The concept of dignity remains disputed, with most studies defining dignity based on its external dimension. Although its inherent dimension is a rooted attribute of dignity, it has received scarce attention. Caregivers have close relationships with their care recipients and thus may perceive their patient’s inherent as well as external dimensions of dignity. Therefore, in this study, we aimed to identify, analyze, and synthesize evidence on human dignity presented in qualitative studies from the perspective of caregivers to gain a deeper comprehension of the preservation of patients’ dignity by their caregivers.A qualitative meta-synthesis was performed by searching for relevant qualitative literature via systematic electronic databases, including MEDLINE, PsycINFO, ProQuest, CINAHL, Embase, Health Source, and Web of Science, from inception to March 15, 2022.Nine studies were eligible for inclusion and included in the meta-synthesis. Three overarching categories were identified: integrated person, “rootedness” and “growth” atmosphere, and balanced state.Dignity is rooted in its inherent dimension, whereas its external dimension may promote individual dignity. Furthermore, caregiver-patient relationships may be a key factor linking the inherent dimension of dignity with its external dimension. Thus, further studies should focus on the mechanism of relationships in preserving dignity. The concept of dignity is anchored in the different rules of conduct and guidelines relating to patient care . AdditioAlthough the term dignity is used in various codes of conduct, guidelines, and criteria for patient care, the concept of dignity continues to be debated because individual perceptions of the attributes of dignity differ based on the perception factors . A literWe employed Florence Nightingale’s environmental theory as a theoretical framework for the research data. According to this theory, a patient’s condition and nature are interrelated with their physical, psychological, and social environment . In 1860A qualitative meta-synthesis was performed to explore caregivers’ perspectives of dignity in care. This comparative and comprehensive qualitative research method yields a rich and extensive understanding the integrity of a given phenomenon. Compared with individual studies, a meta-synthesis presents results with advanced coherence, cogency, and utility that help inform pragmatic decisions. Additionally, we used the ENTREQ statement to improve transparency in reporting the synthesis of our qualitative research . FinallyQualitative literature relevant to the study was searched using systematic electronic databases, including MEDLINE, PsycINFO, ProQuest, CINAHL, Embase, Health Source, and Web of Science, from inception to March 15, 2022. The primary research tactics were based on PICo . The retrieved items were as follows: caregivers, family members, and relatives (population); perceptions of dignity, perspectives of dignity, and meanings of dignity (interest); and care of patients, care of family members, and care quality (context). Titles and abstracts were initially screened for relevance by two authors, who then reviewed the pertinent full text of the selected papers. Additionally, any differing opinions were discussed and sent to a third author if an agreement could not be reached.Papers were selected if they (a) employed qualitative methods in the data collection and analysis, (b) presented in English and published in a peer-reviewed journal, and (c) illustrated the dignity of individuals from the caregiver’s perspective. Furthermore, dignity should have been explicitly emphasized as a main theme in the primary research or a part of the study outcomes. Papers were excluded if (a) their findings did not contain content to realize the synthesis , (b) their results described caregivers’ experience without their views on maintaining dignity, or (c) caregivers were medical workers.The CASP qualitative research checklist was applied by two researchers to assess the quality of the included papers. If any differences arose, they were discussed and sent to a third reviewer (if unresolved after discussion) to obtain a consensus. CASP was used to measure the bias risk and quality of the included studies in the following areas: the research aim, methodology, research design, data collection, recruitment, data analysis, ethical issues, value, relationship, and research findings. Scores were assigned for each paper, ranging from 0–10. A score of 9–10 indicated a high-quality paper, 7.5–9 represented a moderate-quality paper, and < 7.5 indicated a low-quality paper. Studies that scored < 6 were excluded .The synthesis was performed based on the principle of the interpretative synthesis approach , with ann = 7), while the remaining studies originated from Asia (n = 2).Among the 2943 records screened, nine studies met the inclusion criteria and were used for further quality evaluation , 32–39. The evaluation of each study’s quality is presented in Table Our meta-synthesis identified three categories: integrated person, ‘rootedness’ and ‘growth’ atmosphere, and balanced state. The model structure of patient dignity is elaborated in Fig. Integrated individual is centered on the bidirectional meaning of life encompassing a natural life and spiritual life . NaturalThe preservation of autonomy and role maintenance was embodied in the patient’s desire to live a normal life, participate in worthwhile activities, and make decisions. Patients, including those who were terminally ill, did not want to be perceived as a person with an illness, but they desired to be treated as a whole individual and wished to manage their daily lives normally , 37. ActSpirituality was associated with the assertion of life via the patients’ relationship with self, the environment, and God. It can be interpreted as the impetus for meaning and a sense of purpose in life and serves as a source of renewal and emotional support, positively affecting health and fostering life dignity . Further‘Rootedness’ and ‘growth’ atmosphere were perceived as an environment of dignity. Rootedness emphasizes comfort, security, belonging, and emotional connection with families, relatives, or friends , 43. A gConsidering that rootedness signified comfort and security, it could be explained as the sense of ‘homeness’ concerning the notion of home. In this study, the homeness physical environment is regarded as a private, aesthetic, and particularly ‘homelike’ condition. Moreover, caregivers have revealed that patients preferred to live in a room with a private bathroom , and patRootedness also entailed the property of belonging, which could be explained by the psychological environment of ‘belonging’. A feeling of belonging reflected a closely connected relationship with family members, relatives, and other caregivers. Caregivers reported that strong relationships with family members and respect from children and grandchildren provided a strong sense of belonging and served as a source of pride, meaning, and hope for their patients , 37, 39.As mentioned, growth was interpreted as a positive meaning derived from stressful events. In this study, growth represented a great appreciation for life. Numerous studies have reported that caregivers noted that patients expressing thankfulness and reciprocating with courteousness and appreciation had an increased positive sense of self , 36, 39.Balanced state referred to the harmony and well-being of one’s mind , resultiSense of certainty was one aspect related to a balanced state. Our findings suggested that adequate information was the key factor attributed to the certainty of disease and the role transfer of patients and caregivers. In contrast, caregivers expressed that patients experience a sense of uncertainty when provided with inadequate information. Caregivers further emphasized that patients regarded the provision of unsatisfactory medical information as a threat to their sense of dignity and related this to feelings of uncertainty when they were unaware of their medical and rehabilitation information. This uncertainty rendered the patients passive in coping with their disease and undermined their dignity , 36, 39.The sense of less guilt was the second facet of a balanced state, wherein alleviating care pressures allowed the patients to feel less guilt. In contrast, our study found that family caregivers considered that being available round the clock to provide their patients with unconditional support was part of meeting their patients’ needs and being prepared for the worst. However, the heavy care burden perceived by the patients might stimulate their feelings of guilt . AdditioOur study is the first to employ the framework of Nightingale’s environmental theory to interpret the meaning of dignity, which could help explore the complex concept of dignity according to its multidimensions. Our findings revealed that the multidimensions of dignity could be elaborated into integrated person, ‘rootedness’ and ‘growth’ atmosphere, and balanced state.Considering the patient as an integrated person is important in maintaining patient dignity. The concept of an integrated person includes a natural life and spiritual life, wherein natural life emphasizes preserving individual autonomy and role maintenance. Previous studies have highlighted that the satisfaction of autonomy and role maintenance generates an intrinsic value and translates into an improved sense of dignity, whereas the restriction of this ability may trigger a strong motivation in patients to exercise their autonomy and role, even by adopting a negative response –49. ThesSpirituality is recognized as an inner resource for encouraging health maintenance and promotion, raising hope and resilience during illness distress, and improving patient outcomes , 51. Cle‘Rootedness’ emphasizes comfort, security, belonging, and emotional connection with families, relatives, or friends , 43. A sPositive expression is a positive life change and perception of growth, which elevates an individual’s sense of worth and value . PositivOur findings revealed that patients required social support to maintain a balanced state, and excessive care burden may impair their dignity and relationship with their caregivers. In this study, the excessive care burden caused by patients’ health status greatly strained caregivers. This could increase the patients’ feelings of guilt and uselessness, thereby lowering their dignity . HoweverPatient dignity is a multidimensional and complex concept. Our study employed Nightingale’s environmental theory, which was conducive to systematically exploring the concept of dignity. Dignity was defined as a multidimensional concept involving individual, physical, psychological, and social environment aspects. First, an individual with dignity should be viewed as an integrated person. Integrity includes a natural life and spiritual life that feature autonomy preservation, role maintenance, and spiritual health. Second, the environment of dignity should incorporate a ‘rootedness’ and ‘growth’ atmosphere comprising a physical environment of ‘homeness’ and a psychological environment of ‘belonging’ and ‘positive meaning’. Third, social support is necessary to maintain one’s balanced state. Thus, dignity can be considered to originate from its inherent dimension, imbuing a longing for being treated as an integrated person to gain self-worth and promote self-respect, as well as instilling a desire for developing belongingness and an atmosphere with a ‘positive meaning’ to achieve self-value and self-growth. Furthermore, external dimensions, such as social support, may help promote one’s dignity. Our study supplements previous studies that mainly defined dignity according to its external dimension , 13–15. This meta-synthesis study has certain strengths that deserve mention. First, considering that caregivers undertake the main care responsibilities, it is important to provide direct evidence relating to preserving patient dignity from the perspective of caregivers. Second, this research has added new findings illustrating the differing views of patients and nurses. In particular, patients might be reluctant to share spiritual concerns with their nurses; however, they were willing to communicate such concerns with their caregivers. Third, the study results are based on the concept of people, environment, and society and are supported by the framework of Nightingale’s environmental theory, which may help systematically elucidate the complex concept of dignity via its multidimensions. Finally, our study produced a valid framework to reflect on the existing care model and indicated the need for in-depth research to construct an effective dignity care model.Our meta-synthesis analysis has certain limitations that should be considered. The first limitation is that our literature search was confined to articles published in English, and noteworthy research written in other languages might have been ignored. The second limitation relates to using electronic scientific databases to identify eligible studies. Thus, some relevant articles indexed in other databases might have been neglected. The third limitation is that original data was not accessed, and therefore, any original bias in the primary studies could have led to bias in the synthesis. Finally, another limitation is that all the included studies had only conducted research at one time point. Therefore, longitudinal studies are required to investigate the changes in caregivers’ perspectives on dignity preservation over time.The model of patient dignity from the caregivers’ perspective is based on a multidimensional structure of human dignity. Our study offers evidence for understanding patient dignity from the caregivers’ perspective and adds supporting information for improving nursing outcomes in patients. Our findings indicate that dignity is rooted in its inherent dimension, emphasizing treating patients as integrated individuals to preserve their self-worth and self-respect and developing belongingness and an atmosphere with a positive meaning to facilitate them to achieve self-value and self-growth. Furthermore, external dimensions, such as social support, may promote one’s dignity.


Piscine orthoreovirus (PRV), may threaten wild salmon populations in the Pacific Northwest. A relevant work has been published in BMC Biology by Polinksi and colleagues, but their conclusion that PRV has a negligible impact on the energy expenditure and respiratory performance of sockeye salmon is disputed by Mordecai and colleagues, whose re-analysis is presented in a correspondence article. So, what is the true effect and what should follow this unresolved dispute? We suggest a ‘registered multi-lab replication with adversaries’.Canadian policymakers are interested in determining whether farmed Atlantic salmon, frequently infected with  In other words, Polinski and colleagues seemed to arrive at a conclusion of ‘negligible or null effects’, mainly based on statistically non-significant results.This quote comes from a ficance” . Publishgy paper , Polinskp-value cut-offs but has incorporated other information. For example, one’s understanding of the biological system may allow for estimating a biologically meaningful effect size with high precision, the study may have high statistical power, and the conclusion may be congruent with those derived from related previous work. If the second scenario is true for Polinski and colleagues, they should still be very cautious about their conclusion. It is important to remember that supporting the null hypothesis (null effects) usually requires multiple lines of evidence other than a non-significant statistical result from a single experiment.We point out that such practice is prevalent in the scientific literature. Indeed, a survey suggested almost half of the published papers interpret their statistically non-significant results as ‘evidence of absence’ . We confMordecai and colleagues, in their correspondence , describTaken together, we are more in agreement with Mordecai and colleagues, who stated that “A more objective treatment of the data makes clear that a reasonable reader could draw different conclusions than those offered in the original paper—or that it is not possible to draw firm conclusions at all” . HoweverWe do not think that arguing the original results on statistical and other scientific bases would settle the matter . We neeregistered report . A registered report has two stages. At stage 1, a proposal  is reviewed and then revised according to reviewer comments, and once accepted, the project can proceed to stage 2. At this stage, authors will conduct planned experiments and, once finished, they add their Results and Discussion sections without altering their stage 1 Introduction and Methods, although minor alternations and additions to their stage 1 plan would be acceptable [p-hacking, selective reporting and hypothesizing after results are known, or HARKing), many of which are prevalent in the field of ecology and evolution [However, replication is what is needed more in this instance. Here, we mean a close replication study with an improved design as required . But whaceptable . This prvolution .Fig. 1A adversarial collaboration, where people with opposing views work together on a project. The Nobel Prize winner Daniel Kahneman and colleagues have recommended the use of such collaboration to reduce the impact of scientific biases and hidden agendas [Second, this replication should include  agendas . The “temulti-lab replication, where several labs conduct the same experiments following the same protocol, although some heterogeneities can be introduced within and between labs . In responding to Mordecai’s comment on the low statistical power, Polinski and colleagues have replied, “However, as acknowledged by Mordecai et al., the potential benefits must be weighed against the increased monetary, manpower, and animal welfare costs associated with amplified sampling of a very comprehensive study of respiratory physiology and molecular mechanisms. Specifically, samples from more than 140 individuals per treatment per time point  would be necessary to fulfill the requirements proposed by Mordecai et al. to achieve a statistical power of > 80% at the post-hoc test” [Third, it should be a oc test” . TherefoFinally, yet importantly, who should support such a multi-lab replication project based on adversarial collaboration? Since Canadian federal and regional governments and salmon farm industries all have an interest in the question of whether PRV poses a risk to wild salmon, we propose that they all come together to support this new way of replicating a study and thereby help to settle the matter.


There is a lack of research informing service requirements for older (aged≥55 years) forensic mental health patients. The aim of this research was to increase knowledge about older forensic mental health patients’ quality of life, wellbeing, recovery, and progress, in order to make recommendations of how to facilitate and enhance these factors.N = 37) and staff (N = 48) were undertaken; data were analysed using thematic analysis.In-depth interviews with patients , relational  and individual  factors were identified as enablers and/or obstacles to wellbeing, recovery, progress and quality of life.The physical and psychological environment of services needs to be adapted to meet the needs of patients. Therapeutic relationships with staff should be encouraged and a person-centred and individual recovery approach adopted. Prosocial relationships with peers, friends and family need to be fostered to enable positive recovery outcomes. Older patients should be empowered to develop a sense of autonomy to enable quality of life, wellbeing, and recovery, and progress. Changes in demographic trends, including longer life expectancy , increaOlder forensic mental health patients’ needs are complex, and this is likely to impact on their quality of life (QoL). Older forensic mental health patients are often diagnosed with severe mental disorders such as schizophrenia, personality disorder, bipolar disorder, or major depressive disorder  through in-depth interviews with 37 older (aged≥55 years) forensic mental health patients (in-patients and in the community) and 48 staff and professionals working with this patient group, from eight NHS Trusts in England. The authors estimated sample size based on their discussions on information power. Numbers we based on the appraisal model advocated by Malterud et al.  whereby n = 2, patients n = 9), video call  or telephone call (patients n = 1). One member of the research team undertook all the interviews. Face to face and video interviewing methods yielded rich data. The one telephone interview undertaken was deemed more difficult for facilitating the flow of the discussion as this method does not allow for the use non-verbal cues ; however, the interview still yielded rich and detailed data. The semi-structured interview questions were developed based on existing literature in the field, input from the research team, a Lived Experience Advisory Panel , and an expert professional advisory panel. The interviews were piloted with LEAP members to assess if the questions were relevant, appropriate, easy to understand and able to elicit descriptive responses. The interview questions were worded to gather information on quality of life, health and wellbeing, interventions and activities, age, and progress and prompts and adjunctive questions were used to gain more information as needed. Example questions for patients included: In your current situation what facilitates/enables (has helped) you to have good quality of life?; What maintains your mental health/physical health/wellbeing?; What do you think is needed specifically for older patients?; How would you describe what progress looks like for you? For the staff example questions included: How would you know that an older patient did not have good quality of life?; Can you describe if there is anything specifically tailored for supporting older patients’ mental health/physical health/wellbeing?; Do you perceive older patients as different or the same as younger patients and why?; How do you know if older patients are not progressing? (Interview schedules are available from authors on request). Staff interview length ranged from 36 minutes to 106 minutes and from 28 minutes to 80 minutes for the patients. All interviews were transcribed verbatim, anonymized, and uploaded to NVivo (V.20)  . Recruitment of participants was through the support of National Institute for Health and Care Research’s (NIHR) Clinical Research Network (CRN), who provided Principal Investigators (PIs) responsible for local site application of recruitment protocol, ensuring potential participants who met inclusion criteria were offered the opportunity for participation. Participants were invited to participate by PIs at each site and were given a participant information sheet to read. They were given time to consider participation before they were asked to give informed consent. It was explained to all participant about the voluntary nature of participation and that they could withdraw at any point without providing an explanation and—for the patients -without their care and treatment or legal rights being affected. All participants provided informed written or recorded verbal consent prior to the interview. Participants attended a one-to-one semi-structured interview, either face-to-face  and contextualism  within the forensic mental health services (inpatients and community). This integration was undertaken with three members of the research team and the LEAP members. Integrated themes were refined, defined and reviewed to make sure that they accurately represented the patterns across the synthesized data. The synthesized thematic networks were developed arranged, defined and summarized. Staff and patient information weighed the same and the findings and recommendations made were based on this integration of data sets.Strategies as recommended by Shenton  were impThe environment”, “The relationships” and “The person”. These are the external and internal factors that are all interlinked and either act as facilitators/enhancers of, or barriers to QoL, health, and wellbeing. The enablers are therefore what need to be promoted and implemented, whereas the obstacles need to be diminished and if possible, removed from the patients’ lives. The findings are supported with quotes from the interviewees; those from patients are identified by the code P, followed by either LS for low secure, MS for medium secure, HS for high secure, or C for community. Staff are identified by the code S, and an abbreviation of their profession :A range of different professionals were available: psychiatrists, nurses , OTs, physiotherapists, dentists, opticians, dieticians, GPs, specialist nursing practitioners, and speech and language therapists.This “readily available” provision was also seen with patients in the community where they are encouraged to have health checks and monitoring of their physical health. Support comes in the form of reminders as well as supporting and proactively organizing patients to get to health checks. As well as physical health care support there was also psychological and rehabilitation therapy with easy access for the patients. Such support was noted by both staff and patients as an accessible provision, so it appears to become a consistent and constant part of the service provided.I mean physical wise, we can bring in the physical accessories: crutches, wheelchairs, things like that. Lifts should they need bathing. Anything to do with getting out of bed, things like that. It’s just the physical stuff, mechanical things we can bring in.S48(RMN):Although this theme was evident in both the accounts from the patients and staff, it was more prominent in the narratives from the patients. Physical attributes of the built environment were important, for example, ensuite toilets, accessible showers or ramps, and not having stairs. Importance was placed on accommodating the needs of patients as they aged, e.g., as they became less able physically and mobility wise and needed extra support for daily activities.Having plenty of space. They’ve obviously got their own bedroom and, multiple different sort of indoor and outdoor spaces.S07(OT):Having adequate space: communal, private, and outside space was required.Bars on the windows, locked doors. I feel safer in here at the moment. I don’t think I’d do anything while I’m in here to myself or anybody else, but when I’m in here I feel safe. You’re watched all the time.P12(HS):It was important to have an environment minimizing risk for patients from themselves and others; and that offers a feeling of safety for all.They want to kind of be here a lot of them it is kind of like a safe space, like a home for a lot of them … I think a lot of them are very content here, which, which, helps them feel sort of calm and safe.S07(OT):The physical space also had positive psychological impact on the patients, who described that despite being a restricted environment, they still experienced positive feelings and a sense of ownership, where surroundings felt homely and not clinical.I used to be a smoker, any smoker, so coming to an environment where I can’t smoke, has helped tremendously;P22(MS):Secure environments were organized in a way that embedded healthy lifestyle behavioural choices, making healthy opportunities easily accessible for patients. This removed barriers to accessing healthy choices that the general population might typically face, such as obtaining a gym membership, or deciding what food to buy, offering a path of least resistance and nudging patients towards healthy choices, e.g., lack of opportunity for smoking:There have been the changes in the menu, I have to make good choices, the balance between the foods I enjoy as well as the healthy food;P23(MS): promoting healthy eating: Lots of focus on physical health, we’ve a really good physical health programme, we’ve big ground that people can walk in we’ve got the static physical health place, our OT run circuits.S05(PSY):and an environment that supports physical activities:Enablers”.This organizing theme is made up of three basic themes that capture different interpersonal relationships spanning professional and peers/friends/family that are “I’ve got a lot of friends in here that support me. They talk to me, they play cards with me, play other games. They’re always asking me if I’m all right. If I’m looking down, they come and talk to me or make me a brew. They’re always asking if I’m all right.P20(HS): This theme was more widespread in the accounts of the patients and is about the supportive relationships with “friends” made through the circumstances they are in, such as other patients. They might not naturally choose these friendships, but they develop because their circumstances match up. There is a feeling of camaraderie and being part of the “group”, where supportive relationships with other patients contribute to QoL and wellbeing.Those who don’t have any family members, they have the Samaritans who come in and they will sit with them. One of the things that works well for me [a Chaplain] is being a friend to the service user. Just being a friend.S06(N/CLIN):The participants discussed the importance of access to other friends of circumstances such as volunteers  or chaplaincy who become “friends” and part of a support mechanism.Well, there’s a couple of staff nurses I like talking to. There’s a few of them in here I can talk to because they’re right down to earth with you…they’re like you and they have a laugh.P16(HS): QoL, health, wellbeing and progress was enhanced by the characteristics, attitudes, and actions of staff, who created a supportive environment. This included staff being caring, empathetic, compassionate, and putting patients first. The patients considered staff people to trust and confide in. Patients could talk to staff about problems, seek advice from them, socialize with them, or talk about shared interests.One chap he’s just gone over 55, I’ve nursed him for years, and I think for him because he hasn’t got a lot of family, it’s actually building relationships with the staff, they’ve become his surrogate family, and having those positive relationships has been good for him.S17(RMN): Staff get to know patients well and understand them and their experiences. It seems favourable when the staff are of similar ages. Some patients are in hospital for such a long time, that the staff become like “family”; this closeness contributes to developing a successful therapeutic relationship.Family contact … especially if family has been important for them, and has been supportive, if they got an extended family, children, grandchildren, maintaining that earlier on … It’s ensuring that they have got good family contact, good family support, maximizing their quality of life is more likely to get them to progress.S03(PMD):Family and friends external to inpatient settings represent patients’ intentional relationships. These chosen and mutually agreed friendships support the patient through visits, maintaining a presence in their lives, and helping with care planning.Yes, the relationship I’ve got with my kids. Yes, that’s essential for me;P01(C):This contact across different family members was identified by the patients as something really important, including active involvement from children:Seeing my grandkids and children, that’s my best thing. Just seeing my grandkids and children;P31(C): grandchildren:It’s nice to meet my mum, my dad … . They give me good, in terms of well-being, knowing they’re safe and happy, and keep me positive;P10(C): parents:Yes. I have contact with one of my sisters and her son, fortunately enough … she’s quite happy to help me out and support me.P22(MS):and siblings:Meeting with friends, for a coffee or things like that, simple things are quite important for some people … you know I think it’s important for them to have friends to support them it helps their wellbeing and helps them move on with encouragement.S15(C/RMN): Friends of intention external to the friends of circumstance, were also identified as an important support mechanism for the inpatients and was also seen out in the community. Here, they could provide a social mechanism to support the patients and help them move on.This organizing theme includes four basic themes. These factors are at an individual level; underpinning this is a culture and philosophy that enable patients to feel valued, ensuring their lives have worth and meaning.Contributing to QoL was patients being able and empowered to make choices and decisions about their lives. The culture is one of enabling individuals to be active participants in their lives, care and treatment, and not simply being passive and having everything imposed on them.They sort of empower them, when they have morning meetings, they allow the older ones to chair the meeting, give them some form of responsibility, and accountability.S06(N/CLIN):The patient matters in this, so being really clear with the patient about what they want, what they find value in, so I think the model I that I drive particularly for all of my patients, but I find works very well for the older group, is the “Good Lives” model.S05(PSY):Staff talked about how, for the older patients, the philosophy was to use the Good Lives Model :Patients talked extensively about autonomy and the importance of having freedom to decide what they want to do and being able to do this.Having the back up of my team … because if I’ve got something to fall back on, they’re always there. It helps me function better knowing that if I feel that there’s something that I’m not comfortable with, for whatever reason, I can chat with them about it. It’s like having a safety net.P33(C): This theme was noted more by patients than staff and mostly related to patients in the community, who highlighted the value of having support in place to act as a safety-net or back-up, above and beyond the day-to-day care that they have access to. This safety-net gave patients a sense that support is there to draw on if needed, giving them confidence that someone “has their back”.It’s usually just like dieting, make sure—I don’t eat too much takeaways. Physical health. Walk a bit more. Check the mental health to see if the mental health’s all right.P01(C):Back-up can also occur in the form of checks, such as on medication, physical health, activities and mental health. Having staff in the background allows them to monitor patients, identifying potential problems early, and offering support mechanisms if required.I really enjoy the graphics, bookbinding. I was the one they’d come to if they wanted anything doing in the workshop. It would be staff, patients, sending books down to be stripped, taken all apart, resewn or new covers. I used to do all that. I really enjoyed it. I’m useful, proud.P12(HS):Roles and responsibility facilitated feelings of being valued, respected, and doing something worthwhile. This enabled a real sense of purpose, worth and a reason for being, where activities contributed to patients’ sense of agency and identity. Bookbinding gave P12 a sense of status and ownership where he takes on the social role of expert in a given skill, and with this gets a sense of worth and being needed by others.Doing meaningful activities that, that they enjoy. We have got people who, are musicians, who are in their 70s and it’s trying to encourage keeping that identity going.S07(OT):Activities important specifically to the patient, and congruent with things of importance across their lives were particularly valued. This brought meaning to activities and gave a sense of autonomy and choice through exploration of their own identities instead of being pushed to do things that did not fulfil their sense of self.I like drama, sort of plays and that. Poetry. Stuff like that. Takes my mind off other things. Other things for a little while. Takes my mind to other things.P18(LS):Activities were useful in keeping patients’ minds occupied and through focusing on the activities, they are then not thinking about other problems that they may have.We try as best to create a recovery-focused environment. You know, those things like hope, hope for the future, purposefulness, meaning, things around identity.S24(SW): A sense of hope for the future, and a positive future focus enables patients to feel a sense of worth and something to strive towards.Positive frame of mind [P04(C)]; Positive thinking [P08(LS)]; Positive mindset [P06(LS)]; and Positive attitude [P10(C)] was associated with good QoL, wellbeing and progress. There is a feeling that the underpinning philosophy must be a future-focused one, with a mindset of having things to look forward to, as opposed to dwelling on the past and on things that cannot be changed.The main thing is optimism and a positive state of mind. I’m getting older now, I sometimes think about, the end of my life, I try not to do that as much as possible. There is always something new to keep me going and make me look forward rather than backward.P04(C):In the narratives there is a real sense of patients having goals and a future to aim for. It was important for patients to have positive states of mind, and several talked about how: The staff and patients all identified factors that prevented or obstructed good QoL, health, wellbeing, recovery and progress, associated with the environment, relationships, or the person.Safety, rehabilitation and criminal justice requirements create an unnatural and imposed environment, so choices are dictated and defined by staff, resulting in a highly controlled, and low patient agency environment.It’s a sad thing to say, but the regime of the place. To get institutionalized is wrong, but I’ve been, this section I’ve been in 15 years, I’m institutionalized.P05(LS):Participants described that over time they adapt to living in this controlled environment. This involves being institutionalized, which creates a dependency on the system and other people and is particularly problematic for those who have a long length of stay.Some people, even in the community, still think in a very institutionalized way, they still see themselves as part of the system, as being controlled, monitored.S01(C/RMN):This sense of institutionalization followed patients from inpatient settings to the community, where the feeling didn’t simply disappear when physical restrictions were removed.Living in a nice secure, like this one and an en suite and quality of life, food on the table, no bills to pay. I don’t want to move from here, it scares me that does, it scares me moving from here, because I might put the cooker on and forget to turn it off.P07(LS):Patients adapted to having structure and being told what to do, developing a reliance on others, potentially associated with a loss of skills. The system and structure designed to support patients to manage their mental health conditions can leave them ill-equipped to move on and progress.Being scared of going out and facing a big, wild world, technology is changing that fast, maybe can’t deal with it. Things like phones, using computers, using iPads, anything at all to do with televisions, it’s just they don’t know. Even just going outside, how fast and hectic it is.S48(RMN):For long-term patients, the world beyond their inpatient setting has changed, which is frightening for some. Unknown developments in the community such as technological advancements  can create fear and worry, and some patients may prefer to stay as an inpatient where they feel safe.I’m a bit bored twiddling my thumbs and not enough activities. I really need to feel like I’ve got a sense of freedom to get outside and be in an open space. Really missing like the walks and going outside for a long walk, that’s what I’m really missing.P03(MS):This unnatural and imposed environment affords a lack of appropriate activities for patients, particularly meaningful ones. The restricted environment takes away individual choice. The lack of available things to do, or restrictions  leads to feelings of boredom and monotony.Some [activities] are for five or six-year-olds. It’s glitter everywhere. Painting. Making cards” P12(HS). Physical issues associated with ageing could also render some physical activities unsuitable for older patients.You know, the, the young lads that are awesome footballers and basketballers they can do that all, and it is set up great for them, but for people that want to do, lower-level introduction to sport or just gentler, more gentle things, there isn’t as much access.S08(PSY): Certain activities like arts and crafts were not suitable or age-appropriate: “I like getting in the bath, out the bath but it’s standing up after I’ve sat down. I cannot stand up again. I have to be lifted up. I can’t reach. Because of everything I very rarely get to have a bath. I’d like to have to an invalid bath. A hoist, a sort of hoist.P18(LS):Some physical environments were not suited to patients’ needs, and patients don’t have the agency to adapt their environment. The environment cannot accommodate physical issues associated with ageing  or declining physical health. Participants described not having handrails, walking sticks, Zimmer frames  hoists, footstools, raised toilet seats/chairs, and that furniture was fixed and not moveable.His mobility is poorly, he has arthritis, and glaucoma so his eyesight is poor, he lives on the 2nd floor, and it’s not ideal for him, going up two flights of stairs;S01(C/RMN):Buildings were described as dated, multilevel, having too many stairs, having poor access to outside, and not being able to accommodate wheelchairs in the community:If they have got physical health problems, not having en suite bedroom may get in the way of their quality of life. Our rehabilitation units are all upstairs. Individuals, who had problems with knees they need a lift, rather than going up and down the stairs 10 times a day.S04(PMD):and on the wards:It is the restrictions of secure care, so they can’t go out and visit family, don’t have full control of what they eat whether mealtime or snacks, lack of opportunities to go out to do things.S07(OT):Participants expressed that the system, processes, resources, or lack of provision, can be a barrier. Restrictions and rules preventing patients from accessing things that most take for granted, such as technology, visiting and seeing family, deciding what to eat, going out, and being able to do activities they want.For me to improve my quality of life even more would be to be able to go outside…. Having more freedom, more opportunity to go outside. Lack of freedom, I feel a bit cooped up.P03(MS):The restrictions and rules reduced patients’ freedom which they felt impacted their QoL, wellbeing and progress negatively.If it wasn’t for the COVID, I’d be moving on now [to community], because of COVID I think they’ve locked down until about January now.P07(LS):Patients experienced additional restrictions due to COVID-19. Activities were reduced or stopped completely, as were visitors, leave and mixing with other patients. For some in the community, they found themselves back to a restricted environment, almost one akin to being in the unit. The restrictions also prevented some transitions to the community’.S03(PMD): Special permission, that can be time consuming, sometimes people think why bother, people say, “I’m not going to fill out three forms, to justify myself, to get this person one hour of leave, I won’t bother doing it, rather tell the patient it can’t be done, policy won’t allow for it.Policy, processes, administration, and paperwork also impeded patients. This was related to risk and risk assessments, which was a barrier for patients restricting them further.Food-wise putting on weight, I’ve put on weight. I don’t want to become obese. A lot of the problem is obesity, when they make things easy to do. I’ve got loads of bad eating habits.P05(LS): The environment facilitated poor lifestyle choices, e.g., access to take away food, the on-site “tuck” shop (selling confectionery or snacks), lack of exercise facilities, and provision of meals that were not always healthy.A lot of our patients really struggle with obesity, but they’re still able to order takeaways, because there isn’t that want to come and restrict them even further and take a little bit of choice away from them.S12(PHY): The restrictive nature of the settings makes choices such as takeaways highly valued and rewarding as they represent a treat and a way of exercising some choice or control, in comparison to someone not within a unit, who has wider range of options, choices, and treats in more aspects of their lives.The restricted environment creates a situation where patients have a disposable income, and little options to spend it. Patients then buy large quantities of unhealthy food from the tuck shops. S45(I/RMN): They go to the shop and come back with a trolley load of fizzy drinks, crisps, biscuits and stuff, because they have money. They’ve got money, and you could see the obesity.This organizing theme is made up of three basic themes which represent an absence of, or poor, pro-social relationships with three different groups: staff, fellow patients, and family and friends.“I’ll just say there’s a couple of staff who I don’t really get on with” P16(HS). A lack of shared goals and understanding of their care was also problematic resulting in patients feeling excluded from their own care. On occasion patients simply felt they were not listened to, rupturing therapeutic relationships. Patients were “done to”, i.e., staff make all the decisions, with no collaboration and as “experts”, staff pull rank on decision making and what happens to the patients. Patients become passive recipients, are not given a voice and lose their sense of agency.The doctors go “well we will try it again it will be fine”, and kind of overrule them. I don’t think their voice is always heard. It takes away that autonomy and that drive in them, it’s like what’s the point of me having a voice if everyone else is going to make that decision for me.S12(PHY): ‘An absence of therapeutic alliances, and not agreeing on care planning impeded patients’ QoL, health, wellbeing, and progress. Some patients were unable to create the therapeutic relationship because they did not get on with the staff, Having time for people is really important, so I know we’re all busy, but I do think people need a bit more time…it comes down to time and resources, and everyone is running around being busy and, so, I guess a bit more time and maybe a bit more resource would help.S40(OT): High staff turnover, use of bank staff, and lack of staffing time due to low staffing numbers or demands of a busy ward prevented opportunities to develop staff-patient relationships.The staff that should be on that ward shouldn’t be kids … It just needs more staff of the same ages but older generation because you understand each other.P16(HS): Older patients found it difficult developing therapeutic relationships with staff who were a lot younger than them. They felt that they couldn’t relate to younger staff, which suggests having staff of a similar age could allow for more shared experiences and understanding with them.Peer groups, some of the older gentlemen will say “that unit is full of young people, who all talk a certain way and are interested in certain things, and I don’t feel like I fit in”. So, they may not feel part of the, the group as a whole … they are in a minority.S04(PMD): Patients described not getting on with everyone or experiencing the wrong mix of people, such as younger and older patients who did not integrate well together. This could be due to lack of common ground or shared experience or a feeling of being the minority and not fitting in with the group.People bullying me, trying to intimidate me, I’ll take so much. In the past, I’ve just swung at people, hot water, that was my way of dealing with things.P34(HS): The environment becomes unnatural as patients find themselves amongst people, they wouldn’t necessarily choose to be with but have to be. Furthermore, the social dynamics and positioning of older patients as a minority could develop into bullying. Coupled with an inability to remove themselves from such situations this could lead to maladaptive responses such as violence.You have new people coming in who are very acutely unwell or creating disturbances, that’s difficult for the older guys sometimes. The older ones seemed to be more settled, so that’s something. But they tend to get a bit frightened, hide away in their room, become isolated.S35(SW): Inpatient settings can exist in a state of flux as patients are admitted in and transferred out; the changing dynamics often involve new arrivals who are very unwell or violent. This could be intimidating for older patients, who may avoid social spaces to keep out of trouble, and then risk isolating themselves, and reduce the chance of positive social interactions.Some patients experienced an absence of any intentional relationships, due to estrangement from families, relationship breakdown, disconnections or through being shunned or rejected.No, my three children don’t want to know me, they’re all grown up now and they’re only after one thing, the money side.P07(LS): Some of them seem to have less contact with family. I think a lot of our older adults have been in the system for a long, long time, so either haven’t had opportunity to start their own family. Or those ties have been lost over the years. I think we see an awful lot more isolation with this group outside, in terms of outside connections.S36(PSY): The long length of time patients are in units can break social connectedness with family and friends; many patients missed the opportunity to build a family life of their own. They become isolated from family groups and social settings.I used to have my aunty, and my uncle, and my dad, and my mum, I don’t anymore, they’ve passed away. So, I wouldn’t be able to cope outside myself.P21(HS): An issue associated with patients’ ages was that family members had passed away, removing a valuable source of external support in the community that could help them progress.I don’t have any—my friends I’ve put aside. I’ve put my friends aside … I’ve got no friends that I could really consider to be worthwhile outside in my local area.P15(LS): Friendships of intention were difficult to maintain as patients were in secure units for a long time. For some patients the curtailment of these relationships was an active choice.This final organizing theme is made up of three basic themes, which are about patients’ individual characteristics and “the self” that can impact negatively on their QoL, health, wellbeing, and prevent progress.Co-morbid age-related issues experienced by patients were widespread, particularly physical issues associated with ageing, such as heart and respiratory illness, arthritis, chronic illness, and serious diseases.They’re going to have more complex physical health issues, so a lot of our gentlemen have got diabetes, cholesterol, blood pressure, heart conditions, COPD.S10(I/RMN): With cognitive problems or with the diagnosis of dementia, will progressively get worst due to the nature of the illness, with a formal diagnosis of dementia, progress might be a misnomer, you know, just by the virtue of the illness, you know they will deteriorate over time.S04(PMD): A key concern is age-related cognitive changes, due to organic decline and onset of diseases such as dementia, Alzheimer’s, Parkinson’s, and other neuro-degenerative diseases, general decline in cognitive ability, slower cognitive processing as patients age, or simply a poor memory.They need to look at my mobility and my eyesight. Both of them are degenerating.P01(C): It was also apparent that some patients experienced age-related general physical deterioration such as frailty, falls, poor eyesight, loss of hearing, and lack of or poor mobility.The over 55 year old gentleman I’d worked with he had so much guilt over the things he had done in the past;S01(C/RMN): Participants talked about numerous adverse emotions that they felt contributed to poor QoL, health and wellbeing, and that could hamper progress. Examples of this include guilt:I haven’t got it  here. I’ve got negativity and depression and anxiety and panic;P05(LS): negativity and anxiety:Barriers to quality of life… feeling hopeless… I feel like giving up and being self-destructive;P03(MS): hopelessness:They have this massive sense of shame about themselves, so that prevents them from moving on;S01(CRM): shame: I’ve not got very good self-esteem, that overwhelms me, and I just feel I’m good for nothing and life isn’t worth living.P04(C): and low self-esteem: Like that revolving door so someone that keeps coming back into services or they deliberately avoiding compliance with medication to become unwell so they can come into a service where they’re familiar with … They feel like they look at nursing staff like a family they don’t want to leave here and they will try to self-sabotage.S10(RMN): There was also an element of problematic behaviours associated with self-sabotaging. This could result in relapse, violent and abusive behaviours, or for those in the community, taking drugs. For some, self-sabotaging behaviours were a way of remaining in or going back to the secure unit where they felt they wanted to be, but that ultimately prevented progress.Stigma reduced is quite a large part of that … that’s a massive barrier when people have, been in hospital for a large amount of time and they come out. People who are older and maybe committed their crime when they were 20 that one incident, maybe, 40 years ago would still be held and they would still not be able to access things.S27(C/RMN): This theme was predominantly found in the staff data. The stigma and labels of past behaviours, offending, mental health, and patients’ age could become particularly stuck to older patients, even though for many the offending and behaviours were many years ago and they had completed a considerable amount of therapeutic work since.mental health” and a “forensic” label. Decisions were made based on these labels.We’re addressing the stigma of mental health, but the stigma of forensic mental health is another issue altogether. Clearly, forensic puts the frights into people. I wouldn’t like to have to say I’m a forensic mental health patient really. Maybe we ought to get rid of that word “forensic”.S29(C/SW): It was problematic for patients when they were stigmatized with a “forensic” “mental health” and “older people care” service provision. Improvements in QoL for forensic mental health patients can augment perceptions of recovery that in turn promotes scope for progress  and through the provision of equipment  to accommodate for deteriorating physical health, reduced mobility, frailty, and decline in hearing, sight, and cognition. These were the contextual conditions for particular causal mechanism to take effect in relation to quality of life, wellbeing, recovery, and progress. The environment also needed to offer safety and reduced risk. The CHIME-S framework  for patients, with private space, but also good communal and outdoor areas to foster social interactions. Privacy and access to adequate personal space have been identified as important aspects of the physical environment for forensic mental health patients  is important. From a critical realist viewpoint, generative mechanisms are embedded within social structures and are contextually contingent, and work through people’s actions; social structures provide the conditions that constrain or facilitate health-related activities Angus, . There iFor older adults, easy access to gyms and exercise classes is beneficial, particularly where the exercises are adapted and tailored for their needs. Many units now implement a non-smoking policy so that smoking is only allowed on community leave, and this has been found to reduce smoking . Peer support and patient cohesion was observed as important and necessary, and this could be linked to social climate, and the dimension “On an individual level, autonomy, choice and being involved in their care and treatment decisions promoted QoL, health and wellbeing for the older forensic patients. In many ways compulsory detention conflicts with the concept of patient autonomy and likewise intrusive monitoring in the community can restrict autonomy and agency , mental illness, and old age, and the accompanying stigmatization which can prevent recovery, hamper discharge, and persist in the community . A strength of the study was the large sample size gaining representation from patients in different security levels and staff from relevant professions. By taking a qualitative approach this provided a rich dataset and allowed for a systematic unpicking of all these individuals’ experiences and the co-construction of knowledge, however, as it was based on a selection of accounts in specific contexts it may not be generalizable.This methodological approach enabled an exploration and understanding of a phenomenon from the perspective of those experiencing it, but it does not offer the ability to make direct cause and effect inferences in relation to the specific outcomes of interest such as QoL, wellbeing, recovery and progress. The methodology was suited and appropriate for addressing the aims and research question posed. Key concepts were operationalized in interviews via the structured questions posed, but this may limit emergent themes compared to other approaches such as grounded theory. The patient participants, for reason of risk, sometimes had to be interviewed with staff members present , which could have influenced some of their answers. Patients may have therefore felt they could not discuss negative factors as this might influence their ongoing care potentially leading them to focus on the positive aspects more. Participants also took part of their own free will, and this may introduce a selection bias. Finally, it was not possible to have access to the details regarding the length of time that patients stayed within the secure units. Length of stay could be a confounding factor for subjective quality of life and as such the lack of this data limits the discussion related to the interpretation of results around this subjective factor.This research applied qualitative methods to obtain in-depth narratives and views from staff and older forensic mental health patients, who, given the difficulties and complexity in trying to engage and include them in such projects, are commonly not given a voice through research. The environment, interpersonal relationships, and individual characteristics of the patients need careful consideration in relation to service provision and care, given their interconnectedness and impact on patients’ QoL, health, and wellbeing. A “wellness” environment is required, whereby physical and mental health is assessed and addressed (particularly issues and needs associated with the ageing process). The environment needs to be adapted to cater for changing needs for people as they get older and be such that it promotes healthy lifestyle behaviours . In addition, prosocial relationships need to be a feature in patients’ lives; this includes with family and friends, peers on their units as well as therapeutic relationships with staff and professionals. On an individual level, there needs to be the opportunity for autonomy and choice, where individuals have access to meaningful activities and so have a purpose, where a sense of worth and a feeling of hope is enabled and supported. This aligns with the key recovery processes in the CHIME-S framework (Senneseth et al.,


A minority of all individuals with alcohol use disorders (AUD) seek treatment, where stigma is one prominent barrier. Social support is important to facilitate health and increase treatment-seeking. Whether there is an association between stigma and attitudes towards others’ help-seeking for AUD is unknown. The aim of this study was to investigate the associations between stigma and support towards others’ help-seeking for AUD, also to explore possible gender differences.Cross-sectional study, n = 2895, including Danish adults aged 30–65 in the general population. Year 2020, an online questionnaire was administrated, which covered demographics, attitudes towards others’ help-seeking for AUD, and stigma measured with the Difference, Disdain & Blame Scales. Analyses were performed with Restricted Cubic Spline models, and odds ratios were calculated.Lower level of stigma was associated with a higher probability for endorsing an “active support strategy”. Level of stigma was not associated with “not knowing what to say or do” or “sharing my concern with others”. There were few gender differences: among men, higher level of stigma was associated with a higher probability of “avoidance”. Among women, lower level of stigma was associated with a lower probability of “avoidance”.There is a clear association between stigma and attitudes towards supporting others’ help-seeking for AUD. The results highlight the need to reduce stigma and promote engagement towards others’ treatment-seeking.The online version contains supplementary material available at  10.1186/s13722-023-00400-2. Alcohol use disorder (AUD) is among the most highly stigmatized medical conditions in the Western world , 2. PublSome manifestations of stigma, as discrimination, lead to serious consequences for the affected group with diminished opportunities for achieving personal goals such as education, work, and housing . Both thAUD has, compared to other psychiatric disorders, one of the largest gaps between the number of affected individuals and the number of individuals seeking treatment , 13. ThiSocial support is a facilitator of good mental and physical health, particularly in the presence of stressors , 21. SupThe overall aim of this study is to investigate if there are associations between perceived public stigma and attitudes towards supporting individuals, suffering from AUD, in seeking help for their alcohol problems. Moreover, possible gender differences will be explored, as previous studies suggest that women endorse lower level of stigma compared to men .The analyses will take demographic factors, age, education, and previously having alcohol problems into consideration.Cross-sectional study.The participants were recruited by a market research company with access to a panel consisting of adults from all regions in Denmark, representing the general population. Between June and October 2020, a group of adults aged 30–65 years was asked to participate in an online questionnaire. The topic of the survey was not known to the participants beforehand, and took circa 12 to 16 min to complete. The proportion of participants who dropped out before completing the survey was slightly higher compared to surveys from the same market research company of similar length on other topics: 8.5% compared to normally 5–6%. In total, 2895 individuals participated.The outcome measures were attitudes towards others’ help seeking for AUD. Please see “The questionnaire covered demographic data on sex, age category, education and having children. Experience of having alcohol problems was measured with the item: “Have you previously had alcohol problems?”, where the participants could answer “yes” or “no”.Public stigma was measured with the Difference, Disdain & Blame Scales for Public Stigma, a questionnaire where the participant rate nine items on a scale from one  to nine (very much). The Difference and Disdain scale has been used in previous studies , 29, 30,Attitudes towards others’ help-seeking for AUD were measured with the question: “What would you do if you were concerned that someone you knew had developed an alcohol problem?” The participants were given the following alternatives and answered yes or no to each: “I would not know what to say or do”, “Speak to them and support them, as well as I can”, “Help them to seek treatment”, “Seek possibilities for help on the Internet”, “Share my concerns with others in the social circle”, “I would avoid them”, and “I would not do anything and hope they or someone else solved the problem”. All alternatives were used in the analyses, but some were grouped. The groups of attitude items were made from theoretical decisions, where the authors discussed and reached consensus in which items that measured similar behavioral aspects of support. The groups were decided after data was collected, and before the statistical analyses were performed. The following two alternatives were grouped together in the analyses and named “Active strategy”: “Speak to them and support them, as well as I can” and “Help them to seek treatment”. The following two alternatives were grouped together in the analyses and named “Avoidance strategy”: “I would avoid them” and “I would not do anything and hope they or someone else solved the problem”. The five outcomes were: “I would not know what to say or do”; “Active strategy”; “Avoidance strategy”; “Seek possibilities for help on the Internet” and “Share my concerns with others in the social circle”. The grouped outcomes were rated “yes” if at least one of the included items were endorsed.After describing the sample as whole and separately per gender, using chi-square tests to assess association between categorical variables and t-test for the stigma total score, logistic regression models were used to investigate the association between the total score of stigma and the five outcomes, which measure attitudes towards help-seeking . The outcomes were dummy-coded. The data was inspected by visually plotting each exposure and the logit of outcome to check for linearity. When evidence of a non-linear relationship was found, restricted cubic spline transformation was used to model the relationship between the exposure, level of stigma, and each outcome . Stigma The analyses were performed in two steps. First, the crude associations between public stigma and the outcome measures were calculated, separated by sex. Next, all analyses were adjusted for age category, education, and experience of alcohol problems. P values for Bonferroni’s correction (0.05/20 = 0.0025) were calculated in order to decrease the risk of type I error. All analyses were carried out using Stata MP 16.1 .The demographic information for the participants can be seen in Table Figures not knowing what to say or do among men. When adjusting for age, education, and personal experience of alcohol problems, there was no association, either for men or women, between perceived stigma and not knowing what to say or do.As can be seen in Fig. an active strategy.However, as seen in Fig. seeking possibilities for help on the Internet. Among women, there were no associations between stigma and seeking possibilities on the Internet.Figure sharing my concern with others in the social circle.As seen in Fig. an avoidance strategy, and there was a trend towards lower stigma being associated with a lower probability of an avoidance strategy. Among women, lower stigma was associated with lower odds of endorsing an avoidance strategy.Finally, Fig. The aim of this study was to investigate the associations between stigma and attitudes towards others’ help-seeking for AUD; a topic that to our knowledge has not been studied before. Moreover, the aim of our study was to explore possible differences associated with gender. Previous studies have examined the associations between stigma and own treatment-seeking; however, contextual factors such as attitudes in the general population towards others’ treatment-seeking have not previously been explored.avoidance strategy, and there was a trend towards lower perceived stigma associated with a lower probability of an avoidance strategy. Among women, lower perceived stigma was associated with a markedly lower probability of endorsing an avoidance strategy. Avoidance behaviors and the desire for social distancing from individuals with AUD can be seen both as a consequence of stigma and part of the stigma process [The results showed a rather clear association between stigma and attitudes towards others’ help-seeking for AUD. Lower level of stigma was associated with a higher probability of prosocial behaviors and an active strategy towards others’ help-seeking, including addressing and supporting the affected persons, and supporting them in seeking treatment. There were few gender differences: women, compared to men, seemed to a lesser degree to be impacted by level of stigma. Among men, a higher perception of stigma was associated with a markedly higher probability of  process .Our findings highlight two important areas which are intertwined with one another: firstly, the importance of reducing the stigma associated with AUD, and secondly, social support for help-seeking for AUD. We will first discuss how stigma can be reduced.Prior research has shown that the stereotype of differentness decreases empathy and increases anger towards the group affected by stigma . In turnAnother possible aspect to explore further is the messages around AUD and treatment-seeking. The emphasis on biological causes for AUD has been associated with a lower level of social distancing and blame, but also with higher perceived dangerousness . In addiA well-known model of coping strategies among those surrounding individuals with AUD is the “stress-strain-coping-support (SSCS) model” . It descThis is a cross-sectional study, where it is not possible to draw any conclusions about causality or temporal direction of the associations between stigma and support for other’s help seeking. We suggest future studies address this limitation by using a longitudinal cohort design. Another limitation is the use of self-report measures, which do not always correlate with actual behaviours. Questions on stigma, alcohol problems and support for other’s help seeking, can all can be perceived as sensitive, and pose an increased risk of socially desirable answers. Due to social desirability, it is expected that level of stigma and experience of alcohol problems are underreported and that support for other’s help seeking is overreported, also in this type of anonymized survey. This increases the risk that associations between low level of stigma and higher level of support for other’s help seeking is attenuated. To reduce the risk of social desirability response bias, a stigma questionnaire emphasizing the measures of differentness was used, which is considered to impose less risk of biased answers , 43. PreStudies from other areas of research suggest that gender differences can be attenuated and sometimes stems from social desirability response bias, where women seem more sensitive for social desirability response bias compared to men . This poOne limitation in the study is the high number of analyses. When accounting for Bonferroni´s correction the results suggesting that lower stigma was associated with lower odds of endorsing an avoidance strategy among women were not significant. However, no other results changed.Perceptions of AUD and stigma are complex phenomena, where synergistic effects between these and different factors such as socioeconomic position, gender, age are expected. A strength of the current study is that these factors were included, together with a large sample size.There is a clear association between stigma and support towards others’ help-seeking for AUD in this general population sample. The results highlight the need to reduce the stigma associated with AUD, and promote engagement towards others’ treatment-seeking.Additional file 1: Appendix S1. Estimates for the overallstatistical model, presented for each outcome.


There exist substantial patient barriers to accessing medications for opioid use disorder (MOUD), including travel distance, stigma, and availability of MOUD providers. Yet, despite these barriers, there exists a subset of patients who possess the requisite motivation to seek and remain adherent to treatment.To explore patient-derived goals in MOUD treatment-adherent patients.This study used in-depth interviews with patients receiving methadone who were enrolled in opioid treatment programs (OTPs) across Tennessee. Participants were recruited from 12 different OTPs to participate in telephonic semi-structured interviews to a point of saturation. Participants had to be adherent to treatment, in treatment for 6 months or greater, and English speaking. Analysis occurred inductively using a constructivist approach to Grounded Theory.In total, 17 patient interviews were conducted in the spring of 2021. Participants described goal setting across three general stages of treatment: (1) addressing acute physical and emotional needs upon treatment entry, (2) development of supportive structure and routine to develop healthy skills facilitated by treatment team, and (3) identifying and pursuing future-focused goals not directly linked to treatment. A Proximal Goals in MOUD Framework is introduced.In this qualitative study on patient reported goals in MOUD it was found that goals are transitory and relative to the stage of treatment. Further research is needed to better understand goal evolution over the course of treatment and its impact on treatment retention. IA was a female pharmacist post-graduate research assistant, AC is a qualitative researcher, and KH is college of pharmacy faculty member. The interview guide was developed by KC and AC, with input from opioid treatment program stakeholders including clinicians, counselors, and administrators. Participants were made aware of the opportunity to participate in the study by their on-site counselors. As an incentive for participation, the interview could be counted as one of their required counseling sessions. Study participants were also given a $50 gift card as compensation for their time. The project was approved by the Institutional Review Board.Interviews were conducted over the telephone and recorded using a digital recording device until a point of saturation. Audio recordings were professionally transcribed by a third party to avoid any bias. Field notes were taken during the interviews and used along with transcribed interviews in data analysis.Using a Grounded Theory approach, data were first analyzed with open coding. This was followed by axial coding to investigate relationships across emerging categories of codes. Finally, selective coding was used to integrate categories into a cohesive theory. NVivo 12® qualitative software was used to analyze transcripts line-by-line using open, axial, and selective coding. KH and CL refined the code book to and regularly met to review discrepancies and ensure reliability of the themes as they progressed.33.1In total 17 patient interviews were conducted. The average interview length was 65.6 min. Patient demographic data is presented in 3.2Participants described goal setting across three general stages of treatment: (1) addressing acute physical and emotional needs upon treatment entry, (2) development of supportive structure and routine to develop healthy skills facilitated by treatment team, and (3) identifying and pursuing future-focused goals not directly linked to treatment. However, not all participants articulated progression through all three stages.The resulting Proximal Goals in MOUD Framework  presents3.3Participants indicated that PRGs were linked to their success in treatment and emphasized the importance of being involved in the setting of treatment goals.First of all, if you want to beat this, you've got to set yourself goals and you've got to stick to those goals, you've got to do it to make it work.” (P14).“Participants noted that these goals were not fixed at a single point in time. Goals which were most proximal to the stage of recovery the patient was in were prioritized. Less proximal goals, like re-establishing severed relationships, were sometimes set as early on as treatment entry, but were not as readily achieved as more proximal goals like “achieving the right dose.”“My first goal was just to get stable and to be able to function and not have good days and bad days and stuff like that.” (P5).“You set small [goals], and it'll lead up to bigger [goals]. …because I got two sons, and they're grown, and they got kids. I've got five grandkids. And I had to rebuild my relationship with my sons. And that took a while, and now we're in a good place.” (P9).Participants reported goals progressed in terms of difficulty and complexity over time.“… just getting up and making my bed every morning. Just something as simple as that. And I still do that. …It's hard to change the way you've been living your whole entire adolescent life and all of your adult life and just stop and stop talking to anybody and everybody you've ever met and trying to completely forget about that life and turn around and meet new people, better friends that are not using nor addicted to drugs, nor ever have been. It's hard to surround yourself with those kinds of people and stay on the right path.” (P18).Broadly, participants described goals across three main stages: “stabilization,” “scaffolding,” and “future focused” .3.3.1The first stage was “stabilization,” which immediately followed the critical event which led the patient to treatment entry. It includes goals that were short-term and typically addressed acute concerns of the participant . Social goals were lower priority, inwardly focused, and had concerns over autonomy, involvement in decisions, and overall rigidity of the program.“I don't really have no [long-term] goals for it. I mean, I don't wish on stars and stuff. I live one day at a time.” (P1).“My timeline I had in my head literally when I started here, I'm like, I'm just going to go here like one year, maybe two, but then, when you get in there and you realize just to get a dose stabilized and get your right dosing amount, it takes like six to nine months, so that wasn't even realistic.” (P3).The patient-defined treatment goals for this stage include treatment of pain, avoiding withdrawal, and getting “clean”, and finding “normalcy”. Simple, and often short-term, goals were articulated.The first week or so I noticed that my days would start differently. My day would just start better. I wasn't uncomfortable right away. I didn't wake up uncomfortable. I woke up in a better frame of mind. I woke up feeling better… And then, I noticed, as time went on, my sleep has even improved because I had sleep problems in the past, a lot of sleep problems. And it has got to the point now to where, I mean, I sleep eight hours a night… It made a lot of difference in my rest habits, a lot of difference in the way I- and I enjoy my meals more now. I'm more comfortable. So a lot of the normal things that a lot of people take for granted are better now for me.” (P14).“The participants articulated the need to have a treatment team they could trust and establish a relationship early on in treatment.You know, he's not just there to [say], ‘hey, did you go there, are you obeying the rules, are you- okay, goodbye.’ You know, it's, ‘How are you doing today? How are other things in your life? Do you have any other problems?’” (P14).“Now, imagine that you've got to go to this person that you don't really feel comfortable with, and they're going to talk to you, and you're expected to talk to them about something that's the most sensitive and possibly damaging in many kinds of ways subject. And so, it won't work if you don't have a [care provider] that has a way of being understanding, non-judgmental, and always kind.” (P13).“Some hallmarks of this stage include the respect for autonomy, engaging the patient in discussion of the direction of treatment, and subsequently creating buy-in using shared decision making.My counselor and I have discussed my [treatment plan] quite frequently….” (P13).“3.3.2The subsequent proximal stage, termed “scaffolding,” comprises goals that were centered on establishing new routines, treatment structure, a recovery care team, and re-establishing social connections. Participants described their transition from “stabilization” into “scaffolding” as desiring to co-establish their treatment plan in collaboration with care team members. Concepts of “structure,” “routine,” and “support” were used as participants described continuing their treatment and beginning to actively begin to rebuild positive peer, family, and friend networks.“I done suboxone. And, I would go take suboxone and take half my strip of suboxone and go trade it for meth and stuff, you know what I'm saying? Now, like, you know- [methadone] is controlled, you know what I'm saying? Like, because we got to go up there every day…” (P12).My quality of life changed, the people I surrounded myself with changed dramatically. The things I do on a day to day, my habits changed. My routine has definitely changed. I have much better, healthier routine now.“And, well, I have a counselor, and if I got problems, I talk to them, and they kind of help me out. You know, to keep you on course. My life is a lot better when I've been going over there. You don't have no structure [at the beginning of treatment] and, you know, I got to have a kind of structure.” (P9).“The “scaffolding” phase was distinct from the “stabilization” phase in that it seeks to form and reform the participant's life through engagement in routine, social connections, and healthy habits, whereas, “stabilization” focused primarily on avoidance of withdrawals, pain, and negative self-perceptions.Like there had been times when I had tried to come off pills myself, and bought a bunch of methadone and tried to squirrel it away and slowly wean myself down. Now, it didn't work because I didn't have all the rest of the picture. Like the going to the clinic, the correct dose, the daily routine of being able to take it without worry of running out suddenly… There was too much stress trying to dose myself… You know, it didn't work.” (P16).“Here participants desired a clinical focus of actively engaging with them in treatment plan development, including how often the patient needs to come into clinic, how many methadone patients may “take home,” and the structure and scheduling of counseling sessions. Here too, participants made mention of finding the “right” counselor in co-developing their structure, routines, and support.I have a treatment plan, and [the clinician] always like brings me back if I start to get off track or off-center or less focus, she always brings me back to my treatment plan, reminds me of my goals, reminds me of things I can do. Like we worked on things like through my goals and my paperwork and even the classes I took there, they've helped me like realize like triggers and realize like how to manage those and realize like coping skills. So, I mean, there's several, you know, ways that she's like helped kind of guide me.” (P3).“3.3.3Finally, participants described a stage beyond “scaffolding” which described goals of “future self”, including long-term aspirations such as licit work or travel. “Future self,” as distinct from “stabilization,” included concepts that were beyond a return to “normalcy,” which was defined as what life looked like to the participant prior to their addiction. In some cases, it also involved not defining oneself by addiction – and rather by other roles related to family, work, or hobby. As opposed to Stage 1 and 2 goals that were mostly or entirely rooted in clinical support, patient reported goals in this stage are rooted in the patient's newly developed routines and structures – which are more individualized to their own current needs and future desires. This includes strengthening social bonds, establishing meaningful work, engaging in hobbies and other special interests.My life that I have now, the quality of life I have now, my wife that's wanting to start a family, I know to keep everything on track, I need to get up, come in, and stay on this routine and work the steps.” .“… I wanted my life to be manageable and I wanted to get like a part-time job, which I did end up doing. And I wanted to lose weight, which I'm working on that too now. You know, when you're in active addiction, you don't even think about like exercise or how to like improve yourself, and so that's nice that I can actually worry about going to the gym, or am I going to walk around the neighborhood with my daughter, you know, three times this week. So, [now] my goals are really just like all the different ways of being healthy and staying healthy pretty much.” (P3).“Although social bonds may have been a goal in previous stages, it is in the “future self” stage that participants described deeper and strengthened relationships, sometimes beyond what they had been prior to addiction.For the longest time, I didn't tell my kids like what was going on or what I had been through, but then I realized like they might benefit from my mistakes. And so I didn't hide anything. I've always been real honest and upfront and talked to them about it... And then also I've got friends, a close friend that is also supportive. So pretty much everybody that's around me knows my situation and is supportive of it.” (P3).“Work and career aspirations was also a theme in this stage.“Well, I think more than just trying to go after anything big, you just go after small things… and work towards them, like trying to finish my masters, so I can get that. So I'm probably six [credit] hours of away from that. I've been working on that. And then I'm also working on stuff for work to get other licenses so I can do more stuff.” (P5).Identification of purpose or meaning was either implicitly or explicitly central to this stage. Such purpose sometimes related to building or maintaining positive family, other times it was what they did as “meaningful” work or as a hobby.My father is sick with leukemia, so I've been staying up with him, trying to help take care of him, and it was just a job near him, and it kind of feels like it was meant to be because it's just worked out well. First job I've ever- or job I've had in a long time that I like getting up and going to… In my old job, I really just got to sit in the cubicle and never really got to do anything but sit there. Now I get to get out and meet people, and there's just something different all the time.” (Respondent 5).“Once I complete the program I just want to be like an advocate and just to help African American people, so they know that there's actually help out there.” (P4).“4This study explored patient reported goals of methadone in treatment-adherent patients at Opioid Treatment Programs in Tennessee. Participants described how that their reason for remaining adherent to MOUD was different at distinct stages throughout their treatment. Although the goals reported in this study paralleled patient goals described previously in the peer reviewed literature,There has been an increasing interest in PRGs in OUD treatment over the past with a substantial overlap between study findings. Chai et al. reported six PRGs in MOUD treatment for youths aged 16–25 in Canada, including: (1) taper/stop MOUD, (2) avoid recreational substance use, (3) manage OUD symptoms/withdrawal, (4) live normal life, (5) improve mental health, and (6) gain employment.However, there exists divergence among some studies in identifying PRGs as well. For example, O'Reilly et al., identified only three goals, all of which were treatment-specific, including (1) continue, (2) stop immediately, (3) stop eventually.A recent systematic review compiled and categorized patient goals in OUD treatment across 12 domains and 43 goals.For example, the impact of patient goals on treatment success was investigated by Rosic et al. in a population of over 2000 participants who were receiving methadone or buprenorphine-naloxone treatment for OUD.Understanding the larger continuum of how PRGs evolve over the course of a patient's treatment can help to reconcile such disparate goals, and may also explain why PRGs have yet to be associated with treatment retention. Similar to Rosic et al.,Importantly, the three stages of MOUD treatment in the Proximal Goals Framework terminate in a stage whereby the individual is centered on a routine involving social connectedness , work , and special interests . This too mirrors findings from other work investigating addiction treatment retention generally. Both “social factors” and “purpose” have previously found to be in relationship with treatment retention.Although the concept of “proximal goals” has not been previously described in context of treatment for OUD, it borrows from established theory in educational psychology proposed by Lev Vygotsky.,–45Similarly, in our study, participants noted this phenomenon of not only choosing a specific goal but matching that goal to their stage of MOUD treatment.Similar to the Transtheoretical Model of Change,,Finally, this study emphasizes the importance of social connectedness and involvement throughout treatment, and especially in the latter stages of proximal goals. However, this remains a challenge for patients undergoing OUD treatment.4.1This study has several limitations. This was a qualitative study and the sample only included participants from Tennessee, limiting generalizability of results. Convenience sampling was used to recruit patients, introducing potential bias via its inability to ensure collection of all views of the larger community. For instance, those patients who are willing to be interviewed about their MOUD experience may have a different view on goal setting than those unwilling. However, despite this limitation the resulting patient reported goals overlapped to a great extent those found in other populations across the Americas and Western Europe within the published literature. The development of a theoretical framework from these findings lends the results of this study to further testing and validation through cross-sectional and prospective experimental study designs.5In this qualitative study on patient reported goals in MOUD it was found that goals are transitory and relative to the stage of treatment. Further research is needed to better understand goal evolution over the course of treatment and its impact on treatment retention.The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.