Effective provider-patient communication is crucial to the delivery of high-quality care. Communication roadblock such as righting reflex is widely observed among providers and can lead to relational disengagement. In previous work, nurses felt ill-equipped to communicate effectively with HIV-positive patients to support medication adherence. Providing nurses with continuing education opportunities to improve their relational skills is a major target for optimizing the quality of care. Virtual patient simulation is one promising strategy that needs to be evaluated among graduate nurses. This study aimed to assess the acceptability of a virtual patient simulation to improve nurses’ relational skills in a continuing education context.n = 49) working in Quebec, Canada. Participants completed an online sociodemographic questionnaire, consulted the automated virtual patient simulation , and filled out an online post-test survey. Descriptive statistics  were used to present quantitative findings. From the 27 participants who completed the simulation and post-test survey, five participated in a focus group to explore their learning experience. The discussion transcript was subjected to thematic analysis. At the final stage of the study, we used a comparison strategy for the purpose of integrating the quantitative and qualitative results.We conducted a convergent mixed methods study by combining a quantitative pre-experimental, one-group post-test design and a qualitative exploratory study. We used convenience and snowball sampling approaches to select registered nurses (Nurses perceived the simulation to be highly acceptable. They rated the global system quality and the technology acceptance with high scores. They reported having enjoyed the simulation and recommended other providers use it. Four qualitative themes were identified: motivations to engage in the simulation-based research; learning in a realistic, immersive, and non-judgmental environment; perceived utility of the simulation; and perceived difficulty in engaging in the simulation-based research.The simulation contributed to knowledge and skills development on motivational interviewing and enhanced nurses’ self-confidence in applying relational skills. Simulation holds the potential to change practice, as nurses become more self-reflective and aware of the impact of their relational skills on patient care.ISRCTN18243005, retrospectively registered on July 3 2020.The online version contains supplementary material available at 10.1186/s12912-021-00740-x It widely documented that communication is an essential, core competency for all healthcare providers (HCP), including nurses . EffectiConsidering the barriers that keep some HCP from attending CE activities, such as staff shortage, cost, travel time, and competing demands , the useUse of VP simulation in health professional training has grown exponentially in the past decade, as many literature reviews in the field have shown –18. MediThis study aimed to quantitatively and qualitatively assess the acceptability of a VP simulation to improve nurses’ relational skills in a CE context. This study is part of a doctoral dissertation . AcceptaOur specific research objectives were: a) to measure the extent of the VP simulation nurses’ perceived acceptability in regards of the simulation design elements, of the global system quality and the technology acceptance, of the role simulation plays in supporting nurses’ professional practice, and of the achievement of learning objectives (quantitative objective); b) to explore nurses’ learning experience ; c) to deepen understanding of how the VP simulation contributed to nurses’ uptake of relational skills, to overall learning and its transfer into practice (mixed methods objective).To fill the gap in this type of educational intervention available for nurses and to address the communication roadblock , we deveWe conducted a convergent mixed methods study Fig. . This miWe used convenience and snowball sampling approaches to select registered nurses working in Quebec (Canada) who self-reported having basic computer literacy skills. Convenience sampling is advantageous in terms of affordability and of the immediate availability of the participants. Given the engagement required when participating in an online study, we were looking for nurses who had time and were motivated to complete the whole research process. Nurses were also asked to share the information with their colleagues . Snowballing sampling is considered an effective and efficient approach to building a sample through the Internet . We usedWe collected quantitative data with LimeSurvey  with online post-test survey totalizing 80 closed questions on: 1) VP simulation design elements; 2) global system quality and technology acceptance; 3) role of simulation in supporting nurses’ professional practice; 4) achievement of learning objectives. We used a 4-points Likert scale . We developed the majority of the questionnaire for this study  following their participation in the simulation.Open-ended questions were asked in the post-test survey to gain complementary insights about: a) the VP simulation design elements ; b) the achievement of additional learning objectives; c) the most and least appreciated elements of the VP simulation; d) recommendations to improve the simulation.The pre-intervention questionnaire included information on nurses’ sociodemographic characteristics, such as age group, gender, education level, workplace setting, previous MI training, and computer literacy skills.A total of 30 participants was targeted to take part in the simulation and fill out the post-test survey. This sample size was determined according to recommendations for pilot studies , 41, conA descriptive statistical analysis was conducted using Microsoft Excel version 2013 (Microsoft Corporation). Means (m), standard deviations (SD), median (med), and interquartile range (IQR) were calculated for continuous variables as well as for counts and percentages for the categorical variables. Fisher’s exact test was performed to compare the proportions of participants’ characteristics at baseline between completers and non-completers. This statistical test is justified when the sample size is small .The focus group used a semi-structured conversational approach. It aimed to describe in greater detail and further nuance participants’ experience of the VP simulation as well as deepen our understanding of particular quantitative items, such as the utility of the VP simulation. The questions used to guide the focus group Table  covered The focus group recording was transcribed verbatim. Qualitative data analysis followed an inductive and iterative process. We thematically analyzed narratives from the focus group , 45. CodCredibility as a source of trustworthiness , 47 was Once quantitative and qualitative data were collected and analyzed separately, both components were integrated using a comparison of results strategy . We firsWe reported the quantitative component, including the simulation description, with CONSORT EHEALTH  Additio. We usedn = 27) and non-completers (n = 22) is presented in Fig. The participant flow chart of completers (Most of the completers held a bachelor’s degree. They had been working as nurses for an average of 18 years. Eighteen nurses (66.67%) had experience as HIV nurses. Eight nurses (30%) had previous MI training. Majority of participants  reported being confident in their computer skills.From these 27 completers, five nurses took part in the qualitative component: two men and three women. They worked with different clienteles, including people living with HIV (PLHIV). Four nurses were trained in MI. Additional completers and non-completers’ characteristics are presented in Table Participants were recruited in person , i.e. by being informed by a colleague or by the student-researcher; by e-mails sent by the Quebec order of nurses  and the HIV mentoring program .The detailed quantitative findings are presented in the additional files: the simulation design elements  of participants watched the video content and 78% read the corresponding text on the context of the simulation. Most of the participants (89%) felt that, to understand this context, it was key to have access to both text and video.All participants agreed that the labels constructively supported their learning. Some 96% found that these cues were key to qualifying the content of the nurse-patient dialogue. All participants agreed that quizzes made them reflect on their nursing practice and they saw themselves in the quiz answers.Almost all participants (96%) agreed that the feedback was provided in a timely manner (i.e. as the consultation progressed). All participants agreed that the feedback allowed them to make connections between the simulated situations and the theoretical elements of MI.A majority of participants agreed with the simulation’s fidelity: the patient’s story (96%), the HIV-positive man’s appearance (96%), the nurse-patient interactions (93%), and the nurse’s office (85%) were all perceived as authentic.service quality construct among participants who used the VP simulation support services (11/27). The interface design quality (3.54 ± 0.55) was the second construct with the highest score of the global system quality dimension, followed by system quality (3.51 ± 0.54) and by information quality (3.49 ± 0.50).The mean score was rated a 3.65 (±0.48) for the intention to use (3.53 ± 0.60) the VP simulation. Nurses perceived enjoyment (3.47 ± 0.57) and an ease of use (3.42 ± 0.67) with the simulation. The lowest mean score of the technology acceptance dimension was the perceived usefulness (3.35 ± 0.71), which is, above all, highly acceptable.Participants had a good The items with the highest scores were: simulation led nurses to reflect on their practice in general, not just with PLHIV (3.58 ± 0.58); the content will lead nurses to improve their communication skills with clienteles other than PLHIV (3.50 ± 0.51), the health of PLHIV (3.50 ± 0.51), and the quality of therapeutic relationships with PLHIV (3.50 ± 0.51).Scores on the achievement of objectives ranged from 3.35 to 3.58, indicating a favourable assessment by participants. These two learning objectives had the highest scores: identification of traps within nursing interventions that can shut down communication with the patient (3.58 ± 0.50), and those that can optimize openness to the patient’s experience (3.54 ± 0.51).Four main themes are presented: 1) Motivations to engage in the simulation-based research; 2) Learning in a realistic, immersive, and non-judgmental environment; 3) Perceived utility of the simulation; and, 4) Perceived difficulty in engaging in the simulation-based research.I was curious to see this new training modality because I have already followed MI training, and sometimes we’d practice with a coworker. I was curious to see how far we could get with the simulation. Nurses perceived that the simulation could be applicable and coherent in their own practice with different clienteles , and, more broadly, to a variety of contexts:[The simulation] was addressing the issue of adherence to HIV treatment and I felt that [the topic] fit in well with my practice. I thought [the simulation] was something that was interesting and not just about HIV [...] it was something that could be transferred to other areas of activity. Finally, the desire to learn new knowledge or strengthen existing knowledge about MI and HIV were factors motivating nurses’ participation.I found it important to do this training to learn things about HIV but also about motivational interviewing, which we do daily, enormously, at our office. Participants identified several reasons for taking part in the simulation-based research. First, the simulation offered accreditation and was free of charge, which were appealing incentives. Second, nurses reported that their interest and curiosity had been stirred by the learning modality, which was perceived as innovative, stimulating, and interactive, and by the way MI could be transposed into technology:Maybe this is because I’ve done a lot of work around the issue of taking antiretroviral treatment, so I found the [VP’s] situation ... maybe less typical... At the same time, I realized that it was not necessarily very important. Eventually, you forget about the situation, you know, because [the learning activity] is more about how to react to interactions with the patient [...] I was more focused on what he was saying than the image. I think it’s a really strong point of [the learning activity] that we got really into it. One nurse’s first impression was the VP’s resemblance to a puppet, which lead him to wonder about the seriousness of the learning activity. The patient’s appearance could have caused this participant to lose interest in the learning experience, but eventually this image of the VP gave way to a more human and realistic impression:At first, I thought [the VP] looked like a puppet [...] I kind of wondered if [the simulation] was for real. I don’t really want to question its seriousness … Beyond the caricature, I could see the patient asking himself questions; he was squinting a little. Human beings do that. They’re not puppets [...] And as I went along doing the interview, I saw there was communication between the nurse and the patient. And [my impression] faded away. Two participants compared the simulation to physical presence-based group learning, where MI must be practiced through role-playing with a coworker. The simulation was seen as an advantageous way to reproduce a real interaction with a VP, reducing the discomfort and bias of practicing with someone, and fostering the learning progress:In classic training activities, we practice with a coworker. I find that quite biased because we’ve both just learned the theory; we try to apply it; the other person has just learned the same thing so, in the end, well, we help each other only a little bit. But here, we were faced with a virtual character who is very realistic. I find it even more real than with, shall we say, another trainee. But for people who are shy in groups, [the simulation] is really very accessible and allows them to progress. Compared to group training activities, the simulation provides freedom while targeting individual learning and performance:I think that doing it one by one, well, alone, allows something that is not necessarily possible in a group training activity. It’s even more in-tune with what you would actually do. There is no judgment. There are no right or wrong answers. [The simulation] allows you to answer more freely. Two nurses who were experienced in providing HIV care reported the VP’s story to be an uncommon one for non-adherence, but felt that it was nonetheless credible and realistic. What they felt to be most important was the nurse-patient interaction, which allowed to immerse themselves in the simulation:“I feel like I got real practice.” .Finally, this participant summed up her experience: We identified three sub-themes as part of this theme: developing reflective learning and transferring it to practice, being present and revisiting relational skills, and acquiring and consolidating motivational interviewing knowledge and skills.It was fun because it’s like action/reaction. It was immediately obvious if you asked the question wrong, you could see the effect. I found it interesting because if you took a wrong action, you could get back on track. That way, we could understand why it was a mistake. This participant, who did the entire virtual simulation twice, reported a progression of his learning, building on the mistakes he had made:The first time, I made a lot of mistakes because I told myself that I was going to go with my knowledge and experience. The second time, I did it with my new knowledge. It gives you parallel vantage point onto yourself, onto your own beliefs. The simulation thus allowed participants to reflect and take a critical look at themselves and their practice, becoming aware of past mistakes and the impact of their interventions on their relationship and interactions with patients:You’re never neutral in a MI. Yes, you’re the care provider, but you’re a person. It can set certain limits or can even make you get stuck in it. [The simulation] makes you aware of who you are through all this. .Look, if patients don’t react or aren’t motivated, well, maybe it’s because I too am playing a part as the care provider: maybe I am not addressing them in the right way, maybe I am not considering them in their entirety, according to their beliefs and values. The interactivity inherent to the simulation supports this reflexive process, which in turn can lead to transferring learning to real practice, and thus improve it:When you’re one-on-one [with a young person], sometimes you’ll answer off the cuff because you’re in a hurry. If you’ve practiced [the situation] in simulation, you’re going to know that whatever you said was not so great, you know, you’re going to question yourself. So, you’re going to be more careful when a similar situation occurs in reality [...] I’m going to try saying it differently to help the person get a little further. It makes you better. This participant questioned his past interventions, in which he hastily presumed the cause of non-adherence  when interacting with his clientele. After participating in the simulation, this nurse stated his intention of changing his way of intervening so that he better understands the patient’s situation, before drawing conclusions:Do I go too fast sometimes? Telling myself that, well, he didn’t take it [his treatment], that he must have relapsed, always jumping to my conclusions first. Don’t I miss things sometimes, too? I was thinking that maybe now I will be more careful and try to understand the patient’s reasons and stop just saying ‘Ah, well, he didn’t take it.’ All the nurses mentioned the simulation’s capacity to promote mistake-based learning through quizzes and feedback loops:It helps nurses understand or realize that it’s important to listen, to be there in the here and now. More and more, we have our electronic medical records, we write in the record and don’t even look at the patient. We no longer take the time to actually look at the patient because we are so busy on our computer... It’s really worth it to sit down and look at the patient and just be present with them. The simulation had a positive influence on revisiting ways of communicating and asking patients the right questions to support them in reflecting and identifying their own solutions:I’d say it’s more in the way the questions are asked. It’s really focused on open-ended questions, and solutions that come from the patient. We [nurses] may have solutions, but they have to come from them [the patients], and that’s when they are most effective [...] How can we ask questions that bring out the best in the patient? The simulation alerted the nurses and raised their awareness of how they relate to patients, creating optimal conditions for successful relational practice and mobilizing communication skills that allow patients to express themselves and, especially, to find their own solutions.The simulation helped to underscore the importance of listening to patients. This meant being present, available during the consultation and living in the “here and now”:I’d read a little about MI, but I’d never done any training. I didn’t expect to learn so much in such a short time. Moreover, for another participant, who had received training in MI and who does not practice directly with patients, the key lays in putting theoretical elements into action with the VP. Consequently, the simulation-facilitated practice helped reinforce her knowledge and feelings of competence in applying MI:I had already had some MI training. [The simulation] reassured me a bit that, actually, I was competent and that I would have been good, face-to-face, with a patient. So, it just confirmed this for me. Because there’s always a doubt about MI being this huge thing. But in the end, you know, we just lack practice. And I found that the platform meant that I was able to strengthen my nursing practice and my past theoretical learning, since I don’t see patients every day. For the other three participants who had previous MI training, the simulation helped them better understand the theory and refresh their knowledge, as well as learn how to better apply it. Simulation as a learning modality thus seemed to benefit nurses with various levels of MI training and knowledge.One participant with no prior MI training considered the simulation to be an effective and efficient way to achieve intensive learning:I’m not saying the workflow was slow... but maybe that’s why some people didn’t finish the training activity. I’m not saying it was repetitive, but maybe if they feel it was too slow... When the patient talks, he moves his arms around, and sometimes there was a little delay. This was maybe a feeling I had, since I was persistent at first. One participant did not like the simulation’s lack of progress indicators, which she felt might also have discouraged others. Individual and time-related elements were another hypothesis for some participants’ withdrawal:Perhaps a lack of time or a drop in motivation along the way. When I start something, I like to finish it. So maybe it’s question of personality, too. We asked participants in the focus group to reflect on the difficulties they experienced in completing the study, or those they heard their coworkers mention. Technical difficulties were noted as one of the main potential explanations of some participants’ withdrawal, either because of the complexity of creating an account, the delay between the characters’ words and movements, or the system’s slowness. Individual perseverance became important in this context:Using the pillar integration process  and that could be improved. The nurses said that practicing with the VP and getting synchronous feedback that mirrors their actual practice would help them avoid replicating ineffective patterns. The simulation therefore contributed to educating and raising awareness of self, as nurse, and of others (i.e. patients), and underscored the importance of nurses’ presence, open-mindedness, availability, and good listening.role of simulation in supporting nursing practice, participants reported having learned something new. They also expressed having built self-confidence. Indeed, they felt capable of applying communication skills and of facing similar situations with PLHIV and other clienteles in the future. The qualitative results reinforce these findings, reflecting the simulation’s influence on nurses feeling better prepared and equipped to apply MI with their clienteles, to consolidate their practice, and thus to reinforce their sense of confidence and competence.By assessing the Overall, nurses perceived that VP simulation is highly acceptable, if we consider that the great majority of means were above 3, on the 4-point Likert scale. The quantitative results were highly consensual in favour of simulation design elements, global system quality and technology acceptance, the simulation’s role in supporting nursing practice, and the achievement of learning objectives. The qualitative results nuanced, deepened, and even added new elements (e.g. motivation to participate and difficulties encountered) to the quantitative results. The integration of quantitative and qualitative findings drew a full portrait of the continuum of the nurses’ simulation-based experience, the VP elements that contributed to their immersive learning, and its potential transfer to their practice. Four mixed method interpretations were described: 1) Influence of the simulation’s fidelity on nurses’ impression of getting a real practice and having an immersive learning experience; 2) Simulation’s perceived flexibility, efficacy, and control over one’s learning led to a positive learning experience; 3) Taping self-awareness and reflection in relational practice; 4) Acquiring new knowledge and building self-confidence.motivations to engage in the simulation-based research brings a new element to the quantitative results, which could not capture this perspective. We created and reinforced what Moore et al. [teachable moment in order to influence the enrollment, participation, and engagement of nurses in this learning activity. To do so, we shared information about the project via different channels, with a view to reaching a variety of nurse profiles. The majority of nurses who completed the VP simulation was recruited through in-person strategy (16/27). The social influences, such as recommendations by colleagues, are recognized as facilitators to the self-directed learning of physicians in CE, alongside with affective attitude  and training accreditation [The qualitative theme e et al.  call a tditation . Learnerditation , 56.VP simulation led to immersive, realistic, active, and constructive learning experiences. Prebriefing was planned in the VP simulation codevelopment process  and is cFeedback is considered to be the most important feature of effective learning , 59. Indif the learner adopts a relational skill consistent with MI (e.g. a guiding style of counseling vs a directing one), then it will open the dialogue with the patient. One participant clearly expressed this mode of fidelity by the “action/reaction principle.” Finally, participants in the focus group reported the sense of having truly practiced; they found that simulation was an effective learning approach, reflecting the emotional and experiential mode of fidelity [In light of our results and when comparing with the literature, it is reasonable to believe that different modes of fidelity, be it physical, conceptual, emotional/experiential , 63, notfidelity . This mofidelity , 63.n = 168) targeting health professions workers [It would seem that the benefits of the simulation extend beyond the learning of the recommended communication techniques to encompass a relational component: being present, taking the time to listen carefully and understanding patients without falling prematurely into professional preconceptions. This relational component is aligned with partnership, one of the vital aspects of MI  that has workers  sheds lin = 38 articles) [Our findings also corroborate those of a qualitative studies , 68 and rticles)  that exprticles)  and underticles) . The finrticles) . VP simurticles)  and deven = 80 items) and comparing these to the qualitative data that was focused on circumscribed thematic. The second was the unequal sample size . Use of the joint display was helpful in putting together data and results that can be compared and discussed. Limitations of one method associated with the present of the other method are described in further details in Additional file As far as we are aware, this is the first study to examine the acceptability of a VP simulation informed by MI to improve nurses’ relational skills in a CE context. This mixed methods study led to a gain in complementary and rich data, providing a comprehensive picture of nurses’ learning experience. However, two main challenges were encountered during the integration. The first was dealing with huge numbers of items and data in the quantitative survey  and those that are related to healthcare professionals themselves  when using VP simulation to apply the resulting MI-inspired relational skills. Considering that reflective learning was an important finding, this aspect could be deepened by exploring the underlying causal mechanisms that lead users to improve their relational skills and to put these latter into practice. Future work could be guided by these research questions: What are the contexts and mechanisms that allow healthcare professionals to integrate MI-consistent relational skills into their professional practice? How does the VP simulation produce different outcomes? Additional research could be conducted to examine how simulation-based intervention change nurses’ practice and how practice-change behaviour translates into patient outcomes .Relational skills are fundamental to high-quality nursing care. Findings from this mixed methods study provided critical insight into nurses’ perception of the simulation’s high acceptability. It holds potential to change practice, as nurses become more self-reflective and aware of the impact of their relational skills on patients. VP simulation particularly contributed to knowledge development on MI, on how self-confidence in applying relational skills can be increased by practicing with the VP. Nurses’ participation in the simulation contributed to immersive, positive, and constructive learning experiences. The study highlights the value and novelty of VP simulation for CE in nursing.Additional file 1. CONSORT-EHELTH_UNformat_citations - Reporting guidelines - CONSORT-EHEALTH (Quantitative component of the study).Additional file 2. Questionnaire – Online questionnaire developed for the study.Additional file 3. Pillar integration process – Description of the integration of quantitative and qualitative data and categories.Additional file 4. CHERRIES_UNformat citations - Reporting guidelines – CHERRIES (for the online questionnaire).Additional file 5. COREQ_UNformat citations - Reporting guidelines – COREQ .Additional file 6. GRAMMS_UNformat citations- Reporting guidelines – GRAMMS (Mixed methods component of the study).Additional file 7. VP simulation design elements – Quantitative findings.Additional file 8. Techno acceptance – Quantitative findings based on the Technology Acceptance Model.Additional file 9. Simulation’ role to support practice – Quantitative findings.Additional file 10. Achievement learning objectives – Quantitative findings.Additional file 11. Operationalization integration – Application of the pillar integration process and an excerpt of the joint display.


People who use drugs (PWUD) face a multitude of barriers to accessing healthcare and other services. Mobile health clinics (MHC) are an innovative, cost-effective health care delivery approach that increases healthcare access to vulnerable populations and medically underserved areas. There is limited understanding, however, of how PWUD perceive and experience MHCs.Semi-structured interviews were conducted with 31 PWUD – 16 who had received care (clients) on an MHC (The Spot) and 15 who had not (non-clients) – to explore their perceptions and utilization of an MHC partnered with a mobile syringe services program in Baltimore, Maryland. Data analysis of the text was conducted using an iterative thematic constant comparison process informed by grounded theory.Clients and non-clients, once aware of the MHC, had positive perceptions of The Spot and its benefits for their individual health as well as for the wellbeing of their community. These sentiments among clients were largely driven by access to low-barrier buprenorphine and service delivery without stigma around drug use. However, lack of general awareness of the spot and specific service offering were barriers to its use among non-clients.People who use drugs perceive a mobile health clinic in their neighbourhood as a benefit to their communities and themselves by improving access to healthcare services, providing access to low-threshold buprenorphine dispensation, and offering services without drug use stigma.People who use drugs learned about a mobile health clinic in their neighbourhood largely through word-of-mouth. As a result, people received limited information about the mobile health clinic services creating a barrier to its use.MHCs provide an important opportunity to engage PWUD in healthcare and to expand buprenorphine use; however, even with accessibility near where PWUD access injection equipment, barriers to its use remain. Peer dissemination may be able to facilitate program information sharing and recruitment. The U.S. is in the midst of an opioid epidemic with continued increases in opioid-related morbidity and mortality that were worsened by the COVID-19 pandemic . People PWUD, however, face a complex array of barriers to accessing medical care. These barriers occur at the individual – , interpersonal – (e.g. drug-use stigma among providers), healthcare systems – , and structural –  level . As a reMany of the multilevel barriers to accessing healthcare also impede access to medications for opioid use disorder (MOUD). MOUD, specifically methadone or buprenorphine, is the most effective treatment for opioid use disorder (OUD) and has been shown to reduce opioid use and risk of overdose ,33, incrPeople with OUD additionally face barriers to accessing MOUD beyond the service gap. Program and systems-level barriers such as requirements for admission into an OTP and compliance requirements can be burdensome for patients ,47–49. SGiven the challenges PWUD experiences in accessing healthcare services and MOUD, low-threshold service models have the potential to improve utilization. Low-threshold service models emphasize engagement and harm reduction approaches while aiming to reduce barriers to access . Mobile MHC remain underutilized, however, and Yu et al. have identified four categories of challenges and potential limitations to implementing MHC – risk of fragmented care, financial challenges, space and clinic structure barriers, and challenges in logistical planning . For exaDespite these challenges, MHC are a promising tool to provide healthcare to vulnerable populations and medically underserved areas ,59, inclHealthcare on the Spot (henceforth referred to as The Spot), an MHC jointly operated by the Baltimore City Health Department (BCHD) and the Johns Hopkins School of Medicine, was initiated in 2018 to increase access to healthcare among people who use drugs . Like muThis qualitative study was embedded into a cluster-randomized trial designed to determine the community-level effectiveness of an integrated care mobile clinic co-located with a mobile SSP [ClinicalTrials.gov Identifier NCT0356717]. We recruited PWUD from The Spot and SSP vans at four sites in Baltimore, Maryland between March and October 2019. Recruitment site selection  was based on the larger study’s recruitment and/or the days The Spot was able to have recruitment occur based on staffing and client flow. Persons were eligible to participate in an interview if they were 18 years or older and a current client at The Spot and/or the SSP. We aimed to interview approximately equal numbers of participants that had and had not used services on The Spot. By interviewing clients and non-clients, we hoped to better understand the range of perceptions of The Spot and barriers to its utilization by PWUD, and identify potential unique barriers faced by those who had not used the services offered. The number of interviews conducted was determined by the scope and nature of the study (e.g. narrow scope) , recommeEligible individuals were invited to complete the interview in a private room within a nearby research van after receiving their services from The Spot and/or SSP. Interviews were conducted by a medical anthropologist (SG) who was not associated with The Spot or SSP. The interview guide followed a semi-structured format and included discussions about several topics related to healthcare utilization and drug use, including current health concerns and healthcare use, positive and negative healthcare experiences (including experiences of drug use stigma), current drug use behaviours, access to and utilization of harm reduction services, and current and/or previous experiences with MOUD. Clients of The Spot were also asked about their experiences utilizing the mobile clinic, and non-clients were asked about their awareness of The Spot and interest in using an MHC. Demographic information  was collected at the start of each interview. The interview guide was initially developed by SG and SS and then reviewed by other members of the team, including healthcare providers on The Spot. Interviews lasted approximately 1 h and were audio-recorded with participant permission. Participants were compensated $20, and water and snacks were available.The audio recordings were transcribed verbatim by a professional transcription company and cleaned of identifying information (e.g. names). Data analysis of the text was conducted using an iterative, thematic constant comparison process . The leaThirty-one interviews were conducted with PWUD – 16 with persons who were current clients of The Spot and 15 who were current clients of the SSP but had never received services at The Spot. Participant characteristics for each group are reported in Participants had often experienced drug-use stigma while accessing healthcare services previously but felt that The Spot provided an opportunity to receive services without such judgement. Since The Spot was co-located with the SSP, non-clients trusted that The Spot staff would treat them the same as the SSP staff do – without any judgement. For example, a 42-year-old female non-client explained: “They’re coming in this neighborhood so they pretty much know what to expect… Yeah, so I’m thinking they know what to expect so they’ll be a little bit more sympathetic”.Non-clients shared an expectation that The Spot staff would be caring and non-judgmental, and the clients described this as true. When discussing their experiences using services at The Spot, participants overwhelmingly focussed on the van staff: “I think they’re great. I think they help people, they care, they’re nice, I couldn’t imagine it being anything better than that, what they are now. I think they’re doing a good job”. The staff was described as being welcoming, positive, caring, considerate, non-judgemental, encouraging, and supportive. Talking about the support he felt from his provider, a 32-year-old male client discussed being open about drug use:Participant: Yeah, I tell them [about recent drug use], yeah, I’m always honest, that’s the one thing the lady told me was, “Just be honest with me upfront.” And I have, and I have.: How has that been, talking about that?InterviewerParticipant: Helpful…Because first of all I could feel they know I’m telling the truth and then it’s just like they’re not just giving up on me, you know, they’re working with me, they’re trying to work around, seeing how we could fix it or how we can adjust it to make it work and make it better and I really appreciate that.Many participants spoke about the providers with great emotion, getting overwhelmed by the support and encouragement they have received on the van. A 25-year-old female client said, crying, “He [the provider] makes me feel like I can do it. You know, I can do it…People are seeing you. You’re trying to get it [stop using drugs]”.The social and physical space provided by The Spot was viewed as a strength of the MHC among clients, although a few non-clients did acknowledge this, feeling that The Spot allowed for greater privacy:I’d rather walk out and [go to The Spot] than have to get all the way to the hospital. I would probably avoid that because it’s just a longer, drawn-out process. This is, I feel, more secluded and—you know what I mean? Just more one-on-one, like not—to go in front of a hospital and everybody’s around and stuff. Although small, clients were comfortable receiving services in the mobile clinic. This partially was influenced by the social space created by the staff. Clients spoke, for example, of the positive environment on the van: “[The] people are very kind and they sincerely care, they really do and they’re down to earth. You can just feel the aura, it’s definitely a positive feeling as soon as you step on that van” . Similarly, a 53-year-old female client said, “They’re cool. <laughs>… You come in there with your face down and they make you laugh before you leave”. Physically, the space allowed for a confidential conversation, and clients did not have concerns regarding the security of their privacy: “Everybody still has their own personal space [to be seen]” . Similarly, a 63-year-old female client felt comfortable, saying, “They [people waiting on the van to be seen] can’t hear you. Well, I can’t hear nobody when they’re in there”. Overall, the social and physical space was viewed as positive: “The madness is out there [outside]. There’s nothing mad about in here. The madness is out there. So once you get on the van you’re pretty much good” .Non-clients and clients believed that an important benefit of The Spot to their communities was that it allowed people to rapidly access treatment when they were ready to do so. A 59-year-old male client said, for example: “Try to keep them out here as long as they can in this area. Because it’s so many people out there lost, man. They lost. Lost…. Sometime what you could have done you might not be able to do later on down the road, so jump at it while it’s there. Things change every day”. Similarly, a 42-year-old female non-client described how much easier it would be for her to access treatment from The Spot when she was ready:Because, for instance, if I could just walk over there tomorrow, walk in and say, “Listen, I need help, I want to get off the heroin,” and they’re like, “Okay, come on.” Damn! It’s there, instead of me having to find someone’s phone to use, try to call the healthcare provider, make an appointment, wait for the appointment, remember the appointment, get to the appointment, try to survive while waiting for the appointment. That’s a lot. So instant is always better. Among clients, this access to low threshold buprenorphine was the catalyst for utilizing the MHC and was viewed as beneficial to initiating and continuing their treatment:You know, a lot of those programs like that—it’s a lot of—you have to—it’s a whole lot of stuff that’s on you, that you’ve gotta do to make sure you stay qualified. I mean, make sure you can still get the medication and stuff like that. And you have very little here. All you’ve got to do is don’t test dirty and you’re good. Show up, get it, and you’re gone. As opposed to some spots you’ve got to go to groups and you’ve got to do this and you’ve got to—you know what I mean? So if it’s anything that’s one of the benefits. It’s like no hassle. Maybe carve out a half hour, 45 minutes of your day once a week, take care of the process, and it’s over. Some participants had previously been required to attend group sessions as part of their MOUD programs and found this unhelpful – either it did not provide them support and was viewed as a waste of time or talking about drug use increased their desire to use: “By talking about it, talking about it, talking about it that made me want it [drugs] more” . Since participants were aware of multiple groups, such as Narcotics Anonymous, they could join if they wanted, most felt that the lack of requirements such as attending a group was beneficial for their success in their MOUD program at The Spot.More broadly, participants believed that people in their communities were benefitted from the ease at which people could access The Spot for healthcare services, generally. A 57-year-old male non-client said, for example, “If it’s something that can help people like me or anybody else, even people that isn’t, or aren’t addicts or whatever, sure. I mean, I think it’s a positive thing. You got so many people out here that are homeless, have nothing…” The Spot was viewed as convenient and as reducing barriers commonly experienced to receiving healthcare services:We have people [The Spot staff] coming into the community that have the people incoming, that it’s a good thing for people, ‘cause some people don’t have car fare or nothing…but by being right here, I think it’s more convenient, you know what I’m saying, and helpful to the people in the community. Overall, participants did not feel there were many barriers to receiving healthcare services through The Spot. The most important barrier was simply that the participants did not know it existed: “I had no clue what they did, you know?” A 42-year-old male non-client commented, “I don’t see a reason why nobody wouldn’t want to utilise something that’s free that could help them. I’m going to let people know now that I know because I’m figuring that the people I know don’t know”. This lack of awareness similarly created a barrier to use, initially, among clients. Several clients noted that they made assumptions about the services or were provided wrong information about The Spot. A 46-year-old male explained, for example, “I didn’t know it had nothing to do with drug abuse. I just thought it was a needle exchange. That’s what I thought just by seeing it every day at first”. Another client, a 57-year-old male, was provided inaccurate information: “I had met this guy. He had told me about it…He said as long as you got insurance you was cool”. Importantly, many of the clients were not aware of the additional services provided by the van, thus creating a barrier to utilizing other services: “I really don’t know what all the services that they can provide, you know what I mean?” .The lack of perceived need was also important, particularly among male non-clients. Clients overwhelmingly learned about The Spot from word of mouth as a place that provided buprenorphine, and this was commonly how non-clients became aware of The Spot as well. As a result of the association of The Spot with buprenorphine, some did not see a need for it. A 57-year-old male non-client, for example, said, “Well, I mean, I just never really, you know, haven’t been sick enough, I don’t think, or been sick to a point where physically, you know, like, an ailment, besides dope sick, you know, needed it”. In addition to the lack of interest in MOUDs generally, for those utilizing methadone, the association of The Spot with buprenorphine also created a lack of perceived need: “I’m on a methadone program, so there would be no need for me to go and get a prescription. It would completely throw me into withdrawal… If I wasn’t on a methadone program, I would definitely go, definitely go to the truck”.Although less common, a few of the male non-client participants felt that they were more likely to seek healthcare at a hospital when needed as this is what they have always done: “I think I’m just so used to going to the hospital that I would probably just go to the hospital”.Speaking of potential barriers for his peers but not necessarily for himself, a 39-year-old male non-client suggested that people may prioritize their drug use over seeking healthcare services after visiting the SSP: “They’re on the move getting high maybe… they just don’t feel like they have the time”. Prioritization of drug use, however, was not identified by any of the participants as preventing them from accessing healthcare services from The Spot.This study qualitatively explored the perceived benefits and barriers of utilizing a mobile healthcare clinic by people who use drugs in Baltimore, Maryland through in-depth interviews with clients and non-clients of the mobile clinic. Clients and non-clients perceived The Spot as a benefit to their communities and themselves by improving access to healthcare services, providing access to low-threshold buprenorphine dispensation, and offering services without drug use stigma. Clients described The Spot staff as supporting and encouraging and felt comfortable in the physical clinical space. Our findings show that The Spot has become a trusted source of MOUD with strong peer referral but has not fully capitalized on its ability to provide other needed services for this population, such as wound care and treatment for HCV.All of the clients interviewed accessed buprenorphine-based MOUD through The Spot, and the low threshold for access was identified by participants as critical to their use of, and success with, their buprenorphine program on The Spot. Despite being safe and effective, buprenorphine continues to be inaccessible and underutilized in the U.S. partially because of barriers to access ,50. Low An important component of low barrier MOUD programs is the patient-provider relationship, which is focussed on individual needs and desires and the lack of judgement towards the patient ,88. For Despite the achievements of The Spot van, the positive feedback from clients, and its co-location with a mobile syringe service program van, barriers exist with respect to awareness of the MHC, generally, and the specific services provided. Clients and non-clients aware of The Spot overwhelmingly learned about The Spot through word of mouth. Although The Spot offers a range of services, clients typically learned about The Spot through social contacts who informed them of its buprenorphine dispensation, and many referred to The Spot as the “bup van”. As a result, PWUD who are not interested in receiving buprenorphine, and especially those in methadone programs, may be excluded from peer communications about The Spot van. Previous research has documented the importance of peer-to-peer information sharing among PWUD, however, which has been linked to healthcare utilization within populations of PWUD . In addiMobile health clinics offering low-threshold services, such as The Spot, provide an opportunity to increase healthcare accessibility and reduce health disparities among vulnerable populations ,68. The


The global “sport for development and peace” (SDP) sector uses sport as a field of social activity to promote diverse types of non-sport social development. In this short perspective article, I critically examine and advocate the engagement of SDP with environmental issues. I argue for the adoption of a “socio-ecological” approach, to enable a greening of SDP that promotes both environmental and social justice. To that end, the article is organized into four main parts. First, I situate the discussion with respect to key literature on SDP and the environment. I then outline some of the main contextual factors that need to be considered on sport, development, and the environment. Third, I set out several core principles that should underpin the socio-ecological greening of SDP. Fourth, I examine how these principles may be implemented within SDP. The global “sport for development and peace” (SDP) sector uses sport as a field of social activity to promote diverse types of non-sport social development. Most SDP work is undertaken by non-governmental organizations (NGOs) and, to a lesser extent, sport clubs or other agencies, through intervention programs with socially disadvantaged or “at-risk” young people. SDP program objectives usually align closely with the United Nations' development agenda, as encapsulated by the Millennium Development Goals (from 2000 to 2015) and the Sustainable Development Goals  , In this short perspective article, I critically examine and advocate the engagement of SDP with environmental issues. I argue for the adoption of a “socio-ecological” approach, to enable a “greening” of SDP that promotes both environmental and social justice. To that end, the article is organized into four main parts. First, I situate the discussion with respect to key literature on SDP and the environment. I then outline some of the main contextual factors that need to be considered on sport, development, and the environment. Third, I set out several core principles that should underpin the socio-ecological greening of SDP. Fourth, I examine how these principles may be embedded within SDP.While there has been a relative lack of literature on SDP and the environment, growing interest in this area in recent years is noteworthy.inter alia the pressing requirement to address the social inequalities of climate change. They also advance two concepts that may be utilized in future SDP/environment studies. First, the concept of “ecological modernization” draws critical scrutiny toward policy assumptions that environmental degradation will be successfully tackled through future scientific advances , during the COVID-19 (coronavirus disease 2019) pandemic, or even the claims from global business  that “shareholder capitalism” is over and that “stakeholder capitalism” is the way forward, including recognition of the need to tackle climate change and to protect the environment.The “socio-ecological” approach that I advocate for SDP and wider development must be located within these three broad policy contexts. This approach is aligned with the critical, progressive standpoints on development outlined here and seeks to build on the positive signs and trends in this direction in recent times.The socio-ecological approach to development combines environmental and social justice. It is “attentive to ways in which social and ecological systems are intertwined in ways that are currently driving ecological devastation and social inequality but which might be transformed along more sustainable and socially just lines” Newell, , p. 5. TFirst, any development philosophy or strategy must be anchored in a fundamental commitment to genuinely sustainable development, which protects, preserves, and nurtures the natural environment. In line with earlier work  and SDG5 .Second, a socio-ecological approach tackles environmental and social inequalities and injustices . These social divisions shape the diverging, often opposing interests, between groups over social justice and environmental protection.within low- and middle-income countries to consider. In the Indian megacity of Delhi, Baviskar  middle-class pursuit of order, hygiene and safety, and ecological conservation”; “mobilize[s] the discourse of “public interest”; and “citizenship” to advance elite interests through the media, courts, and state; protects “luxury emissions” and “resource-intensive affluent lifestyles” ; and harbors a deep “hostility to the poor in the pursuit of a ‘clean and green' environment, where the very presence of the poor is equated with pollution” . In transcendental terms, the NGO should work with local people to develop a socio-ecological vision of the community that may be worked toward, which might include, for example, new housing, sanitation, and transport systems, or transformed public spaces for sport, physical activity, and recreation.A socio-ecological approach is marked by flexible and holistic ways of planning, implementing, and assessing  programs, according to context. The specific socio-ecological conditions and needs of local people need to be carefully identified, to shape programs; for example, some communities may be badly affected by climate change and, for example, need better access to scarce water, or protection from flooding; others may be worse affected by waste and pollution and so may target cleanup initiatives, recycling schemes, or campaigns against polluting industries. NGOs should adapt delivery techniques to context, for example, in selecting sports or physical activities that will appeal to local young people. MEL should avoid “audit culture” approaches and instead utilize diverse, locally attuned methods and criteria of success. For example, in communities with strong narrative traditions, “storytelling” methods for data gathering will be valuable. MEL should also ensure that local knowledge systems and cultural beliefs on the environment are embedded in program implementation  and evaluation.A socio-ecological approach requires all stakeholders to exercise critical reflexivity on the environmental sustainability of SDP and sport more broadly. Thus, for example, NGOs need to assess the environmental impacts or costs of key SDP activities, such as running intervention programs, the transportation of staff, volunteers and user groups to events and meetings, and the production of sport equipment or single-use materials utilized in programs.Here, I follow Lamont  in arguiI have sought here to set out the case for a particular socio-ecological approach to policy and practice within SDP. This approach requires us to recognize the interdependence of environmental and social forms of (in)justice with respect to development; thus, we need to engage with SDGs that center on the environment, social inequality, and social exclusion. In preparing the ground for this approach, we need to be fully aware of critical contextual issues, challenges, and opportunities, including diverse skepticisms toward SDP and global development agendas. As highlighted, the socio-ecological approach has several strands and implementational aspects. These include, among other points, the needs to establish SDP as a “recognition space” that privileges marginalized groups, their social struggles, and environmental interests; to nurture “associative democracy” within local development contexts; and to pursue pragmatic and visionary approaches when establishing development aims, objectives, and priorities.For academics in SDP, the socio-ecological approach offers rich opportunities for critical, participatory research that is socially and ecologically engaged. A final observation here concerns the need to pay attention to global scale. For social and environmental injustices to be tackled with maximum effect, actions and changes are needed at transnational levels. Similarly, for academics, if a green or socio-ecological approach is to have real consequence—whether in the academy or in the SDP and development field—then research dialogue and collaborations also need to proceed across a transnational terrain.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.The author confirms being the sole contributor of this work and has approved it for publication.The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Cultural and religious norms and expectations may influence the needs and behavior of single women. This is particularly true in those countries where religion and cultural expectations are salient in everyday life. In this context, the present study investigated the needs and concerns of Iranian never-married women aged 35 and older.This qualitative study involved a conventional content analysis. Interviews were done with 23 never-married women aged 36–64 years in Iran.A total of 773 codes, 22 subcategories, 8 categories, and 3 themes were extracted from the interviews. The 3 themes were: (1) mental-spiritual lack; categories were lack of emotional support, uncertain future, mental rumination, and sexual worries; (2) reform of culture and society; categories were an adverse effect of culture and being overlooked in society; (3) loneliness arising from disability; categories were aging and loneliness and sickness and loneliness.The results of the analysis indicate that the needs and concerns of never-married women over the age of 35 years in Iran remain unmet. This suggests that policymakers and health planners should take into consideration the growing number of never-married women as a societal reality deserving of attention. Maslow’s argument for a hierarchy of needs is based on the idea that the people different needs have ranged from the basic level of physical needs to the highest level of self-actualization . All indAccording to the International Conference on Population and Development (ICPD), reproductive health refers to a state of complete physical, mental, and social well-being associated with the reproductive system and its processes and functions. Despite an urgent need to improve all aspects of reproductive health, there are unfortunately social barriers and discrimination with respect to access to reproductive health .Studies have shown that single females feel lonely, less attractive, less satisfied with life, and have functional problems with respect to social relationships and self-confidence , 4. SingIn contrast to so-called individualistic societies, in collectivistic societies such as those in Africa, South and Central America, Southern Europe, and Asia , stayingDespite the expectations obtain in collectivistic societies, in recent years the number of single women has increased globally . StatistMost studies of single women have focused on young unmarried women, but it is important to consider all age groups and the full range of individual and social characteristics . FurtherResearch on the psychosocial health of never-married women in Iran is scarce and consequently little is yet known in any detail about the needs and concerns of this group. Knowing more about these matters would also help inform society’s response and what might be done to address them. To this end, this study tried to answer to the question: “What are the needs and concerns of never-married women over 35 in Iran?“This qualitative study aimed at discovering the needs and concerns of never-married women over 35 years of age in Iran.23 never-married women aged 36–64 years were selected from groups differing in age, education, employment status, living status , and city of residence through purposive sampling. Inclusion criteria included Iranian nationality and signature of written informed consent (see below). Exclusion criteria were severe mental issues such as substance use disorder, major depressive disorders, bipolar disorders, or schizophrenia (based on self-declarations).Sampling was purposeful and then snowball method. For sampling, at first, the researcher, with the help of her supervisor, identified and invited the never-married women with inclusion criteria who were working in her school to take part in the study. After that, for access to more participants with more maximum variation, she asked participants to introduce other never-married women between their friends and relatives. On the other hand, the researcher started looking for never-married women among her own relatives and friends, and also she went to religious places that many people, as well as never-married women, go there to pray, too.At the time of recruitment, participants were informed about the study goals, the confidential situation of interviews, secure data handling, and their voluntary participation. Then informed consent was obtained. The researcher tried to select participants with maximum variation . Data were collected from semi-structured, in-depth, face-to-face, and individual interviews until data saturation. Data saturation means that the interviews were continued until no new data was obtained. In fact, data saturation occurred when a code or a new category did not emerge from data analysis as Strauss (2014) said . The lanData triangulation can be reached by collecting data at different times and settings and by using different sampling protocols. In the present study, data triangulation was obtained by using two methods of data sampling .After drafting the interview questions, if the researcher did not understand some parts of the interview or if further questions emerged, a second interview was arranged. In this study, the number of participants was 23. But five participants were interviewed two times. So, we had 28 interviews with 23 participants. After transcribing some interviews, the researcher confused in some places and did not understand the deep meaning of some participants’ statements, so another interview was necessary. In this case, the researcher contacted the participant, arranged another interview time, and interviewed them again. So, a total of 28 interviews were conducted with 23 participants, and their needs and concerns were examined thoroughly. Each interview lasted about 60–90 min (average 75 min). Interview location was selected according to participants’ preferences and included, health centers, religious institutes, parks, and workplaces. The following questions were posed to gain entry to the interviewee’s world: “In your opinion, what are the needs of never-married women?”; “What is your understanding and experience of such needs?”; “Do such women have preoccupations?” and “How about you?” Analytical questions such as “Can you explain more or give an example?” assisted the researcher during the interviews.Data were analyzed using Graneheim and Lundman’s  method. The recorded interviews were all transcribed, immediately after the interview, and then read through several times to build up a general impression.The text was divided into semantic units that were summarized in the next step and converted into codes.Codes were compared based on their differences and similarities and organized into subcategories based on similarities, in the next step, subcategories were compared with each other, and similar subcategories were combined  that the main categories finally emerge.Finally, the themes were created as latent content in the text.Four Guba and Lincoln  criteriaParticipants’ socio-demographic characteristics are summarized in Table A total of 773 codes, 22 subcategories, 8 categories, and 3 themes were extracted from the interviews (Table The most common and powerful theme that was formed from the most codes (465 codes) was labeled “mental-spiritual lack”; the following topics were the basis of the first theme: lack of emotional support, uncertain future, mental rumination, and sexual concerns:Lack of emotional supportThis category was formed by combining three sub-categories, (1) Need for a companion, (2) Need to love and be loved, and (3) Striving to be a mother:“… When an older person gets married, she actually wants a companion” (64 years old).One of the unmet needs that the never-married women suffered from was not having a companion. One participant said, “I have everything now …, I just want someone to love me” (38 years old).The participants also needed someone to love and to be loved by him. “Everyone gathers around me calling me ‘Madam or Professor’, but I wish someone would call me Mom instead!” (41 years old).From the participants’ point of view, the desire to become a mother is an innate need for women. One participant said, 2.Uncertain futureThis category had three subcategories: (1) Fear of permanent celibacy, (2) Fear of unsuccessful marriage in the future, and (3) Fear of being an imposition on family members.“I’m always afraid that I’ll grow old and stay single …” (40 years old).One participant said, “I’m worried that I can’t be able to cope with married life, and he may not be the person who can comfort me ….“ (36 years old).At the same time, participants were worried about an unsuccessful marriage in the future. “When I see everyone going somewhere with their family, but I have to go with my brother’s family, I feel I’m a burden on their lives” (38 years old).Being an imposition on others was another concern of the participants. 3.Mental ruminationThis was composed of sub-categories: (1) Psychological insecurity (2) Incessant never-ending despair, (3) Feeling guilty, and (4) Incessant continuous regret formed this category.“As you grow older, you need mental security; you want to have peace of mind with your husband …” (39 years old).One participant, talking about psychological insecurity, said, “How can I know whether someone will marry me in the future …” (43 years old).Despair was another psychological concern of the participants. “We wronged ourselves by not getting married and hurt ourselves mentally and physically” (37 years old).Some participants also felt guilty. “It’s very difficult to see girls younger than you got married, but you got nothing …” (42 years old).At the same time, the women also had a desire for married life. 4.Sexual worriesThis category consisted of two sub-categories: (1) Concerns if meeting sexual needs, and (2) Forced to ignore sexual needs.“Well, a never-married woman who wants to satisfy her sexual needs in any way will not have a good result and will cause harm …” (36 years old).Concerns about the consequences of meeting sexual needs were seen in the interviews. “We do not have a husband to meet this need … So, this feeling is lost in us” (37 years old). Some participants had to ignore their sexual needs. The second theme in the study (the reform of culture and society) was formed from 211 codes and two categories: 1 adverse effect of culture, and 2. being overlooked in society.Adverse effect of cultureThis category had three sub-categories as (1) Stigma of being single, (2) Stereotypical thinking of people, and (3) Failure to provide reproductive health services without judgment.“When I say somewhere that I’m not married, people totally change their opinions about me … They think I must have a problem that I’m single” (42 years old).Stigma was one of the concerns seen in the participants. “When people know a single woman lives in an apartment, they have negative opinions about her … they think their husbands are in danger” (39 years old).Never-married women believed that people’s opinions about them should change. “… Once when I went to the hospital for my vaginal infection, the ladies asked me why did you get the infection!?” (37 years old).At the same time, the stigma of receiving reproductive health services and Iranian laws and traditions regarding the hymen was one of the obstacles for participants attending a woman’s clinics for problems with their reproductive system. 2.Being overlooked in societyThis category had three sub-categories: (1) Need to set up partner-finding agencies for singles, (2) Need for skills to live alone, and (3) Need for financial support. Under this heading are the following observations by interviewees:“It is necessary to establish institutions for never-married people where they can receive some services … to find someone to marry“(42 years old).“Educational institutions should be established to teach never-married women how to have a single life because no one has taught us this before …” (52 years old).“My problem today is an economic problem. If I had a salary, I could live very well …” (64 years old).Other responses referred to the need to have income and concerns about financial problems. The “loneliness arising from disability” theme was formed from the least codes (97 codes) in this study. The theme consisted of two categories: (1) aging, and (2) disease. They felt that aging and disease are difficult given that everyone experiences one if not both, but they are much more difficult for a single person.3.Aging and lonelinessTwo subcategories, (1) Fear of aging due to disability, and (2) Fear of losing fertility formed this category.“When you grow older, your efficiency and power decline. I hope it doesn’t happen to me, but if it does, a bitter future awaits me” (42 years old).One of the things that never-married women mentioned was fear of aging associated with disability. “One of my worries is that my reproductive age is coming to an end” (45 years old).At the same time, fear of losing fertility with age was another important issue in the lives of the participants. 4.Sickness and lonelinessThis category also had two subcategories: (1) Fear of emerging diseases, and (2) Fear of diseases without a supporter. Participants stated:“… I always say thank God that I am healthy now, but what should I do if I come down with a disease in the future? …” (58 years old).“The only person who takes care of me is my mother, and if one day she dies, who will take care of me when I come down with a disease” (37 years old).The key findings of the present qualitative study were that never-married women aged 35 years and older reported particular needs and concerns. Specifically, responses yielded three key themes: mental-spiritual lack, reform of culture and society, and disability-associated loneliness (each of which was comprised of categories and subcategories). The results of the present study add significantly to the current literature in that participants’ views covered a broad variety of neglected emotional, psychological, sexual, and social needs and concerns. The range of responses also provides an illustrative portrait of how their needs and concerns related to culture and of their desire for society and the people within it to view them differently. Results are now discussed in more detail.Participants in this study wanted to get married to have a companion, to become a mother, to love and be loved. In this respect, the present findings are consistent with the results reported by Greitemeyer (2009); this study showed that single individuals feel lonely and want company in their social lives . Sharp ; in this study, never-married women cited one of their concerns as not finding a suitable mate over time and consequently accepting marriage to the wrong person . In IranMental rumination followed by such emotions as psychological insecurity, despair, guilt, and regret from witnessing the lives of married people were frequently seen in the participants’ responses. Having mental security is one of the basic human needs that, if met, can give a person peace of mind . The resEvidence suggests that in Iran, never-married women over 35 years of age are less likely to get married . Thus, nFulfilling sexual needs  was one of the major concerns of participants. Given that the cultural and religious rules of Iran mandate that the only way to satisfy sexual needs is to get married , people Participants also expressed the view that their society’s culture is unfair to single people and should be corrected. In the present study, most participants were concerned about singleness stigma, and they considered this stigma to be a product of society’s stereotypes about single individuals. This stigma caused feelings of low self-esteem, low value, and incompetence in never-married women . These fAnother problem for single women was the fear of being labeled when in receipt of health services for genital problems. The results of Abedini’s (2014) study on never-married female students showed that these women avoided seeking help from health services for genital problems . As womeCreating agencies that can introduce single people to one another for marriage was a need expressed by several participants in this study. In traditional societies, single women are not supposed to express their feelings or take the initiative when encountering a suitable marriage partner and instead accept that marriage proposal should be made by men. Thus, many of these women, despite knowing of potential appropriate partners, fail to marry. These findings are consistent with Ibrahim’s (2009) study in Malaysia . Teaching life skills to this group of women was another prominent topic in participants’ statements. The growing number of never-married older women has been a disconcerting development for a traditional society such as Iran . Thus, iIn the present study, most women had a job or were looking for a job, but a small number who did not have a job complained about their dependence on their families and considered it one of the duties of the government to give them a job or insure them for old age. Having higher education and a job is one of the most important reasons for not marrying among women, and having a job allows them to live happily, freely, and independently , 46. TheLoneliness arising from aging was another concern of never-married women. Loss of fertility with age was a significant concern in the lives of the participants. Loss of fertility and subsequent anxiety were also apparent among the participants in Saili’s 2018) study [18 study Fear of emerging diseases such as cancer as they aged and, on the other hand, lack of support in times of illness caused concern among participants. Women who have never been married are forced to accept loneliness in old age, and instead of living with husbands and children and receiving support from them, rely on substitutes such as friends . The res Lack of cooperation of some women in the interview was a limitation in this study, though the researcher tried to encourage them to participate by establishing appropriate communication and explaining the confidentiality of information. Also, by extending the study time, the researcher tried to interview more participants to get the necessary information, maximum variation and achieve data saturation.According to the census in Iran and in the world, the number of never-married women is increasing. In Iran, there is no basic organization to support this group of women. The results of the study revealed that some of these women live in suffering. So, policymakers should pay more attention to this issue. This data can help policymakers and planners to organize some programs to establish more facilities to improve the lives of never-married women.This study was the first study that has broken the silence of never-married women in Iran regarding their needs and concerns and showed that they have a variety of neglected needs and concerns in a religious country with specific culture and norms. It showed that although they have some similar needs and concerns  with other never-married women all over the world, it presented other aspects of these women’s life concerns such as mental rumination and feeling of guilt about their status that was not mentioned in past studies. As well as these women mentioned that they needed some institutions to meet single men and have more chances for marriage which was new data. Also, they stated that as they don’t educate about single life skills before, they expect from the government some facilities to educate them these kinds of life skills. To meet these needs and address their concerns, the collaborative effort of various organizations, politicians, planners, sociologists, and even families is essential. In the meantime, reforming society’s culture and government support could be very helpful.


The original article has been corrected.The article: “Oscillometric versus invasive blood pressure measurement in patients with shock: a prospective observational study in the emergency department”, written by Agnes S. Meidert, Michael E. Dolch, Konstanze Mühlbauer, Bernhard Zwissler, Matthias Klein, Josef Briegel and Stephan Czerner, was originally published electronically on the publisher’s internet portal on 13 February 2020 without open access. With the author(s)’ decision to opt for Open Choice the copyright of the article changed on 18 October 2021 to ©The Author(s) 2021 and the article is forthwith distributed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit


Paid work is one of the most important aspects in life among working-aged women diagnosed with breast cancer. Despite several attempts, no previous study provides a comprehensive overview from the women’s perspective about factors of importance for being able to work or not. Therefore, the aim of this study was to gain knowledge about factors that women themselves state are of decisive importance for being able to work or not during the first two years after breast cancer surgery.Data was collected in a two-year follow-up questionnaire within the frame of a prospective cohort study of working-aged women who had undergone breast cancer surgery. 749 were included in the questionnaire study and of the 616 (82%) responding women, 462 (75%) wrote statements on an open-ended question about factors of decisive importance for being able to work or not work during the past two years. The statements were analyzed with content analysis.Five categories of factors of importance for being able to  work or not were identified, each covering several sub-categories: Health and wellbeing, Contacts and encounters, Flexibility and adjustment possibilities, Socioeconomic consequences from working/not working, and Own motivation and characteristics. A wide variety of factors were mentioned by the women and the findings give a multifaceted picture of many single but interrelated factors of decisive importance for being able to work/not work. The importance of flexibility in the return-to-work process was stressed, as well as the importance of supportive encounters from, e.g., colleagues, managers, as well as relatives.The results give a comprehensive overview over a variety of different types of factors for being able to return to/remain in work or to not work after breast cancer surgery, adding new knowledge about e.g. the importance of colleagues, and the women’s own preferences or characteristics. These are factors that different stakeholders, both from healthcare but also from the work place and the insurance office, need to be aware of and collaborate around to support women with breast cancer during the period of treatment, rehabilitation and return to work. About 50% of women diagnosed with breast cancer (BC) are of working age and paid work has been shown to be one of the most important aspects in life in these women , 2. AmonSeveral attempts have been made to understand factors of importance for RTW after BC and in 2018 a systematic review of 26 reviews ” or “Our spare time is precious now. Newlyweds, work at our summer house, worried husband due to cancer progression and spread”. Some women stated that other health conditions than the BC had hindered them from being in work, “My otherwise bad health is the reason for not being able to work”.B.Contacts and encountersEncounters from different stakeholders, such as colleagues, workplace managers, family, friends, and healthcare professionals, or experiences of such encounters were stated and almost one third of the codes fell in this category. Colleagues and workplace managers were most frequently mentioned, followed by family and friends and healthcare professionals and these were stated in positive and supportive terms by most women. Some women also stated encounters without specifying from whom, such as being understood or listened to or “had back-up for some time after the surgery” or just “be listened to”.At the workplaceFrom the workplace, colleagues were most often mentioned, sometimes just by one word, but also described as supportive, good, or understanding. The possibility for openness and dialogue with the colleagues was also stressed. No one mentioned colleagues in negative terms. Managers or employers were also mostly described as supportive, good, flexible, or understanding. However, here negative experiences were also mentioned, such as having had a bad or un-supportive manager that was showing lack of understanding, and one woman mentioned being bullied. Having to change manager after the BC diagnosis was also experienced as problematic. Some women reported factors regarding the work environment in general terms. Either as a general good, understanding, or supportive atmosphere, but also in terms of flexibility or providing adjustment possibilities, both regarding tasks and work hours. Others mentioned the importance of staying in contact with the workplace as well as the feeling of being welcomed back. Some reported negative experiences such as being deprived tasks, not being given adjustment possibilities, or experiencing a distance to the workplace after being sickness absent. Others stated that support from customers, clients, or from children and parents if working in a nursery or school.B.2.Family, relatives, and friendsFamily, relatives, and friends is another sub-category, by most women these persons were described as supportive, understanding, helpful, or loving. The most frequently mentioned specific person in this subcategory was a husband or a partner but also children and, in some cases, more extended family members. A couple of women wrote that they were working together with their husband and got support and understanding from him. Some stated support from friends. Other positive statements were having found a new partner, having good social contacts, becoming a parent, gaining a better relationship with the children, or becoming a grandparent. However, others described loneliness, lack of support, or negative reactions from the husband, e.g., "[My] husband wants a divorce because our economy has become worse and I do not manage to do and take responsibility for everything at home ”. One woman also mentioned that support from the family had enabled her to keep working but that this, on the other hand, had resulted in her being constantly tired. Other stressful events in the family that were mentioned were children having a hard time, or that close relatives had become ill or died.B.3.HealthcareMost statements about the role of healthcare professionals for being able to work or not were stated in positive terms, even if some statements about encounters from individual professionals were described as negative. Some women described good support from healthcare in general, while others mentioned certain professionals, such as physicians, nurses, or medical social workers. Physicians were most often mentioned as supportive in general and especially in writing sickness absence certificates, while nurses were mentioned as kind or supportive in more general terms. Medical social workers were mostly mentioned as supportive in different phases of the disease even if one woman mentioned a negative contact with a medical social worker. The only other negative examples that were stated concerned a physician who did not ask about the woman´s actual work situation, e.g., heavy lifting, which had worsened her physical state, or the more general statement that healthcare was poor at acknowledging strong reactions, or perhaps afraid of such reactions. Besides the above-mentioned professions, only one other profession was mentioned: a chiropractor helping out with back problems.B.4.Other organizationsAmong other organizations than the above mentioned, work and healthcare, the Swedish Social Insurance Agency (SIA) was most often mentioned, while only two statements mentioned the Employment Office. Most statements about the SIA were positive, some were neutral, and about one third of the statements concerned negative aspects. Positive statements about SIA concerned support, positive encounters, or being flexible. The negative statements concerned the opposite; inflexibility, hassle, or ruining things or routines that were working for the woman. An overall lack of support, without organizational specification, was also mentioned, e.g., “…all the effort needed to find out my rights is demanding” and “Had whished for support in changing job”. Two statements concerned patient organizations: both held general positive experiences from participating in group discussions.C.Flexibility and adjustments possibilitiesThe category Flexibility and adjustment possibilities covered several areas in life and the following four subcategories were identified; C.1.Work content, scheduling, and place, C.2. Extent and timing of work or SA, C.3. Treatment and healthcare appointments, and C.4. Transportation and communication. About one fifth of the codes fell in this category.Work content, scheduling, and placeFlexibility regarding work-content, scheduling, and place was the largest subcategory, also including statements about having changed work or workplace, becoming unemployed, or having retired. The possibility to have flexible work schedules or work hours was the most frequently mentioned factor, and some women who were self-employed stated this as positive since being able to decide how and when to work. Others mentioned possibilities to adjust work tasks or content in general, while some specified the possibility to ease physically heavy work, limit contacts with clients or costumers, or reduce stress and amount of work. Flexibility was by most expressed as something that was supported by, e.g., employers, managers, and colleagues, while some also mentioned having been encountered with non-flexibility. Many women stressed the possibility to work from home, at least to some extent, or being able to limit work-related traveling as important factors for being able to work. Another aspect mentioned was if not having the possibility to have a substitute, e.g., making it more difficult to be sickness absent, “My knowledge is unique/cannot easily be substituted”. The nature of specific jobs was also mentioned in having no needs for flexibility or adjustments, often referring to that her work was not physically straining.C.2.Extent and timing of work or SAMany women stated different aspects of extent, flexibility, and timing of SA or of resuming work as important for being able to work or not. One factor mentioned was the possibility to reduce work hours by being on part-time SA  or by combining SA benefits with vacation to get a longer leave. Some women stated that they had continued working part-time after having been on part-time SA during the treatment, while others had been working full-time throughout the period of surgery and treatment, e.g., only taking a week off. The possibility to dispose the time on SA or at work according to ones needs both during, after, or to fit treatment was also stressed, e.g., “the SIA was flexible and allowed me to work when I could”. Some also mentioned sickness certificates written in a way that made it possible for themselves to choose whether, or to what extent, they should work or be sickness absent. Others expressed lack of flexibility or adjustment, e.g., that they wished that they had been able to reduce their work hours. Some stated that they returned to work too early or to a too high extent which sometimes had consequences for their health, “Sick leave. Would have coped better and felt better if having been on part-time SA for a longer time”. One woman stated that she had to make up for the work hours during which she had been absent for treatment.C.3.Treatment and healthcare appointmentsA few statements concerned flexibility or adjustment possibilities regarding healthcare or treatment. Having the time for treatment or physician consultations adjusted to their work hours, e.g., having appointments for radiotherapy adjusted to suit the women’s needs was important for being able to work or not. If this was not possible it hindered work “radiotherapy at irregular hours that were announced late – impossible to combine with the time booking at work”.C.4.TransportationA few women mentioned transportation as a factor of importance, e.g., “transportations home-hospital-workplace during radiotherapy”, while others had changed their means of transportation, e.g., from public transport to own car. Further, some women mentioned that they lived close to the hospital or to their work why that such adjustments were not necessary.D.Socioeconomic consequences from working/not workingThis category, socioeconomic consequences from working/not working, covered about a tenth of the codes and included two sub-categories: (1) distraction and normalcy and (2) economic security or economic stress.Distraction and normalcyThe importance of the social aspects of work was stressed, e.g., in terms of that work provided social contacts, fellowship, or belonging. Sometimes this was related to colleagues but also to third part, e.g., customers or the children that one was teaching in school. Some women described work as a distraction from thoughts of the disease, which contributed to a sense of things being normal. Others mentioned the workplace as such, e.g., that they thrived at work or had a safe workplace. Other women focused on the content of their work. Some described their work as fun, that they had an important, stimulating, or satisfying work, or that working made them feel good, e.g., “after the sickness absence it is fun to work again”. However, one woman described negative feelings regarding being left behind others when she returned to work, not feeling good enough any longer.D.2.Economic security or economic stressAnother factor related to consequences from working was economy. Some just stated economy or salary and some women wrote that they had to work due to poor economy, economic worries, or were dependent on their work income. On the other hand, some women described that they had economic security, e.g., that they were provided for by their husband, that their good economy or salary gave them the opportunity to reduce work hours, or to feel safe.E.Own motivation or characteristicsIn the statement in this category covering almost every tenth of the codes, the women referred to themselves; their own personality and motivation, or their own preferences or approaches regarding work—sometimes described as taking actions in order to accomplish certain goals related to being able to work. The statements regarding own preferences were expressed as the woman’s own desire or wish to work, to RTW, and/or own motivation, e.g., “could start working again due to a strong will to come back”. Contrary, a few statements expressed an own desire or will to work less. Some women described personality characteristics or views of oneself, e.g., positive thinking, a positive view of life, stubbornness, or inner strength. Some expressed that the BC had led to a changed view of life that impacted their preferences or strength of will, e.g., “If possible, I have an even more positive view of life which also makes work more fun”, or “I think more ‘do I want this? Is it important?’”. In some statements the preferences and characteristics were more clearly described as turned into taking actions, often in terms of taking care of oneself regarding, i.e., exercise, food, or rest. Some also described how this was done “[I have] seen to that I was becoming as mobile in the upper body/left arm as before” or “That I ‘listen’ to myself and do not push myself to be ‘a good girl’”.In the analyses of the written statements, five categories were identified covering a wide range of areas, each holding several sub-categories. These five categories were: (A) Health and wellbeing, (B) Contacts and encounters, (C) Flexibility and adjustment possibilities, (D) Socioeconomic consequences from working/not working, and (E) Own motivation and characteristics Table . Some stOf the 616 women answering the two-year follow-up questionnaire, 462 women made statements to the open-ended question about factors of decisive importance for being able to work/not work and more than 1500 codes were identified for analysis from these statements. Five main categories were identified, covering a wide range of areas: Health and wellbeing, Encounters and support, Flexibility and adjustment possibilities, Socioeconomic consequences as factors for working/not working, and Own motivation or characteristics. While some of these factors have been well studied before, both in this population, e.g., health- and treatment-related factors, adjustment possibilities including encounters from different stakeholders such as managers, SIA officers, and healthcare professionals , 12, 28,What is interesting in the results from the women´s open answers are the comprehensive picture they give over different type of factors. Factors that also may be interdependent for being able to work or not. For example, it was not surprising that factors related to health and wellbeing and to disease and treatment were the most often mentioned factors , 16, andOther mentioned factors that may be related to overcome disease and treatment consequences are flexibility and adjustment possibilities. These were mainly mentioned in relation to the workplace, concerning work content, scheduling, and place. These aspects have previously been described as adjustment latitude; possibilities to (temporarily) adjust work demands to loss of function due to disease , 18. In Statements about flexibility and adjustment possibilities was, however, not only found in relation to the workplace but also in relation to other stakeholders, and the flexibility or adjustment possibilities provided by different stakeholder’s may be interdependent. If, e.g., the treatment appointments are adjusted to working hours, then working hours do not need to be adjusted to treatment appointments, even if adjustment or flexibility possibilities from health care in terms of, e.g., treatment or appointments, seldom were mentioned by the women.It has been stated in, e.g., in the Cancer and work model  that undTo facilitate the possibility to work during and after treatment, many women also stressed the importance of flexibility regarding the extent and timing of work and/or SA. The possibility in Sweden to be on SA for part-time is rather unique. The possibility to gradually increase work hours, as well as adjusting the timing of this to one’s own situation was stressed as important for being able to work or not. Despite Sweden’s comparably extensive social insurance system, granting SA benefits up to 80% of lost income if having reduced work capacity due to injury or disease , some woAnother important factor for being able to work or not as mentioned by the women were their own motivation or characteristics, where they described themselves as taking actions through, e.g., exercise, ‘healthy food’, and rest. The importance of internal and motivational factors in the RTW process has been shown previously  where leA strength of this study is the large number of participants who answered the question about factors they experienced as being of importance for them to be work or not. The short statements did not always allow a deeper understanding of, e.g., how the factors are related or in what way they are considered important. Still the large number of statements in various fields is a strength of the study showing the complexity of what is of importance for being able to work or not work following breast cancer. Another strength is that the study is conducted in Sweden with a very high female employment rate, also in higher ages , meaningThe results give a comprehensive overview over a variety of different types of factors for being able to return to/remain in work or to not work for women of working ages during the two years after a first breast cancer surgery. Some known before, and some not so well studied, e.g., the importance of colleagues and the women’s own preferences or characteristics. The results may facilitate the support for women after breast cancer from different stakeholders that are encountering them during the period of treatment and rehabilitation measures. Further studies are needed to capture the complexity of the interplay between these factors.