"Make yourself un-NIMBY-able": stakeholder perspectives on strategies to mobilize public and political support for overdose prevention centers in the United States of America.

BACKGROUND: Overdose prevention centers (OPCs), also known as supervised injection facilities and safe consumption sites, are evidenced-based interventions for preventing overdose deaths and drug-related morbidities. The pathways to legalizing OPCs in the USA have confronted multiple social, political, and legal obstacles. We conducted a multi-site, qualitative study to explore heterogeneities in these pathways in four jurisdictions, as well as to understand stakeholder perspectives on valuable strategies for galvanizing political and public support for OPCs. METHODS: From July 2022 to February 2023, we conducted 17 semi-structured, in-depth interviews with OPC policymakers, service providers, advocates, and researchers from California, New York City, Philadelphia, and Rhode Island, where efforts have been undertaken to authorize OPCs. Using inductive thematic analysis, we identified and compared contextually relevant, salient approaches for increasing support for OPCs. RESULTS: Participants described several strategies clustering around five distinct domains: (1) embedding OPC advocacy into broader overdose prevention coalitions to shape policy dialogs; (2) building rapport with a plurality of powerbrokers (e.g., lawmakers, health departments, law enforcement) who could amplify the impact of OPC advocacy; (3) emphasizing specific benefits of OPCs to different audiences in different contexts; (4) leveraging relationships with frontline workers (e.g., emergency medicine and substance use treatment providers) to challenge OPC opposition, including 'NIMBY-ism,' and misinformation; and (5) prioritizing transparency in OPC decision-making to foster public trust. CONCLUSION: While tailored to the specific socio-political context of each locality, multiple OPC advocacy strategies have been deployed to cultivate support for OPCs in the USA. Advocacy strategies that are multi-pronged, leverage partnerships with stakeholders at multiple levels, and tailor communications to different audiences and settings could yield the greatest impact in increasing support for, and diffusing opposition to, future OPC implementation.

"I Don't Go Overboard": Perceptions of Overdose Risk and Risk Reduction Strategies among People Who Use Drugs in Rhode Island.

Background: North America experiencing an unprecedented overdose epidemic, with data estimating almost 110,000 overdose deaths occurring in 2022 in the United States (US). To address fatal overdoses in the US, community organizations and local health departments in some jurisdictions have expanded community distribution of naloxone, and increased overdose prevention education, and other harm reduction supplies and services (e.g., fentanyl test strips, drug checking programs) to reduce harm for people who use drugs (PWUD). Objectives: Understanding how PWUD manage overdose risk within the context of these expanded services is important for ensuring public health services are meeting their needs. Semi-structured qualitative interviews were conducted with 25 PWUD who were accessing harm reduction services in Rhode Island. Data were imported into NVivo where they were coded and analyzed thematically. Results: Our findings demonstrate the complexity of managing overdose risk in the context of a fentanyl drug supply. While most participants were concerned about overdosing, they sought to manage overdose risk through their own harm reduction practices (e.g., testing their drugs, going slow) and drug purchasing dynamics, even when using alone. Conclusions: Study findings point to the need to implement and scale-up community-level interventions to better support PWUD within the context of the current US overdose crisis.

Managing offshore multi-use settings: Use of conceptual mapping to reduce uncertainty of co-locating seaweed aquaculture and wind farms.

The offshore Multi-use Setting (MUS) is a concept that aims to co-locate marine industrial activities, including wind farms and aquaculture. MUS is considered an innovative approach to promoting efficiency in space and resource use whilst contributing global policy priorities. However, the impacts of MUS development across social, economic, and environmental domains are uncertain, hindering the commercialisation of the concept. In this study, we initially demonstrate the potential consequences of co-locating seaweed aquaculture and a wind farm as a step towards MUS. Using a hypothetical case study and modified Delphi methodology, 14 subject matter experts predicted potential outcomes across social and environmental objectives. Five Cognitive maps and impact tables of 58 potential consequences were generated based on experts' perspective on co-locating seaweed aquaculture and a wind farm. The findings highlight the potential to exasperate pressures in the area, including those already attributed to wind farm operations, such as species mortality and stakeholder conflict. However, it may also enhance social-ecological conditions, such as resource provisioning and promoting habitat functionality in the region, through the addition of seaweed aquaculture. The cognitive maps demonstrate the complexity of managing MUS implementation, where high degree of variability and uncertainty about the outcomes is present. The findings of this study provide the vital entry point to performing further integrative assessment and modelling approaches, such as probabilistic analysis and simulations, in support of MUS decision-making. The research also strongly recommends alternative strategies in the pursuit of combining seaweed production and wind farms to avoid significant financial (among many other) trade-offs and risks. More broadly, we have found that our approach's ability to visually represent a complex situation while considering multiple objectives could be immensely valuable for other bioeconomy innovations or nature-based solutions. It helps mitigate the potential for expensive investments without a comprehensive evaluation of the associated risks and negative impacts, as necessitated by the principles of sustainability in decision-making.

Cannabis Use Patterns and Whole-Blood Cannabinoid Profiles of Emergency Department Patients With Suspected Cannabinoid Hyperemesis Syndrome.

STUDY OBJECTIVES: The objectives of this study were to characterize the detailed cannabis use patterns (eg, frequency, mode, and product) and determine the differences in the whole-blood cannabinoid profiles during symptomatic versus asymptomatic periods of participants with suspected cannabinoid hyperemesis syndrome recruited from the emergency department (ED) during a symptomatic episode. METHODS: This is a prospective observational cohort study of participants with symptomatic cyclic vomiting onset after chronic cannabis use. Standardized assessments were conducted to evaluate for lifetime and recent cannabis use, cannabis use disorder, and cannabis withdrawal symptoms. Quantitative whole-blood cannabinoid testing was performed at 2 times, first when symptomatic (ie, baseline) and at least 2 weeks after the ED visit when asymptomatic. The differences in cannabinoid concentrations were compared between symptomatic and asymptomatic testing. The study was conducted from September 2021 to August 2022. RESULTS: There was a difference observed between delta-9-tetrahydrocannabinol metabolites, but not the parent compound during symptomatic episodes and asymptomatic periods. Most participants (84%) reported using cannabis > once per day (median 3 times per day on weekdays, 4 times per day on weekends). Hazardous cannabis use was universal among participants; the mean cannabis withdrawal discomfort score was 13, indicating clinically significant rates of cannabis withdrawal symptoms with cessation of use. Most participants (79%) previously tried to stop cannabis use, but a few (13%) of them had sought treatment. CONCLUSION: Patients presenting to the ED with cannabinoid hyperemesis syndrome have high cannabis use disorder scores. Further studies are needed to better understand the influence of THC metabolism and concentrations on symptomatic cyclic vomiting.

Perceptions of Long-Acting Injectable Antiretroviral Therapy Among People Living with HIV Who Use Drugs and Service Providers: a Qualitative Analysis in Rhode Island.

Long-acting injectable antiretroviral therapy (LAI-ART) is a novel method to deliver HIV treatment, and the first regimen was approved in the USA in 2021. LAI-ART may mitigate barriers to oral treatment adherence, but little is known about LAI-ART perceptions among people living with HIV (PLWH) who use drugs, despite these populations facing greater barriers to treatment retention and ART adherence. We assessed LAI-ART perceptions and implementation considerations among PLWH who use drugs and health and ancillary service providers in Rhode Island. Data was collected from November 2021 to September 2022, and include in-depth interviews with 15 PLWH who use drugs and two focus groups with HIV clinical providers (n = 8) and ancillary service providers (n = 5) working with PLWH who use drugs. Data were analyzed thematically, with attention paid to how levels of structural vulnerability and social-structural environments shaped participants' LAI-ART perceptions and the HIV care continuum. Willingness to consider LAI-ART was impacted by HIV outcomes (e.g., viral suppression) and previous experiences with oral regimens, with those on stable regimens reluctant to consider alternative therapies. However, LAI-ART was seen as potentially improving HIV outcomes for PLWH who use drugs and enhancing people's quality of life by reducing stress related to daily pill-taking. Recommendations for optimal implementation of LAI-ART varied across participants and included decentralized approaches to delivery. HIV care delivery must consider the needs of PLWH who use drugs. Developing patient-centered and community-based delivery approaches to LAI-ART may address adherence challenges specific to PLWH who use drugs.

Experiences of patients at high risk of opioid overdose accessing emergency department and behavioral health interventions: a qualitative analysis in an urban emergency department.

BACKGROUND: Emergency Departments (EDs) have become critical 'touchpoints' for the identification and early engagement of patients at risk of overdose or who have an opioid use disorder (OUD). Our objectives were to examine patients' ED experiences, identify barriers and facilitators of service uptake in ED settings, and explore patients' experiences with ED staff. METHODS: This qualitative study was part of a randomized controlled trial that evaluated the effectiveness of clinical social workers and certified peer recovery specialists in increasing treatment uptake and reducing opioid overdose rates for people with OUD. Between September 2019 and March 2020, semi-structured interviews were conducted 19 participants from the trial. Interviews sought to assess participants' ED care experiences across intervention type (i.e., clinical social worker or peer recovery specialist). Participants were purposively sampled across intervention arm (social work, n = 11; peer recovery specialist, n = 7; control, n = 1). Data were analyzed thematically with a focus on participant experiences in the ED and social and structural factors shaping care experiences and service utilization. RESULTS: Participants reported varied ED experiences, including instances of discrimination and stigma due to their substance use. However, participants underscored the need for increased engagement of people with lived experience in ED settings, including the use of peer recovery specialists. Participants highlighted that ED provider interactions were critical drivers of shaping care and service utilization and needed to be improved across EDs to improve post-overdose care. CONCLUSIONS: While the ED provides an opportunity to reach patients at risk of overdose, our results demonstrate how ED-based interactions and service provision can impact ED care engagement and service utilization. Modifications to care delivery may improve experiences for patients with OUD or at high risk for overdose. TRIAL REGISTRATION: Clinical trial registration: NCT03684681.

Women who use drugs: engagement in practices of harm reduction care.

BACKGROUND: Harm reduction services that employ or are operated by people who use drugs are an effective means of mitigating overdose risks and other drug-related harms. However, stereotypes portraying people who use criminalized drugs as incapable caregivers persist. This is especially true for women who use drugs, and to a greater extent racialized women, who are characterized as having diverged from traditional ideals of womanhood as a result of drug-user stigma and the intersections of gender- and class-based and racist stereotypes. In an effort to identify and understand how women who use drugs practise care through harm reduction, we explored the experiences of women accessing a low-threshold supervised consumption site exclusively for women (transgender and non-binary inclusive) in Vancouver, Canada. METHODS: Data were drawn from research conducted from May 2017 to June 2018 exploring women's experiences accessing the supervised consumption site during an overdose crisis. Data included forty-five semistructured interviews with women recruited from the site, analysed thematically to explore practices of care through harm reduction. FINDINGS: Participants reported engaging in both formal and informal care. Acts of care included interventions that both aligned with and deviated from conventional understandings of care practices, including overdose reversal and education, overdose supervision/care, and assisted injection. CONCLUSION: The boundary between formal and informal harm reduction care is fluid. Women who use drugs engage in harm reduction across these borders with acts of care that align with or fill the gaps in current harm reduction services in order to meet the needs of drug-using communities, challenging negative stereotypes of women who use drugs. However, these caregiving practices can increase risks to care providers' physical, mental, and emotional health and wellness. Increased financial, social, and institutional supports, including safer supply, assisted injection, and community resources, are needed to better support women as they continue to engage in harm reduction care.

Multi-level influences on increased overdose risk behaviors during the COVID-19 pandemic among people who use drugs in Rhode Island: a qualitative investigation.

BACKGROUND: The ongoing COVID-19 pandemic has disproportionately affected structurally vulnerable populations including people who use drugs (PWUD). Increased overdose risk behaviors among PWUD during the pandemic have been documented, with research underscoring the role of influencing factors such as isolation and job loss in these behaviors. Here, we use qualitative methods to examine the impact of the COVID-19 pandemic and pandemic-related response measures on drug use behaviors in a sample of PWUD in Rhode Island. Using a social-ecological framework, we highlight the nested, interactive levels of the pandemic's influence on increased overdose risk behaviors. METHODS: From July to October 2021, semi-structured interviews were conducted with 18 PWUD who self-reported any increase in behaviors associated with overdose risk (e.g., increased use, change in drug type and/or more solitary drug use) relative to before the pandemic. Thematic analysis was conducted using a codebook with salient themes identified from interview guides and those that emerged through close reading of transcribed interviews. Guided by a social-ecological framework, themes were grouped into individual, network, institutional, and policy-level influences of the pandemic on drug use behaviors. RESULTS: Individual-level influences on increased overdose risk behaviors included self-reported anxiety and depression, isolation and loneliness, and boredom. Network-level influences included changes in local drug supply and changes in social network composition specific to housing. At the institutional level, drug use patterns were influenced by reduced access to harm reduction or treatment services. At the policy level, increased overdose risk behaviors were related to financial changes, job loss, and business closures. All participants identified factors influencing overdose risk behaviors that corresponded to several nested social-ecological levels. CONCLUSIONS: Participants identified multi-level influences of the COVID-19 pandemic and pandemic-related response measures on their drug use behavior patterns and overdose risk. These findings suggest that effective harm reduction during large-scale crises, such as the COVID-19 pandemic, must address several levels of influence concurrently.

Measuring and Improving Adherence to Crisaborole 2% Ointment in Patients With Atopic Dermatitis.

BACKGROUND: Atopic dermatitis (AD) is an inflammatory skin condition with dry, scaly, and intensely itchy skin. Treatment failure is the result of poor adherence. OBJECTIVE: In this study, we assessed the impact of an internet-based survey on adherence to topical crisaborole 2% ointment in patients with mild AD. METHODS: Participants were randomized to the intervention or control group. The intervention group received weekly email surveys regarding adherence for 6 weeks, then monthly for 12 months. All participants came in for 5 visits over the year. RESULTS: Twenty-eight subjects were recruited for the study (n=19 adults, n=9 pediatrics). Adherence for adults that remained in study (n=6) was 60%. Adherence of the adult control and intervention groups were 49% and 45%, respectively (P>0.05). Adherence for pediatric participants that remained in study (n=2) was 6%. The adherence of the pediatric control and intervention groups were 27% and 29%, respectively (P>0.05). DISCUSSION: Medication adherence was low. The survey intervention did not improve adherence. However, more participants in the intervention group completed the study than in the control group of adults. Regular communication from the provider may help patients feel supported and continue treatment. CLINICALTRIALS: gov identifier: NCT03250663 J Drugs Dermatol. 2022;21(10):1043-1048. doi:10.36849/JDD.6280.

Characteristics of events in which police responded to overdoses: an examination of incident reports in Rhode Island.

BACKGROUND: Narrow or non-existent Good Samaritan Law protections and harsh drug selling statutes in the USA have been shown to deter bystanders from seeking medical assistance for overdoses. Additionally, little is known about the actions that police take when responding to overdose events. The objectives of this study were to assess the prevalence and correlates of naloxone administration by police, as well as to examine overdose events where arrests were made and those in which the person who overdosed was described as combative. METHODS: We analyzed incident reports of police responding to an overdose between September 1, 2019, and August 31, 2020 (i.e., 6 months prior to and during the COVID-19 pandemic), from a city in Rhode Island. We examined characteristics of incidents, as well as individual characteristics of the person who overdosed. Correlates of police naloxone administration were assessed using Wilcoxon rank sum tests and Fisher's exact tests, and we examined incidents where arrests occurred and incidents in which the person who overdosed was described as combative descriptively. RESULTS: Among the 211 incidents in which police responded to an overdose during the study period, we found that police administered naloxone in approximately 10% of incidents. In most incidents, police were the last group of first responders to arrive on scene (59%), and most often, naloxone was administered by others (65%). Police were significantly more likely to administer naloxone when they were the first professionals to arrive, when naloxone had not been administered by others, and when the overdose occurred in public or in a vehicle. Arrests at overdose events were rarely reported (1%), and people who overdosed were rarely (1%) documented in incident reports as being 'combative.' CONCLUSIONS: Considering these findings, ideally, all jurisdictions should have sufficient first responder staffing and resources to ensure a rapid response to overdose events, with police rarely or never dispatched to respond to overdoses. However, until this ideal can be achieved, any available responders should be dispatched concurrently, with police instructed to resume patrol once other professional responders arrive on scene; additionally, warrant searches of persons on scene should be prohibited.

"It's Helped Me a Lot, Just Like to Stay Alive": a Qualitative Analysis of Outcomes of a Novel Hydromorphone Tablet Distribution Program in Vancouver, Canada.

North America is experiencing an overdose crisis driven by fentanyl, related analogues, and fentanyl-adulterated drugs. In response, there have been increased calls for "safe supply" interventions based on the premise that providing a safer alternative (i.e., pharmaceutical drugs of known quality/quantity, non-adulterated, with user agency in consumption methods) to the street drug supply will limit people's use of fentanyl-adulterated drugs and reduce overdose events. This study examined outcomes of a hydromorphone tablet distribution program intended to prevent overdose events among people who use drugs (PWUD) at high risk of fatal overdose. Semi-structured qualitative interviews were conducted with 42 people enrolled in the hydromorphone distribution program. Additionally, over 100 h of ethnographic observation were undertaken in and around the study site. Transcripts were coded using NVivo and based on categories extracted from the interview guides and those identified during initial interviews and ethnographic fieldwork. Analysis focused on narratives around experiences with the program, focusing on program-related outcomes. Our analysis identified the following positive outcomes of being enrolled in the hydromorphone tablet distribution program: (1) reduced street drug use and overdose risk, (2) improvements to health and well-being, (3) improvements in co-management of pain, and (4) economic improvements. Our findings indicate that the hydromorphone distribution program not only is effective in responding to the current overdose crisis by reducing people's use of illicit drugs but also addresses inequities stemming from the intersection of drug use and social inequality. Safe supply programs should be further implemented and evaluated in both urban and rural setting across North America as a strategy to reduce exposure to the toxic drug supply and fatal overdose.

Factors influencing retention among hospital nurses: systematic review.

BACKGROUND: Recruitment and retention of nursing staff is the biggest workforce challenge faced by healthcare institutions. Across the UK, there are currently around 50 000 nursing vacancies, and the number of people leaving the Nursing and Midwifery Council register is increasing. OBJECTIVE: This review comprehensively compiled an update on factors affecting retention among hospital nursing staff. METHODS: Five online databases; EMBASE, MEDLINE, SCOPUS, CINAHL and NICE Evidence were searched for relevant primary studies published until 31 December 2018 on retention among nurses in hospitals. RESULTS: Forty-seven studies met the inclusion criteria. Nine domains influencing staff turnover were found: nursing leadership and management, education and career advancement, organisational (work) environment, staffing levels, professional issues, support at work, personal influences, demographic influences, and financial remuneration. CONCLUSION: Identified turnover factors are long-standing. To mitigate the impact of these factors, evaluation of current workforce strategies should be high priority.

Assessing the impact of food insecurity on HIV medication adherence in the context of an integrated care programme for people living with HIV in Vancouver, Canada.

OBJECTIVE: Food insecurity, or self-reports of inadequate food access due to limited financial resources, remains prevalent among people living with HIV (PLHIV). We examined the impact of food insecurity on combination antiretroviral therapy (cART) adherence within an integrated care programme that provides services to PLHIV, including two meals per day. DESIGN: Adjusted OR (aOR) were estimated by generalized estimating equations, quantifying the relationship between food insecurity (exposure) and cART adherence (outcome) with multivariable logistic regression. SETTING: We drew on survey data collected between February 2014 and March 2016 from the Dr. Peter Centre Study based in Vancouver, Canada. PARTICIPANTS: The study included 116 PLHIV at baseline, with ninety-nine participants completing a 12-month follow-up interview. The median (quartile 1-quartile 3) age was 46 (39-52) years at baseline and 87 % (n 101) were biologically male at birth. RESULTS: At baseline, 74 % (n 86) of participants were food insecure (≥2 affirmative responses on Health Canada's Household Food Security Survey Module) and 67 % (n 78) were adherent to cART ≥95 % of the time. In the adjusted regression analysis, food insecurity was associated with suboptimal cART adherence (aOR = 0·47, 95 % CI 0·24, 0·93). CONCLUSIONS: While food provision may reduce some health-related harms, there remains a relationship between this prevalent experience and suboptimal cART adherence in this integrated care programme. Future studies that elucidate strategies to mitigate food insecurity and its effects on cART adherence among PLHIV in this setting and in other similar environments are necessary.

Addressing Intersecting Housing and Overdose Crises in Vancouver, Canada: Opportunities and Challenges from a Tenant-Led Overdose Response Intervention in Single Room Occupancy Hotels.

We examined the acceptability, feasibility, and implementation of the Tenant Overdose Response Organizers program (TORO)-a tenant-led naloxone training and distribution intervention. This pilot project was implemented in privately owned single room occupancy (SRO) hotels that were disproportionately affected by overdose in Vancouver's Downtown Eastside (DTES) neighborhood. Semi-structured qualitative interviews were conducted with 20 tenants who had participated in a TORO training session and administered naloxone to someone in their SRO hotel or had overdosed in their SRO hotel and received naloxone from another tenant. Focus groups were conducted with 15 peer workers who led the TORO program in their SRO building. Interviews and focus groups were transcribed and analyzed thematically. Ethnographic observation at SRO hotels involved in the intervention was also co-led with peer research assistants. Ten SROs were included in the study. The level of acceptability of the TORO program was high, with participants describing the urgency for an intervention amid the frequency of overdoses in their buildings. Overdose response training enhanced participants' knowledge and skills, and provided them a sense of recognition. Additionally, the TORO program was feasible in some buildings more than others. While it provided important training and engaged isolated tenants, there were structural barriers to program feasibility. The implementation of the TORO program was met with some successes in terms of its reach and community development, but participants also discussed a lack of emotional support due to overdose frequency, leading to burnout and vulnerability. Our findings suggest that the TORO program was affected by social, structural, and physical environmental constraints that impacted program feasibility and implementation. Despite these constraints, peer-led in-reach overdose response interventions are effective tools in addressing overdose risk in SROs. Future housing interventions should consider the intersecting pathways of overdose risk, including how these interventions may exacerbate other harms for people who use drugs. Further research should explore the impacts of environmental factors on overdose response interventions in other housing contexts.

Adherence to a novel home phototherapy system with integrated features.

OBJECTIVE: To measure adherence using a novel home UVB phototherapy system designed to promote adherence. STUDY DESIGN: A retrospective, observational study conducted to evaluate patients' adherence to a prescribed three-times-per-week treatment protocol using a novel home phototherapy system with integrated features designed to improve adherence. METHODS: Data was collected from 18 psoriasis patients, 27 vitiligo patients, and three atopic dermatitis patients using a novel home phototherapy system under normal use conditions. Adherence was also calculated using two alternative methods to allow for comparison between published phototherapy adherence studies. RESULTS: The median patient adherence (N= 48) to treatment with the home phototherapy system was 80%. There were no significant differences in adherence between different ages, genders, or diseases (P>0.05). Early adherence (N=48) to the home phototherapy system was 90% and dichotomous adherence (N=32) was 71%. CONCLUSIONS: By implementing a smartphone application and web-based portal with the home phototherapy system, patients have multiple mechanisms in place to ensure adherence.

A novel ultraviolet B home phototherapy system: Efficacy, tolerability, adherence, and satisfaction.

BACKGROUND: Phototherapy is effective in treating psoriasis and other skin conditions. However, clinic-based phototherapy can be time-consuming, expensive, and inconvenient. Conventional home phototherapy addresses many hurdles, but has other limitations. OBJECTIVE: Assess the treatment efficacy, adherence, and satisfaction of a novel ultraviolet B home phototherapy system. METHODS: Eight patients with stable plaque psoriasis completed a multicenter, prospective, open label, interventional study using a home phototherapy device designed to improve treatment control and adherence. Matched control and study lesions were assessed on each subject. A dosing protocol based on American Academy of Dermatology guidelines for narrowband UVB phototherapy was managed by the phototherapy system. Responsiveness to the treatment was measured using the Psoriasis Severity Index (PSI) at 10 weeks versus control. Patient satisfaction was graded on a five-star Likert scale. RESULTS: At 10 weeks, all patients experienced improvement in the treated lesions, with a mean improvement of 57% in PSI (P<0.0001 compared to baseline and P<0.0002 compared to the control lesions). Patient treatment adherence was 96% and treatment satisfaction was 100% five-star rated. Control lesions did not significantly change in PSI over the 10-week period (P=0.1411). CONCLUSIONS: The home phototherapy system provided a safe and effective means to manage plaque psoriasis.

Corrigendum: A novel ultraviolet B home phototherapy system: Efficacy, tolerability, adherence, and satisfaction.

The original article was published on February 15, 2019 and corrected on April 15, 2019. The third pair of panes of Figure 2 were reversed, such that the pane previously depicted on the left was after phototherapy. The corrected sequence is now before phototherapy, on the left, and after, on the right. This change appears in the revised online PDF copy of this article.

Factors associated with low neighborhood cohesion among women living with HIV impacted by social-structural inequities in British Columbia.

Built and social environments, including one's perception of their environment, are important determinants of health. The intersection of gender and HIV status may complicate the role of neighborhood cohesion in safety, personal well-being, and health outcomes for populations impacted by social and structural inequities. Among women in particular, social cohesion within the neighborhood they reside in may have a greater influence on health outcomes compared to their male counterparts. We sought to examine perception of neighborhood cohesion (validated scale with a range 0-100, with higher scores indicating higher perceived neighborhood cohesion) among women living with HIV, impacted by social-structural inequities, receiving combination antiretroviral therapy, and enrolled in the Longitudinal Investigations into Supportive Ancillary health services (LISA) study in British Columbia, Canada. Cross-sectional data on neighborhood cohesion and socio-demographic data were collected in an interviewer-administered survey. Of the 1,000 LISA participants interviewed, 908 (including 249 women and 659 men) had complete data for the variables of interest. At the bivariate level, women had worse perceived neighborhood cohesion scores compared to men (median: 56 [95% CI: 44-66] vs. 60 [95% CI: 47-71]). Multivariable model results indicated that for women living with HIV in our sample, greater neighborhood cohesion scores were positively associated with stable housing (ß coefficient = 7.85; 95% CI: 3.61, 12.10, p < 0.001), and negatively associated with greater perceived HIV stigma (ß coefficient = -1.19; 95% CI: -2.24 to-0.15; p = 0.025). The results illustrate the gendered nature of experiencing built and social environments, and highlight the need for women-centred interventions to address the social determinants of HIV burden associated with negative perceptions of neighborhood cohesion.

Housing and overdose: an opportunity for the scale-up of overdose prevention interventions?

BACKGROUND: North America is currently experiencing an overdose epidemic due to a significant increase of fentanyl-adulterated opioids and related analogs. Multiple jurisdictions have declared a public health emergency given the increasing number of overdose deaths. In the province of British Columbia (BC) in Canada, people who use drugs and who are unstably housed are disproportionately affected by a rising overdose crisis, with close to 90% of overdose deaths occurring indoors. Despite this alarming number, overdose prevention and response interventions have yet to be widely implemented in a range of housing settings. OVERDOSE PREVENTION INTERVENTIONS: There are few examples of overdose prevention interventions in housing environments. In BC, for example, there are peer-led naloxone training and distribution programs targeted at some housing environments. There are also "supervised" spaces such as overdose prevention sites (similar to supervised consumption sites (SCS)) located in some housing environments; however, their coverage remains limited and the impacts of these programs are unclear due to the lack of evaluation work undertaken to date. A small number of SCS exist globally in housing environments (e.g., Germany), but like overdose prevention sites in BC, little is known about the design or effectiveness, as they remain under-evaluated. CONCLUSIONS: Implementing SCS and other overdose prevention interventions across a range of housing sites provides multiple opportunities to address overdose risk and drug-related harms for marginalized people who use drugs. Given the current overdose crisis rising across North America, and the growing evidence of the relationship between housing and overdose, the continued implementation and evaluation of novel overdose prevention interventions in housing environments should be a public health priority. A failure to do so will simply perpetuate what has proven to be a devastating epidemic of preventable death.

Ecological assessments of surface water bodies at the river basin level: a case study from England.

Ecological assessments of surface water bodies are essential in order to evaluate the level of degradation in freshwater ecosystems and to address the subsequent decline in services they provide. These assessments cover multiple aspects of the aquatic environment, particularly biological elements due to their ability to respond to all pressures within an ecosystem. Such assessments can enable the identification of the multiple pressures which threaten water bodies, facilitating sustainable decisions regarding their management to be identified. Here, the design requirements of the networks which facilitate ecological assessments are presented. A river basin district in England is used as a case study to investigate the number of elements monitored, the number of failing elements and the relationship between failing elements. Findings demonstrate the value of ensuring that monitoring networks are risk based and appropriately designed to meet their objectives. This therefore requires that monitoring is not only for the communicating of compliance but also for use iteratively so that the design of monitoring networks and ultimately management can be continually improved.