The findings are presented by trajectory point of; (1) Initiation of ATS use; (2) continued and increased ATS use and (3) decreased and remitted ATS use. This work helps to develop understanding around the complex and bi-directional relationship between ATS use and mental health. Many ATS users lead chaotic lives and engage in multiple risk behaviours, however there is a need to better understand and conceptualise the dynamic interaction between different individual, social, environment and cultural factors that determine individuals’ mental health and substance use. There is no ‘one size fits all’ approach to prevention and treatment, and these findings highlight the need for more joined-up, tailored and holistic approaches to intervention development.Substance use and mental ill health constitute a major public health burden, and a key global policy priority is to reduce illicit and other harmful substance use. Amphetamine-type stimulants (ATS) are the second most used class of illicit drugs and a range of mental health issues have been documented amongst users. This paper explores the relationship between mental health and ATS use, through a thematic analysis of qualitative interviews with n  Amphetamine-type stimulants (ATS) such as amphetamine, methamphetamine and methylenedioxy-methamphetamine (MDMA/Ecstasy) are the second most commonly used illicit drug worldwide, with an increase in production and use seen in recent years.4 In 2018 lifetime prevalence of ATS use was estimated at 13.5 million (4.1%) for MDMA, and 11.9 million (3.6%) for amphetamines amongst 15 to 64 year olds in Europe, with an estimated 1 in 11 adults in the UK reporting consumption at some point in their lives.6 In England and Wales, the social and economic cost of illicit drug use, including policing, crime and healthcare is £10.7 billion per year. However, the societal impacts are further reaching, with the practice of problematic substance use in our communities leading to increased levels of blood-borne viruses, drug-related deaths and drug-driven crime. Mental ill health, domestic abuse, offending and bereavement are often associated with problematic substance use, impacting upon substance users themselves, their children, and other significant individuals. There is evidence of discrepancies in care quality for those with co-occurring mental health and substance use disorders, highlighting the need for more to be done to reduce this inequality, and support these individuals.Substance use and mental ill health constitute a major public health burden amongst the population10 However, ATS use has been identified as a risk factor for poor mental health, and even serious mental illness,12 with a range of issues documented amongst users, including depression, anxiety and changes in mood. Heavy or prolonged use of some ATS, such as methamphetamine or novel psychoactive substances (NPS) have been noted to impact negatively upon individuals’ physical health, mental health and neurological functioning, with some users experiencing transient or persistent psychotic symptoms, agitation and insomnia.1518 Short-term issues may be due to the acute effects of ATS intoxication, however prolonged effects may be related to withdrawal. The relationship between, and co-occurrence of, mental health issues and substance use is complex and bi-directional in nature, and both may have a common set of underlying and often compounded causes located across individual and structural factors.1921 It has also been argued that individuals who experience mental ill health problems are more likely to be or become dependent on substances and similarly, individuals who misuse substances appear to be more likely to develop or suffer from mental health problems. Determining whether the mental health issue or problematic substance use occurred first is further complicated because the relationship between psychological symptoms and substance use is temporal, meaning that many individuals may experience both substance-induced and substance-independent mental health issues throughout the course of their substance use careers.25 Despite existing research having established a link between ATS use and mental health issues, there is little known about the order of onset and the implications of this for treatment.27ATS have sometimes been viewed as recreational or ‘safe’ drugs, with users reporting perceived positive effects, such as increased sociability, energy, talkativeness and positive mood, whilst underestimating and less frequently reporting the negative social and health effects.29 This paper reports on a sub-sample of ATTUNE qualitative data collected from interview participants in the North East of England, and aims to specifically explore individual experiences of, and perspectives on the relationship between mental health and ATS consumption. This is important, as there has been little investigation of the relationship between ATS use and co-occurring mental health problems, the management of which continues to be challenging for clinicians. There is not yet an established substitute pharmacological treatment for dependent ATS users. Whilst some considerable psychological and psychosocial intervention developments have been made in recent years,34 treatment services are predominantly based on a medical model, geared towards alcohol and opioid dependencies, which ignores the social and environmental drivers of substance use, and characterises people who use substances as requiring external control.The mixed-methods European ‘ATTUNE’ study aimed to address a gap in knowledge on what shapes ATS use across the life-course; how to prevent and treat harmful ATS use and what influences different trajectories of consumption through individuals’ lives. Prior to this, there was limited understanding around which factors lead to increased ATS use, or what could help to facilitate decreased use, or desistance. The qualitative phase of the ATTUNE study used in-depth semi-structured interviews with ATS users and non-users, to provide an in-depth understanding of the lived experiences of participants and the factors which shape different trajectories of ATS use through the life-course. Ethical approval was granted by Newcastle University, Faculty of Medical Sciences, Ethics Committee (REF: 01204/2016) on 8th September 2016. Interviews were conducted between February and July 2017.Qualitative research is recognised as enabling in-depth analysis of socially situated experiences, and can help to provide insight into otherwise unknown practices; ensuring better-informed public health policy decisions through the identification of optimal opportunities for intervention, prevention and treatment.38 To be eligible to participate, individuals must: have first used, or had the opportunity to use ATS at least 5 years previously; be over 18 years of age; have lived in the North East of England and have appropriate verbal and cognitive skills to provide informed consent. Relevant organisations, such as homeless charities, substance use services and probation teams across the North East region signposted potentially eligible participants to study information. Flyers and posters advertising the study were distributed amongst local community spaces, including cafes, bars and libraries. The study was also advertised online, through social media and via national academic, policy and practice community networks. ATS use was categorised as current (use within the past 12 months) and former (use over 12 months ago). Users were further categorised according to whether they were: current/former dependent users ; current/former frequent users ; or current/former non-frequent users (less than 10 days use in a 12 month period).40Interviews were conducted in the North East of England, a region that has experienced substantial economic decline since the 1980s, with high levels of unemployment, disability and economic inactivity.; and data saturation was believed to have been achieved, as identified through repetition of responses and sufficient data to answer the research questions. Participants received a £10 shopping voucher incentive for participating. Interviews lasted between 18 and 106 minutes (mean = 48 minutes).Potential participants were provided with an information leaflet, explaining that their participation was confidential and anonymous, and were given the opportunity to ask any questions. If the individual was willing, able and eligible to participate, then written informed consent was obtained. The interviews were conducted face-to-face by 1 of 3 members of the research team . A semi-structured interview topic guide was used, with questions and follow-up probes related to family, physical and mental health and key turning points in drug use trajectories, namely initiation, continuation, decrease, desistance and relapse of ATS use. The interviews were digitally audio-recorded and transcribed verbatim. We continued data collection until there was maximum diversity across the sample in terms of ATS use, age, gender and socioeconomic status of the whole sample of n = 70 interviews, a sub-sample of n = 18 current and former ATS users were identified. The relationship between mental health and ATS consumption was already an identified knowledge gap in this area,3035 therefore further analysis was conducted using a thematic approach by LS, to focus specifically on this issue. It is however important to note that this does not mean that the remainder of the whole sample experienced no mental health challenges, just that the focus here was on those for whom these challenges were a recurrent theme and central issue. Data were coded iteratively, using a combination of inductive and deductive approaches and emergent themes were discussed with AOD and HA. Bronfenbrenner’s ecological theory was drawn upon in order to help better understand and unpack patterns and risk factors associated with co-occurring substance use and mental health. This theory was used to guide the interpretation of data; and states that individuals are shaped not only by individual factors, but to a great extent by the social, economic and physical environments in which they are situated. Considering interactions within and between these different ecological systems offers a way to focus on both intrapersonal and environmental factors, and the dynamic interplay between these factors in determining behaviours and health outcomes,47 which was useful to consider whilst exploring the complex issue of interest. All data were coded and organised using NVivo 11.During an initial framework analysisThe 18 current and former ATS users interviewed were aged 20 to 45 . The characteristics of the participants are presented in Participants discussed the initiation of ATS use with reference to a variety of factors, both in terms of strategies to promote or improve positive mental health and wellbeing, as well as functional or preventative strategies to cope with or prevent further deterioration of existing mental health issues. For many individuals, a combination of these were evident, and experiencing co-occurring stressors and chaotic life circumstances further compounded their ability to cope.A perceived mental health promoting benefit of ATS was improved alertness and increased energy levels, which participants believed allowed them to function better, and to negotiate the demands of their day-to-day lives. Many participants experienced multiple stressors in their lives, and this was one of the main contributing factors in their initiation of ATS use. They normalised their use as a way of as managing childcare (particularly mothers), and employment.‘I was managing work, full-time employment, with football, with two children’. ‘I was getting up during the night to feed (the baby) and stuff like that. Then his dad came in one day and he had something, and I just took it’. Some participants also spoke about experiencing low self-esteem and a lack of confidence, therefore turning to ATS use to boost their self-belief, and navigation of social situations. They believed that using ATS improved self-concept, and fortified personality traits which they had previously perceived as fragile, making them feel more extraverted, presenting fewer neurotic symptoms and therefore better positioned to cope in their day-to-day lives.‘The drugs did for me what I couldn’t do for myself. They made me confident. They made me talkative, especially drugs like Ecstasy’. ‘It was quite good for confidence at first, it’s not until later on you realise what it does’. Participants also reported that ATS provided them with an opportunity to escape problems they faced in their lives, which were causing significant distress, when they felt that it was not possible to overcome these issues or find solutions to improve their situation. These concerns included strained relationships with partners and family members, financial worries, as well as issues associated with existing mental ill health. Many participants spoke about being offered ATS from concerned others, such as friends and family members, who suggested it as an alternative way of coping with the chaotic facets of their lives.‘I heard people take drugs just to escape from the arguing. That’s what I wanted at first, so I started taking it like that’. ‘Folk take it to hide their feelings, to cover up stuff, just to make themselves feel better because when you’re on drugs, you’re on top of the world. Nothing can hurt you; you feel invincible’. Participants referred to the impact of particularly traumatic events in their lives, and how ATS use was something they engaged with to cope with the emotional distress they felt. Many of these traumatic events had occurred recently, such as the dissolution of a romantic or intimate relationship, or bereavement from the loss of a partner or family member. However, participants also referred to the lasting impact of adverse events which had occurred in the past (including adverse childhood experiences), such as traumatic childhood events and historic sexual abuse, and how ATS use lessened the impact of these painful memories on their present-day lives.‘When our relationship completely broke down, he hung himself. This was the point where my life spiralled out of control’. ‘I came from obviously a dysfunctional childhood, a dysfunctional family. I was in and out of the care system until I was quite old actually. That would also give me a release from everything I used to think about’. When participants discussed factors that encouraged them to continue and potentially increase their use of ATS, they referred to the continued management of multiple stressors in their lives, the perception of apparent positive effects on their mental health and wellbeing, and the need to self-manage deleterious effects of ATS use.Many participants highlighted the perceived positive effects on their mental health, as a result of using ATS. These included feeling more confident and less anxious, a perceived sense of better life management, and feeling they were better equipped to cope with their day-to-day circumstances. These individuals continued using ATS as an attempt to sustain these desirable effects, which were associated with an overall sense of bolstered wellbeing.‘I felt like I was invincible, honest to God, I could run five Great North Runs. It took the weight off my shoulders. It like my problems had just gone. I got my confidence. I liked it’. ‘They made me confident. They made me talkative, especially drugs like Ecstasy and stuff like that’. Several participants also described the ongoing management of their ‘chaotic’ lives, the negotiation of multiple individual, social and environmental stressors and deteriorating mental health as motivation for continued ATS use. As their circumstances became increasingly demanding and pressurised, ATS use became increasingly normalised and a part of their daily routine. Over time, most dependent users could not see a way of pursuing their lives without using ATS to support them, even if their ATS was contributing to their deteriorating mental health.‘I was dealing with the death of my children’s dad, and I think because without it I had no energy at all. Looking back now I was probably very severely depressed, so I was kind of using it as a coping mechanism’. -year-old male, former frequent non-dependent user)‘My mental state just got a bit erratic. I started getting very angry once I’d been up for a couple of days, so my head was just a bit all over the place’. ‘On a come down and you’re like, fuck my life. Genuinely, that’s what it’s like and then you feel sorry for yourself again for like two days, three days and then you’re fine. Then before you know it, again, another one’s been ordered’. ‘I’ve used various things in between that, but I always went back to amphetamines. It’s the only thing that’s kept us normal. I’m paranoid when I’m not in it, but when I have it, it takes away the paranoia’. Participants discussed the negative impacts of continued ATS use, such as a decline in overall mental health functioning, and negative changes to their personality as motivating factors in reducing or ceasing their ATS use. Participants also referred to a desire for change and wanting a ‘better life’. ATS users who had managed to reduce or cease their use spoke about the restoration of ‘normality’ in their lives.Many participants had previously referred to perceived positive impacts on their wellbeing due to ATS use, including increased confidence. However, after prolonged use several participants described becoming increasingly aware of negative traits and changes to their personas, including paranoia, which they attributed to their ATS use. These perceived changes in personality often motivated a desire to reduce or cease ATS use.former non-frequent user)‘Your personality can flip side, you know, popular, sociable, outgoing person and then you’re going to lose the grip on who you are’. ‘I changed in the sense of the drugs I as taking. I wasn’t the nice fella. I became very controlling, very paranoid, really insecure’. ‘I was dead August last year, everything, and no feelings, nothing, soul gone, the lot. You know, it was just black dog’. ‘I was suicidal. I wanted to die. I didn’t want to live, and I hated myself, all that self-loathing and stuff and self-hatred. I thought everybody hated me’. ‘It got to a point where I thought, “I’ve got to sort my head out,” because I’d gotten myself into a bit of a rut’. ‘For me it was 25, which I’m really grateful for that I hit that rock bottom and I realised I’d had enough because I did’. ‘I can smile. I can brush my hair, put a bit of make-up on. I walked up here. I am going to bed at nine, ten o’clock on a night and I am sleeping all night. Usually, I wouldn’t be able to sleep until three, four o’clock in the morning’. ‘Basically, I’ve resurrected my own mind, body and soul and it took me three and a half months’.  and eudaimonic well-being  reduces the risk of mental health and substance use disorders, but only when taking into consideration the impact of life-events and social support. This is particularly relevant here, as existing research has shown that dependent ATS users experience a greater number of negative life events, and that individuals’ social environment is affected by these negative life events.In society, ATS are often perceived as safe and recreational substances,1921 and importantly highlights that individuals change their use of substances throughout their drug use careers as both antecedents to and consequences of their mental health. The findings from this study highlight that there is no ‘one size fits all’ approach to prevention and treatment, and rather than focussing on whether it is the mental health or substance use issue which occurred first, it is important to focus on users’ individual circumstances and work to address these issues in co-occurrence.65This work helps to develop understanding around the complex and bi-directional relationship between ATS use and mental health, These findings help to challenge stereotypes about substance use, develop a deeper understanding of hidden populations and behaviours, and further demonstrate that substance use is shaped by a complex set of individual, social, environmental and cultural factors.36 Whilst the sub-sample was relatively small, it was diverse in terms of age, gender and current or former ATS use status, and recruitment was undertaken via multiple sources, which allowed individuals from a variety of backgrounds to engage with the research and provide rich accounts of their experiences. The ATTUNE study only collected data in the North East of England, an area which has its own cultural dynamics, and economic challenges67; with a higher rate of drug-related deaths (96.3 per million people) than any other region in England or Wales69; the highest suicide rate in England, and low levels of ethnic diversity, which may not make the findings generalisable to other regional contexts, or countries. Whilst we attempted recruitment via organisations representing lesbian, gay, bisexual, transgender, queer/questioning and intersex (LGBTQI) communities, we had no success; and additionally, sexuality and gender identity information about participants was not collected. This is a further limitation of the study, as we know that gay and bisexual men use illicit drugs, including ATS, at higher rates than most other population groups.73The principle strength of this work is the qualitative nature of enquiry, which responds to a growing momentum and commitment to include the experiences and views of those whose voices are often overlooked or under-represented.4547 The early identification of issues associated with both mental health and ATS use is universally important, to ensure they do not perpetuate one another, and these findings highlight the need for more joined-up, tailored and holistic approaches to intervention development. A public health approach could be through preventative work in schools, particularly focussing on misconceptions about the safety of ATS; the relationship between mental health and substance use and reducing stigmatisation. Policymakers must also remain mindful that the prevalence of both ATS and mental health issues are higher in more deprived areas, and therefore preventative strategies should be targetted at these areas accordingly. Future research should also engage with varied and diverse population groups; and explore in-depth individuals’ preferences for, and acceptability of treatment opportunities, and the barriers and facilitators to accessing treatment.Many ATS users lead chaotic lives and engage in multiple risk behaviours, however there is a need to better understand and conceptualise the dynamic interaction between different individual, social, environment and cultural factors that determine individuals’ mental health and substance use trajectories, as they are not a homogenous group.


There is increasing interest in the potential to deliver participatory dialogical HIV and intimate partner violence (IPV) prevention interventions via digital platforms, though the majority of mHealth interventions have been didactic in approach. We undertook 10 in-depth interviews with male Peer Navigators (PNs) who had been extensively trained and working on a larger intervention promoting young people's sexual and reproductive rights, in rural KwaZulu-Natal. Interviews focused on their, and their peers', use of technology in their everyday lives. Data were transcribed and translated, and subjected to thematic analysis. PNs described structural barriers to the use of technology, including poor connectivity, high data costs, and erratic electricity. They primarily used Facebook and WhatsApp for communication and highlighted how reading messages asynchronously was important to overcome connectivity challenges. PNs shared how groups were primarily for information sharing, they also discussed ‘sensitive’ issues online. Privacy was a concern, especially for conversations, and there was recognition of how confidentiality could be breached. It was also felt that WhatsApp could potentially support greater openness in discussions. We reflect on the potential for online interventions to support dialogical health communication, highlighting how dialogical health communication may be enabled through information provision, the asynchronous communication enhancing the potential for reflection, and greater participation in discussion by those who are shyer. Despite this potential there remain important risks around privacy of discussions and how to implement these approaches online. •Qualitative research with young men showed high levels of cellphone usage.•Emphasizes the importance of sharing information and personal discussions online.•Suggests potential opportunities for discussion and reflection via WhatsApp.•Recognises limitations of WhatsApp communication for health communication. South AThese exceedingly high rates of HIV and IPV are intimately connected to South Africa's brutal history of apartheid, and apartheid's legacies of poverty, the destruction of family systems and the normalization of violence in everyday life . These sParticipatory, group-based interventions have been a mainstay of IPV-prevention and HIV-prevention and treatment adherence interventions  driven bmHealth approaches to promoting health have often focused on information transfer, or didactic health communication. Much work has focused on the use of Short Messaging Service (SMS) messages to support improved health outcomes. For instance, a 2016 review of mHealth interventions in low- and middle-income (LMIC) settings found that the majority of interventions relied on SMS messaging, often in one-way approaches . SimilarAlongside the rapid expansion of information and communications technology (ICT) in the global south, the COVID-19 pandemic and subsequent lockdowns has led to a consideration of the role of online methods to deliver HIV- and IPV-interventions. While there has been a growth in research on the delivery of participatory research online, this has primarily been in the global north . Given t22.1The research was conducted in the Hlabisa sub-district of UMkhanyakude district in northern KwaZulu-Natal, South Africa, which is a mostly rural setting with some small but more dense communities and a large town to which people often travel. There are high levels of youth unemployment, with an estimated 85% of those aged 18–24 unemployed, and two-thirds of households receive social grants. The HIV-treatment cascade for young men (16–29 years) is also poor; in a recent trial, less than 80% knew their HIV-status, 25% were on treatment and 18% were virally suppressed , 2018. A2.2The study received ethical approval from the South African Medical Research Council's Human Research Ethics Committee, the Biomedical Research Committee of the University of KwaZulu-Natal, and the ethics committee of the University College London, UK. Participants provided verbal (recorded) informed consent for the study, prior to the interview commencing, because of the limitations imposed by COVID-19 on face-to-face interaction. Participants received no compensation for their time as they were paid a salary for their employment as Peer Navigators during this project, although they received airtime for related costs.2.3The study was conducted among young men who were hired as Peer Navigators as part of the African Health Research Institute (AHRI's) ongoing Thetha Nami peer navigator support intervention . Thetha 2.4We conducted one-on-one telephonic in-depth interviews with male Peer Navigators. The interviews were all remote, i.e. over the phone, because of COVID-19 regulations limiting physical interactions. Interviewers were trained researchers who spoke isiZulu fluently. Interviews took between 26 and 48 min, and were audio recorded. The interviews were then transcribed in isiZulu and then translated into English, and quality checked. All identifying information was removed.Data were thematically analysed . Initial3In total, 10 Peer Navigators undertook an in-depth interview. They described using smartphones, though they highlighted how structural factors, including poor network connectivity and high data costs, limited their use of the internet. The Peer Navigators (PN) also described primarily using WhatsApp and Facebook to share information, but also how they shared more personal information online. PNs had lots of thoughts about the possibility of online interventions, including how its asynchronous nature could be helpful, as well as how the use of voice notes, rather than written messages, may improve communication. There was continued concern about the risks of sharing information online, but some PNs also highlighted how the relative anonymity of sharing online could help those who were shyer, and also enable people to speak who normally did not.In all interviews, Peer Navigators described how almost all men in their communities had access to smartphones: “Yeah, let me say that in my community approximately 99 percent of men use smartphones.” (PN5) However, significantly fewer had access to laptops: “What can I say, some of them [men] have laptops and some don't. In fact, most don't have them.” (PN6). In terms of the apps men access via their smartphones, Peer Navigators generally spoke only about men using two main apps, WhatsApp and Facebook: “Yeah they have smartphones. They use them a lot. Especially for social networks like Facebook and WhatsApp.” (PN10). Other forms of apps were mentioned, including Twitter, Instagram, and betting apps, though these were much less commonly referred to.While smartphones were common, not everyone had a smartphone, as one Peer Navigator commented: “Some guys have dumbphones here, but they [Facebook and WhatsApp] are not accessible, they are only accessible on smart phones.” (PN4). More widely smartphones were often old and had trouble working: “… sometimes you find that your phone isn't working well … it just has a few problems like the battery for instance.” (PN10).“Yeah, network connection is usually problematic for video calls and WhatsApp calls. As you can hear from the call we are having, it's rare to have problems with this ordinary kind of call.” (PN7)All Peer Navigators described two sets of issues with smartphones as modes of communication: connectivity challenges and high data costs. In this relatively rural and remote area - though in reality experienced across much of South Africa, including in urban settings – men described how they often struggled with connectivity, especially for video calls:“You want to communicate with other people perhaps through Facebook, when the power goes off the network also automatically goes off. So, it becomes difficult to communicate if there's no power.” (PN1)“Where I am, the network connection is only a problem if the weather conditions are not good” (PN4)The challenges with network connections were partly linked to poor overall telecommunications network coverage, and these could be exacerbated by weather conditions and electricity outages:High data costs were also a significant problem for the use of smartphones as a communication tool: “Another challenge is the affordability of data, not everyone can afford it. Smartphones constantly need updates.” (PN7).PN10: Like Facebook has Free Mode that doesn't need you to have airtime to communicate with people.Interviewer: Mhmm.PN10: Yeah, if you have a small amount of data, you can also access WhatsApp you know. You don't need to go buy airtime and call someone. (PN10)Men did describe a range of strategies to try and overcome high data costs, including knowing where there were free Wi-Fi connections, which were often in shopping centres  located in the nearest town, or having neighbours nearby willing to share their Wi-Fi connection. Other men described how they used apps which used less data:PN5: So, in most cases you used to bump into other guys in tuck shops there to buy data SIM cards; that SIM card used to cost R10, and it has 250MBs of data.Others described how men would buy new SIM cards when these were offers from their mobile network provider offered along with free or cheaper data:“On Facebook I'm in a group that keeps me up to date with the current affairs taking place in [local community] and another one about movies so I can stay abreast of the latest movies and series releases … And then in the group about job opportunities, everyone posts about job opportunities they may have seen so it enables me to apply to those I'm interested in.” (PN7)Men described how they primarily used the two apps, Facebook, and WhatsApp, on their smartphones for talking with friends: “I think it's a good means of relaxing and communicating” (PN6). The Peer Navigators described how they were often part of many groups where a variety of information was shared:An important aspect of WhatsApp for men's communication was that messages could be read asynchronously: “The benefit of WhatsApp groups is that one can reply to messages whenever they see them, regardless of what time it came through and what time you see it” (PN9). And similarly, PN8 said: “With WhatsApp, you can respond when it suits you.”PN1: … getting perhaps 300 WhatsApp messages that I would hardly read because of not even knowing where to start reading them. Yet if there are voice notes I can just touch play and listen to that well: he said this, he said this, he said this. And then I can respond to something I understood clearly. It becomes difficult if you find lots of messages. So, perhaps if we could use voice notes, I could engage much better.While group chats were generally seen positively, a number expressed concern with written messages. One issue was that some men may struggle to read (in either isiZulu or English) messages given the low levels of literacy among young men. A second challenge was when there were multiple written messages on a group chat and reading them was too much. One Peer Navigator suggested voice notes as a solution to this:PN2: Ah, other information we share used to be those chats about life in general around the area which has nothing to do with serious stuff. Perhaps we will discuss about girls or when do we go out together as guys …The Peer Navigators also discussed that groups could be more than simply information sharing spaces and could also be used to discuss personal issues:Yet, a few Peer Navigators felt that maybe WhatsApp messages and group chats would not be perceived as ‘serious’ discussion: “Texting via WhatsApp or Facebook may dilute the seriousness of these conversations and there are already people that don't take AHRI's work seriously here. They will wonder: ‘this person says they want to talk to me about serious matters, yet they are texting me?’” (PN7).PN8: Oh no, for starters it could be like 30 minutes.Interviewer: Oh, that's how long our group discussions should last for starters?PN:8 Yeah, because sometimes lots of information at once can be so overwhelming that one ends up not grasping anything. Some people even shut down and alienate themselves completely.We found a sophisticated digital literacy emerging around the challenges and opportunities of how to communicate online, as well as strategies to deal with this. Many of the Peer Navigators mentioned that people had limited concentration online. The maximum length of time that Peer Navigators felt that people could focus online ranged from 30 min to 2 h, though almost all felt that an hour or less was the correct time: “Perhaps 30–45 min to people is good because once it's above an hour, ay people can become bored” (PN4). As one Peer Navigator commented, any online conversation that was too long would lead to people disengaging:Peer Navigators were also able to think of strategies to overcome challenges of concentration: “People can engage for long periods over the phone as long as they find the conversation interesting” (PN7). The use of humour was also suggested: “We should crack a joke every now and then so that people can feel relaxed. It should feel like a conversation we are having face-to-face” (PN10).“Okay yeah it may happen the way it may happen but once we've discussed for a bit longer perhaps you may end up talking alone, or else when there's nothing that will free or make them laugh during the discussion you may find yourself lonely, they may all disconnect.” (PN2)Peer Navigators were also aware of the challenges of not being able to see people and how this impacted on reading body language:PN7: Sometimes you are shouting, and you are angry when you type, but it's hard to convey that via text.Interviewer: [Laughs] and sometimes you're not shouting or angry but you're talking very politely.PN7: But then it comes across as shouting to the person on the receiving end.Similarly, conveying tone was described as a challenge in written messages:PN9: I think not being able to see one another face to face is a disadvantage as it can breed misinterpretation and confusion in some people. There are certain emotions that don't quite come across when communicating via social media as opposed to face-to-face.More widely, driven by their prior experiences of discussions online, some men were worried that groups could end up having arguments, particularly about challenging issues, and these were often hard to moderate and deal with online:PN2: Yeah, those are some of the things, to find that other guys sleep in the bedroom and his mother has full access to it perhaps she is the one who washes his clothes or anything like that. Then you find that the discussion is about something serious, and the mother will just pop in, and then find that you can't do anything after that.Three interlinked issues of privacy, confidentiality and anonymity of online discussions and group chats were raised by Peer Navigators. Many of the men described how privacy in the ‘real world’ was shaped by whether or not a man had his own room – particularly an outside room he had built within their family plot of land: “Yes, men in most cases have their own backrooms. Even if there is the main house, guys don't usually stay in it or do his own things there. He has his own house [backroom]. So, that's where I think they also get their privacy” (PN1). It was clear though that not all young men had such a space and would therefore potentially struggle with privacy. Other participants would have no way of knowing that a person was not in a private space, and this could disrupt discussions:Interviewer: What's good and bad about using things like WhatsApp and Facebook to communicate.PN8: Please say that again?Interviewer: It sounds like there are people there in the background, so you won't hear me properly now.PN8: I will be able to speak, we can continue.Interviewer: Pardon.PN8: I said I will manage. Let's continue.The possibility of other persons being present and over-hearing a conversation concerned Peer Navigators because of the implications for ensuring confidentiality of private group discussions. Indeed, this was experienced by the research team during one of the interviews with a Peer Navigator. Despite the team checking verbally with the Peer Navigator that he was in a private space, it became evident that he was not, but in a setting with other people:While in the case of this interview, the background noise and other voices were not a significant challenge as nothing sensitive was discussed, for more sensitive discussions envisaged during online interventions, the possibility of others over-hearing conversations could concern all participants and inhibit discussion.PN10: Oh. Adverse outcomes include people revealing other people's secrets in groups, telling lies about others on Facebook and pretending to be someone you're not.There were also concerns with how sensitive information could be shared by some participants with others outside the group, breaking confidentiality of online discussions:PN1: Yes, because I used to notice what I'm pointing out in my team's group that you find some people made their points in writing, but when they have to say something in the field face-to-face, no, he doesn't say anything. So, I just feel they become free when they are talking over his phone alone.In contrast to concerns about privacy and confidentiality, several Peer Navigators suggested that the relative anonymity that the mobile phone provided enabled some people to have greater confidence to express themselves openly:This was particularly the case with being able to type out messages, rather than contribute to an oral discussion: “Yeah, some people are afraid to speak, and they prefer to type out their problems.” (PN10).PN8: I prefer WhatsApp because one will be able to write out their problems.Interviewer: Pardon?PN8: We will be in a group, and everyone will be writing their problems, right?Interviewer: Yeah.PN8: There might not be a need for one to look … they can learn in the group because people aren't all the same, some of us can't open up and express ourselves. So, if we have a group in which we can do that as men, we might realise that our problems are similar.Another Peer Navigator also suggested that using text to share problems in a group, rather than discussing them verbally, may be a good way to encourage people to share their own thoughts and issues, especially among a group of similar young men:4Among young men engaged in an ongoing HIV-prevention and treatment intervention as Peer Navigators supporting other young men's access to healthcare in rural KwaZulu-Natal, there was a strong emerging understanding around digital literacy, and the opportunities digital technologies could offer to support interventions: sharing information, enabling some inhibited men to share information, and providing opportunities to talk about important topics. Yet, the Peer Navigators' views and sense of opportunities were constrained by two sets of interlinked structural realities. The first was the very poor network and slow connectivity in the community they lived in, which was significantly worse than in other areas of South Africa because of hills and more limited base stations. This was exacerbated by a range of issues, including the high costs of data and electricity outages, further limiting their ability to engage with and use smartphones to their full capability, and reflects findings elsewhere . The secA clear finding was that virtual communication could support the sharing of information on many topics. Peer Navigators described how they, and other men, were widely engaged in sharing information on a range of issues including job opportunities and community issues. The role of cellphones in sharing information around livelihoods and job opportunities is something described previously . Many mHThere was also recognition by the Peer Navigators that it was possible to move beyond information sharing to discuss ‘sensitive’ issues online. Many of the men themselves described how they engaged in lively discussion and debate online, regarding topics including, but not limited to, relationships. They also noted that there were numerous challenges associated with this, ranging from connectivity and data issues through to others misreading tone and body language. They were also aware of the way online discussions did not necessarily reflect ‘real world’ discussion.A key finding was that Peer Navigators thought discussions online through text messages or voice notes enabled a sense of greater anonymity and thus supported shyer participants to be more open in discussions of sensitive topics. This anonymity was different to that described in online chat forums in high-income settings, where people do not know each other and use pseudonyms, and were more comfortable discussing sensitive topics as compared to face-to-face conversations . Rather,Despite the recognition that discussions of sensitive topics could occur online, Peer Navigators also recognised that simultaneous discussion was unlikely given connectivity challenges and the ways in which people engaged with mobile phones, and asynchronous communication was more common . ParticiThroughout interviews there were ongoing concerns about privacy and the risk of breaching confidentiality of discussions that were conducted online. One issue was whether other people could overhear what was being discussed by participants, although the issue was less of a concern for Peer Navigators who often had private spaces (rooms) to do discussions in. Another issue was the confidentiality of messages. Although not explicitly raised, prior research has highlighted how intimate partners often access the phone messages of each other as a way of checking for infidelity , which hThis study has a number of limitations. We only interviewed a small, very selective group of young men about their use of technology and their perceptions of their peers’ use of technology. As such, this limits the generalizability of findings. However, the group of Peer Navigators had some understanding of participatory activities and interventions, through being involved in multiple group activities in their training, and were closely embedded in the community which they came from through their involvement in the Thetha Nami intervention. Expanding this research to other groups of young men would be an important step in improving reliability of the work. We also interviewed men, and it is not clear the extent to which young women had similar or different access to cellphone technology and data in this context, as previous studies have suggested that this is often shaped by gendered power relations . The are5The potential for dialogical interventions to be delivered online, given the massive constraints for young men in rural South Africa in terms of poor network access, high costs and limited access to technology, suggests that simply transferring the methodology of face-to-face participatory interventions from physical to virtual spaces is unrealistic. This is in stark contrast to work and research in the global north, where participatory research and interventions are being developed and implemented . DespiteThis study suggests that there are potential areas in which dialogical health communication can be supported online. First, at a basic level, using technology to promote key messages and information supporting the objectives of an intervention, such as where to access health systems or look for jobs, supports basic didactic health communication. Second, there needs to be an expansion towards imaging what dialogical communication online could look like. WhatsApp communication, though asynchronous, can give greater time for reflection and promote quieter participants to engage more given the relative anonymity of online communication. This prompts a series of future research questions primarily around implementing online interventions. Questions include how to build trust and relationships online, and whether blended interventions, combining both physical and remote sessions work better than online only sessions. It also requires answering questions such as how best to create privacy in online discussions, and importantly, how to ensure dialogical communication – discussion and reflection – can be achieved. This will be best resolved through small pilots with extensive qualitative research.UK Medical Research Council (MR/T025832/1). Africa Health Research Institute is supported by a grant from the 10.13039/100010269Wellcome Trust (082384/Z/07/Z). MS is supported by the 10.13039/100000002National Institutes of Health under award number 5R01MH114560-03. Additional funding was from the 10.13039/501100001322South African Medical Research Council (YS). The funders had no input into study design, data collection, analysis or decision to publish.Funding for this project was received from the Andrew Gibbs – conceptualization; Formal analysis; Funding acquisition; Methodology; roles/writing – original draft. Dumsani Gumede – data curation, Investigation, Project administration, Writing – review & editing. Manono Luthuli – data curation, Investigation, Project administration, Writing – review & editing. Zakhele Xulu – data curation, Investigation, Project administration, Writing – review & editing. Laura Washington – conceptualization, Writing – review & editing. Yandisa Sikweyiya–; conceptualization, Writing – review & editing. Oluwafemi Adeagbo – conceptualization, Writing – review & editing. Maryam Shahmanesh – conceptualization, Funding acquisition, Project administration, Writing – review & editing.


Aphasia, a language disability, can profoundly affect a person’s mood and identity. The experiences of participants who received Solution-Focused Brief Therapy, a psychological intervention, were explored in the Solution-Focused brief therapy In poststroke Aphasia (SOFIA) Trial. Thirty participants with chronic aphasia, 14 with severe aphasia, participated in in-depth interviews that were analyzed using framework analysis. Two overarching themes emerged: valued therapy components  and perceptions of progress . Participants were categorized into four groups: (a) “changed,” where therapy had a meaningful impact on a person’s life; (b) “connected,” where therapy was valued primarily for companionship; (c) “complemental,” where therapy complemented a participant’s upward trajectory; and (d) “discordant,” where therapy misaligned with participants’ preference for impairment-based language work. This study suggests that it is feasible to adapt a psychological therapy for people with aphasia, who perceive it as valuable. Around 30% of people who have a stroke experience aphasia , a langud = 0.34, p < .05) for health-related psychosocial outcomes : How do people with aphasia experience receiving SFBT?Research Question 2 (RQ2): What is the perceived value of the intervention to participants?Research Question 3 (RQ3): What factors lead people to respond differently to the intervention?This qualitative research was embedded within the SOFIA Trial . SOFIA was a single-blind, randomized, wait-list-controlled feasibility trial. It aimed to explore the acceptability of SFBT for people with aphasia and assess the feasibility of conducting a future definitive trial determining the effectiveness of the approach to enhance well-being . QuantitParticipants were either randomized to the intervention group (started intervention immediately post-randomization) or to the wait-list group (started intervention 6 months post-randomization). Although SFBT is often brief . An illustrative case study of SFBT is provided in online Supplemental File 1.SFBT is a language-based intervention, which typically relies on complex linguistic structures, for example, questions exploring hypothetical future states. To adapt the approach for people with aphasia, the therapists used total communication strategies, drawing on the person with aphasia’s communicative strengths, for example, writing keywords, using gesture, drawing, pictures, and objects in the environment . ParticuThe theoretical model underpinning how the SOFIA therapy was conceptualized to build change was the dual process model of bereavement DPM; . An indin = 30) were invited to take part in the in-depth interviews. Through inviting all participants, we aimed to capture a diverse range of perspectives. To be eligible to participate in the SOFIA study, participants had a diagnosis of ischemic or hemorrhagic stroke, were at least 6 months poststroke, aged 18 years or older, and had aphasia as determined by the clinical judgment of an SLT. Participants with any severity of aphasia were included provided they had the mental capacity to consent to take part. Aphasia was assessed using the Frenchay Aphasia Screening Test . Exclusion criteria were as follows: having other diagnoses affecting cognition such as dementia or advanced Parkinson’s disease, severe uncorrected visual or hearing problems, severe or potentially terminal comorbidity, being in receipt of a psychological or psychiatric intervention at the time of recruitment, non-fluent English speaker prior to the stroke (based on self or family report), or not having mental capacity. Use of antidepressants or rehabilitation therapy was not a reason for exclusion, nor were participants excluded on the basis of their well-being or depression scores.All participants who received the SOFIA intervention. It was based on an earlier version trialed in a pilot study with people with severe aphasia and refined through discussion with the project’s advisory group of people with aphasia. The topic guide did not include specific questions, but instead outlined topics to be explored in an organic way following participant responses. Topics included how participants experienced receiving the intervention; observations around logistics, dosage, and ending of therapy; and their reflections on any change that may have occurred. How they experienced study procedures was also explored and is reported elsewhere. To facilitate the person with aphasia, interviewers used the total communication strategies described above. They also referred to the schematic diagram of the therapy components .There were three female interviewers, all of whom had extensive experience of working with people with aphasia and were experienced qualitative researchers. One of the interviewers was also a SOFIA therapist; to avoid biasing responses, she did not conduct interviews with participants where she had been the therapist. One of the interviewers had met all participants prior to the interview when consenting them into the trial; for all other interviews, the participant had not previously met the interviewer.Data were analyzed using the “Framework” method . FramewoThe matrix-based system facilitated the development of a typology exploring the variation in how people experienced the therapy. The typology was multifactorial and thus a person was assigned to a category as determined by two key variables: (a) participant perceptions of the main value of the therapy, and (b) therapy-related change. Each participant was assigned to only one category. The second analyst independently categorized all participants within the proposed typology. For two participants, the second analyst was undecided. This was resolved through both analysts rereading the transcripts, further reflection and discussion, leading to a consensus decision. Data were managed using NVivo Version 12.Supplemental File 4); individual participant profiles, grouped according to the developed typology ; a CONSORT diagram of the SOFIA Trial ; and prevalence of the different therapy components within participants’ accounts .Thirty-two participants were recruited into the SOFIA Trial. Of these 32 participants, 30 received the intervention and agreed to take part in an in-depth interview post intervention. Twenty-nine participants elected to receive all six sessions; one participant elected to receive five sessions. Sixteen participants were women and 14 were men; 43% were more than two years post stroke. The majority were White (73.3%), with 26.7% from Black, Asian, and minority ethnic backgrounds. Most lived with family members (60%). Sixteen participants had mild to moderate aphasia; 14 had severe aphasia (participants scoring <7/15 on either the receptive or expressive domains of the Frenchay Aphasia Screening Test categorised as ‘severe’). The following is presented online as supplementary material: participant characteristics  valued therapy components, and (b) perceptions around progress. There was variation in how people responded to the therapy. A typology is presented as a way of capturing patterns and to aid interpretation of the variation. Finally, participant reflections around receiving therapy in the context of a research study are described. These themes are displayed in Participants perceived the therapy sessions as conversations, rather than being therapist-led activities or exercises. There was a strong endorsement that the approach was suitable for people with aphasia, including severe aphasia. . In terms of what participants valued about the conversations, five subthemes emerged: noticing achievements, encouragement to explore future hopes, explaining feelings and experiences, companionship and “time out,” and their relationship with the therapist. These are explored below. Participants described how the therapy celebrated their successes. Sessions were a chance for them to share things that had gone well or that were good in their lives, including progress they were making poststroke. For example, one participant described how the therapist would make a list of “everything, everything, all lovely,” that she and her husband felt proud of, such as her gardening, cooking, and going to the gym. She described this process as “lovely . . . [therapist] was very good,” and agreed that it had helped her to notice positive things in her life.When the therapist noticed participants’ achievements and personal qualities, this had a positive impact on their mood and could bolster their self-esteem and self-belief: “I have a lot of self-respect now . . . it changed um, my, my self-perception, my, my perception of myself got better.”Because I said I’m going to go to, erm, Dad’s house in [market town] and I said, and I, I want, erm, the train and I’ll do it, and I did . . . It was really good, I was proud.It was perceived as helpful to talk through what a person wanted to be happening in the future. Within the therapy, participants described both their long-term ambitions  and goals which they achieved within the therapy block . Some participants made a direct link between these conversations and their motivation to do more:Participants also had conversations around their hopes for future feeling states, such as feeling happier. They described how in therapy they talked through “just small things” that might help them to get there.Many expressed a belief that it was important to look forward rather than backwards. It was not universal, however, that therapy included a future-focused component. An example is a participant who was frail with deteriorating health. She chose not to discuss the future, and instead she found it more valuable when therapy sessions focused on noticing what was going well and joking and having fun.A common theme was that participants valued being enabled to explain how they were feeling. Within the therapy, feelings of sadness, panic, anger, or despair were shared. The context for some was that it was hard for them to have this conversation with others, often exacerbated by the aphasia. The feeling that someone understood their difficulties and experiences was perceived to make a difference as they felt supported instead of on their own. For example, one participant explained that in the therapy, “You can speak, you, you, to explain.” This contrasted with how he normally experienced conversations: “There’s the err, the panic, you, you, you, feel, the words with your mind, you, you racing, racing, yes, and is angry, angry . . . you can’t, you can’t speak, you, you can’t explain.” Post therapy, he described feeling less panicky, more confident, and better inside himself. He attributed this change to “explain, explained, yes, yes.” The interviewer clarified with him that he was referring to explaining about his feelings.Not all participants reported that sharing distress and other difficult emotions was a part of the therapy, however. For participants who were not experiencing low mood or distress, this therapy component was perceived as less necessary. A further subset reported that, while they did sometimes feel sad or had difficult life situations, they had not wanted this to be the focus of therapy.They preferred to use therapy sessions as a distraction, or had a belief that it was not for others to solve their problems, or wanted to focus on future plans.The visits were a source of valued companionship, particularly for more socially isolated participants. A female participant in her 80s explained, “I haven’t got many friends because practically they are ill or they’re dead because everybody’s so ill, old you see, naturally.” She observed, “It’s nice, somebody, to see somebody . . . everything is something to see peoples.” Participants described how they valued having someone different to talk to when horizons had become narrower poststroke and to be able to talk about topics that were not discussed in everyday family or patient-carer interactions, such as stories from their family history.Interviewer: And what was most important to you of all the things (in therapy)?Participant: Mm, well, life.Interviewer: Talking about your life?Participant: Yeah, yeah.Interviewer: Have you had to do that with many other people after your stroke?Participant: Er, not really, not really.For people with severe aphasia, the opportunity to express themselves and feel included in a conversation that was centered around them, and their life, was perceived as important. It was sometimes described as a relatively unusual occurrence:Some participants reported that “time out,” including laughing and joking with their therapist, was the best part of the project. They described how they talked “about this and that and the other . . . we joked on the subjects,” and spoke about TV programs, children, laughed together at politicians, and sharing “tea, coffee.” For example, one female participant who had severe aphasia and limited mobility, explained how much she enjoyed chatting and sharing stories with her therapist  and pointed to “Time Out” on the diagram see  to show The relationship with the therapist appeared to be a key factor in how participants experienced the therapy. For example, a participant described his therapist as “delightful,” and the “best thing about [the study],” and agreed with his wife that he “enjoyed the therapy because he enjoyed [the therapist].” The relationship with the therapist was proffered as an explanation for how the therapy worked. This is illustrated by a participant who described the therapy as “uplifting.” When this was probed in the interview, she reflected, “[the therapist] is lovely person, isn’t she? So she, I think that’s what it was, you know, the way she spoke and she was gentle and she was nice.”Participants reported getting on well with their therapist. They described being able to talk freely, feeling comfortable to share and disclose, and felt accepted by the therapist: “I felt comfortable with her, very nice . . . you could talk about anything to her.” It was common that interactions were perceived as two-way, with the therapist sharing from their own life. For example, one person described how the therapist was “Open and honest . . . it was a chance to speak to somebody who brought themselves.” The sense that their therapist cared about them, noticed their qualities, and gave them one-to-one time was perceived as important (“Something to make me somebody that cared . . . [made] a lot of difference.”). Several participants described feeling real affection for their therapist.Participants rarely conceptualized their involvement in the project as leading to “change,” and not all participants were seeking to make changes. To describe the impact of the therapy, participants used words such as reinforced, mended, connected, improved, “a bettering,” and uplifted. These shifts were seen across the following domains: mood and identity, communication, relationships, independence, mobility, and participation. The next section reports on these domains as subthemes, before reporting on the final subtheme: perspectives around little or no change.The therapy was perceived by many to lift their mood. Participants described newly enjoying activities or feeling happier in themselves. An example is a participant who had her stroke 5 years previously. She described herself as depressed prior to therapy. The therapy helped her to “bring me out of myself.” She noted the difference this made to her mood: “I mean I’d wake up now sometimes and I smile, you know, because I’m glad to wake up, whereas . . . I didn’t want to wake up.”The therapy was also seen as enhancing calmness, reducing stress and anxiety, and enabling people to feel more optimistic about the future (“At first I couldn’t feel good about the future but now I can look forwards not backwards.”). For a subset, the therapy was described as facilitating a renegotiation of poststroke identity. This could be in terms of increasing self-respect and noticing personal strengths. It could also enable people to connect with their sense of who they are.It make you somebody, hey . . . oh, it good, good, good, good, and so, it give me courage, courage, courage . . . Now, now I am myself.There was no one who attributed worsening of mood to participating in the project. However, there was variation between participants in how much their mood was affected by receiving therapy. There were participants whose mood improved during the study, but they attributed the change partially or wholly to other causes . Conversely, external life events, such as deteriorating health, could impact on mood negatively. A further subset reported that they were cheerful both before and after therapy. Finally, there was a subset who reported low mood that was unchanged by the therapy.A minority felt that the therapy had resulted in improvements in their talking, reading, or writing. More commonly, participants spoke about progress with talking coinciding with taking part in the project and attributed it to various factors, including the passage of time, having a positive outlook, or the combination of the different therapy inputs they had received. Nonetheless, a common theme was that participants described increased confidence to talk in different situations post therapy, such as speaking on the phone to family or having coffee with friends.Persisting difficulties with talking were a cause of frustration and distress for many participants. This could color their view of their therapy gains. For example, one participant described his aphasia as “frustrating, I can’t tell you how frustrating it is.” The therapy had enabled him to speak more to friends, and resume playing bridge: “It’s given me more confidence. Yes, it’s, that’s helped me making, making me feel confident about talking with other people. And I haven’t found that before . . . [makes me] happier, happier.” Nonetheless, he expressed disappointment that the therapy had not improved his aphasia: “[The therapy] has given me a bit more confidence. But I suppose I am hoping [laughs] I suppose I’m hoping that someone’s going to give me, give me a miracle and it’s not going to happen.”It helped me, for example, I start talk [on the phone] to my, my, my son [who lives abroad] . . . oh two years, two, two years I don’t, couldn’t do it, but [therapist] is there, I try to make it . . . my son is very happy now.Several participants spoke about seeing friends more. There were also changes to how some participants related to their grown-up children: They described feeling closer, increasing contact, and speaking more openly:For a small subset of participants, the therapy caused positive shifts within the marital relationship. This is illustrated by a participant who was several years poststroke and had severe aphasia. She perceived that her husband had been protective of her following the stroke, for example, taking over the cooking. Following the therapy, her husband gave her more space and they became comfortable to give each other time apart. They renavigated their roles within the relationship, for example, she was doing the cooking again, even Sunday roasts, which she confirmed was “lovely, lovely.”It was common that participants described increasing confidence with various activities of daily living post therapy, such as putting out the rubbish, getting dressed, food preparation, and managing to use a purse one-handed. Another theme was making progress with walking. Participants also described increased participation, such as going to restaurants, starting to volunteer, and using public transport. There was an acknowledgment of balancing risks, the need to be careful, and that progress could come in small steps. Feeling they were making progress was positive and could make someone feel proud: “If I’m good today to walk somewhere, yes, yes, for me it’s one victory, you know.”Some directly attributed their progress to the therapy; for others, there were additional reasons, such as having as a new paid carer. It could also be hard to tease apart what was causing change (“Time or the sessions?”). There were persisting limits to participation due to poststroke physical disability, other comorbidities, and old age A theme that emerged was that “change” was not what some participants wanted from the therapy. For this subset, the main value of the therapy appeared to lie in the warmth of the companionship and feeling noticed and valued as people by their therapist. This is illustrated by a participant who lived alone and characterized herself as being content with “the little things,” such as being able to go out independently and speak with friends. She had not wanted to make any changes in herself or her life prior to the therapy and reported that the therapy had not resulted in any change. Nonetheless, she felt strongly that the therapy was right for her and she valued it highly. She noted the therapy, “makes you happy because you, you talk to the person,” and felt a close bond with her therapist, “we’re human being . . . especially when you get to know each other, you get very close, don’t you?” She gave examples of the therapist noticing her skills, for example, in needlework, and appreciating what made her special as a person: “I was very pleased. She was pleased too. She said that you’re a remarkable woman.”A subset, however, expressed disappointment that the therapy had not improved their aphasia. They would have preferred the focus of the therapy to be language exercises and discussed wanting more tangible therapy activities or worksheets. This is illustrated by a participant with severe aphasia who was 6 months poststroke when receiving the SOFIA intervention. His motivation for participating was to improve his talking. As such, he had hoped the focus would be, “Speech a little bit.” The therapy did not match what he was looking for: “I do like it, but it doesn’t me, it just doesn’t really . . . it wasn’t really what I wanted.”online Supplemental File 5). The primary factor used to categorize participants was their perception of the main value of the therapy. Consideration was also given to their reflections on therapy-related change. Each group is defined below.There was variation in how people experienced the therapy, what impact it had on their life, and which aspects of the therapy process they valued most. Participants were categorized into four groups  companionship: participants liked the idea of regular conversations; (c) curiosity and interest: participants were interested, curious about research, and liked feeling connected to the university; and (d) progressing their talking: participants hoped that taking part would mean receiving additional language therapy to improve their talking. Commonly, participants described a combination of these factors, with some suggesting that they took “any little thing” that was offered in case it turned out to be useful. Only one participant stated that she participated for support with her own emotional well-being.Participants took part in the study mainly for four reasons: (a) Some participants were satisfied with having six sessions (the upper limit) and considered this sufficient to enable a “bettering of my condition.” However, alternative perspectives included a preference for more sessions, having follow-up sessions, a more intensive schedule, or sessions spaced over a longer time frame. The rationale for wanting more sessions or follow-up sessions varied: Six sessions were perceived as insufficient and they wanted further sessions to support their progress; they enjoyed the sessions and so wanted them to continue indefinitely, particularly where they had developed a close relationship with the therapist; and they wanted to see the therapist from time to time to feel that someone cared.The experiences of people with aphasia who received an adapted version of SFBT were explored in this study. Thirty participants took part in in-depth interviews and overwhelmingly reported that they found the intervention acceptable. Four main areas were identified as valued therapy components: exploring hopes for the future, noticing achievements, sharing feelings and experiences, and companionship. Underpinning all these components was the therapeutic relationship. Participants reported therapy-related change in areas such as improved mood and participation. The variation in how people responded to the therapy was captured through sectoring participants into four groups: (a) “changed,” where therapy was highly valued and had a meaningful impact on a person’s life; (b) “connected,” where therapy was valued primarily for the sense of connection and companionship; (c) “complemental,” where the therapy complemented a participant’s upward trajectory; and (d) “discordant,” where the therapy focus did not fit well with the participant’s preference for language-based work.A striking finding from this study is that it was possible to adapt a psychological therapy to be accessible for people with a significant language disability: 47% of participants had severe aphasia. People with severe aphasia arguably have more need for psychological support than those with milder aphasia poststroke as they have worse quality of life , and parOne factor that may have facilitated the inclusion of people with severe aphasia is that the therapy was delivered by SLTs. There has been recognition that psychological care is the responsibility of all health care professionals . A steppParticipant perceptions around valued therapy components support the DPM  as a fraTo turn first to the “restoration work,” participants reported finding it useful to have the opportunity to explore their hopes, as well as notice their own achievements and successes. This matches other research, which has found that hope is a “critical resource for people with aphasia,” sustaining them through uncertain times and creating a sense of possibility for constructing a poststroke life . InstillA criticism leveled at SFBT is that, through focusing on solutions, there may be a lack of acknowledgment of the difficulties a person is experiencing . Within The final element of the DPM model is “Time Out,” endorsed by many participants as a valued therapy component. The DPM model suggests that time out provides a useful reprieve from grief. Having fun perhaps also aligns with what some people with aphasia want from therapy. In a study exploring people with aphasia’s experiences of co-constructing personal narrative within therapy, a theme to emerge was “having fun” . SimilarOne of the purposes of conducting qualitative research within a trial is to enable interpretation of the variation in outcomes . To helpAn unanticipated category was “Companionship.” People with aphasia are at risk of becoming isolated and having reduced social networks , which mThe group that perceived least benefit were the “Discordant” group, who were dissatisfied not to receive “traditional” language therapy. There was potentially a tension between expectations of what therapy would be delivered by an SLT and the therapy delivered within SOFIA. The approach may also have been perceived as more useful for this group had it been integrated with language impairment-based therapy. Where SLTs use SFBT in clinical practice, they report blending it with other SLT therapy approaches .It is noticeable that participant motivation to participate in the trial rarely corresponded with the stated aim of the study (enhancing well-being): They participated to contribute to society, out of curiosity or loneliness, or to improve their language. Furthermore, many participants did not have low mood or well-being. SFBT was developed as an approach to enable people to build change in their lives ; clinicaA main aim of the SOFIA Trial was to explore acceptability of the intervention: This qualitative study has addressed this question and enabled nuanced interpretation of how the intervention was valued. A strength of the study is that people with severe aphasia were enabled to participate in both the therapy and interviews. All 30 participants who received the intervention agreed to be interviewed, providing some reassurance that a variety of perspectives have been elicited. Nonetheless, a potential source of bias is that the lead analyst was also the principal investigator and one of the interviewers. To counter this, the interviewers stressed that they were interested in hearing participants’ honest reflections including negative appraisals, and a second analyst was involved in the analysis. An aphasia screening test, rather than a more comprehensive aphasia assessment, was used to minimize participant burden. SOFIA therapists reported that there were challenges in adapting the therapy for people with more fluent aphasia (reported elsewhere), however, aphasia type was not formally assessed. Another weakness of the study design was that family members were not also participants. As some family members participated in the therapy, they would likely have given further insights into the therapy process and the impact it had on them.Participants in the intervention group were interviewed 3 months after finishing the intervention. It was anticipated they would be able to reflect on any long-term impact of therapy. However, a disadvantage was that some participants reported difficulty in remembering details about the intervention. Nonetheless, the themes that emerged were similar for both the wait-list group (who were interviewed immediately post intervention), and the intervention group.This qualitative study suggests that adapted SFBTis an acceptable approach, potentially warranting further investigation in a definitive trial. Implications for the future trial from this study include enabling potential participants to have a clearer understanding of the therapy approach to manage expectations around language recovery; considering how to target those most likely to gain benefit from the therapy; reflecting on how best to manage endings, including reconsidering the training and support provided to the therapists, and exploring ongoing support options, particularly for those in the “Connected” group.Mental health professionals are key to provision of mental health services, yet have been described as feeling uncomfortable and inexperienced providing psychological treatments to people with aphasia . FurtherIt was feasible to adapt SFBT, so that it was acceptable to people with aphasia, including those with a severe communication disability. The approach facilitated many participants to achieve meaningful change, including in their mood and identity. Participants valued being able to explore their hopes, share feelings and achievements, and the companionship and connection they felt with their therapist. There appeared to be value in therapy interactions that enabled participants to feel noticed and validated as people.Click here for additional data file.Supplemental material, sj-pdf-1-qhr-10.1177_10497323211020290 for “Now I Am Myself”: Exploring How People With Poststroke Aphasia Experienced Solution-Focused Brief Therapy Within the SOFIA Trial by Sarah Northcott, Alan Simpson, Shirley Thomas, Rachel Barnard, Kidge Burns, Shashivadan P. Hirani and Katerina Hilari in Qualitative Health ResearchClick here for additional data file.Supplemental material, sj-pdf-2-qhr-10.1177_10497323211020290 for “Now I Am Myself”: Exploring How People With Poststroke Aphasia Experienced Solution-Focused Brief Therapy Within the SOFIA Trial by Sarah Northcott, Alan Simpson, Shirley Thomas, Rachel Barnard, Kidge Burns, Shashivadan P. Hirani and Katerina Hilari in Qualitative Health ResearchClick here for additional data file.Supplemental material, sj-pdf-3-qhr-10.1177_10497323211020290 for “Now I Am Myself”: Exploring How People With Poststroke Aphasia Experienced Solution-Focused Brief Therapy Within the SOFIA Trial by Sarah Northcott, Alan Simpson, Shirley Thomas, Rachel Barnard, Kidge Burns, Shashivadan P. Hirani and Katerina Hilari in Qualitative Health ResearchClick here for additional data file.Supplemental material, sj-pdf-4-qhr-10.1177_10497323211020290 for “Now I Am Myself”: Exploring How People With Poststroke Aphasia Experienced Solution-Focused Brief Therapy Within the SOFIA Trial by Sarah Northcott, Alan Simpson, Shirley Thomas, Rachel Barnard, Kidge Burns, Shashivadan P. Hirani and Katerina Hilari in Qualitative Health ResearchClick here for additional data file.Supplemental material, sj-pdf-5-qhr-10.1177_10497323211020290 for “Now I Am Myself”: Exploring How People With Poststroke Aphasia Experienced Solution-Focused Brief Therapy Within the SOFIA Trial by Sarah Northcott, Alan Simpson, Shirley Thomas, Rachel Barnard, Kidge Burns, Shashivadan P. Hirani and Katerina Hilari in Qualitative Health ResearchClick here for additional data file.Supplemental material, sj-pdf-6-qhr-10.1177_10497323211020290 for “Now I Am Myself”: Exploring How People With Poststroke Aphasia Experienced Solution-Focused Brief Therapy Within the SOFIA Trial by Sarah Northcott, Alan Simpson, Shirley Thomas, Rachel Barnard, Kidge Burns, Shashivadan P. Hirani and Katerina Hilari in Qualitative Health ResearchClick here for additional data file.Supplemental material, sj-pdf-7-qhr-10.1177_10497323211020290 for “Now I Am Myself”: Exploring How People With Poststroke Aphasia Experienced Solution-Focused Brief Therapy Within the SOFIA Trial by Sarah Northcott, Alan Simpson, Shirley Thomas, Rachel Barnard, Kidge Burns, Shashivadan P. Hirani and Katerina Hilari in Qualitative Health ResearchClick here for additional data file.Supplemental material, sj-pdf-8-qhr-10.1177_10497323211020290 for “Now I Am Myself”: Exploring How People With Poststroke Aphasia Experienced Solution-Focused Brief Therapy Within the SOFIA Trial by Sarah Northcott, Alan Simpson, Shirley Thomas, Rachel Barnard, Kidge Burns, Shashivadan P. Hirani and Katerina Hilari in Qualitative Health Research