There but not really involved: The meanings of loneliness for people with chronic illness.

Loneliness is one of the most pressing and rapidly growing contemporary social challenges around the world. Yet we still lack a good understanding of how loneliness is constituted and experienced by those most affected. We conducted semi-structured interviews with 40 people with chronic illness who were experiencing loneliness to explore what loneliness means to them and how it impacts in their daily lives. Drawing on ideas around liquidity and performativity, we identified the relational, temporal and social layers of loneliness. Our analysis revealed the interconnectedness of chronic illness and loneliness in participants' daily lives, as well as how chronic illness shifts temporal orientation, and transforms interpersonal relationships and relationship with self, contributing to the experiences of loneliness. Though participants described the many social conditions that restricted their opportunities for social participation, giving them a sense of being left behind and spectating the social life of others, a rhetoric of loneliness as a problem and responsibility of the individual was still prominent. A narrative of the need to perform social connection emerged in the absence of meaningful social bonds with others. We argue that normative ideals of wellness and positivity circulating in chronic illness communities and society more broadly are implicated in the experience of loneliness for people with chronic conditions. We conclude by considering how more expansive representations of how to live well with chronic illness may be important in reducing personal and collective loneliness.

Health and correctional staff acceptability of depot buprenorphine in NSW prisons.

BACKGROUND: Provision of opioid agonist treatment (OAT) in custodial settings is resource-intensive and may be associated with diversion, non-medical use, and violence. A clinical trial of a new OAT, depot buprenorphine (the UNLOC-T study), provided the opportunity to obtain health and correctional staff perspectives regarding this treatment prior to widespread roll-out. METHODS: Sixteen focus groups with 52 participants were conducted, including 44 health staff (nurses, nurse practitioners, doctors, and operational staff) and eight correctional staff. RESULTS: Key challenges to providing OAT identified as potentially being addressed by depot buprenorphine included 1) patient access, 2) OAT program capacity, 3) treatment administration procedures, 4) medication diversion and other safety issues and, 5) impact on other service delivery. CONCLUSIONS: The introduction of depot buprenorphine into correctional settings was considered to have the potential to increase safety for patients, improve staff / patient relations and advance patient health outcomes via expanded treatment coverage and efficiencies gained through enhanced health service delivery. Support was almost universal from both correctional and health staff participating in this study. These findings build on emerging research regarding the positive impact of more flexible OAT programs and could be used to engage support for the implementation of depot buprenorphine from staff in other secure settings.

Obvious benefits but hidden costs: A critical exploration of the impact of adopting the "master narrative" in Alcoholics Anonymous.

INTRODUCTION: New members of Alcoholics Anonymous (AA) typically acquire a distinct "alcoholic" identity, including AA-specific understandings of their "alcoholism" and what it means to be in recovery. Although much qualitative research on AA has presented the experiences of members who have embraced this identity and have been wholly praising of AA, other theorists have been strongly critical of the organization, often arguing that it emulates a cult. To contribute towards reconciling these competing bodies of research, the current study aimed to critically explore the impact of adopting AA's master narrative. METHODS: The study involved 19 prospective, in-depth semi-structured interviews with six AA members recruited from meetings across Sydney, Australia. Data were analyzed thematically using a master narrative theoretical framework. RESULTS: The study identified three core components of AA's master narrative: (1) Powerlessness over alcohol ("alcoholics" are powerless over alcohol); (2) Internalized pathologization ("alcoholics" are mentally and emotionally sick, above and beyond their problems with alcohol); and (3) AA as the only solution for wellness (involvement in AA is the necessary requirement for "alcoholics" to become and remain well). Although most participants emphasized the positive experiences from internalizing the AA narrative, our analysis also revealed potentially negative ramifications of this narrative on their self-conceptions and worldviews that were seemingly unrecognized by participants themselves. CONCLUSIONS: The master narrative framework facilitated a critical and balanced exploration of AA members' experiences. Although AA's master narrative is valuable for members, it could also carry costs that need to be mitigated by resources both inside and outside of AA.

Examining Relational Dimensions of Service Encounters for Disadvantaged People Who Use Drugs.

INTRODUCTION: Disadvantaged groups in general, and people who use illicit drugs in particular, have consistently been found to mistrust welfare services and service providers. Therefore, knowledge is needed on the relational aspects of service design that facilitate engagement and supportive relationships with disadvantaged consumers. METHODS: We draw on qualitative interviews investigating the experiences of adults with histories of problematic drug use participating in a health justice partnership, to identify facilitators of engagement from the perspective of the consumers. FINDINGS: Common relational facilitators of engagement were identified. These included embedding the service into the local community, foregrounding proximity and relationships in the service encounters, giving consumers' agency, priorities, and concerns primacy over program aims, and safe services acting as gateways to accessing a wider range of resources, services, and programs. CONCLUSION/CONTRIBUTION: The findings suggest that the centrality of relationships may be further heightened in services seeking to assist people in positions of severe disadvantage, including the drug and alcohol arena. In addition, the findings highlight the importance of services paying greater attention to how social and community embeddedness shapes experiences of inclusion and exclusion and designing services best able to accommodate this. This research contributes to the broader understanding of consumer engagement with services by developing a more nuanced understanding of consumer refusal and resistance to service engagement. These findings are important in the development of justice programs for disadvantaged people and people who use illicit substances specifically.

Collectively learning to talk about personal concerns in a peer-led youth program: A field study of a community of practice.

Youth peer-support is an increasingly established approach to youth work. Drawing on Wenger's theory of a 'community of practice', this study explored social learning processes in an Australian community-based and peer-led youth program for young people from disadvantaged backgrounds. Social learning was conceptualised as arising from processes of 'negotiated meaning', which Wenger described as a duality of 'participation' and 'reification'. The study was designed as a qualitative field study drawing on participant observation data from weekend workshops and 16 semi-structured interviews with young program participants. Results indicate that the program was highly conventionalised with repeated practices reifying the meaning negotiated by the participants. However, it was also open for participatory negotiation of meaning through which participants learned to recognise and share their own and others' vulnerabilities, which created a strong sense of belonging to a community of equals. The study's conception of social learning offers a novel explanation of how the youth program created and sustained alternative transformative spaces. This was done through simple, repetitive and highly conventionalised practices, brokered by peers, that allowed participants to recognise and address their own and others' vulnerabilities in new ways.

The politics of belonging in Alcoholics Anonymous: A qualitative interview study.

A prevalent critique of Alcoholics Anonymous (AA) is that members must adopt an inflexible illness narrative, taking on an "alcoholic" identity and performing a set of practices to address this condition. Conversely, a small body of research suggests that, rather than comprising the uniform adoption of a rigid narrative, integration into AA is achieved by negotiating individual beliefs, values, and preferences with the AA model. To investigate such processes of negotiation, the current study aimed to explore the politics of belonging in AA. The study involved semi-structured interviews with 15 AA members recruited from meetings across Sydney, Australia, and data were analyzed thematically. Findings illustrated how participants navigated the politics of inclusion/exclusion within AA. While some aspects of AA were found to be negotiable by participants, a non-negotiable aspect of AA ideology that emerged was the axiom that "alcoholics" have no control over alcohol and therefore should maintain abstinence. Findings raise questions about how the politics of belonging in AA may shift over time following broader patterns of societal change.

Developing a model of care for substance use in pregnancy and parenting services, Sydney, Australia: Service provider perspectives.

INTRODUCTION: The absence of a clear model of care for services supporting pregnant women and mothers with substance use disorders has impeded opportunities to build an evidence base for the effectiveness of these services. Previous research has typically focused on the needs of pregnant women or mothers, as two distinct groups. This paper explores service providers' perceptions of key components of a model of care, extending from perinatal care to community-based support for up to 17 years post-delivery. A model of care is outlined and feasibility factors affecting implementation are highlighted. METHODS: Qualitative methods were adopted as a first step to informing development of the model of care. Semi-structured in-depth interviews were conducted with thirty-eight staff providing a range of substance use in pregnancy and parenting services (SUPPS) in hospital and community-based agencies, in a metropolitan health district in Sydney, Australia. Interview data was entered into NVivo and analysed using constant comparative methods. RESULTS: Guiding principles for the model of care included integrated care, harm reduction and person-centredness. Practice approaches integral to the model of care were promoting engagement with women, flexible service provision, trauma-informed care, and continuity of care. Feasibility factors influencing implementation of the model of care included fragmentation or siloing of the service network and workforce sustainability. CONCLUSIONS: A harm reduction approach was crucial for promoting engagement of women with SUPPS, particularly child protection services. A greater focus on providing ongoing community-based support for mothers also has the potential to achieve sustainable positive outcomes for women and children. Implementation of the SUPPS model of care could be undermined by threats to integration of service delivery and continuity of care. Further research is needed to explore consumer perspectives and inform the model of care as a framework for evaluation.

Care Coordination for Vulnerable Families in the Sydney Local Health District: What Works for Whom, under What Circumstances, and Why?

INTRODUCTION: Healthy Homes and Neighbourhoods (HHAN), an integrated care programme in the Sydney Local Health District (SLHD), seeks to address the needs of disadvantaged families through care coordination, as one of its components. This research aims to determine for whom, when and why the care coordination component of HHAN works, and establish the reported outcomes for clients, service-providers and partner organisations. METHODS: Critical realist methodology was utilised to undertake a qualitative evaluation of the impact of care coordination. Purposive sampling was used to select a total of 37 participants for interview, including consumers, service-providers and key stakeholders. Thematic analysis was undertaken to derive the major modes of intervention of HHAN, and data representing these elements was coded and summarised under contexts, mechanisms and outcomes. RESULTS: Analysis indicates that care coordination has a positive impact on clients' sense of independence, self-awareness and outlook on life. Trust and favourable interpersonal relations were identified as major underlying mechanisms for a successful client-provider working relationship. The identified modes of intervention facilitating positive consumer outcomes included accessibility, flexibility and service navigation. Persistent siloes in health and systemic resistance to collaboration was seen to hinder effective care delivery. CONCLUSIONS: This study suggests that a care coordination model may be effective in engaging disadvantaged families in healthcare, assist them in navigating the health system and can lead to beneficial health and social outcomes. Successful implementation of care coordination requires flexible programme design and experienced and skilful clinicians to fulfil the care coordinator role. There is a need to appreciate the negative impact that the complex and siloed health system can have on disadvantaged families.

Health and social interventions in the context of support and control: The experiences of marginalised people who use drugs in Australia.

People who use illicit drugs frequently become targets for welfare intervention, often positioned both as complicit in the reproduction of intergenerational poverty and marginalisation, and as sources of hope for interrupting such patterns. This article draws on empirical research exploring the experiences of highly marginalised people with histories of illicit drug-use to investigate how they negotiate service encounters in the context of the participants' previous experiences with welfare interventions. In doing so, the article seeks to texture the conception of the support and control nexus, drawing out the systemic and service level factors of welfare services which inhibit people who use drugs from benefitting from available support. We conducted 12 in-depth interviews with participants subject to interventions by health, social or legal services between July and September 2018. All interviews were audio-recorded, transcribed verbatim and coded in NVivo. Transcripts were analysed using a grounded theory approach where data were subject to an iterative process of constant comparisons to identify emergent themes and theoretical concepts. The findings suggest that the blending of welfare services and systems of control has unintended and often negative consequences for highly marginalised people. In effect, the drug treatment programme's aims of assisting people to reduce harm and increase stability are significantly undermined by control mechanisms such as mandatory reporting policies. A better understanding of the ways in which welfare service processes alienate marginalised people from seeking support, as well as from benefitting from the support available, might provide a way to address these concerns.