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Frankis J, Flowers P, McDaid L, Bourne A. Low levels of chemsex among men who have sex with men, but high levels of risk among men who engage in chemsex: analysis of a cross-sectional online survey across four countries. Sex Health 2019; 15:144-150. [PMID: 29592829 DOI: 10.1071/sh17159] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 12/08/2017] [Indexed: 11/23/2022]
Abstract
Background This paper establishes the prevalence of chemsex drug use among men who have sex with men (MSM), the extent to which these drugs are used in a sexual context, as well as their associated behaviours and circumstances of use. METHODS Data from a cross-sectional, online survey of 2328 MSM recruited via gay sociosexual media in Scotland, Wales, Northern Ireland and the Republic of Ireland were analysed. RESULTS While almost half (48.8%) of participants had ever taken illicit drugs, lifetime chemsex drug use was less common (18.0%) and far fewer reported chemsex drug use in the last year (8.2%) or last 4 weeks (3.0%). Just over one-quarter (27.1%) of men who used chemsex drugs in the last year reported no sexualised drug use, but almost three-quarters (72.9%) did. Only 6.1% of the whole sample reported sexualised chemsex drug use in the last year. The odds of reporting chemsex in the last year were significantly higher for men aged 36-45 years (AOR=1.96), single men (AOR=1.83), men who were HIV positive (AOR=4.01), men who report high-risk sex (AOR=4.46), being fisted (AOR=7.77) or had sex in exchange for goods other than money (AOR=4.7) in the last year and men who reported an HIV test in the last 3 months (AOR=1.53). DISCUSSION Only a small proportion of MSM in Scotland, Wales, Northern Ireland and the Republic of Ireland reported chemsex, and, for the first time, it is demonstrated that not all chemsex drug use was sexualised. Nevertheless, MSM who engage in chemsex (MWEC) reported substantial sexual risk inequalities. These novel findings highlight several opportunities for intervention, particularly around the multiple vulnerabilities of MWEC, opportunities for early identification of those most vulnerable to chemsex-related harm and the potential to develop a specialised responsive patient pathway.
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Patterson S, McDaid L, Hunt K, Hilton S, Flowers P, McMillan L, Milne D, Lorimer K. How men and women learn about sex: multi-generational perspectives on insufficient preparedness and prevailing gender norms in Scotland. SEX EDUCATION 2019; 20:441-456. [PMID: 32939157 PMCID: PMC7455048 DOI: 10.1080/14681811.2019.1683534] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 10/18/2019] [Indexed: 06/11/2023]
Abstract
Attitudes towards sexual health and relationships are learned from a young age, and there is an ongoing need for innovative and comprehensive approaches to sex education that keep pace with rapidly changing contexts of people's lives. We used thematic analysis of data from two qualitative studies in Scotland to explore learning contexts from a multi-generational perspective, as well as the influence of different socio-cultural factors on provision, access to and experience of sex education. The importance, but inadequacy, of school as a source of learning, was a persistent theme over time. Participants' strategies to address perceived gaps in knowledge included experience, conversations, vicarious and online learning. Gender and age differences emerged, with younger participants more likely to go online for information, and prevailing gender norms shaping attitudes and behaviours across both study groups. Participants who identified as gay, lesbian or bisexual described feeling particularly unprepared for sex and relationships due to the narrow, heteronormative content received. Although schools continue to be a common source of information, it appears that they fail to equip young people for their post-school sexual life-course. We recommend the mandatory provision of comprehensive, positive, inclusive and skills-based learning to improve people's chances of forming and building healthy, positive relationships across the lifespan.
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Hickman M, Dillon JF, Elliott L, De Angelis D, Vickerman P, Foster G, Donnan P, Eriksen A, Flowers P, Goldberg D, Hollingworth W, Ijaz S, Liddell D, Mandal S, Martin N, Beer LJZ, Drysdale K, Fraser H, Glass R, Graham L, Gunson RN, Hamilton E, Harris H, Harris M, Harris R, Heinsbroek E, Hope V, Horwood J, Inglis SK, Innes H, Lane A, Meadows J, McAuley A, Metcalfe C, Migchelsen S, Murray A, Myring G, Palmateer NE, Presanis A, Radley A, Ramsay M, Samartsidis P, Simmons R, Sinka K, Vojt G, Ward Z, Whiteley D, Yeung A, Hutchinson SJ. Evaluating the population impact of hepatitis C direct acting antiviral treatment as prevention for people who inject drugs (EPIToPe) - a natural experiment (protocol). BMJ Open 2019; 9:e029538. [PMID: 31551376 PMCID: PMC6773339 DOI: 10.1136/bmjopen-2019-029538] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 07/25/2019] [Accepted: 07/29/2019] [Indexed: 01/15/2023] Open
Abstract
INTRODUCTION Hepatitis 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 ANALYSIS We 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 DISSEMINATION Extending 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.
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Price L, Gozdzielewska L, Young M, Smith F, MacDonald J, McParland J, Williams L, Langdridge D, Davis M, Flowers P. Effectiveness of interventions to improve the public's antimicrobial resistance awareness and behaviours associated with prudent use of antimicrobials: a systematic review. J Antimicrob Chemother 2019; 73:1464-1478. [PMID: 29554263 DOI: 10.1093/jac/dky076] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 02/07/2018] [Indexed: 11/14/2022] Open
Abstract
Background A global antimicrobial resistance (AMR) awareness intervention targeting the general public has been prioritized. Objectives To evaluate the effectiveness of interventions that aim to change AMR awareness and subsequent stewardship behaviours amongst the public. Methods Five databases were searched between 2000 and 2016 for interventions to change the public's AMR awareness and/or antimicrobial stewardship behaviours. Study designs meeting the Cochrane Effective Practice and Organization of Care (EPOC) criteria, non-controlled before-and-after studies and prospective cohort studies were considered eligible. Participants recruited from healthcare settings and studies measuring stewardship behaviours of healthcare professionals were excluded. Quality of studies was assessed using EPOC risk of bias criteria. Data were extracted and synthesized narratively. Registration: PROSPERO international prospective register of systematic reviews (PROSPERO 2016: CRD42016050343). Results Twenty studies were included in the review with nine meeting the EPOC criteria. The overall risk of bias was high. Nineteen studies were conducted in high-income countries. Mass media interventions were most common (n = 7), followed by school-based (n = 6) and printed material interventions (n = 6). Seventeen studies demonstrated a significant effect on changing knowledge, attitudes or the public's antimicrobial stewardship behaviours. Analysis showed that interventions targeting schoolchildren and parents have notable potential, but for the general public the picture is less clear. Conclusions Our work provides an in-depth examination of the effectiveness of AMR interventions for the public. However, the studies were heterogeneous and the quality of evidence was poor. Well-designed, experimental studies on behavioural outcomes of such interventions are required.
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McDaid L, Riddell J, Teal G, Boydell N, Coia N, Flowers P. The Effectiveness of Social Marketing Interventions to Improve HIV Testing Among Gay, Bisexual and Other Men Who Have Sex with Men: A Systematic Review. AIDS Behav 2019; 23:2273-2303. [PMID: 31006047 PMCID: PMC6766472 DOI: 10.1007/s10461-019-02507-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
HIV testing is central to biomedical HIV prevention, but testing among men who have sex with men remains suboptimal. We evaluated effectiveness of mass media and communication interventions to increase HIV testing and explored patterns between study type, internal validity and intervention effectiveness for the first time. Five databases were searched for articles published between 2009 and 2016 using standard MeSH terms. Eligible studies were quality appraised using standard checklists for risk of bias. Data were extracted and synthesised narratively. Nineteen studies met inclusion criteria; 11 were cross-sectional/non-comparative studies, four were pre/post or interrupted time series, three were randomised controlled trials (RCTs) and one was a case study. Risk of bias was high. Five cross-sectional (two graded as high internal validity, one medium and two low) and one RCT (medium validity) reported increased HIV testing. Further work is required to develop and evaluate interventions to increase frequency and maintenance of HIV testing.
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Flowers P, Riddell J, Boydell N, Teal G, Coia N, McDaid L. What are mass media interventions made of? Exploring the active content of interventions designed to increase HIV testing in gay men within a systematic review. Br J Health Psychol 2019; 24:704-737. [PMID: 31267624 PMCID: PMC7058418 DOI: 10.1111/bjhp.12377] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 05/12/2019] [Indexed: 12/31/2022]
Abstract
PURPOSE Mass media HIV testing interventions are effective in increasing testing, but there has been no examination of their theory or behaviour change technique (BCT) content. Within a heterogeneous body of studies with weak evaluative designs and differing outcomes, we attempted to gain useful knowledge to shape future interventions. METHODS Within a systematic review, following repeated requests to the authors of included studies for intervention materials, the Theory Coding Scheme, the Theoretical Domains Framework (TDF), and Behaviour Change Technique Taxonomy (BCTT) were used to extract data relating to active intervention content. RESULTS Of 19 studies, five reported an explicit theoretical basis to their intervention. TDF analysis highlighted the key domains employed within the majority of interventions: 'knowledge', 'social roles and identities', and 'beliefs about consequences'. BCT analysis showed three BCT groupings commonly reported within interventions: 'Comparison of outcomes', 'Natural consequences', and 'Shaping knowledge'. Three individual BCTs formed the backbone of most interventions and can be considered 'standard' content: 'Instructions on how to perform behaviour'; 'Credible source'; and 'Information about health consequences'. CONCLUSIONS This is the first study to examine and detail active intervention content in this field. It suggests future interventions should improve knowledge about testing, and use well-branded and trusted sources that endorse testing. Future interventions should also provide clear information about the health benefits of testing. Our analysis also suggests that to improve levels of effectiveness characterizing the current field, it may be useful to elicit commitment, and action plans, relating to how to implement testing intentions. STATEMENT OF CONTRIBUTION What is already known on this subject? Interventions are urgently needed to increase HIV testing among men who have sex with men (MSM) and enable increased access to effective treatment for HIV infection. There is some evidence of the effectiveness of mass media interventions in increasing HIV testing among MSM. Nothing is known about the active components of existing mass media interventions targeting HIV testing. What does this study add? It describes the available literature concerning evaluated mass media interventions to increase HIV testing. It shows few interventions report any explicit theoretical basis although many interventions share common components, including coherently connected causal mechanisms and behaviour change techniques to moderate them. As a minimum, future interventions should improve knowledge about testing; use well-branded and trusted sources that endorse testing; and provide clear information about the health benefits of testing. Our analysis also tentatively suggests it may be useful to elicit commitment and planning of how to implement testing intentions.
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Flowers P, Estcourt C, Sonnenberg P, Burns F. HIV testing intervention development among men who have sex with men in the developed world. Sex Health 2019; 14:80-88. [PMID: 28080947 DOI: 10.1071/sh16081] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2016] [Accepted: 10/19/2016] [Indexed: 11/23/2022]
Abstract
HIV testing is a 'gateway' technology, enabling access to treatment and HIV prevention. Biomedical approaches to prevention, such as pre-exposure prophylaxis and treatment as prevention, require accurate and regular HIV test results. HIV testing also represents a powerful 'teachable moment' for behavioural prevention. An increasing range of HIV tests and the emergence of self-managed diagnostic technologies (e.g. self-testing) means there is now considerable diversification of when, where and how results are available to those who test. These changes have profound implications for intervention development and, indeed, health service redesign. This paper highlights the need for better ways of conceptualising testing in order to capitalise on the health benefits that diverse HIV testing interventions will bring. A multidimensional framework is proposed to capture ongoing developments in HIV testing among men who have sex with men and focus on the intersection of: (1) the growing variety of HIV testing technologies and the associated diversification of their pathways into care; (2) psychosocial insights into the behavioural domain of HIV testing; and (3) better appreciation of population factors associated with heterogeneity and concomitant inequities. By considering these three aspects of HIV testing in parallel, it is possible to identify gaps, limitations and opportunities in future HIV testing-related interventions. Moreover, it is possible to explore and map how diverse interventions may work together having additive effects. Only a holistic and dynamic framework that captures the increasing complexity of HIV testing is fit for purpose to deliver the maximum public health benefit of HIV testing.
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Dalrymple J, McAloney-Kocaman K, Flowers P, McDaid LM, Frankis JS. Age-related factors influence HIV testing within subpopulations: a cross-sectional survey of MSM within the Celtic nations. Sex Transm Infect 2019; 95:351-357. [PMID: 31201278 DOI: 10.1136/sextrans-2018-053935] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 05/02/2019] [Accepted: 05/18/2019] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES Despite a recent fall in the incidence of HIV within the UK, men who have sex with men (MSM) continue to be disproportionately affected. As biomedical prevention technologies including pre-exposure prophylaxis are increasingly taken up to reduce transmission, the role of HIV testing has become central to the management of risk. Against a background of lower testing rates among older MSM, this study aimed to identify age-related factors influencing recent (≤12 months) HIV testing. METHODS Cross-sectional subpopulation data from an online survey of sexually active MSM in the Celtic nations-Scotland, Wales, Northern Ireland and Ireland (n=2436)-were analysed to compare demographic, behavioural and sociocultural factors influencing HIV testing between MSM aged 16-25 (n=447), 26-45 (n=1092) and ≥46 (n=897). RESULTS Multivariate logistic regression demonstrated that for men aged ≥46, not identifying as gay (OR 0.62, CI 0.41 to 0.95), location (Wales) (OR 0.49, CI 0.32 to 0.76) and scoring higher on the personalised Stigma Scale (OR 0.97, CI 0.94 to 1.00) significantly reduced the odds for HIV testing in the preceding year. Men aged 26-45 who did not identify as gay (OR 0.61, CI 0.41 to 0.92) were also significantly less likely to have recently tested for HIV. For men aged 16-25, not having a degree (OR 0.48, CI 0.29 to 0.79), location (Republic of Ireland) (OR 0.55, CI 0.30 to 1.00) and scoring higher on emotional competence (OR 0.57, CI 0.42 to 0.77) were also significantly associated with not having recently tested for HIV. CONCLUSION Key differences in age-related factors influencing HIV testing suggest health improvement interventions should accommodate the wide diversities among MSM populations across the life course. Future research should seek to identify barriers and enablers to HIV testing among the oldest and youngest MSM, with specific focus on education and stigma.
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Krzeczkowska A, Flowers P, Chouliara Z, Hayes P, Dickson A. Experiences of diagnosis, stigma, culpability and disclosure in male patients with hepatitis C virus: An interpretative phenomenological analysis. Health (London) 2019; 25:69-85. [DOI: 10.1177/1363459319846939] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The current study aimed to explore the lived experience of patients with hepatitis C virus infection. Semi-structured interviews were conducted with seven male participants living with hepatitis C virus and were analysed using interpretative phenomenological analysis. Two master themes were identified: (1) diagnosis and the search for meaning and (2) impact of stigma on disclosure. Participants reported fears of contaminating others, feelings of stigma and concerns of disclosing the condition to others. Response to diagnosis, stigma and disclosure among the participants appeared to be interrelated and directly related to locus of blame for virus contraction. More specifically, hepatitis C virus transmission via medical routes led to an externalisation of culpability and an openness to disclosure. Transmission of hepatitis C virus as a direct result of intravenous drug use led to internalised blame and a fear of disclosure. The inter- and intra-personal consequences of hepatitis C virus explored in the current study have potential implications for tailoring future psychological therapy and psychoeducation to the specific needs of the hepatitis C virus population.
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Patterson SP, Hilton S, Flowers P, McDaid LM. What are the barriers and challenges faced by adolescents when searching for sexual health information on the internet? Implications for policy and practice from a qualitative study. Sex Transm Infect 2019; 95:462-467. [PMID: 31040251 DOI: 10.1136/sextrans-2018-053710] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 12/13/2018] [Accepted: 01/26/2019] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES As sexual health information is increasingly presented digitally, and adolescents are increasingly seeking sexual health information on the internet, it is important to explore the challenges presented by this developing source of information provision. This study examined the key barriers and challenges faced by young people when accessing and using sexual health information online. METHODS A novel qualitative approach was used which combined paired interviews with real-time online activities. A purposive sample of 49 young people aged between 16 and 19 years and diverse in terms of gender, sexuality, religion and socio-demographic background were recruited from areas across Scotland. Data analysis comprised framework analysis of conversational data (including pair interactions), descriptive analysis of observational data, and data integration. RESULTS This study highlighted practical and socio-cultural barriers to engagement with online sexual health content. Key practical barriers included difficulty filtering overabundant content; limited awareness of specific, relevant, trusted online sources; difficulties in finding locally relevant information about services; and difficulties in navigating large organisations' websites. Key socio-cultural barriers included fear of being observed; wariness about engaging with visual and auditory content; concern about unintentionally accessing sexually explicit content; and reticence to access sexual health information on social networking platforms or through smartphone applications. These practical and socio-cultural barriers restricted access to information and influenced searching practices. CONCLUSION This study provides insights into some of the key barriers faced by young people in accessing and engaging with sexual health information and support online. Reducing such challenges is essential. We highlight the need for sexual health information providers and intervention developers to produce online information that is accurate and accessible; to increase awareness of and promote reliable, accessible sources; and to be sensitive to young people's concerns about 'being seen' accessing sexual health information regarding audio-visual content and platform choice.
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Seguin M, Dodds C, Mugweni E, McDaid L, Flowers P, Wayal S, Zomer E, Weatherburn P, Fakoya I, Hartney T, McDonagh L, Hunter R, Young I, Khan S, Freemantle N, Chwaula J, Sachikonye M, Anderson J, Singh S, Nastouli E, Rait G, Burns F. Self-sampling kits to increase HIV testing among black Africans in the UK: the HAUS mixed-methods study. Health Technol Assess 2019; 22:1-158. [PMID: 29717978 DOI: 10.3310/hta22220] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Timely diagnosis of human immunodeficiency virus (HIV) enables access to antiretroviral treatment, which reduces mortality, morbidity and further transmission in people living with HIV. In the UK, late diagnosis among black African people persists. Novel methods to enhance HIV testing in this population are needed. OBJECTIVES To develop a self-sampling kit (SSK) intervention to increase HIV testing among black Africans, using existing community and health-care settings (stage 1) and to assess the feasibility for a Phase III evaluation (stage 2). DESIGN A two-stage, mixed-methods design. Stage 1 involved a systematic literature review, focus groups and interviews with key stakeholders and black Africans. Data obtained provided the theoretical base for intervention development and operationalisation. Stage 2 was a prospective, non-randomised study of a provider-initiated, HIV SSK distribution intervention targeted at black Africans. The intervention was assessed for cost-effectiveness. A process evaluation explored feasibility, acceptability and fidelity. SETTING Twelve general practices and three community settings in London. MAIN OUTCOME MEASURE HIV SSK return rate. RESULTS Stage 1 - the systematic review revealed support for HIV SSKs, but with scant evidence on their use and clinical effectiveness among black Africans. Although the qualitative findings supported SSK distribution in settings already used by black Africans, concerns were raised about the complexity of the SSK and the acceptability of targeting. These findings were used to develop a theoretically informed intervention. Stage 2 - of the 349 eligible people approached, 125 (35.8%) agreed to participate. Data from 119 were included in the analysis; 54.5% (65/119) of those who took a kit returned a sample; 83.1% of tests returned were HIV negative; and 16.9% were not processed, because of insufficient samples. Process evaluation showed the time pressures of the research process to be a significant barrier to feasibility. Other major barriers were difficulties with the SSK itself and ethnic targeting in general practice settings. The convenience and privacy associated with the SSK were described as beneficial aspects, and those who used the kit mostly found the intervention to be acceptable. Research governance delays prevented implementation in Glasgow. LIMITATIONS Owing to the study failing to recruit adequate numbers (the intended sample was 1200 participants), we were unable to evaluate the clinical effectiveness of SSKs in increasing HIV testing in black African people. No samples were reactive, so we were unable to assess pathways to confirmatory testing and linkage to care. CONCLUSIONS Our findings indicate that, although aspects of the intervention were acceptable, ethnic targeting and the SSK itself were problematic, and scale-up of the intervention to a Phase III trial was not feasible. The preliminary economic model suggests that, for the acceptance rate and test return seen in the trial, the SSK is potentially a cost-effective way to identify new infections of HIV. FUTURE WORK Sexual and public health services are increasingly utilising self-sampling technologies. However, alternative, user-friendly SSKs that meet user and provider preferences and UK regulatory requirements are needed, and additional research is required to understand clinical effectiveness and cost-effectiveness for black African communities. STUDY REGISTRATION This study is registered as PROSPERO CRD42014010698 and Integrated Research Application System project identification 184223. FUNDING The National Institute for Health Research Health Technology Assessment programme and the BHA for Equality in Health and Social Care.
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Dickson A, Smith M, Smith F, Park J, King C, Currie K, Langdridge D, Davis M, Flowers P. Understanding the relationship between pet owners and their companion animals as a key context for antimicrobial resistance-related behaviours: an interpretative phenomenological analysis. Health Psychol Behav Med 2019; 7:45-61. [PMID: 34040838 PMCID: PMC8114347 DOI: 10.1080/21642850.2019.1577738] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 01/28/2019] [Indexed: 12/24/2022] Open
Abstract
Objectives: Drivers of antimicrobial resistance (AMR) are diffuse and complex including a range of interspecies behaviours between pet owners and their animals. We employed interpretative phenomenological analysis (IPA) to explore the relationship between pet owners and their companion animals in relation to AMR. Design: Cross sectional, qualitative study. Methods: Semi-structured interviews were conducted with twenty-three British pet owners, transcribed verbatim and subjected to Interpretative Phenomenological Analysis (IPA). Results: Three, inter-related Superordinate themes are presented 1) 'They're my fur babies': unconditional love and anthropomorphism; 2) 'They share everything with you': affection and transmission behaviours; and 3) 'We would err on the side of caution': decision making and antibiotic use'. Conclusions: Affectionate behaviours between companion animals and their owners pose a risk for AMR transmission but they are so deeply treasured that they are unlikely to be amenable to change. In contrast, the promotion of appropriate antibiotic stewardship for pet owners and vets may offer a viable pathway for intervention development, benefitting from synergies with other interventions that target prescribers.
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Young I, Davis M, Flowers P, McDaid LM. Navigating HIV citizenship: identities, risks and biological citizenship in the treatment as prevention era. HEALTH, RISK & SOCIETY 2019; 21:1-16. [PMID: 31105468 PMCID: PMC6494283 DOI: 10.1080/13698575.2019.1572869] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 01/17/2019] [Indexed: 02/06/2023]
Abstract
The use of HIV Treatment as Prevention (TasP) has radically changed our understandings of HIV risk and revolutionised global HIV prevention policy to focus on the use of pharmaceuticals. Yet, there has been little engagement with the very people expected to comply with a daily pharmaceutical regime. We employ the concept of HIV citizenship to explore responses by people living with HIV in the UK to TasP. We consider how a treatment-based public health strategy has the potential to reshape identities, self-governance and forms of citizenship, domains which play a critical role not only in compliance with new TasP policies, but in how HIV prevention, serodiscordant relationships and (sexual) health are negotiated and enacted. Our findings disrupt the biomedical narrative which claims an end to HIV through scaling up access to treatment. Responses to TasP were framed through shifting negotiations of identity, linked to biomarkers, cure and managing treatment. Toxicity of drugs - and bodies - were seen as something to manage and linked to the shifting possibilities in serodiscordant environments. Finally, a sense of being healthy and responsible, including appropriate use of resources, meant conflicting relationships with if and when to start treatment. Our research highlights how HIV citizenship in the TasP era is negotiated and influenced by intersectional experiences of community, health systems, illness and treatment. Our findings show that the complexities of HIV citizenship and ongoing inequalities, and their biopolitical implications, will intimately shape the implementation and sustainability of TasP.
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Flowers P, Frankis J. Imagining Interventions for Collective Sex Environments. ARCHIVES OF SEXUAL BEHAVIOR 2019; 48:35-39. [PMID: 29748786 PMCID: PMC6349797 DOI: 10.1007/s10508-018-1222-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Accepted: 04/26/2018] [Indexed: 06/08/2023]
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Currie K, King C, McAloney-Kocaman K, Roberts NJ, MacDonald J, Dickson A, Cairns S, Khanna N, Flowers P, Reilly J, Price L. The acceptability of screening for Carbapenemase Producing Enterobacteriaceae (CPE): cross-sectional survey of nursing staff and the general publics' perceptions. Antimicrob Resist Infect Control 2018; 7:144. [PMID: 30534365 PMCID: PMC6260859 DOI: 10.1186/s13756-018-0434-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 11/08/2018] [Indexed: 12/29/2022] Open
Abstract
Background Carbapenemase Producing Enterobacteriaceae (CPE) has spread rapidly and presents a growing challenge in antimicrobial resistance (AMR) management internationally. Screening for CPE may involve a rectal swab, there are limited treatment options for affected patients, and colonised patients are cared for in isolation to protect others. These measures are sound infection prevention precautions; however, the acceptability of CPE screening and its consequences are currently unknown. The aim of this study was ‘To determine factors influencing acceptability of CPE screening from the perspectives of nursing staff and the general public.’ Methods National cross-sectional surveys of nursing staff (n = 450) and the general public (n = 261). The Theoretical Domains Framework (TDF) guided data collection and analysis. Regression modelling was used to identify factors that predicted acceptability of CPE screening. Results For nursing staff, the following predictor variables were significant: intention to conduct CPE screening (OR 14.19, CI 5.14–39.22); belief in the severity of the consequences of CPE (OR 7.13, CI 3.26–15.60); knowledge of hospital policy for screening (OR 3.04, CI 1.45–6.34); preference to ask patients to take their own rectal swab (OR 2.89, CI 1.39–6.0); awareness that CPE is an organism of growing concern (OR 2.44, CI 1.22–4.88). The following predictor variables were significant for the general public: lack of knowledge of AMR (β − .11, p = .01); social influences (β .14,p = .032); social norms (β .21p = .00); acceptability of being isolated if colonised (β .22, p = .000), beliefs about the acceptability of rectal swabbing (β .15, p = .00), beliefs about the impact of careful explanation about CPE screening from a health professional (β .32, p = .00). Integrating results from staff and public perspectives points to the importance of knowledge of AMR, environmental resources, and social influences in shaping acceptability. Conclusions This is the first study to systematically examine the acceptability of CPE screening across nursing staff and the public. The use of TDF enabled identification of the mechanisms of action, or theoretical constructs, likely to be important in understanding and changing CPE related behaviour amongst professionals and public alike. Electronic supplementary material The online version of this article (10.1186/s13756-018-0434-x) contains supplementary material, which is available to authorized users.
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Larkin M, Shaw R, Flowers P. Multiperspectival designs and processes in interpretative phenomenological analysis research. QUALITATIVE RESEARCH IN PSYCHOLOGY 2018. [DOI: 10.1080/14780887.2018.1540655] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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King C, Smith M, Currie K, Dickson A, Smith F, Davis M, Flowers P. Exploring the behavioural drivers of veterinary surgeon antibiotic prescribing: a qualitative study of companion animal veterinary surgeons in the UK. BMC Vet Res 2018; 14:332. [PMID: 30404649 PMCID: PMC6223057 DOI: 10.1186/s12917-018-1646-2] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 10/11/2018] [Indexed: 11/30/2022] Open
Abstract
Background Multi-drug resistant bacteria are an increasing concern in both human and veterinary medicine. Inappropriate prescribing and use of antibiotics within veterinary medicine may be a contributory factor to antimicrobial resistance (AMR). The ‘One Health’ Initiative aims to work across species and environments to reduce AMR, however; little is currently known about the factors which influence antibiotic prescribing among veterinary surgeons in companion animal practice. This paper reports on qualitative data analysis of interviews with veterinary surgeons whose practice partially or wholly focuses on companion animals (N = 16). The objective of the research was to explore the drivers of companion animal veterinary surgeons’ antibiotic prescribing behaviours. The veterinary surgeons interviewed were all practising within the UK (England (n = 4), Scotland (n = 11), Northern Ireland (n = 1)). A behavioural thematic analysis of the data was undertaken, which identified barriers and facilitators to specific prescribing-related behaviours. Results Five components of prescribing behaviours were identified: 1) confirming clinical need for antibiotics; 2) responding to clients; 3) confirming diagnosis; 4) determining dose, duration and type of antibiotic; and 5) preventing infection around surgery (with attendant appropriate and inappropriate antibiotic prescribing behaviours). Barriers to appropriate prescribing identified include: business, diagnostic, fear, habitual practice and pharmaceutical factors. Facilitators include: AMR awareness, infection prevention, professional learning and regulation and government factors. Conclusion This paper uses a behavioural lens to examine drivers which are an influence on veterinary surgeons’ prescribing behaviours. The paper contributes new understandings about factors which influence antibiotic prescribing behaviours among companion animal veterinary surgeons. This analysis provides evidence to inform future interventions, which are focused on changing prescribing behaviours, in order to address the pressing public health concern of AMR.
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Miller Renfrew L, Flowers P, Lord AC, Rafferty D, McFadyen AK, Bowers R, Mattison P, Paul L. An exploration of the experiences and utility of functional electrical stimulation for foot drop in people with multiple sclerosis. Disabil Rehabil 2018; 42:510-518. [PMID: 30299176 DOI: 10.1080/09638288.2018.1501100] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Purpose: Functional electrical stimulation (FES) is effective in improving walking in people with multiple sclerosis (MS) with foot drop. There is limited research exploring people's experiences of using this device. This study aims to explore the utility, efficacy, acceptability, and impact on daily life of the device in people with MS.Methods: An interpretative phenomenological approach was employed. Ten participants who had used FES for 12 months were interviewed. Transcripts were analysed, and emergent themes identified.Results: Nine participants continued to use the device. Three relevant super-ordinate themes were identified; impact of functional electrical stimulation, sticking with functional electrical stimulation, and autonomy and control. Participants reported challenges using the device; however, all reported positive physical and psychological benefits. Intrinsic and external influences such as; access to professional help, the influence of others, an individual's ability to adapt, and experiences using the device, influenced their decisions to continue with the device. A thematic model of these factors was developed.Conclusions: This study has contributed to our understanding of people with MS experiences of using the device and will help inform prescribing decisions and support the continued, appropriate use of FES over the longer term.Implications for RehabilitationPeople with multiple sclerosis using functional electrical stimulation report benefits in many aspects of walking, improved psychological well-being and increased engagement in valued activities.A number of challenges impact on functional electrical stimulation use. Factors such as; a positive experience using the device, access to professional help, the influence of others, a strong sense of personal autonomy and an individual's ability to adapt, influence an individual's decision to continue using functional electrical stimulation.Clinicians prescribing functional electrical stimulation should be aware of these factors so that the right support and guidance can be provided to people with multiple sclerosis, thus improving outcomes and compliance over the long term.
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Langdridge D, Davis M, Gozdzielewska L, McParland J, Williams L, Young M, Smith F, MacDonald J, Price L, Flowers P. A visual affective analysis of mass media interventions to increase antimicrobial stewardship amongst the public. Br J Health Psychol 2018; 24:66-87. [PMID: 30221433 PMCID: PMC6585774 DOI: 10.1111/bjhp.12339] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 08/08/2018] [Indexed: 11/26/2022]
Abstract
Objectives In an innovative approach to improve the contribution of health psychology to public health we have analysed the presence and nature of affect within the visual materials deployed in antimicrobial stewardship interventions targeting the public identified through systematic review. Design A qualitative analysis focused on the affective content of visual materials garnered from a systematic review of antibiotic stewardship (k = 20). Methods A novel method was devised drawing on concepts from semiotics to analyse the affective elements within intervention materials. Results Whilst all studies examined tacitly rely on affect, only one sought to explicitly deploy affect. Three thematic categories of affect are identified within the materials in which specific ideological machinery is deployed: (1) monsters, bugs, and superheroes; (2) responsibility, threat, and the misuse/abuse of antibiotics; (3) the figure of the child. Conclusions The study demonstrates how affect is a present but tacit communication strategy of antimicrobial stewardship interventions but has not – to date – been adequately theorized or explicitly considered in the intervention design process. Certain affective features were explored in relation to the effectiveness of antimicrobial resistance interventions and warrant further investigation. We argue that further research is needed to systematically illuminate and capitalize upon the use of affect to effect behaviour change concerning antimicrobial stewardship. Statement of contribution What is already known on this subject? The (mis)use of antibiotics and consequent risk of antimicrobial resistance is a critical public health problem. If sufficient action is not taken, global society will face the ‘post‐antibiotic’ era, in which common infections will lead to death for many millions. Key desirable behavioural changes are decreased patient demands for antibiotics, use of them for targeted purposes alone, and compliance with prescribed dosing. There is a growth of interest in the role of affect in mass media interventions designed to engage publics and produce health‐related behavioural change.
What does this study add? This article presents a novel analytic approach to understanding and intervening within behaviour change in public health that may complement other types of analysis. We present findings specifically from an ‘affective’ analysis based on semiotics in which we critically interrogated the visual imagery being deployed in mass media public health interventions concerning antimicrobial stewardship. Three thematic categories of affect are identified within the materials in which specific ideological machinery is deployed and that demonstrate some association with intervention effectiveness worthy of further investigation and testing.
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Semlyen J, Ali A, Flowers P. Intersectional identities and dilemmas in interactions with healthcare professionals: an interpretative phenomenological analysis of British Muslim gay men. CULTURE, HEALTH & SEXUALITY 2018; 20:1023-1035. [PMID: 29268660 DOI: 10.1080/13691058.2017.1411526] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Individual interviews were conducted with six self-identified Muslim gay men living in London focusing on their experience of health service use. Transcripts were analysed using interpretative phenomenological analysis. Analysis identified two major themes: the close(d) community and self-management with healthcare professionals, detailing participants' concerns regarding the risks of disclosing sexuality; and the authentic identity - 'you're either a Muslim or you're gay, you can't be both' - which delineated notions of incommensurate identity. Analysis highlights the need for health practitioners to have insight into the complexity of intersectional identities, identity disclosure dynamics and the negative consequences of assumptions made, be these heteronormative or faith-related.
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Currie K, King C, McAloney-Kocaman K, Roberts NJ, MacDonald J, Dickson A, Cairns S, Khanna N, Flowers P, Reilly J, Price L. Barriers and enablers to meticillin-resistant Staphylococcus aureus admission screening in hospitals: a mixed-methods study. J Hosp Infect 2018; 101:100-108. [PMID: 30098382 DOI: 10.1016/j.jhin.2018.08.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 08/03/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND To reduce the risk of transmission of meticillin-resistant Staphylococcus aureus (MRSA), international guidelines recommend admission screening to identify hospital patients at risk of colonization. However, routine monitoring indicates that optimum screening compliance levels are not always achieved. In order to enhance compliance, we must better understand those factors which influence staff screening behaviours. AIM To identify factors which influence staff compliance with hospital MRSA screening policies. METHODS A sequential two-stage mixed-methods design applied constructs from normalization process theory and the theoretical domains framework to guide data collection and analysis. Initial qualitative findings informed subsequent development of a national cross-sectional survey of nursing staff (N = 450). Multiple regression modelling identified which barriers and enablers best predict staff compliance. FINDINGS Three factors were significant in predicting optimum (>90%) compliance with MRSA screening: having MRSA screening routinized within the admission process; category of clinical area; feedback of MRSA screening compliance within the clinical area. Integration of data-sets indicated that organizational systems which 'make doing the right thing easy' influence compliance, as does local ward culture. Embedded values and beliefs regarding the relative (de)prioritization of MRSA screening are important. CONCLUSION To our knowledge, this is the first study to provide original evidence of barriers and enablers to MRSA screening, applying both sociological and psychological theory. As antimicrobial resistance is a global health concern, these findings have international relevance for screening programmes. Future policy recommendations or behaviour change interventions, based on the insights presented here, could have significant impact upon improving screening compliance.
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Dodds C, Mugweni E, Phillips G, Park C, Young I, Fakoya I, Wayal S, McDaid L, Sachikonye M, Chwaula J, Flowers P, Burns F. Correction to: Acceptability of HIV self-sampling kits (TINY vial) among people of black African ethnicity in the UK: a qualitative study. BMC Public Health 2018; 18:866. [PMID: 30001193 PMCID: PMC6043976 DOI: 10.1186/s12889-018-5775-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 06/28/2018] [Indexed: 11/10/2022] Open
Abstract
It has been highlighted that in the original article [1] there is a typesetting mistake in the name of I. Fakoya. This was incorrectly captured as F. Fakoya. This correction article clarifies the correct name of the author.
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Madill A, Flowers P, Frost N, Locke A. A meta-methodology to enhance pluralist qualitative research: One man's use of socio-sexual media and midlife adjustment to HIV. Psychol Health 2018; 33:1209-1228. [PMID: 29974810 DOI: 10.1080/08870446.2018.1475670] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
AIM Our aim is to offer and illustrate a novel meta-methodology to enhance the rigour of method selection and understanding of results in pluralist qualitative research (PQR). METHOD To do so, we make innovative use of articulation of four discrete dimensions characterising different forms of thematic analysis. We provide secondary analyses of an interview from the Social Media, Men who have Sex with Men and Sexual Health project using critical discursive psychology, dialogical analysis, interpretative phenomenological analysis and psychosocial narrative analysis. RESULTS All four methods identified aspects of three central foci: Compartmentalisation, Detachment and Jouissance. CONCLUSION We discuss how our proposed meta-methodology provides a rationale for the selection of methods in a PQR, offer evidence that it can anticipate the relative similarity in focus of the methods employed, and argue that our meta-methodology reveals the possibility of identifying an 'axial' or 'hub' method of a PQR which might be particularly fruitful in exploring commonalities and differences in results. Finally, we examine the synergies and challenges of combining pairs of the methods we used.
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Krzeczkowska A, Flowers P, Chouliara Z, Hayes P, Dickson A. 'It's been a long haul, a big haul, but we've made it': hepatitis C virus treatment in post-transplant patients with virus recurrence: An interpretative phenomenological analysis. Health Psychol Open 2018; 5:2055102918792673. [PMID: 30094056 PMCID: PMC6080080 DOI: 10.1177/2055102918792673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
The lived experience of both interferon-based and new interferon-free treatments in patients with hepatitis C virus remains understudied. To explore their journey through hepatitis C virus treatment, we interviewed seven post-transplant patients with recurrent hepatitis C virus. Three themes were identified using interpretative phenomenological analysis. Participants reported an ongoing sense of ontological uncertainty characterized by lack of control over their condition and treatment. Furthermore, an apposition of scepticism and hope accompanying each stage of hepatitis C virus treatment was described. A staged approach to psychological intervention tailored to the needs of the patient and their associated 'stage' of hepatitis C virus treatment was recommended.
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Price L, Melone L, McLarnon N, Bunyan D, Kilpatrick C, Flowers P, Reilly J. A systematic review to evaluate the evidence base for the World Health Organization's adopted hand hygiene technique for reducing the microbial load on the hands of healthcare workers. Am J Infect Control 2018; 46:814-823. [PMID: 29602496 DOI: 10.1016/j.ajic.2018.01.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Revised: 01/25/2018] [Accepted: 01/25/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Effective hand hygiene prevents healthcare-associated infections. This systematic review evaluates the evidence for the World Health Organization's (WHO) technique in reducing the microbial load on the hands of healthcare workers (HCWs). METHODS This study was conducted in accordance with Joanna Briggs Protocol 531. Index and free-text terms for technique, HCW, and microbial load were searched in CINAHL, Medline, Web of Science, Mednar, Proquest, and Google Scholar. Inclusion criteria were articles in English that evaluated the WHO 6-step hand hygiene technique for healthcare staff. Two reviewers independently performed quality assessment and data extraction. RESULTS All 7 studies found that the WHO technique reduced bacterial load on HCW hands, but the strongest evidence came from 3 randomized controlled trials, which reported conflicting evidence. One study found no difference in the effectiveness of the WHO 6-step technique compared to the Centers for Disease Control and Prevention's 3-step technique (P = .08); another study found the WHO 6-step technique to be more effective (P = .02); and the third study found that a modified 3-step technique was more effective than the 6-step technique (P = .021). CONCLUSIONS This review provides evidence of the effectiveness of the WHO technique but does not identify the most effective hand hygiene technique. Questions to be addressed by further research are identified. Meanwhile, current practices should continue.
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