When Black and White Turns Gray: Navigating the Ethical Challenges of Implementing Shared Infant Feeding Decisions for Persons Living with Human Immunodeficiency Virus in the United States.

In 2023, US guidelines for feeding perinatally human immunodeficiency virus (HIV)-exposed infants were revised to encourage collaborative decision-making in lieu of categorical proscription of breastfeeding. This change advances autonomy and health equity for persons living with HIV in the United States, for the first time supporting those who prioritize the maternal and infant benefits of breastfeeding in the setting of effective, well-established HIV risk mitigation. The authors review key moral dilemmas facing clinicians and patients who must navigate the reversal of longstanding dogma against breastfeeding and provide recommendations for implementation of a new ethical paradigm.

Epistemic Risk Reduction in Psychedelic-Assisted Therapy.

Belief change is crucial to therapeutic benefit in psychedelic-assisted therapy as well as in more traditional forms of therapy. However, the use of psychedelics comes with a few unique challenges that require extra caution. First, drastic belief changes may occur faster than in regular therapy. Facing radical and transformative insights all at once rather than through a gradual process of discovery and integration can lead patients to a volatile, confusing or disorienting epistemic state. Additionally, we know psychedelic substances generate hallucinatory experiences that come with a high degree of confidence and noetic certainty despite not necessarily being connected with reality. On the other hand, telling a patient which ones of her beliefs are true and which ones are not seems beyond the competence of a psychotherapist, if not an abuse of their authority and power. This is even more dangerous when psychedelics are involved, because power imbalance between patient and therapist is exacerbated by the therapist's role as a guiding figure throughout an intense altered state of consciousness. Because of this suggestible state, the therapist's beliefs might have a disproportionate influence, and even well-intentioned nudging might significantly stray the patient's beliefs.How can a therapist help a patient navigate their epistemic uncertainty around psychedelic insights while preserving the patient's autonomy? This chapter will attempt to answer this question through a philosophical and epistemological lens. We will review different strategies to mitigate epistemic risks in psychedelic-assisted therapy and argue that such risks can be significantly reduced by adapting these strategies dynamically to the individual patient's needs.

Experiences of harm and mental ill-health among gay, bisexual and other men-who-have-sex-with-men who use methamphetamine or GHB/GBL in different combinations: findings from the COMeT study in Taiwan.

INTRODUCTION: Polydrug use in the context of chemsex is commonplace among gay, bisexual, and other men-who-have-sex-with-men (GBMSM). This study aimed to examine the differences in experiences of physical, social, and psychological harms, as well as mental ill-health among GBMSM who use different combinations of methamphetamine and gamma-hydroxybutyric acid/gamma-butyrolactone (GHB/GBL) during chemsex. METHOD: Adult GBMSM participants who had experience of chemsex in the past 12 months participated in a cross-sectional online survey in Taiwan and self-reported their sociodemographic background, sexual behaviours, mental health, and experiences of harm following a chemsex session. We used univariable and multivariable logistic regression to assess the different experiences of harm and mental ill-health among GBMSM who engaged in chemsex without using methamphetamine, used methamphetamine but not GHB/GBL, and who used both drugs. RESULTS: Out of 510 participants who completed all items included in the analysis, 24.1% engaged in chemsex without using methamphetamine, 36.9% used methamphetamine but not GHB/GBL, and 39.0% used both drugs. Eighty five percent of men who used both methamphetamine and GHB/GBL reported at least one kind of social harm after a chemsex session, such as missing dates or appointments, or appearing "high" at work, followed by used methamphetamine but not GHB/GBL (69.7%) and those without using methamphetamine (37.4%). After controlling for polydrug and frequency of drug use in the multivariable logistic regression, those who used methamphetamine but not GHB/GBL and those who used both drugs were more likely to report experiencing physical and psychological harms compared to those who did not use methamphetamine (p < 0.003). CONCLUSION: GBMSM who used both methamphetamine and GHB/GBL in a chemsex context were more likely to report experience of harms than those who only used a single chemsex drug or engaged in chemsex without methamphetamine or GHB/GBL. Harm reduction should focus on both preventing HIV and STI transmission and on minimising psychosocial harm to GBMSM, with varying impacts depending on drug use.

From Response to Prevention: Enhancing EMS Impact With Harm Reduction and HIV Education.

EMS are crucial not only for immediate life-saving interventions but also for broader public health initiatives, particularly in harm reduction and HIV prevention. However, many EMS training programs lack comprehensive education and training in these areas, resulting in significant gaps in patient care and provider safety. As the opioid epidemic continues to devastate communities, the need for EMS personnel to be trained in harm reduction strategies, such as naloxone administration, and HIV prevention, has become increasingly urgent. Integrating harm reduction and HIV prevention into EMS training is essential for equipping first responders to effectively address the complex needs of individuals affected by addiction. This training is not only vital for improving public health outcomes but also for ensuring the safety and efficacy of EMS providers in their critical roles on the front lines. The evidence strongly supports the immediate inclusion of harm reduction and HIV prevention in EMS curricula to enhance care quality, reduce the spread of HIV, and combat the ongoing opioid crisis.

"I drink less and that's no small matter": a qualitative descriptive study of a managed alcohol program evaluation in Barcelona.

Background: The concurrence of homelessness and alcohol use disorder (AUD) has negative consequences in affected individuals. Managed alcohol programs (MAPs), a harm reduction strategy based on providing regular doses of alcohol to individuals with AUD, have emerged as a potential solution to reduce alcohol-related harms.Objectives: This study examined the impact of a MAP implemented in Barcelona on patterns of alcohol and other psychoactive substance use, health, and quality of life among people who use drugs and were experiencing homelessness. The research also incorporated a gender perspective and focused on individuals who had accessed a residential center.Methods: A descriptive qualitative design was used, employing semi-structured interviews with eight participants who were enrolled in the MAP (three women, five men) and four program professionals. Thematic analysis was used to analyze the resulting data.Results: The domains guiding the study appeared as outcome themes: patterns of use of alcohol and other substances, health, quality of life and impact on female-identified participants. Participants reported improved health due to reduced consumption of alcohol and other substances, better anxiety management, and reconnection to health services. The participants reported enhanced quality of life, including feeling safer, and better use of time, which had been spent on meeting their basic needs. Women reported that a key benefit of the program was living in a sexism-free environment.Conclusion: These results appear to demonstrate that harm reduction strategies prioritizing basic needs and adopting a gender-sensitive perspective can positively impact the health and quality of life of people experiencing homelessness with AUD.

How post overdose response efforts can address social determinants of health among people who use drugs: perspectives from the New York State Department of Health (NYSDOH) Post Overdose Response Team (PORT).

Individuals who have survived an overdose often have myriad needs that extend far beyond their drug use. The social determinants of health (SDOH) framework has been underutilized throughout the opioid overdose crisis, despite widespread acknowledgment that SDOH are contributors to the majority of health outcomes. Post Overdose Response Teams (PORTs) engage with individuals who have experienced 1 or more nonfatal overdoses and bear witness to the many ways in which overdose survivors experience instability with healthcare, housing, employment, and family structure. Employing a harm reduction model, PORTs are well-positioned to reach people who use drugs (PWUD) and to address gaps in basic needs on an individualized basis, including providing social support and a sense of personal connection during a period of heightened vulnerability. The New York State Department of Health (NYSDOH) PORT program is a harm reduction initiative that utilizes law enforcement data and several public databases to obtain accurate referral information and has been active since 2019 in NYC. This PORT program offers various services from overdose prevention education and resources, referrals to health and treatment services, and support services to overdose survivors and individuals within their social network. This perspective paper provides an in-depth overview of the program and shares quantitative and qualitative findings from the pilot phase and Year 1 of the program collected via client referral data, interviews, and case note reviews. It also examines the barriers and successes the program encountered during the pilot phase and Year 1. The team's approach to addressing complex needs is centered around human connection and working toward addressing SDOH one individualized solution at a time. Application of the NYSDOH PORT model as outlined has the potential to create significant positive impacts on the lives of PWUD, while potentially becoming a new avenue to reduce SDOH-related issues among PWUD.

Diagnosis of Alcohol Use Disorder and Alcohol-Associated Liver Disease.

Harmful alcohol use and alcohol use disorder (AUD) are common worldwide, and rates of alcohol-associated liver disease (ALD) are also increasing. AUD is a disease that is treatable and can be diagnosed and managed, and recovery from AUD through abstinence or reductions in drinking is possible. Management of AUD among individuals with ALD is increasingly being addressed via integrated medical and psychosocial treatment teams that can support reductions in drinking and prevent progression of liver disease. Early diagnosis of AUD and ALD can improve lives and reduce mortality.

Harm reduction for addictive consumption: When does it improve health and when does it backfire?

Some harm reduction strategies encourage individuals to switch from a harmful addictive good to a less harmful addictive good; examples include e-cigarettes (substitutes for combustible cigarettes) and methadone and buprenorphine (substitutes for opioids). These have proven to be controversial. Advocates argue that people struggling with addiction benefit because they can switch to a less harmful substance, but opponents argue that this could encourage abstainers to begin using the harm-reduction method or even, eventually, the original addictive good. This paper builds on theories of addiction to model the introduction of a harm reduction method, and demonstrates the conditions under which each side is correct.

Harm Reduction and Substance Use in Adolescents.

This article discusses the use of substances among adolescents, the unacceptable overdose death rates they bear, and the relevant evidence-based harm reduction strategies available in primary care, including medications for opioid use disorder. Access to these medications, as well as to harm reduction strategies generally, is insufficient for adolescents. Many adolescents who use substances and who are most at risk for overdose regularly visit primary care, which is an appropriate setting for treatment and harm reduction delivery.

"We're Not Gonna Aid You in Shooting Up": Stigma's Relationship to Harm Reduction in People Who Inject Drugs.

BACKGROUND: Harm reduction, when applied to drug use, prioritizes improving patient-centered health outcomes and reducing drug-related harm. In order for harm reduction strategies to be adopted by people who inject drugs (PWID), they need to be promoted, accessible, and accepted in that population and the community-at-large. While PWID face stigma at multiple levels, less is known about how stigma influences uptake and acceptance of harm reduction services and strategies among PWID. OBJECTIVE: We aim to characterize the stigmatizing experiences PWID have had related to harm reduction and the role of stigma in influencing their acceptance and adoption of harm reduction services and strategies. DESIGN: A qualitative study using in-person, semi-structured interviews. PARTICIPANTS: We recruited hospitalized participants, age 18 and over, with a history of injection drug use. APPROACH: We developed an interview guide asking about various aspects of stigma and participants' experiences with naloxone, syringe service programs, fentanyl test strips, HIV and hepatitis C testing, and any other harm reduction strategies. Key themes were generated using a thematic analysis. We reached thematic saturation at 16 participants. KEY RESULTS: PWID reported multi-level stigma related to harm reduction from themselves, the public, the healthcare system, and the legal and carceral systems. Themes were grouped into four main categories: internalized, interpersonal, intervention, and structural stigma. Stigma across all of these domains negatively impacted the ability of PWID to access harm reduction resources. Positive, non-stigmatizing experiences from others, such as syringe service programs and peer navigators, countered historically negative experiences and promoted greater education and comfort about using harm reduction resources among PWID. CONCLUSIONS: To expand the reach of harm reduction services, it is critical to develop interventions that can reduce the stigma against PWID and harm reduction.

What Psychiatrists Should Know About Prescribed Safer Opioid Supply.

In this invited commentary, we provide an overview of safer opioid supply (SOS) initiatives, specifically aiming to examine the evidence base for SOS programs and the ensuing implications for clinical practice, particularly in the context of psychiatric care.

What Psychiatrists Should Know About Prescribed Safer Opioid SupplyPlain Language SummaryIn this invited commentary, we provide an overview of safer opioid supply (SOS) initiatives, specifically aiming to examine the evidence base for SOS programs and the ensuing implications for clinical practice, particularly in the context of psychiatric care.

Consuming 'God Juice': Using 'ethnopharmacological-connoisseurship' to situate trenbolone use and knowledge among image and performance enhancing drug communities.

INTRODUCTION: Trenbolone, a potent anabolic-androgenic steroid (AAS), is used for its muscle growth benefits but poses significant health risks, including psychosocial issues. Existing research among humans is limited by lack of targeted investigation. This study addresses gaps in existing research by leveraging the ethnopharmacological expertise of trenbolone consumers. By engaging with the community's connoisseurship, we sought to enhance harm reduction strategies and foster collaboration between consumers, scholars and health practitioners. METHODS: An international sample of trenbolone consumers (N = 30) were interviewed. Interviews explored trenbolone use, knowledge levels and harm reduction strategies. Analysis involved an iterative categorisation approach, incorporating the lead author's lived experience with trenbolone. RESULTS: Participants described trenbolone as both a physical enhancer and a source of psychological boosts, tempered by adverse effects such as emotional volatility and intrusive thoughts. Despite warnings about its dangers the drug's allure was amplified by social media and community visibility. Consumers spoke of a developing connoisseur-like knowledge about trenbolone through personal and shared experiences. Through this collective expertise, they developed harm reduction strategies such as conservative dosing and regular health monitoring. DISCUSSION AND CONCLUSIONS: This study demonstrates the importance of integrating ethnopharmacological-connoisseurship from the image and performance enhancing drug community to develop a contextually relevant understanding of AAS use-trenbolone being one of these. By elevating community insights, we advocate for a collaborative approach to harm reduction. Ultimately, we call for partnerships between researchers, health professionals and consumers to enhance health and reduce harm in image and performance enhancing drug communities.

A hand-washing community-based educational intervention to reduce abscess incidence among people who inject drugs: a cluster randomised controlled clinical trial protocol (the HAWA study protocol).

BACKGROUND: Besides the high prevalence of HIV and HCV infections, people who inject drugs (PWID) have a cumulative risk of acquiring skin and soft tissue infections (SSTI) from, among other things, social precariousness, homelessness/unstable housing, and unhygienic injecting practices. We propose to evaluate whether a two-component educational hand hygiene intervention which combines training in hand-washing with the supply of a single-use alcohol-based hand rub, called MONO-RUB, is effective in reducing injection-related abscesses in the PWID population. Specifically, we shall implement a nationwide, two-arm, multi-centre, cluster randomised controlled trial to evaluate the effectiveness and cost-effectiveness of this intervention in PWID. METHODS: HAWA is a community-based participatory research study to be conducted in 22 harm reduction centres (HR) in France (not yet recruiting); the latter will be randomised into two clusters: centres providing standard HR services and the intervention (i.e., intervention group) and those providing standard HR services only (i.e., control group). After randomization, each cluster will include 220 PWID, with an inclusion period of 12 months and an individual follow-up period of 6 months. For each participant, we will collect data at M0, M3 and M6 from photos of injection sites on the participant's body, a face-to-face injection-related SSTI questionnaire, and a CATI questionnaire. The primary outcome is the reduction in abscess prevalence between M0 and M6, which will be compared between the control and intervention arms, and measured from observed (photographs) and self-declared (SSTI questionnaire) data. We will also assess the cost-effectiveness of the intervention. DISCUSSION: The HAWA trial will be the first cluster randomized controlled trial to improve hand hygiene among PWID with a view to reducing SSTI. If effective and cost-effective, the intervention combined with the distribution of MONO-RUBs (or a similar cleaning product) may prove to be an important HR tool, helping to reduce the enormous burden of infection-related deaths and diseases in PWID. TRIAL REGISTRATION: NCT06131788, received on 2 January 2024.

Publics in local media reporting on harm reduction: Rightfully worried local witnesses or uneducated obstacles to change.

BACKGROUND: In 2018, the planned opening of a second Needle and Syringe Exchange Program (NSP) unit in Stockholm, Sweden, was stopped with reference to protests from the public. Local Stockholm media cited stakeholders who claimed that the initiative was led by politicians with "zero knowledge about what makes citizens upset" and referred to reported public concern over a preschool located near the planned NSP unit. This case highlights the significant role of the public - and the idea of public opinion - in relation to political and medial aspects of alcohol and other drug (AOD) issues. Our aim is to scrutinize how "the public" is produced in local print media reports on harm reduction measures such as the NSP, to illuminate how these representations operate and what reality/ies they co-produce. METHODS: We analyzed 171 articles reporting on harm reduction in local Stockholm print media from 2012 to 2023. The themes identified in the analysis emerged from a combination of data-driven empirical observations and a theory-driven approach grounded in the influential literature on publics and counterpublics by Michael Warner and Nancy Fraser. RESULTS: The overarching articulation in the material is that of a singular and homogeneous public. Public opinion regarding local experiences of individual drug use and harm reduction is depicted as being driven by fear and worry over living alongside "messy others", thereby producing a public of worried local community witnesses. This production of the public takes on two different meanings depending on the narrative of the articles: 1) as righteous and entitled, 2) as ignorant and irrational. As a result, the public comes to operate as either a consulted public deserving consideration in the implementation of harm reduction policies or as an uneducated political obstacle to change. Consequently, the public is assigned both a counterpublic and a dominant public identity. CONCLUSIONS: When the representation of the worried public is repeatedly echoed by the media, it becomes hard to ignore in policy-making processes. The implications of such media representations are significant, as they risk disguising the complex nature of publics as a diverse group of individuals while reproducing taken-for-granted ideas about local communities opposing harm reduction measures. In addition, the appropriation of a counterpublic identity narrows the discursive space for action. Taken together, the repetition of a singular worried public and the appropriation of the counterpublic position make it nearly impossible to imagine alternative public responses to harm reduction. As a consequence, this can limit well-needed policy responses to AOD issues.

Clinicians' Perspectives and an Ethical Analysis of Safer Supply Opioid Prescribing.

In British Columbia, Canada, many physicians providing care to individuals with high-risk opioid use disorder adopted safer supply (SS) opioid prescribing in the spring of 2020 with the goal of facilitating public health measures for COVID-19. This prescribing practice continued after measures were lifted. This study aimed to explore prescribers' perspectives following several years of local experience in prescribing SS opioids, primarily in the form of hydromorphone tablets, and to apply ethical concepts to explore current challenges and ongoing sources of provider distress. Addiction medicine SS prescribers participated in individual or small group semi-structured interviews. Each interview was transcribed and analysed for recurrent themes. Themes were then integrated into a narrative ethics discussion. Eleven addiction medicine physicians practicing in various settings within Vancouver participated in this study. Six themes were identified: clinical assessment, clinician distress, gaps in care, models of safer supply, research, and special populations. Ethical dilemmas in prescribing SS are identified and explored through a discussion of biomedical ethics principles and the physician role.

Naloxone Coprescribing and the Prevention of Opioid Overdoses: Quasi-Experimental Metacognitive Assessment of a Novel Education Initiative.

Background: Critical evaluation of naloxone coprescription academic detailing programs has been positive, but little research has focused on how participant thinking changes during academic detailing. Objective: The dual purposes of this study were to (1) present a metacognitive evaluation of a naloxone coprescription academic detailing intervention and (2) describe the application of a metacognitive evaluation for future medical education interventions. Methods: Data were obtained from a pre-post knowledge assessment of a web-based, self-paced intervention designed to increase knowledge of clinical and organizational best practices for the coprescription of naloxone. To assess metacognition, items were designed with confidence-weighted true-false scoring. Multiple metacognitive scores were calculated: 3 content knowledge scores and 5 confidence-weighted true-false scores. Statistical analysis examined whether there were significant differences in scores before and after intervention. Analysis of overall content knowledge showed significant improvement at posttest. Results: There was a significant positive increase in absolute accuracy of participant confidence judgments, confidence in correct probability, and confidence in incorrect probability (all P values were <.05). Overall, results suggest an improvement in content knowledge scores after intervention and, metacognitively, suggest that individuals were more confident in their answer choices, regardless of correctness. Conclusions: Implications include the potential application of metacognitive evaluations to assess nuances in learner performance during academic detailing interventions and as a feedback mechanism to reinforce learning and guide curricular design.

Differences in Religious Commitment and Harm Reduction Attitudes Among US Medical Students by Sex Assigned at Birth: A Pilot Study.

Harm reduction emphasizes positive change by working with individuals without judgment, coercion, discrimination, or requiring abstinence from drugs to receive support. This study examines how religious commitment and medical student attitudes toward harm reduction approaches for substance use differ based on sex assigned at birth. Participants from a US osteopathic medical school completed the revised Harm Reduction Acceptability Scale and the Belief into Action Scale. Statistical analyses revealed that males had significantly higher harm reduction acceptability scores than females. Moreover, a significant negative correlation between religious commitment and harm reduction acceptance was found, indicating that stronger religious commitment was linked to lower acceptance of harm reduction. To build on this cross-sectional exploratory study, further research is needed to delve deeper into sex differences in medical students' attitudes and the role of religious commitment in harm reduction. Future studies should explore the direction and causality of these relationships.

Co-use of psychedelics with other substances: Findings from the global psychedelic survey.

BACKGROUND/AIMS: While most psychedelic substances are considered to carry a relatively low risk of acute or long-term harm, co-use with other psychoactive substances may increase health and social harm. Using a large international survey of adults who use psychedelics, we sought to comprehensively characterize psychedelic co-use. METHODS: We used data from the 2023 Global Psychedelic Survey, a web-based survey of adults ⩾21 with lifetime use of psychedelics. We explored patterns of co-use (prevalence, secondary substances used, timing, and motives of co-use) and examined sociodemographic and psychedelic use-related characteristics associated with co-use overall and by specific psychedelics. RESULTS: In total, 5370 respondents were included in this analysis, of whom 3228 (56.3%) reported typically co-using at least one of the 11 psychedelic substances of interest, with co-use lowest for ayahuasca (14.8%) and highest for nitrous oxide (54.5%). Cannabis and alcohol were the most common secondary substances. Depressants were the only secondary substance class that increased in use following psychedelic experiences. Greater experience with psychedelics was significantly associated with co-use, as was using for recreational purposes or to reduce/substitute the use of other substances. Personal exploration and therapeutic purposes for psychedelic use were negatively associated with co-use. CONCLUSIONS: In this detailed analysis of psychedelic co-use, we observed high rates of co-use with certain psychedelics, specifically when used recreationally. Our findings highlight psychedelic-specific consumers for whom harm reduction messaging around co-use practices may be best tailored. Further research is justified to assess whether specific patterns of co-use might reduce or increase potential harms.

Virtual/Mobile Overdose Response in Canada: A Social Return on Investment Analysis.

OBJECTIVES: The overdose epidemic continues to be one of the leading causes of death in North America and continues to contribute to high healthcare costs. While harm reduction initiatives have significantly reduced the aforementioned costs, there is a dearth of evidence regarding overdose response hotlines and applications. We aim to evaluate the social return on investment (SROI) from a payer perspective of one such overdose response hotline, Canada's National Overdose Response Service, and its implications for service users, service operators, the Canadian healthcare system, and program funders. METHODS: Outcome variables determined from theory of change models were developed in consultation with the aforementioned vested interest groups. Proxy values were attributed to each variable identified through values present within existing literature and databases. These values were then compared to operational costs accounting for deadweight, attribution, and displacement to determine a final SROI ratio. A discount rate was then applied based on the influence of risk on the outcome achieved. RESULTS: The ratio illustrating the value created for all stakeholders, resulting from the $1,592,00 investment made over two years, is $15.84 per single dollar invested. The value generated stems primarily from overdose prevention, mental health support, staff employment, reductions in emergency service utilization, service referrals, and volunteer well-being, which outweigh costs including operational funding, work-related stressors, compassion fatigue, and false calls. CONCLUSION: The results of our study demonstrate that the National Overdose Response Service provides a social value that far outweighs the costs attributed to the program's operation.

Facilitators of and obstacles to practitioners' adoption of harm reduction in cannabis use: a scoping review.

BACKGROUND: Cannabis use can generate potential avoidable harms, hence the need for effective preventive measures and treatment. Studies show the efficacy of harm reduction (HR) in minimizing undesirable consequences associated with this use. Despite its proven efficacy, HR in cannabis use remains poorly applied by many health and social services (HSS) practitioners, especially with young people. However, knowledge regarding the underlying reasons for this is limited. To fill this gap, we aimed to identify facilitators of and obstacles to HSS practitioners' adoption of HR in cannabis use across OECD countries. METHODS: We conducted a scoping review, guided by Arksey and O'Malley's model. The search strategy, executed on health databases and in the grey literature, captured 1804 studies, of which 35 were retained. Data from these studies were extracted in summary sheets for qualitative and numerical analysis. RESULTS: Facilitators and obstacles were grouped into four themes: stakeholders' characteristics (e.g., education, practice experience); clients' characteristics (e.g., personal, medical); factors related to HR (e.g., perceived efficacy, misconceptions); factors related to the workplace (e.g., type of workplace). Data were also extracted to describe the populations recruited in the selected studies: type of population, clientele, workplace. CONCLUSION: Several factors might facilitate or hinder HSS practitioners' adoption of HR in cannabis use. Taking these into consideration when translating knowledge about HR can improve its acceptability and applicability. Future research and action should focus on this when addressing practitioners' adoption of HR.