release to overcome structural barriers to service engagement. [ABSTRACT FROM AUTHOR]

This paper explores the perceptions of 35 key informants (KIs) in a range of relevant health and community sectors regarding the stigmatisation of GBM's crystal methamphetamine use and sexual practice with view to informing stigma reduction efforts. A modified social ecological model was used to guide analysis and interpretation. At the individual level, KI participants indicated that crystal methamphetamine was used by some GBM to reduce the effects of internalised stigma. At the network level, KIs thought that some drugs and types of use could attract more stigma and that this could erode support from GBM networks for men who use crystal. KIs felt that few "mainstream" organisations could provide appropriate services for GBM who use crystal and furthermore, that there was significant work to "undo" misperceptions of the harms of crystal use. At the policy level, mass media anti-drug campaigns were seen to be a significant generator of stigma with irrelevant and patronising messages that lacked useful information. Efforts to reduce stigma about crystal methamphetamine use amongst GBM must address individual, network, organisation and policy issues and be underpinned by understandings of social power in relation to sex, sexuality, drug use, infectious status and sexual minorities. [ABSTRACT FROM AUTHOR]

Little is understood about the self-care activities undertaken by drug treatment clients. Using data from a qualitative study of drug treatment and mental health we identify the self-care practices of drug treatment clients diagnosed with anxiety and depression. Seventy-seven participants were interviewed in four sites across Australia. Participants described a range of self-care practices for mental health including: self-medication, seeking social support, physical exercise, counselling-derived techniques, keeping busy and other less common strategies. These findings show that drug treatment clients undertake similar self-care practices to the general population and illicit drug users and that these activities echo beneficial practices identified in the research literature. The results suggest opportunities for service providers to work with clients on self-care activities that may improve mental health. Tensions between consumer and professional views of self-care, and the limits to encouraging self-care as a substitute for treatment, are discussed. [ABSTRACT FROM AUTHOR]

Hepatitis C treatment is known to produce significant physical and psychiatric side-effects. Healthcare workers in hepatitis C treatment clinics focus on preparing people to cope with these side-effects. Unrealistic optimism, or judging oneself to be at low risk of negative events, has been implicated in contributing to practices that place health at risk and to delays in seeking help or facilitating coping with negative events. In the context of hepatitis C treatment, patients with overly optimistic expectations of their ability to cope with treatment-related side-effects are less prepared for their impact and therefore may be more likely to discontinue treatment. In this exploratory qualitative study, data from semi-structured interviews with 20 people undergoing hepatitis C treatment and six healthcare workers at three hepatitis C treatment clinics in Sydney, Australia were explored for the presence of unrealistic optimism and also the impact that this had on patients' processing of information pre-treatment and management of side-effects during treatment. The concept of unrealistic optimism was evident in both patients' and healthcare workers' interview transcripts. Patients' descriptions of their preparation for hepatitis C treatment included references to delays in seeking help for depressive symptoms attributable to unrealistic optimism. Healthcare workers also discussed their observations of the effects of unrealistic optimism on patients' coping strategies. Data from this study contribute to an understanding of unrealistic optimism and its impact on the experience of hepatitis C treatment side-effects, patients' coping styles and potential for delays in seeking help. Unrealistic optimism should be explored as part of pre-treatment assessments for hepatitis C treatment and considered throughout treatment to avoid delays in help seeking. [ABSTRACT FROM AUTHOR]

Background: Drug treatment clients are significantly more likely to remain in treatment if ancillary life issues and complex needs are addressed. Aim: to document and analyse the complex needs ('complex vulnerabilities') of people experiencing both problems with drug dependence and common mental health problems, with a particular focus on barriers and incentives to drug treatment. Method: A qualitative interview-based study of 77 participants in four sites (three metropolitan, one regional) in Australia. Results: Complex vulnerabilities were deeply embedded in participants' lives and unlikely to be quickly resolved. Poor housing, criminal justice issues and the experience of poverty or debt affected participants' ability to secure basic needs, and their ability to participate in drug or mental health treatment. Difficulties in finding assistance for complex vulnerabilities, especially at times of crisis, were reported by many participants. Conclusions: There is an urgent need to reform the health system to better meet the needs of this group and ensure a 'no wrong door' policy. The resilience demonstrated by participants in managing complex issues should be acknowledged, although the deleterious effect of complex vulnerabilities on treatment participation and outcomes should be recognised. [ABSTRACT FROM AUTHOR]

Abstract: Blood awareness messages have been used for some years in hepatitis C prevention efforts. However, hepatitis C prevention education has achieved only limited success. Innovative means of reaching people who inject drugs (PWIDs) are required. This study involved video recording injecting episodes of 13 clients of the Sydney Medically Supervised Injecting Centre in Kings Cross. Participants were interviewed the following day and asked to review their video and comment on their injecting practice. Also, feedback was provided to the participants on injecting technique and hepatitis C prevention. A peer researcher was present and engaged the participant in discussion around safer practice and explored the participants’ explanations of their practice. This analysis provides information about the common aspects of “safer” and “unsafer” injecting technique observed in the video recordings. Unsafer in this context was defined as any practice which could cause harm including blood borne virus transmission risks, vein damage and introduction of other pathogens to the blood stream. Analysis of the video data show that common “unsafer” practices which have implications for blood borne virus transmission include: not washing hands before injecting; using fingers to stop bleeding; wiping injection site with swab (instead of applying pressure) to stop bleeding after injecting; and using the same swab to wipe another site. Analysis of interview data provided participants’ explanations of their practices. Analysis of the discussions between the interview team and the participant provides insight into the types of messages and communication strategies which had credibility with the participants. These data show that broadening of hepatitis C education discussions to include other aspects of “safer” injecting can be useful in engaging experienced PWIDs in prevention. Embedding blood borne virus prevention messages in discussions about vein care may provide innovative ways to reinvigorate hepatitis C prevention efforts and impart these messages in a context which acknowledges the skills and knowledge of experienced PWIDs. [Copyright &y& Elsevier]

Social marginalization is associated with poor health outcomes for affected people. However, in a psychosocial study of treatment for hepatitis C infection conducted in Sydney, Australia, participants living in socially disadvantaged circumstances applied adaptive approaches learned from past experiences of drug dependence, living with symptoms of chronic illness, coping with depression and childhood sexual abuse to enable them to cope with severe treatment-related side-effects. This finding has implications for the clinical management of hepatitis C treatment; the factors and processes that facilitate adaptive coping to adversity associated with social marginalization can be assessed for their clinical contribution to coping with an arduous regimen. [ABSTRACT FROM AUTHOR]

Abstract: Exploration of patients’ illicit drug use during treatment for hepatitis C virus (HCV) infection is largely absent from the clinical literature. This paper explores injecting and other illicit drug use among people receiving interferon-based treatment for HCV infection, from the perspective of one group of health professionals. Data are presented from a qualitative study of six health professionals responsible for managing HCV treatment regimens at three major metropolitan hospitals across Sydney, Australia. During semi-structured in-depth interviews, participants discussed patients’ use of injected and non-injected illicit drugs while coping with a demanding therapeutic regimen. Health professionals highlighted the socially conservative environment of healthcare and its negative perceptions of illicit drug users. Also discussed are the management of people who inject during treatment and the efficacy of cannabis to reduce side effects. The findings of this study indicate that while the health professionals adopted a harm reduction approach to patients’ illicit drug use during HCV treatment, information regarding the risks and benefits of illicit drug use is silenced in this context. While ever prohibition remains Australia''s illicit drug policy this situation appears unlikely to change. Research which investigates the extent of illicit drug use during HCV treatment, the risks and benefits associated with their use in this context, and the harms of perpetuating a duplicitous healthcare system is required. [Copyright &y& Elsevier]

Despite evidence for their effectiveness, harm reduction services such as needle and syringe programmes (NSPs) are highly vulnerable to perceptions of community disapproval. This paper reviews Australian research on community attitudes to harm reduction services and its impact on research, policy and practice. The literature on community attitudes to NSPs in Australia comprises a small number of representative national samples and surveys of local communities affected by specific services. Despite these extremely limited data, negative community attitudes are often cited by policy-makers and health professionals as a primary constraint on policy-making. The main finding of this literature review is that community perceptions of NSPs are largely positive. Also, support for NSPs was not synonymous with condoning drug use. The failure of policy-makers and politicians to recognise positive community attitudes to NSPs has led in some instances to hasty political responses to adverse media reports, including the closure of services. This literature review showing positive community attitudes to harm reduction services should embolden researchers, practitioners and policy-makers to challenge such reactionary responses. Further, this evidence should be used in countering negative publicity surrounding these services. [Treloar C, Fraser S. Public opinion on needle and syringe programmes: avoiding assumptions for policy and practice. Drug Alcohol Rev 2007;26:355 - 361] [ABSTRACT FROM AUTHOR]

Aims and design This study investigated equity of access to treatment and barriers to treatment for illicit drug use, using Andersen's behavioural model of health service utilization. Setting and participants The study involved 492 drug users who had received treatment and 193 who had not. Measurements Participants were interviewed to gather data relating to 19 predisposing, need and enabling variables. Findings Never-treated participants exhibited less need for treatment than those who had received treatment. They experienced less negative emotion, used their main drug less often, had fewer drug-related health problems and fewer drug-using friends, were less likely to have blood-borne virus infections and were more likely to be using drugs for ‘fun’. They also had more negative attitudes towards drug treatment staff, were less likely to believe that appropriate treatment was available and less likely to believe that professional help was necessary to get off drugs. Prevalence of physical and mental health problems was high in both groups. Conclusions The study documented significant unmet treatment need and identified several sources of inequity and barriers to treatment that would be amenable to policy and service development. Drug user organizations and peer educators and motivational interventions in primary care settings should be utilized to market the nature and benefits of treatment effectively, and to address the causes of drug users' negative attitudes towards treatment. [ABSTRACT FROM AUTHOR]

This paper explores differences between women's and men's first experience of injecting in relation to socio-demographic context, drug use, and the role of others. We collected cross-sectional retrospective data from 334 recently initiated (≤5 years) injecting drug users in New South Wales and Queensland, Australia using a structured questionnaire in face-to-face interviews. Logistic regression was used to estimate crude and adjusted odds ratios (OR). Findings from the adjusted analysis show that women had a shorter duration of illicit drug use prior to initiation (adjusted OR 0.84, 95%CI: 0.74 - 0.94), and were more likely to have their romantic-sexual partner facilitate the initiation by paying for the drugs (adjusted OR 4.64, 95%CI: 1.21 - 17.73). Women also reported a greater likelihood of being initiated in groups of other women (adjusted OR 2.87, 95%CI: 1.24 - 6.67), suggesting that some women play an active role in their initiation experience rather than relying on, or being lead by, a romantic-sexual partner. These findings demonstrate the crucial role that romantic-sexual partners play in women's initiation experience, but also provide evidence for the way that women can be active participants in their own initiation and in initiating other women. [Bryant J, Treloar C. The gendered context of initiation to injecting drug use: evidence for women as active initiates. Drug Alcohol Rev 2007;26:] [ABSTRACT FROM AUTHOR]

Unlike health policy in the United Kingdom, Australian health policy does not provide a strong endorsement for the involvement of service users in the design, delivery and evaluation of drug treatment services. There has been no research into service-users’ views on the contentious issue of methadone takeaway doses. This study explores the value of takeaway doses from service-users’ perspectives and highlights the contributions that service-user involvement can make to further drug treatment planning, delivery and evaluation. Twenty-five methadone clients were interviewed about the value of methadone takeaway doses. Benefits cited by participants included convenience, less travel and lower costs, protection of confidentiality and less restriction on employment as well as less tangible issues related to feelings of ‘normality’ and flexibility in daily life patterns. Feeling trusted as a methadone client was also an important result of accessing takeaway doses. The inclusion of service-user perspectives is important for ensuring that services are not wrongly targeted and that evaluations of those services do not underestimate or misrepresent their value to clients. This is particularly important in policy around illicit drug use where public and political opinion is often a key driver in decision making. [ABSTRACT FROM AUTHOR]

The aim of this study was to compare demographic and drug use profiles of non-needle and syringe programmes (NSP) attendees with NSP attendees from the same geographic area. Two data sources were used. One was from an annual national survey of injecting drug users (IDU) at NSP and analysis was restricted to survey sites in Kings Cross and Kogarah in 2003 (NSP survey). The other was from a survey of IDU who do not use NSP as their primary source of injecting equipment within the same broad geographical region (Access survey). Of the total 264 survey participants, 102 had never attended a NSP (non-NSP attendees) and 162 had previous experience of NSP (NSP attendees). Compared with NSP attendees, non-NSP attendees were less likely to report severe drug problems and more likely to report lower prevalence of HIV, hepatitis B and hepatitis C infection. Nevertheless, about 20% of non-NSP attendees reported re-use of needles and syringes after someone else in the previous month. Compared to NSP attendees, a lower rate of usage of health services was reported by non-NSP attendees. Strategies to promote access to NSP and harm reduction services, including testing for blood-borne viruses, information provision and consideration of referral to treatment among non-NSP attendees are recommended. [Cao W, Treloar C. Comparison of needle and syringe programme attendees and non-attendees from a high drug-using area in Sydney, New South Wales . Drug Alcohol Rev 2006;25:439 – 444] [ABSTRACT FROM AUTHOR]

Abstract: Most of what is known about injecting drug users in Australia is based on those who attend formal harm reduction services. Little is known about those who primarily use other sources to obtain injecting equipment. This paper examines key characteristics and risk practices amongst two groups of Australian injectors: (1) those that obtain sterile equipment primarily through pharmacies; and (2) the more ‘hidden’ group of those that obtain equipment from their personal networks. A convenience sample of 227 recent injectors who identified either pharmacies (n =167) or personal networks (n =60) as their regular source of sterile needles and syringes completed an interviewer-administered structured questionnaire. Results show that respondents who obtained equipment from their personal networks reported similar rates of reusing needles and syringes as pharmacy attenders (30.5% and 31.3%, respectively). Comparisons of demographic profile and drug use patterns show that respondents who obtained equipment from personal networks were more likely to identify as gay, lesbian or bisexual (28% versus 16%, χ 2 =4.18, 1 d.f., p =0.04) and live in unstable housing (22% versus 8%, χ 2 =8.03, 1 d.f., p <0.01) compared to those who obtained equipment from pharmacies. The finding that respondents who obtained sterile needles and syringes from personal networks were no more likely to reuse needles and syringes may suggest that there is informal ‘outreach’ of primary harm reduction services through ‘network nannies’ or, possibly, a hidden needle syringe economy. The findings also suggest the possibility for greater harm reduction efforts in pharmacy distribution programs and in more extensively resourced peer education initiatives. [Copyright &y& Elsevier]

Aims: To ascertain service providers’ views on barriers and incentives to illicit drug users accessing or remaining in treatment. Methods: Interviews with service providers in Australia were conducted. Results: Two main themes were explored. Service providers suggested that the perception of a person seeking treatment was strongly associated with the image of that person as deficient, defective or lacking, and that this could impede treatment. Service providers also suggested that differing treatment philosophies and their related treatment goals were at the core of many barriers to treatment. We argue that it is important to find a balance between a model of treatment which works and is responsive to clients’ needs while also avoiding the potential for feeding stigma of those who seek treatment for drug dependence. Conclusion: Our results suggest that knowledge and understanding of treatment philosophies are important for people seeking treatment so that clients can find services that match their needs and treatment goals. [ABSTRACT FROM AUTHOR]

Hepatitis C is a potentially debilitating disease of the liver, the impact of and prognosis for which vary significantly from person to person. Although the health consequences of contracting hepatitis C are extremely diverse, becoming infected with the disease is sometimes experienced in terms of an absolute shift from healthy to sick, clean to contaminated, good to bad. In this paper, we use interview material derived from a study on hepatitis C and blood awareness to look at one rarely discussed response to diagnosis with hepatitis C: a sense of despair and absolute contamination, leading to a belief that contraction of other blood-borne viruses is of no consequence. By considering the effects of hepatitis C diagnosis in light of Goffman's theory of stigma, and by linking stigmatization to the binary logic common to thinking about infection, health and identity, we offer a starting point for designing health-promotion materials that minimize despairing responses to infection. [ABSTRACT FROM AUTHOR]

Aims This paper examines differences between early- and late-onset injection drug users (12–16 years versus 17–24 years) in terms of the antecedents and circumstances of first injection. Design Cross-sectional retrospective design, using logistic regression. Setting Australia: Sydney, Brisbane, rural New South Wales. Participants A total of 336 injection drug users aged 16–25 years at the time of interview. Measurements Independent variables included family injection drug use, homelessness and other demographic variables, drugs used prior to the first injection, length of pre-injection drug career, behaviours at time of first injection (e.g. drug injected, reasons/motives for the first injection, risk behaviours). Findings Early-onset injection was associated independently with: having a family who injected drugs, having left school early, an unreliable source of income, a short pre-injection drug career, planning of the first injection, reliance on others for administration of the first injection and denial that experimentation was the motive for the first injection. In bivariate analysis, early-onset injection was associated further with: homelessness, being an Indigenous Australian, omission of use of certain pre-injection drugs, group presence at first injection, reliance on others for acquisition of the first needle and syringe and having injected the first time because an injection was offered. Conclusions The research shows that early-onset, compared with late-onset injectors, are more likely to have an immediate family who inject drugs and other problematic beginnings in early life. They have an accelerated transition to injection, and differences in autonomy and motivation at first injection. These characteristics may make them more vulnerable to risk taking. [ABSTRACT FROM AUTHOR]

Hepatitis C-related discrimination is reportedly common, however few studies have investigated this phenomenon. This paper presents findings from a cross-sectional study of people with self-reported hepatitis C virus (HCV) infection ( N ?=?504) conducted in New South Wales (NSW), Australia throughout 2001 and 2002. Participants completed a self-administered questionnaire enquiring into their experience of living with HCV. Over a half of the participants (57.5%, n ?=?290) reported that they had acquired their infection from injecting drug use. Discrimination was reported by 64.7% ( n ?=?326) of participants and healthcare was the most commonly reported site where discrimination occurred. A logistic regression identified the predictors of any discrimination as: knowing many other people with HCV infection; feeling tired due to HCV symptoms; and being younger ( [ABSTRACT FROM AUTHOR]

Abstract: Objective:: Most surveillance of injecting drug users (IDUs) in Australia is done with samples of participants drawn from those who attend Needle and Syringe Programmes (NSPs). We investigated the barriers and preferences to NSP access of a group of IDUs who do not use NSPs as their primary source of injecting equipment from a defined geographical area in Sydney, which has been estimated to house the highest number of IDUs in Australia. Method:: A cross-sectional, interviewer-administered questionnaire was completed by 294 participants, most of whom were recruited through the personal and extended networks of peer interviewers. Participants were considered in two groups: those who did not use NSPs (non-NSP users) and those who used NSPs infrequently (infrequent NSP users). Results:: Infrequent NSP users were more likely than non-NSP users to report reasons of convenience and NSP operation as barriers to access. Non-NSP users reported barriers related to lack of awareness of NSPs and that they did not need to access NSPs. Fixed locations and vending machines were most frequently endorsed by both groups as the “best way” to distribute injecting equipment. However, issues of stigma and maintaining anonymity were concerns for participants in both groups. Compared to non-NSP users, infrequent users were more likely to reside in areas with a large drug user population, obtain safe injecting information from health workers, have injected drugs for longer, have injected alone, have been tested for blood borne viruses, report greater connectedness to drug user networks and be less concerned about contacting NSP staff. Conclusion:: Understanding the preferences of IDU, including those who do not attend NSP, is central to providing health services which meet their needs and in developing hepatitis C prevention programmes which reach this target group. The effects of stigma on the health care choices of IDUs must be recognised in planning developments in NSP service, or alternatives to NSPs. [Copyright &y& Elsevier]

The article argues the recent research on harm reduction. The author stresses that the harm reduction research has failed to articulate an agreed moral framework. Harm reduction could not be defined as a value neutral as what was stated in the recent research, since the overarching goal of reducing harm is in itself a value notion. He also added that the discussion on the ethical underpinnings of harm reduction do not perpetrate to the moralistic definitions of drug use or a punitive moral stance.

Clinical trials of interferon-based treatments for hepatitis C infection show decrements in patients' health-related quality of life due to side effects of therapy. The impact of side effects on patients' overall quality of life still remains unclear. To explore this issue, the authors interviewed people living in New South Wales, Australia, who had undergone treatment for hepatitis C. Their aim in this article is to report participants' experiences of treatment side effects. In Australia, this information is important, because a new interferon-based regimen has been adopted as the mainstay of hepatitis C treatment, and it is predicted that many more people will seek treatment. The authors argue for further qualitative research to enhance knowledge of the impact of this therapy. [ABSTRACT FROM AUTHOR]

Despite recent improvements in outcomes of treatment for infection with hepatitis C virus (HCV), very few current injection drug users (IDUs) have access to treatment programs. We examined the natural history of and treatment knowledge about HCV infection and barriers and willingness to seek treatment for HCV infection. A convenience sample of current IDUs (n = 100) with self-reported HCV-positive status drawn from a primary health facility and methadone clinic in inner Sydney completed an interviewer-administered questionnaire. Participants had a reasonable knowledge of the natural history of HCV infection but poorer knowledge of treatment for HCV infection. Most believed that being a current IDU was an exclusion criterion for treatment. Despite this, 70%-80% of IDUs reported that they would consider treatment under current scenarios in Australia: requirement for liver biopsy, subcutaneous injections, common adverse effects, and 40% efficacy. Study participants at the methadone clinic had higher levels of consideration of treatment. These findings support the development of specific education programs regarding treatment for HCV infection for current IDUs. [ABSTRACT FROM AUTHOR]

Risk of blood borne virus among injecting drug users is high and is a significant challenge for public health efforts. Mindlessness/mindfulness theory provides an alternative lens through which to understand social phenomena. Interview transcripts of 32 current and former injectors were explored for evidence of mindless injecting (or automatic behaviour). Mindlessness in injecting practices can be important as opportunities to reduce injecting risk can emerge from understanding 'expert' approaches to injecting. Further work is required to generate fuller understandings of this construct on injecting drug use and to incorporate carefully and sensitively this tool into health promotion efforts. [ABSTRACT FROM AUTHOR]

Abstract: Hepatitis C incidence continues to be high among people who use injecting drugs (IDUs), particularly those in late teenage years, which corresponds with the typical age of initiation of injecting. Initiates are rarely, if ever, in touch with services supplying safe injecting information. Alternative ways of providing this information are needed. This study included a quantitative survey of 336 young IDUs (<25 years) from three sites in Australia. A sample of 24 young IDUs also participated in in-depth qualitative interviews. Quantitative results indicated that the majority of participants acquired information from formal sources such as pamphlets and NSPs. However, interview data suggest that information acquisition occurred well after initiation: initiates possessed at best “common sense” knowledge about injecting. The majority of survey participants passed on information to their peers. However, the qualitative data show that many issues were discussed among injectors, not only safe injecting, and that inaccuracy of information from some IDUs could result in perpetuation of myths and misinformation. These findings suggest a need to expand the scope and content of peer education activities by building on the demonstrated culture of information exchange between IDUs. Particularly useful may be a workforce model of peer education managed by non-government organisations. [Copyright &y& Elsevier]

Hepatitis C is a major public health challenge, and efforts to reduce the transmission of hepatitis C among people who inject drugs (IDU) have had limited success. From within a harm minimization perspective, this study sought to examine the models of blood and the body used in health promotion materials designed to encourage safer injecting practice, and aspects of the body emphasized in interviews with 32 IDU. Of particular interest were the unstated, implicit models of blood and the body evoked in metaphors, language and symbols used to describe blood and the body. Health promotion messages relied heavily on fortress models of the body, that is, rigid definitions of bodily boundaries that define outside or foreign substances as hostile. Descriptions of blood by IDU were more complex including strong views of blood as both vital and fatal to life. Blood was seen as generally life saving and, at the societal level in terms of blood banking, in need of protection. An alternative model of education was, therefore, developed to highlight the multi-level responsibilities in caring for blood, to position blood as a shared social resource and to acknowledge the positive value in sharing resources. This model has the potential to reduce harm within the context of hepatitis C prevention without contributing to the further stigmatization of IDU. [ABSTRACT FROM AUTHOR]

Introduction: Previous investigation has shown that the health sector is a main source of discrimination against people with hepatitis C. This paper examines the perceptions and experiences of people with hepatitis C of their interactions with healthcare workers, particularly examining the implementation of infection control precautions. We contend that rather than applying infection control precautions universally, health care workers make judgements about individual patients and the likelihood that they are infected with hepatitis C. Thus, infection control practices can be used as a tool to discriminate against people with hepatitis C. Social identity theory is used to illustrate these insights and to propose recommendations for education of health care workers. Method: Semi-structured interviews with 19 people who had hepatitis C were conducted. The analysis examines issues of diagnosis, discrimination and disclosure in relation to healthcare workers' use of infection control procedures during clinical interactions. Results: Participants described non-compliance with infection control guidelines by healthcare workers in a range of settings. In some instances, participants expressed disapproval of non-compliance, at other times participants felt vulnerable and discriminated against. Participants felt obliged to disclose their infections, but some decided against future disclosure because of negative reactions from healthcare workers. Infection control procedures were used as a tool to discriminate against some participants. Discussion: Non-compliance with infection control guidelines persists among healthcare workers and can be identified by patients. A minority of workers use infection control as a discriminatory tool against those with hepatitis C. Further intervention is required to ensure infection control guidelines are enacted in the manner intended. [ABSTRACT FROM AUTHOR]

The Australian National Council on Drugs (ANCD) recently recommended that media organisations commit to balanced and accurate reporting about the costs and benefits of needle and syringe programmes (NSPs), and recognise the harm of sensationalist reporting. This paper is concerned with the newspaper reporting of syringes found in or near a Sydney primary school, which resulted in the closure of the nearby NSP. Four news reports, one editorial and two letters to the editor in three regional papers dealt with this issue. We examined the intertextual links between and within texts: which speaking subjects are included, whose messages are foregrounded or backgrounded, how are these messages represented by the reporters, and how are alternative positions negotiated. Our analysis shows that in spite of an absence of overt judgements and sensationalism by the reporters, representations are not value free. Choices made by the writers of news reports show alignment with various convergent and divergent positions relating to NSPs in general and the closure of this needle exchange in particular. [Copyright &y& Elsevier]

Comments on the state of multidisciplinary cross-national qualitative studies based on the involvement with two international projects. Challenges posed by qualitative research; Value of cross-case analysis; Comparison of two multidisciplinary cross-national studies.

ContextResearch on the factors affecting progress in medical schools has typically focused on mainstream (non-Indigenous Australian, non-international) students in traditional, didactic programmes. These results may not be applicable to students, particularly those from culturally diverse backgrounds, undertaking problem-based learning courses. ObjectiveThis study used qualitative methodology to explore and compare factors affecting progress for mainstream Australian students (non-Indigenous Australian, non-international) and international students (full fee-paying students who had relocated countries to study) in a problem-based learning medical course. Intervention strategies were devised on the basis of the participants’ experiences. MethodsSix focus group discussions were conducted (three with mainstream Australian and three with international participants). Transcripts of these discussions were coded and analysed independently by two researchers and discussed until consensus was attained. ResultsParticipants identified both positive and negative experiences related to the course structure, which were consistent with previous findings. The participants’ experiences demonstrated a relationship between sense of ‘belongingness’ to the medical school community, participation in learning opportunities and progress through the course. ConclusionsThe results suggest that interventions aimed at reducing barriers to progress need to promote students’ confidence, motivation and subsequent participation in course learning opportunities. These results have application to other problem-based learning courses particularly those which face the challenge of providing an optimal learning environment for students from diverse backgrounds. [ABSTRACT FROM AUTHOR]

Context The factors determining intern attendance at ‘resident rounds’ training programmes are not known. Aims This study aimed to use a behavioural model (the Triandis theory of social behaviour) to predict intern attendance at the resident round programme at a metropolitan teaching hospital. Subjects These included 109 interns in a large metropolitan teaching hospital, in the 1996 and 1997 cohorts. Methods Tabulated responses from a structured interview administered to 10 randomly selected interns were used to develop survey items related to the Triandis variables. Attendance was monitored using a sessional logbook and by self-report. Item analysis was conducted for each variable scale. Stepwise multiple regression models were constructed to predict attendance and intention. Results The average proportion of resident rounds attended was 43% (95% confidence intervals (CI) 40–47%) from logbook attendance, and 63% (95% CI 61–65%) by self-report. Cronbach’s alpha for the subscales ranged from 0·62 to 0·91. Intern attendance was predicted by the habit of attendance and negatively predicted by facilitating conditions (AdjR2=0·26, P < 0·0001). The intention to attend was only independently predicted by perceived consequences (AdjR2= 0·19, P < 0·0001). Conclusions The establishment of resident education programmes within teaching hospitals requires attention to and modification of facilitating conditions that may allow improvements in attendance and in quality of the programme. [ABSTRACT FROM AUTHOR]

This paper describes the strategies used by Aboriginal young people to build positive relationships and sexual wellbeing. It does so to counter the risk-focussed narratives present in much existing research and to showcase the resourcefulness of Aboriginal young people. We used peer-interview methods to collect qualitative data from 52 Aboriginal young people living in western Sydney, Australia. Participants reported a strong desire to stay safe and healthy in their sexual relationships and to achieve this they relied heavily on oral communication and yarning strategies. Participants viewed communication as a way to gain or give advice (about bodies, infections, pregnancy, relationships); to assess the acceptability and safety of potential partners; to negotiate consent with partners; to build positive relationships; and to get themselves out of unhealthy relationships. Participants also discussed 'self-talk' as a strategy for building sexual wellbeing, referring to narratives of self-respect and pride in culture as important in establishing Aboriginal young people's positive views of self and as deserving of respectful and safe sexual relationships. These findings suggest that future programmes and interventions based on yarning could be well-regarded, given it is a cultural form of pedagogy and a strategy Aboriginal young people already use to build positive relationships and identities. [ABSTRACT FROM AUTHOR]

Despite high hepatitis B (HBV) prevalence among people of Vietnamese ethnicity in Australia and elsewhere, there is limited research on levels of HBV knowledge and factors associated with such knowledge. The aim of this study was to examine HBV knowledge and associated demographic and attitudinal factors among people of Vietnamese ethnicity in Australia. People of Vietnamese ethnicity (n = 966) were recruited through community events and social media groups to complete online surveys measuring HBV knowledge, attitudes towards HBV, levels of mistrust in Western medicine, and demographic characteristics. Findings of this study indicate that levels of knowledge are mixed, with gaps in knowledge related to transmission and treatment of the virus. Those with greater knowledge of HBV tended to be older, have higher levels of formal education, have been tested for HBV, and know someone living with HBV. Those with lower levels of knowledge tended to have more negative attitudes towards the virus and greater levels of mistrust in Western medicine. Given that health literacy is connected to effective communication from health providers, we suggest that there is a need for the development of health promotion and education resources targeted at people of Vietnamese ethnicity and translated into Vietnamese. We propose that such resources be developed in consultation with Vietnamese communities and health providers to ensure that they are culturally appropriate and sensitive to people of Vietnamese ethnicity living in Australia. [ABSTRACT FROM AUTHOR]

Introduction: Understanding needle/syringe sharing is crucial for reducing hepatitis C virus (HCV) infection and reinfection. This study aimed to assess the prevalence and factors associated with needle/syringe sharing among people who inject drugs in Australia, including those previously receiving HCV treatment. Methods: The ETHOS Engage study was an observational cohort study which collected self‐reported survey data on demographic and drug use information from people who inject drugs attending drug treatment clinics and needle and syringe programs over two waves between May 2018 and June 2021. Logistic regression was used to identify factors associated with needle/syringe sharing. Results: Overall, 1555/2395 people enrolled in ETHOS Engage (65%) injected drugs in the past month. Among these, 432 (28%) reported needle/syringe sharing in the past month and 276 (18%) reported receptive sharing. Factors associated with receptive sharing included younger age (adjusted odds ratio [aOR] 1.72; 95% confidence interval [CI] 1.28–2.30), recent incarceration (aOR 2.04; 95% CI 1.40–2.94), more frequent injecting (≥daily vs. less than weekly; aOR 2.59; 95% CI 1.75–3.84) and unstable housing (aOR 1.78; 95% CI 1.26–2.52). Among 560 participants with prior HCV treatment, 87 (16%) reported receptive sharing with younger age (aOR 2.42; 95% CI 1.45–4.05) and daily or greater injection frequency (aOR 2.51; 95% CI 1.31–4.83) associated with receptive sharing. Discussion and Conclusions: Needle/syringe sharing was common among this population accessing harm reduction services. This study identifies high‐risk populations with needle/syringe sharing. Research is needed to optimise HCV treatment to ensure people with ongoing risk behaviours receive adequate harm reduction following treatment to prevent reinfection. [ABSTRACT FROM AUTHOR]

Introduction: Contact interventions have shown short‐term effectiveness in reducing stigmatising attitudes and behaviours of the public towards marginalised population groups, including people who inject drugs. We theorised that the effectiveness of an intervention differs according to peoples' underlying social values and undertook a study to test this. Methods: We recruited participants from the Australian public by social media and measured their attitudes, desire to maintain personal distance, and support for structural stigma towards people who inject drugs before and after a brief online video intervention (n = 314). We divided participants into tertile groups according to their responses to a conservatism scale and compared group differences in post‐intervention stigma scores (n = 242–244), controlling for pre‐intervention scores and demographic variables. Results: Adjusting for baseline levels, the post‐intervention scores in all measures showed significant improvement but scores of the moderate group were consistently most improved. Stigmatising attitudes in the moderate group were significantly reduced when compared with the conservative and progressive groups. However, reductions in desire for personal distance and support for structural stigma did not significantly differ by conservatism group. Discussion and Conclusions: A brief online contact intervention showed immediate effectiveness in reducing stigma towards people who inject drugs. As people with moderate values were found to be more amenable to changing their perspectives, audience social values may need consideration when designing and evaluating stigma interventions. More research is needed to understand how to influence people with more conservative values, and how to increase public support for policies and practices that reduce stigma. [ABSTRACT FROM AUTHOR]

Explores the experiences of heart disease patients in Australia hospitalized in 1994. Identification of recurrent themes illustrating the main concerns of heart disease patients; Demonstration of how a multilevel analysis of patients' health and illness experiences is applicable to provide patient care tips for health providers.

Distance education (DE) has been used as a teaching mode for over 100 years for a variety of academic, vocational and recreational courses. This paper describes a postgraduate clinical epidemiology course conducted by DE for Australian and international health professionals, and compares the educational experiences of three groups of students (on-campus part-time, Australian DE and international DE). The groups were not expected to differ in academic achievement (marks) in eight subjects or in degree completion rates. The marks in each subject were not significantly different and typically were within five marks across all student groups. Approximately 40–50% of Australian DE students complete the graduate diploma coursework requirements in the minimum 2 years study. The completion rate increases to 70–80% as the period of candidature increases. The completion rates of Australian DE students were not significantly different from those of on-campus part-time students. Evaluation of the course by degree completion rates, comparison of academic achievement between off-campus and on-campus students, and qualitative feedback from students demonstrates that DE is as successful as on-campus teaching in providing training in clinical epidemiology at the postgraduate level. The flexibility of this mode of training as a means of providing public health training is discussed. [ABSTRACT FROM AUTHOR]

Chinese immigrants to Australia have an increased prevalence of hepatitis B virus (HBV) infection compared to the general population. Despite this, engagement with HBV screening and healthcare for chronic hepatitis B (CHB) among immigrants of Chinese background is relatively low. This study investigated knowledge about HBV among this high‐risk community and explored sociodemographic factors that might influence this knowledge. During February to September 2019, first generation Chinese immigrants from mainland China and their immediate descents residing in Sydney and Melbourne were recruited via convenience and snowball sampling and completed a survey in either English or Chinese. Survey items included HBV knowledge, attitudes towards people living with CHB and demographic information. Three hundred and ninety‐six participants completed the survey. The median HBV knowledge score was 53% correct, indicating that knowledge about HBV was low to middle range among participants. While participants had the most knowledge in the domain of perceptions and understandings of HBV, this was still low. Participants also had limited knowledge about HBV prevention, transmission and treatment. Those with higher English proficiency, post‐secondary education, lower levels of HBV‐related stigma and those who had contact with people living with CHB appeared to have greater HBV knowledge. This study showed that HBV knowledge among Chinese people originally from mainland China living in Australia is limited and even deficient in some key areas. Additionally, the relationships between HBV knowledge and particular sociodemographic variables, knowing someone living with HBV and stigma associated with HBV provides key information to assist in the development of targeted health promotion to increase HBV knowledge and change stigmatising attitudes towards HBV among the Chinese community in Australia. [ABSTRACT FROM AUTHOR]

Sex workers may experience stigma both related to their occupation as well as to mental health issues that they face. There is limited research on the lived experience of sex workers managing mental health and stigma. This study examined the experiences of sex workers in Australia in relation to stigma surrounding sex work, and sex workers' mental health, including self-management and experiences of accessing mental health services. Six focus groups and two interviews were conducted with 31 sex workers. Data collection was co-moderated by a sex worker and a university-based researcher. Analysis was informed by an approach which positioned sex workers as agential and capable, and which drew attention to structural aspects of stigma. Sex workers identified that the stigma surrounding their profession had a significant impact on their mental health. The need to manage risks through selective disclosure of sex work was a pervasive experience. Management of mental health and the stigma associated with sex work was described as a responsibility primarily of the individual through self-care activities and occasional access to mental health services. Participants reported poor treatment from mental health practitioners who saw sex workers as victims lacking agency, imposed beliefs that sex work was the pathological root cause of mental health issues, or approached the issue with fascination or voyeurism. Other presenting issues (especially mental health) were lost or obscured in therapeutic encounters resulting in suboptimal care. The threat of stigma is pervasive and has mental health implications for sex workers. Our findings point to the need for increased training and capacity development for mental health practitioners, funding for peer support services to ameliorate internalised stigma, and action from governments to introduce enabling legal environments, stigma reduction programs and structural protections from sex work stigma. • Sex work stigma is pervasive and has mental health implications for sex workers. • Mental health professionals need training to engage appropriately with sex workers. • Peer support services are important in ameliorating internalised stigma. • Decriminalisation is necessary but not sufficient alone to reduce sex work stigma. • Reducing sex work stigma requires additional, specific interventions. [ABSTRACT FROM AUTHOR]

Abstract: Significant advances have been made in preventing HIV infection among injectors but we still know little about preventing hepatitis C (HCV). Both prevalence and incidence of hepatitis C can remain high among IDUs even in the context of widespread implementation of harm reduction programmes. We need to develop new ways to fill the knowledge gap regarding HCV prevention. One way is to learn from the experts—those IDUs who, after long-term injection in social milieus of high hepatitis C prevalence, nonetheless remain uninfected. We describe a recently commenced program of research that focuses on understanding the strategies, behaviours, and environmental factors associated with “staying safe”. This represents a 180-degree turn in IDU research where the focus has traditionally been on risk. Since social, cultural and environmental factors, as well as the vagaries of human strategic discovery by drug users can vary among localities, researchers in four different contexts—New York City, Valencia, Sydney and London—are collaborating in parallel Staying Safe studies. These studies aim to provide the conceptual basis for developing a new generation of HCV prevention programs to assist both new and experienced IDUs to remain uninfected over the long run. [Copyright &y& Elsevier]