The Inflamed Feeling is a brief tour through psychoneuroimmunology (PNI), a relatively young and interdisciplinary field concerned with understanding the reciprocal links between the brain, psychological processes, and the immune system. PNI is particularly ripe for evolutionary approaches (particularly given the selective pressure that infectious diseases are thought to have on human evolution), although most research tends toward outlining mechanisms and specifying the biological connections between the systems and processes under its purview. By stepping back to consider how the brain and immune system interact in a variety of real-world contexts, this book is a step toward applying explicit evolutionary thinking to PNI. The book is broadly divided into three parts: the brain-body connection (chapters 1 and 2), bio-behavioral immunity/defense , and psychosomatic health, broadly construed (chapters 6 to 10).The first section explores the role of prediction and error in the brain/mind  through examples of visual illusions, some of which (e.g. the ‘Cheshire Cat’ illusion) could be an effective in-class teaching demonstration. Lekander then applies this Bayesian thinking to connections between the brain and body with a particular eye for how this might influence health. He sums up this central argument—that perception and context play a key role in health—nicely: ‘The body is a hypothesis—once again, one that is normally reasonable and well-functioning, but sometimes completely inaccurate, with a potential for both ill health and recovery that is of great relevance to medical practice (pg. 33)’. The application of Bayesian logic, currently in vogue in psychology, to immune function is a fascinating avenue for generating new research questions and a key contribution of Lekander’s book.In keeping with the conversational tone of the book, Chapter 3 provides a broad, high-level introduction to the immune system. Although it would be easy to get bogged down in cell types, signaling molecules, and the other mechanisms of PNI, Lekander manages to provide sufficient context for readers not versed in immunology to follow along. Similarly, the chapter includes an introduction on sleep, stress, and immunity that outlines the biological and  evolutionary logic of the relationship between physical and psychosocial stress and changing immune function. While this chapter is generally effective, providing additional citations to introductory immunology texts for interested readers would have been a welcome addition. Including some of the considerable literature on stress and immune function in non-human animals would also have demonstrated the wide applicability of PNI. Chapter 4 covers the ‘sickness response’, or sickness behavior—a constellation of behavioral changes occurring during inflammatory states. This chapter covers the classical thinking regarding sickness behavior: that it serves to reduce energy expenditure on temporarily unnecessary social behaviors, minimize exposure to predators in a weakened state, and so on. However, additional research has shown that sickness behavior is responsive to social conditions and competing adaptive drives, albeit predominantly in non-human animal models ’, that is the ‘behavioral immune system’ . It is p’, that iet al. [The final—and longest—section deals broadly with psychosomatic health, ranging from self-rated health, inflammation, and interoception  to social and cultural influences on health and wellbeing (Ch. 9). As this is a slightly more speculative portion of the book, it is these chapters that readers are likely to find helpful in generating novel research questions. For instance, Chapter 7 suggests that ‘feeling sick’, or the sickness response, could be akin to an emotion. Lekander draws heavily from LeDoux’s view  that emoet al.  publisheThe Inflamed Feeling is an approachable, conversationally written book that neatly encapsulates the intersection of inflammation, immunity, and behavior. This, combined with its relatively short length and low price, make it a good option for undergraduate classes or early graduate seminars on psychoneuroimmunology or health psychology. Similarly, researchers new to PNI may also find it useful as an introduction and inspiration for their own research questions, though it would need to be supplemented by more in-depth texts.In all,


Major depressive disorder (MDD) is the leading cause of global disability; however, the existing treatments do not always address cognitive dysfunction—a core feature of MDD. Immersive virtual reality (VR) has emerged as a promising modality to enhance the real-world effectiveness of cognitive remediation.This study aimed to develop the first prototype VR cognitive remediation program for MDD (“bWell-D”). This study gathered qualitative data from end users early in the design process to enhance its efficacy and feasibility in clinical settings.Semistructured end-user interviews were conducted remotely (n=15 patients and n=12 clinicians), assessing the participants’ perceptions and goals for a VR cognitive remediation program. Video samples of bWell-D were also shared to obtain feedback regarding the program. The interviews were transcribed, coded, and analyzed via thematic analysis.End users showed an optimistic outlook toward VR as a treatment modality, and perceived it as a novel approach with the potential of having multiple applications. The participants expressed a need for an engaging VR treatment that included realistic and multisensorial settings and activities, as well as customizable features. Some skepticism regarding its effectiveness was also reported, especially when the real-world applications of the practiced skills were not made explicit, as well as some concerns regarding equipment accessibility. A home-based or hybrid  treatment modality was preferred.Patients and clinicians considered bWell-D interesting, acceptable, and potentially feasible, and provided suggestions to enhance its real-world applicability. The inclusion of end-user feedback is encouraged when developing future VR programs for clinical purposes. Major depressive disorder (MDD) affects approximately 5.4% of the Canadian population . Most reCurrent treatments, although effective in improving core symptoms of MDD, fall short in addressing MDD-related disability -10. SympTo enhance occupational functioning in MDD, cognition is an important intermediate target . CognitiCognitive remediation has emerged as a promising treatment strategy for addressing cognitive deficits in psychiatric disorders ,27. ThisImmersive virtual reality (VR) has attributes which could enhance the delivery of cognitive remediation and has preliminary evidence for efficacy in other neurological and psychiatric disorders . The immDespite the burgeoning applications of VR technologies and growing use in psychiatric populations, a sustained course of VR cognitive remediation has not been specifically evaluated in depression. As enthusiasm for using VR in clinical settings has grown, so have the questions regarding how to best design VR clinical applications to be usable and efficacious for the target population. A working group of international experts published the first consensus guidelines for best practices in the design and testing of VR clinical applications . In thesBuilding on the existing body of work relating to cognitive remediation in clinical populations, the National Research Council Canada and the University of British Columbia have developed the bWell Cognitive Care Platform for Depression (“bWell-D”), a prototype immersive VR cognitive remediation program for individuals with depression. Following best practices in VR clinical application design, this study collected qualitative data from clinicians and care providers regarding their perceptions and experience with VR, desired outcomes from a cognitive or functional remediation program, and perceived barriers to use of VR cognitive remediation in clinical settings. Later, participants provided their thoughts and opinions specifically regarding the bWell-D program. This information was used to guide program and protocol refinements to bWell-D to boost clinical efficacy and feasibility.This research was reviewed and approved by the Behavioural Research Ethics Board of the University of British Columbia . It was also approved by the Research Ethics Board of the National Research Council Canada (NRC 2020-122).A sample of 15 patients who self-reported a diagnosis of depression were recruited to participate in this study. Recruitment was carried out on the web through the Vancouver Coastal Health Research Institute and REACH BC websites, as well as on a classified advertisements website. Interested participants were screened to ensure they met the eligibility criteria:1. Aged 18 to 65 years2. Self-reported diagnosis of previous or current major depressive episodes3. Self-reported subjective cognitive or functional deficits at baseline, as indicated by a battery of self-report questionnaires. All participants were included in the analysis, regardless of their scores in the clinical measures.4. Engaged in full-time employment (currently or in the past), with self-reported ongoing functional deficits resulting from depressive symptoms, or off work or on reduced hours with depressive symptoms reported as the primary reason.5. Sufficient proficiency in English to complete the questionnaires and interviewPatients who were eligible and completed the entire process were compensated for their participation with CAD $20 (US $14.55).A convenience sample of 12 clinicians participated, with recruitment occurring through the Vancouver Coastal Health Research Institute and REACH BC websites, as well as physical posters displayed on-site at relevant health units. Clinicians were also contacted through the researchers’ professional contacts. Interested clinicians were provided a letter of invitation and confirmed their interest in participating via email. Clinicians must have been allied health professionals  with experience working with populations with depression, and experience with cognitive or functional remediation in psychiatric populations. Clinicians were not offered a monetary compensation.Measures section), whereas clinicians answered questions related to their clinical practice. After completing the questionnaires, a semistructured interview was conducted, in which participants were asked regarding their perceptions and experiences with VR, their desired outcomes from a workplace cognitive or functional remediation program (bWell-D), and perceived barriers to use this type of treatment in a clinical setting. Participants were then shown previously recorded video samples of the bWell-D tasks and were asked to provide their thoughts on them, their potential relevance to daily life, and suggestions on how to improve the tasks to enhance engagement and real-world applicability  tutorial, (2) assessment, and (3) training. Tutorial has the aim of familiarizing the patient with the virtual environment and showing them the actions they must perform in the tasks. Assessment mode has the purpose of identifying the patients’ individual needs by assessing their task performance with a fixed difficulty level. In the training mode, the level of difficulty is adaptable based on the patients’ performance. Real-time feedback is provided to the patient, showing them level or score changes and successes and errors.Along with the demographic questions included in the Qualtrics questionnaire, patients also responded to the following psychiatric and psychological measures:The Lam Employment Absence Productivity Scale  is a worThe Generalized Anxiety Disorder–7 items  is a shoThe Sheehan Disability Scale  is a shoThe Perceived Deficits Questionnaire–Depression  is a 20-The Beck Depression Inventory  is a 21-The Cognitive Failures Questionnaire  is a meaInterviews were recorded and transcribed verbatim. The transcriptions were made with Otter.ai, a web-based service that uses artificial intelligence to transcribe audio recordings. The transcriptions were reviewed and corrected by hand after being processed by Otter.ai. The initial 5 interviews (3 clinician interviews and 2 patient interviews) were coded by the first author to identify an emerging thematic framework . Coding Participants were aged between 21 and 63 years, with a median age of 31  years. Most participants self-identified as women (n=10), with 3 as men and 2 as nonbinary. The most common diagnosis was MDD (n=8), and 1 patient was diagnosed with dysthymia, 1 with bipolar disorder, 4 of them reported being diagnosed with depression but did not remember the specific diagnosis, and 1 did not have a formal depression diagnosis, but manifested having all the clinical symptoms for it (this was later confirmed at the screening stage). Patients with a formal diagnosis reported being diagnosed between 3 and 16 years ago. At the time of the interview, none of the patient participants were undertaking any psychological treatment, however, 4 of them were taking medication to treat their depression symptoms.Patients’ clinical scores are provided in According to the open-ended questions in the Lam Employment Absence Productivity Scale, employed participants had between 50 and 80 scheduled work hours in the previous 2 weeks, and although most of them worked their full shifts, 2 participants only worked between 15 and 20 hours. Four participants were currently working reduced hours, and they have been in this work modality between 2 months and 1 year. The responses to the open-ended questions of the Sheehan Disability Scale indicated that employed participants had lost between 1 and 20 days of work in the past month because of their depression symptoms. Even when attending work or school, participants reported that depression affected their performance in the last month, ranging from 30% of the days to 50% of the days. One participant reported feeling these effects daily.Participants self-identified as 5 women and 7 men. There were 7 psychiatrists, 2 occupational therapists, 1 psychologist, 1 clinical counselor, and 1 neuropsychologist. They had varied years of experience as mental health practitioners, ranging from 2 to 50 years, with a median of 17.5 years. Five clinicians reported having <5 years of experience in clinical practice, while 6 of them reported having >20. One clinician reported having between 5 and 10 years of experience.Most of the clinicians worked in an outpatient setting (n=10), either at hospital clinics or private practice. Only 1 clinician worked at an inpatient psychiatric hospital, and another one worked at a community health center. In total, 7 clinicians provided a consultation and assessment and short-term follow-up model of care, 3 of them offered long-term follow-up, and 2 of them did single consultation and assessment with no follow-up. Furthermore, 4 clinicians offered primarily pharmacological and medication treatment modality, 3 of them offered primarily psychotherapy, 3 of them a combination of medication and psychotherapy, and 2 focused primarily in functional rehabilitation. Clinicians who provided psychotherapy offered behavioral treatments, such as cognitive behavioral therapy, dialectical behavior therapy, and acceptance and commitment therapy.A total of 7 clinicians estimated <50% of their patients had a depressive disorder, while the remaining 5 estimated that more of the 50% of their patients had depression. Five clinicians had experience with cognitive or functional remediation, and they had between 0.5 and 5 years of experience with this type of treatment. Most clinicians (n=9) had been working remotely because the start of the COVID-19 pandemic, mostly relying on videocalls, phone calls, and (less commonly) computer tasks with their patients.Participants held mostly positive opinions regarding bWell-D, considering it an entertaining and safe treatment modality. Five themes were identified during the thematic analysis, specifically participants’ previous knowledge regarding VR technology, its potential for clinical uses, a desire for realistic settings and situations, the entertaining features of VR, and the need for an inclusive treatment. A description of each theme and representative quotes are presented below.Both patients and clinicians had at least some degree of familiarity with VR. Patients were familiar with VR mostly from videogames and movies, while clinicians were also aware of its use for clinical purposes, especially for anxiety-related conditions, psychosis, and brain injury. When participants did not have direct experience with VR, they mentioned hearing good things regarding it. Participants with little or no exposure to the technology spoke of their curiosity regarding trying it.I mean, I’m curious to see if it could, in any way, help my own mental health issues. And, I don’t know, it’s something I haven’t tried yet. And I’m open to trying things that might improve my wellness.Patient 003; woman; 43 yearsI don’t really know too much about it. But I’m very open to learning more. I guess, like I don’t know enough to say whether I see potential or not, so I’m eager to learn more.Clinician 005; woman; occupational therapistParticipants with a higher exposure to VR, and the ones who enjoyed videogames, were the ones who showed higher enthusiasm regarding this technology.Although both patients and clinicians often considered mood symptoms as the most salient symptom in depression, they acknowledged that cognitive symptoms are also affected. They described cognitive issues as particularly harmful for work life, because they have a direct effect on job performance, which can in turn exacerbate feelings of shame and stigma:It was just a really hard time. I just, I couldn’t concentrate, well, I still have a hard time concentrating. Just my, my work ethics went down. I don’t know, everything became really hard. I missed a few days here and there, like I felt, but at the same time, like even though I was told by the doctors like, ‘No, you need to take time off,’ I kept going because I didn’t want to be judged behind my back. But if anything that made it worse [...] But I know that my, my work has gone down, like, and I have a really hard time concentrating.Patient 001; woman; 21 yearsSeveral patients considered that training their cognitive skills through VR can help them not only for work purposes but also with their day-to-day life:I go into a room to get band aids, I forget what I’m in there for, literally my house is not that big. And I go back in the living room wondering what the hell I was looking for. So it, I feel like it would help with work and with my personal life, which is just a double bonus.Patient 003; woman; 43 yearsThey were confident that their cognitive abilities can be re-established after experiencing depression. When asked regarding the potential applications of VR for depression, 2 clinicians and half of the patient sample struggled to see how this technology could be used for this condition:I’m aware of the promise of virtual reality treatments for anxiety disorders and things like that. I would be, I don’t see the application to depression or bipolar disorder. So you know, in that end, those are the two disorders I treat the most. So therefore, I’m not particularly looking at this. And I’m surprised to hear about a virtual reality treatment for depressionClinician 009; man; psychiatristParticipants considered VR a safe alternative to conventional psychiatric treatments, and most patients were willing to try it because of its perceived lack of serious side effects. Participants believed that more effective treatments for mood disorders are needed, and therefore, VR can be a promising alternative.I don’t always enjoy the medication approach, like the side effects can be quite frustrating at times. So I think something without, like, a less medicalized approach could be really helpful. And you could avoid some of the negative side effects.Patient 014; woman; 21 yearsI think we need all the treatments we can get for mood disorders. So I’m curious.Clinician 009; man; psychiatristParticipants believed that VR is a novel approach to treat depression, and because it is becoming increasingly popular for clinical purposes, they would like to explore this treatment modality further:I think will become more common in the future. So I think it might be like a good way to look into it and learn about it before it like the, as is, you know, gaining more popularity.Clinician 005; woman; occupational therapistA few participants, however, considered this “newness” a limitation to start using VR, because it is not standard practice in most health care institutions:I practice in a large university hospital type setting. The university hospital always is incredibly bureaucratic, and never wants anything that’s innovative or different. They only want things that are standard. So anytime you try to introduce something new, it’s very challenging. So I would say that it would be unlikely that even if this treatment were approved tomorrow by Health Canada or the FDA, I would say it’s very unlikely that our system would use it for anytime in the next few years.Clinician 009; man; psychiatristDespite the general enthusiasm regarding using VR and cognitive remediation, both patients and clinicians had some further reservations, and mentioned needing more evidence before undertaking a treatment of this nature. Most clinicians mentioned that, although this type of treatment has shown promising results in some conditions, they would like to have more evidence for its specific use in depression. They would like to obtain this information from methodologically sound research studies:If there is going to be evidence for that, for the type of patients that I’ve seen, and the patients are willing to participate? So yeah, for sure [...] It’s not part of the kind of the regular practice, or part of the standard guidelines. But once the evidence is there, for sure.Clinician 012; man; psychiatristFurthermore, approximately half of the patient sample mentioned that the VR format might not have any particular advantages over other modalities of cognitive remediation delivery:I think the only like, pushback that might be received is like, what is the difference between doing this and playing like, a task related like, video game, I guess? Like, I think that there’s an, there’s maybe an opportunity for, like, people who are depressed to be like, “Well, if I if I’m basically just going to a lab to play a game, what’s the difference between me doing that, and me just like downloading a game on my phone where you’re being asked to, like, do memory parts?”Patient 008; woman; 30 yearsSeveral patients mentioned that they would like to understand exactly how the tasks practiced in bWell-D work, so they do not feel like they are “just playing a game.” They also mentioned needing an explanation regarding how to extrapolate the trained skills to their real-life world:My honest opinion on the games, they all seem like kid games. They all seem very simple and straightforward, but simple animation. And I find like, I might think it’s just a silly game, but I think once I start actually playing them, I would realize how it’s helping.Patient 007; woman; 28 yearsI think I would need the therapist to, like, fully explain what this was training and helping with, because, like, the one thing that triggered me when I was in a depressive state was that, like, I knew I was smart, but then like, when I was in a depression, I wasn’t functioning, that, like, as normal, and then I would feel really, really dumb. And like, seeing this kind of activity makes me feel like, you know, it gives a reaction like, I’m not a child, like, why am I putting shapes together?Patient 10; woman; 27 yearsMost participants mentioned that VR offers the possibility of immersing themselves in settings and situations that resemble real life in a highly accurate manner:It’s very interesting in the way that all new technology is very interesting. And it’s remarkable, you know, the sense of presence when you’re in the VR environment. It, you know, unless you’ve experienced it, it’s hard to imagine, you know, it’s very much like being in the real world.Clinician 011; man; psychiatristMost patients mentioned they would like the virtual environments to look like their own work or school setting, as well as including objects  and situations  that emulate real life . They believed that these naturalistic aspects can enhance skill extrapolation:I think that it would also require some effort relevant to their daily activities, or have some translational component.Clinician 004; man; psychiatristI think if I work in an office, it would, it would be better because I’d be able to take what I’m doing within that virtual reality, and apply it more to the environment that I’m hoping to improve my concentration in. But because it doesn’t look like where I work it’s difficult to connect the two.Patient 007; woman; 27 yearsParticipants considered VR as “the second-best thing to real life,” because it allows an immersion in highly realistic environments. Participants desired to obtain this realism through several ways, (1) by having virtual settings that emulated patients’ own real-life environments, (2) by including distractors in the VR world that would occur in real life, and (to a lesser extent) (3) by having realistic-looking graphics. Patients and clinicians also stated that VR environments allow for the practice of skills and exercises in a more controlled and less intimidating setting:If I were able, was able to get better at that, and because it’s a low stress environment in the game, maybe having it, having that experience in a low stress situation would help me in my more stressful situations.Patient 014; woman; 21 yearsIt’s like the traditional thing when you, when you’re nervous about speaking in front of a crowd is that, you like, you practice your speech in the mirror. It could be something similar to that but in a VR setting, with there being more of a...I don’t quite know how to articulate it, exactly.Patient 005; nonbinary; 25 yearsA few patient participants mentioned that VR can allow them to focus on only training their skills without getting sidetracked. However, they emphasized the need for improving their cognitive symptoms overall, rather than just improving their performance in the virtual tasks:I’m skeptical because of the literature that’s behind this, because there’s a lot of evidence saying that you only get better at the game instead of the skill itself, or the cognitive aspect that you’re focusing on itself.Patient 001; woman; 21 yearsThree clinicians mentioned the importance of ensuring that the skills practiced in programs like bWell-D are actually training what they intend to train, and that the tasks are representative of the actual cognitive processes that patients must perform at their work or day-to-day life:If there’s evidence that depressed people have trouble on that sort of task, it makes sense. If you’re pulling it out of thin air, because they have trouble on an attempt and inhibition task that’s not like that one, then you better rethink how close that task mimics the process you’re interested in.Clinician 011; man; psychiatristApproximately a quarter of the participants were concerned regarding the long-term effectiveness of the treatment. To address this, a patient suggested having a lengthier VR cognitive remediation treatment, whereas a clinician suggested adding booster sessions. Several participants expressed a desire to obtain treatment progress data through a reliable instrument. Although a few of participants mentioned wanting improved graphics in bWell-D , others mentioned that this is not too important if the content of the tasks is well designed, and the objects are clear to see. Most participants mentioned that any possible glitches and malfunctions should be minimal or nonexistent for the treatment to be effective and enjoyable.Most participants mentioned that the gamified experience of VR adds fun, engaging, and immersive elements to the treatment. A need for multisensory stimuli  was mentioned by most of the participants and was considered key for the immersion and involvement in the virtual tasks. Participants also stressed the importance of having a difficulty progression in the tasks, to enhance the challenging aspect of the treatment (without it turning so difficult that it becomes discouraging). A clinician mentioned how this difficulty progression can provide a sense of accomplishment for patients:It definitely gives you kind of that drive, while at the same time being complicated and interesting enough to keep your attention wanting to keep going [...] – I found that one was always a really fun task, a difficult task. Not difficult, but it required enough energy without being overwhelming.Patient 015; woman; 33 yearsMost clinicians and patients stressed the importance of having a simple, user-friendly VR interface that included some training period and clear instructions to practice the tasks. A few clinicians considered important to assess patients’ satisfaction with the program session to session.Several participants, especially clinicians, found the versatility of VR to be beneficial for the treatment. They noted that the flexibility provided by VR allows a wide variety of virtual settings, going beyond what is achievable in real life:I think you can help us create a very realistic environment to do some therapeutic work in and potentially make some progress that we haven’t been able to outside.Clinician 007; woman; psychologistA few participants considered a treatment, such as bWell-D less emotionally draining treatment modality than medications or talking therapy:When I was watching it, it occurred to me it’s kind of nice to have these videos not relating to real life experiences, and things that are supposed to be kind of fun, because it doesn’t feel like you’re doing work, even though you are. And that is, at least for me, isn’t as emotionally or cognitively draining.Patient 015; woman; 33 yearsSeven participants (both patients and clinicians) mentioned that the game-like setting of VR also allows for progress tracking , either from the beginning to the end of a session, or from session to session.Most patients and clinicians mentioned that they would like to have some agency in the manner the VR treatment is conducted. One of the most recurring comments among patients and clinicians was a preference for the patient to have the treatment individually at home, either partially or completely. Participants believe this modality provides a sense of comfort and control:It seems like a nice way to do it yourself. Like, in your own time in, in quiet, in a quiet environment and not have to go anywhere.Patient 002; woman; 36 yearsI think it would be helpful for people who can’t get there, like remotely. Like, there are days when I can’t like, get out of bed or like, get overwhelmed by taking the bus, and like, that might be super helpful to be able to join in like that.Patient 10; woman; 27 yearsHowever, a few patients and clinicians believed a treatment of this nature would be better performed at a clinic. In particular, patients with limited space, or with suboptimal conditions to carry out the treatment at home, would like to have the option to do it at a clinic if necessary:If I had to use it at my own home, that would be almost impossible with three kids and, I think, life.Patient 012; womana; 42 yearsParticipants mentioned wanting a person involved in the treatment even if they choose to do it remotely. Several patients stated that the involved person should be a well-trained facilitator who they trusted. Most of the patients and clinicians mentioned they would like to engage in a VR treatment when mood symptoms and other potential comorbidities are under control, and therefore had enough motivation to undertake the treatment:It depends on the severity, so I think it could be quite hard for some individuals to sustain, you know, attention or memory, if they’re having more severe symptoms. But I think as a symptom, sort of subside or set, you know, it’s more mild to moderate, we might be able to focus a bit more and pay attention to it a bit better.Clinician 007; woman; psychologistI think like when you are depressed, like, it’d be really hard [...] if there’s any sort of resistance in that process. I think like, a really anxious person or really depressed person would be like, ‘Nope, I can’t deal with it. It’s not working. I’m done with it. Not going to use it today’ sort of mentality.Patient 008; woman; 30 yearsIn fact, several patients and a few clinicians mentioned the usefulness of including an activity in bWell-D that specifically targeted mood. After looking at the task video samples, 4 patients also mentioned that some tasks could be more useful than others . Therefore, they would like to tailor the treatment according to their own cognitive struggles and needs. A clinician also commented that, although the office or school-like VR settings could be useful to emulate naturalistic settings, these settings can trigger emotional responses from some people:For people who are not working, many people with depression are on short or long term disability from work, I was just wondering if seeing the office environment might trigger something.Clinician 010; woman; psychologistDespite the overall positive perceptions regarding bWell-D, approximately half of the clinician sample and one patient stated they would like to do a VR treatment in parallel with other conventional depression treatments :You target that symptom, but then you work with the clinician long term to, to use this as sort of one of the other interventions that you’re using, and I would see this not being a single intervention being used. I see this being used in combination.Patient 001; woman, 21 yearsAnother of the most mentioned topics among patients and clinicians was how age could be an important factor when undertaking a VR cognitive remediation treatment. In particular, participants believed that the more technologically savvy individuals (often the younger generations) would like the treatment better. In turn, participants believed that older patients might need more coaching and adjustment time to become used to bWell-D. Several participants also believed that people prone to sensorial issues might dislike a VR treatment, because it can make them feel physically ill:The other problem with all of this is that people go into their depression with some of them, depression of course worsens all of this, it can worsen this, but some people have pre-existing audio processing difficulties or visual processing difficulties either genetically or by head injury or a stroke or medical injuries, etc..Clinician 002; man; psychiatristParticipants also mentioned that the treatment should be accommodating to people from different backgrounds and with different needs, such as people with color blindness or visual impairments, people whose English is their second language, and people with limited mobility. One of the most common concerns was the actual access to the bWell-D program and the necessary equipment . Most participants acknowledged that these technological devices, although they are becoming cheaper with time, may still be inaccessible for people with more limited economical resources:They [VR sets] cost a little bit of money, and most people with mental illness don’t have any money. So yeah, just having access to it, having access to a headsetPatient 004; man; 49 yearsThe job that I work, I don’t have coverage yet, and when I do get coverage, I don’t know how much it is. And maybe, I’m not sure if the city offers it, like if it’s readily available. So I guess cost and availability would be the biggest challenges for that.Patient 007; woman; 28 yearsHowever, a clinician mentioned that, if the treatment shows to be effective for patients, then every effort should be made to open access to it.Following the guidelines proposed by Birckhead et al , the chaAlthough efforts were made to cover as many of the suggested changes as possible to bWell-D, there were some areas that the research team determined to address with alternative strategies. In particular, one of the suggestions made by several participants was the addition of more VR environments that better emulated patients’ real-life settings, such as their own workplace or school. However, the research team concluded that the addition of these VR environments would be too demanding in terms of resources required for software development. Instead, it was decided that such need would be addressed trough bridging exercises, which are clinician-led discussions that help cognitive remediation participants to apply what is trained in the tasks to everyday life .As part of the iterative process in the design of bWell-D, the changes made to bWell-D were later shown to a subset of 4 patient participants, once more as prerecorded video samples. After looking at the updated version of the program, participants were provided with additional information regarding bWell-D and were asked regarding their general opinions regarding the implemented changes (see The main aim of this study was to explore the opinions of patients and clinicians regarding the use of VR for the treatment of depression-related cognitive disfunction. bWell-D, a VR treatment specifically designed for treating cognitive symptoms of depression, was used as the main VR treatment example for the participants. The results indicate that VR interventions for treating depression and its cognitive symptoms are generally accepted by both patients and clinicians. In the particular case of bWell-D, they considered it an innovative and fun alternative for the treatment of mental health issues. Some suggestions were made for the improvement of bWell-D, such as including multisensorial tasks, cues, and distractors, a progression in the difficulty of the tasks, realistic virtual settings and activities, having a user-friendly interface, including tutorials and an opportunity to practice the tasks before initiating the treatment, and adding a task or VR activity that targets patients’ emotional state.Although the general perceptions regarding VR for clinical purposes and bWell-D were mostly positive, participants also expressed some reservations. In particular, clinicians needed more evidence before implementing a treatment of this nature in their own clinical practice. Although there is a growing body of evidence supporting cognitive remediation  and VR iSimilarly, patients mentioned wanting a thorough explanation regarding how the skills trained in programs such as bWell-D can extrapolate to the real world. To this end, psychoeducation has been identified as a key component in the treatment of depression , which cPatients also commented regarding the need of a customizable VR treatment in which they could decide over how, when, and where the treatment was conducted. There was a strong preference for doing the treatment individually at home, because this was considered the most convenient modality for patients. Although considering patients’ opinions within any psychiatric or psychological intervention is essential, clinicians should be mindful regarding not losing key components of the intervention when accommodating patients’ preferences. By doing so, clinicians might be drifting away from best practice, preventing patients of receiving the best treatment available .There was an overall positive perception toward VR interventions for depression and other mental health conditions, and toward bWell-D itself. Participants indicated that they would use this type of treatment if available, and this acceptance was mainly motivated by the fact that a VR intervention was perceived as a treatment with no adverse long-lasting consequences or side effects. Participants believed that, in the worst-case scenario, the treatment may not improve their cognitive skills but would not worsen them, which was an advantage when compared with other more conventional treatments, such as medication. This relative safety provided by VR treatments can be highly beneficial by end users, given that, besides the economical investment, there are little to no risks associated with this treatment. However, the accessibility concerns manifested by end users should be a consideration for implementation and future directions in the bWell-D development process, given that currently there are no clear plans regarding how this treatment will be made available for clinicians and patients.This study shares some specific findings with previous literature. In the study by Kramer et al , cliniciThis research had some limitations. Further insights might have been obtained from participants if they have had hands-on experience with bWell-D, instead of watching prerecorded samples. While it was initially intended that participants would trial bWell-D before completing the qualitative interview, COVID-19 pandemic restrictions prohibited on-site testing during the data collection period, necessitating the change to the virtual format used here. Related to these COVID-19 pandemic restrictions, patient participants were recruited through various web-based sources and self-reported their depression symptoms. Future studies might benefit from in-person assessments in which a health care professional administers the clinical questionnaires. In addition, most of the clinician sample did not have practical experience with cognitive remediation, clinicians with direct experience could have clearer expectations of a VR cognitive remediation treatment and may have therefore provided more extensive feedback. The sample included both people who were still working or in school but had depression-related impairments, as well as people who were off work—these 2 groups might conceivably have different concerns and needs from cognitive remediation. Finally, the clinician sample was formed mostly by psychiatrists working in outpatient settings—a more diverse clinician sample might have provided broader perspectives regarding the use of cognitive remediation and VR for depression. In terms of strengths, this is, to our knowledge, the first study that focused on obtaining end-user feedback regarding a VR intervention for cognitive symptoms of depression with a qualitative approach. We were able to obtain rich and extensive feedback from a varied sample that included patients from a wide range of ages, backgrounds, and genders, which offers an inclusive and comprehensive perspective toward the use of VR and cognitive remediation. Finally, reinterviewing the participants reaffirmed the relevance of the changes made to the program and enhanced the user-centered design, which will continue to be central in the iterative process of bWell-D development until its application in clinical populations.Virtual interventions for the improvement of cognitive symptoms in depression are generally acceptable and potentially feasible for patients and clinicians. Although VR and its use for the treatment of health-related conditions is relatively new, participants were familiar with it and open to try it, given its perceived safety. They were curious regarding a treatment of this nature and saw potential in its implementation. Participants considered it to be important to have realistic virtual settings, tasks, and cues to enhance the extrapolability of the skills trained in the VR program. The virtual format of this intervention was perceived as an advantage, and participants believed it offered a versatile and fun alternative to conventional depression treatments. Patients’ own needs and preferences should be considered when implementing a VR treatment for psychiatric conditions, and all efforts should be made to make it more accessible and convenient for end users.


This study investigates the persuasive mechanism of slogans employed in responsible gambling campaigns. We analyse slogans from official posters in the U.S., Singapore, and Macau, focusing on two domains. First, the Theory of Planned Behaviour is applied to examine the intention to gamble expressed in the slogans to reveal how gambling is positioned in social contexts. Second, two framing devices—i.e., conceptual metaphors and the frame of gains/losses—are examined to understand how these framing devices reinforce the persuasive message while interacting with each other. Two models of persuasion emerge from our data—one encouraged ‘grounded games’ for enjoyment, while the other discouraged gambling due to its potentially ‘harmful’ consequences. We advocate for a gestalt view on the theoretical constructs that contribute to the overall effectiveness of persuasive messaging. These constructs should be integrated into an analytical framework, with particular attention given to the framing effect of conceptual metaphors and the gain/loss frame, and their interplay. Commercial gambling has evolved into a “global business” in the 21st century, with its worldwide gross revenue doubling from 2000 to 2019 ,4. The rAt this juncture, responsible gambling (RG) has emerged as a pivotal concept, forming the basis for the development of measures, strategies, and policies aimed at preventing and reducing harm related to gambling ,11,12,13In RG campaigns, slogans prominently displayed on posters and banners in public spaces play a key role in conveying messages about healthy gambling to audiences ,21. ThesAside from the stance and positioning expressed by the slogans, the framing of a message can significantly enhance its appeal and persuasiveness. Based on the existing literature, we examine two notable framing devices—i.e., conceptual metaphors  and the housework, was proposed as a valuable tool for effectively communicating the responsibility for addressing health concerns, including the reduction of gambling-related harm, within the Maori community in New Zealand [pilgrimage as a meaningful metaphor, enabling outbound Chinese gambling tourists to interpret their experiences [the act of love’, ‘a market’, ‘a sport’, and ‘a natural environment’ used to illustrate and promote betting activities [Our literature survey suggests that neither type of framing has garnered significant attention in RG research. Only a few studies have investigated the use of metaphors in the context of gambling. One noteworthy metaphor,  Zealand . In addi Zealand . Moreoveeriences . The othtivities . From outivities —researchhttps://www.ncpgambling.org/programs-resources/responsible-gambling/, accessed on 13 October 2023) and gambling operators. This research collected data from the U.S., Singapore, and Macau to unpack the theoretical constructs underlying persuasive messaging. The three locations merit special attention in their own right. First, the U.S. commercial gambling industry generated a record revenue of USD 60 billion in 2022 . While tSecond, Macau has a long history of legalised gambling dating back to 1847 . It surpFinally, in 2005, the Singapore government decided to construct two casino resorts to enhance its tourism industry, in line with its self-styled image as the ‘Renaissance city of Asia’, supplementing traditional lotteries and horse racing . The Nat(a)What stance is expressed in the slogans concerning the positioning of gambling in relation to players’ financial well-being and social lives?(b)What conceptual metaphors are employed in the slogans, and how do they contribute to the message to gamble responsibly?(c)Is the frame of gains or the frame of losses conveyed in the slogans, and how do these frames contribute to the message to gamble responsibly?This research undertakes an analysis of slogans for RG messaging employed in the three locations. We are interested in examining both the stance on gambling expressed in the slogans and the framing devices used to further reinforce that stance. Our research questions are the following:In order to collect slogans from the three target locations, we first conducted image searches via Google Chrome, using the keywords ‘responsible gambling’ and ‘responsible gaming’ to yield a range of 200–300 image snapshots, incorporating location-specific words such as ‘Singapore’, ‘the U.S.’, and ‘Macau/Macao’ as necessary. We also conducted searches via other web browsers such as Firefox and Microsoft Edge and found that the search results were very comparable with those generated by Google Chrome. By manually browsing through the images and single-clicking on the relevant ones to display similar images, we collected images that feature slogans specific to the three locations. Our selection criteria prioritised slogans that verbally articulate the concept of responsible gambling, with a particular emphasis on those that employ a catchy phrase designed to resonate with—and impart a particular message to—the audience. We therefore excluded a substantial number of images that lacked a specific slogan. This category includes, for instance, posters—predominantly from various U.S. states—that simply announce events such as “Responsible Gambling Week” or “Problem Gambling Awareness Month”, with specific event dates appended.https://www.americangaming.org/, accessed on 13 October 2023), the Singapore National Council on Problem Gambling , and the Direcção de Inspecção e Coordenação de Jogos . We accessed the websites of these institutions to retrieve their slogans and posters. From our searches, we also identified the key institutions that appeared in the images—for example, the American Gaming Association  and Resorts World Sentosa Singapore , also contributed slogans and posters. In Macau, major gambling corporations regularly participate in the promotion of RG events coordinated by the Macau government and also provide relevant educational materials through kiosks installed within casinos. However, the design of the most widely circulated and noticeable annual campaign slogan and poster in Macau is undertaken by the Institute for the Study of Commercial Gaming. We retrieved the slogans for Macau from this source, covering a period of more than ten years. Our data from the U.S. and Singapore primarily encompass the past three years. In addition, entities within the gambling and entertainment industry, such as the New York Lottery  ,23 to exSecond, we investigated how the message expressed by the campaigners’ stance on gambling is further enhanced by framing devices, including conceptual metaphors and the frame of gains/losses. We employed the Metaphor Identification Procedure VU University Amsterdam (MIPVU)  to examiconstruction, driving, war, and even the strategy of playing all-in (in a poker game) to elucidate the concept of responsible gambling, while the metaphors of tornado and child’s play are utilised to demonstrate what gambling is and is not, respectively. The slogans and their associated posters vary not only in their use of metaphor but also in the way in which they promote RG. One subset of slogans portrays positive scenarios, characterised by excitement, smiling faces, and cheerful body language to affirm that gambling can be enjoyable when the players maintain control. By contrast, another subset presents images of sad faces, desperate body language, and a gloomy environment to discourage individuals from engaging in gambling activities.We therefore identified two main methods of promoting RG in our data—i.e., Models A and B in We investigated the two models that promote RG in terms of (a) their construal of the intention of gambling, using the conceptual framework of the Theory of Planned Behaviour (TPB) , and (b)In this section, we apply TPB to examine how gambling is portrayed in the two models of persuasion by slogans. In the light of TPB, people’s gambling behaviours are closely related to their intention of gambling, and the latter is a strong predictor of the former. TPB proposes that people’s intention to carry out a certain activity mainly relies on three factors—i.e., their attitude towards the behaviour, the subjective norms about the performance of the behaviour and its acceptability, and their perceived behaviour control over the activity in which they are engaged. In the following sections, we investigate the intention of gambling and its three constructs, which are expressed in the two models for RG promotion .The first model demonstrates a favourable attitude towards gambling. Of the three constructs of attitude, the attitude on gambling expressed in this model is largely positive. The model portrays gambling as a form of entertainment, often light-hearted enjoyment. It does not present gambling as a means of making money, though, or as an exciting adventure in search of good fortune. For example, in the 2019 version of the “Are you playing smart” slogan presented by the Responsible Gambling Forum (RGF) in Singapore , a well-Second, the subjective norms expressed in this model strongly suggest that gambling is acceptable to the general public and it is fine to engage in it, as long as it is under control. This model treats gambling as something morally permissible rather than controversial, and this position is observed, for example, in the “grounded” and “playing smart” slogans. Similarly, in the slogan “set limits to control your spend, deposits, and the time spent wagering” cf. , which wThird, the perceived control over gambling is emphasised particularly strongly in this model of “grounded games”. The type of control explicitly referred to here is not about gamblers’ control over the outcome of gambling though—such as through an individual’s gambling skills or competence, let alone through the superstitious behaviours practised by some gamblers to manipulate the results of games. The scope of control promoted in this model is about individuals’ ability to keep their gambling activities grounded without exceeding the limit they have set on their spending. For example, the “setting limits for spending” slogan cf.  featuresIn summary, this model of persuasion promotes “grounded games” and conveys the message that people’s intention to gamble is acceptable, and this is in line with the social norms of gambling by the general public. This model does not seek to dissuade people from betting but focuses on conveying the message that individuals should exercise self-control in order to act responsibly and make their betting enjoyable, reasonable, and sustainable.Unlike Model A, this model aims to frustrate people’s intention of gambling. We again apply the TPB framework to examine the constructs of intention, and observe that, first of all, the attitude towards gambling is depicted in a strongly negative light and is even stigmatised at times. The negative attitude derives from the gloomy prospect depicted in the slogans that gamblers will lose their money, car, home, and so on rather than making money, and there is therefore no reason to want to gamble. For reasonable individuals, the loss of valuable belongings and close family relationships would be disheartening and distressing, akin to being ravaged by a powerful tornado cf. , left. CIn addition, the subjective norms invoked in this model indicate that gambling is abnormal, harmful, and hazardous, entirely at odds with maintaining a functional, caring, and united family. It is considered to be dangerously disruptive, as illustrated by the 2022 poster with the “lost control” slogan developed by the Institute for the Study of Commercial Gaming (ISCG) in Macau , right, Finally, in terms of perceived behaviour control, this model shows little confidence in gamblers’ ability to exercise self-control. As demonstrated in the slogan from Macau , left, gTherefore, the second model of persuasion for RG endeavours to thwart gamblers’ intention to gamble by vigorously highlighting the disastrous consequences of gambling. In terms of attitudes, subjective norms, and perceived behaviour control in relation to gambling, the model works to reduce the ground that supports each of the three constructs of the intention of gambling. Model B employs a relatively more aggressive approach to address the problem of pathological gambling than Model A. In this section, we examine how persuasive messages expressed in Models A and B are further framed using two types of framing devices—(a) conceptual metaphor and (b) the frame of gains and losses—to enhance their appeal. construction, or more specifically, the building of a sturdy and stable structure. The metaphor selectively borrows the characteristic of a firmly grounded building from the source domain of construction and applies this quality to advocate the optimal method of gambling in the target domain. The mapping principle can be postulated as follows: engaging in gambling can be understood as constructing a building, in that a soundly grounded building is firm, secure, and robust and so is sensible gambling practice. This concept is also communicated through the design of the animation.This model positions gambling as a pleasant and socially and ethically permissible activity that can be enjoyed by gamers with self-control. Our analysis of the slogans and the graphic designs of the posters associated with this model reveals the use of conceptual metaphors to reinforce the message. For example, the slogan “Keep your game grounded”  uses theconstruction metaphor is therefore apt to convey the message that only when people make their gambling well-grounded can they achieve pleasant social lives and build a harmonious community.The web-based version of the promotional material uses video animation that shows letters in robust fonts joining together to form words such as “keep”, “your”, “game”… and the words stacking together to construct the phrase “keep your game grounded”. The phrase is visually presented in a solid structure that is firmly grounded see . The aniAside from the use of metaphors, the persuasiveness of the message is further enhanced by the frame of gains. According to Prospect Theory , people In Model A, the integration of metaphors and the incorporation of a frame of gains synergistically convey the message that gambling should be approached with a solid grounding, much like a well-constructed building. The frame of gains further cultivates a tendency for risk aversion, potentially fostering RG behaviours that enable players to maintain enjoyable, well-balanced, and sustainable lives. construction is utilised in both Models A  frames gambling as a disease and underscores the collective suffering of the gambler’s family. Gathering evidence on how individuals perceive the constructs and framing features of such messages would significantly enhance our understanding.We see that both an individual’s self-control and external factors such as legislation, entry restrictions, and non-proximity to casinos are important factors contributing to his/her engagement with gambling. There is a pressing need for empirical evidence; however, our literature survey identified only one empirical study. This study found a limited impact of a statewide advertising campaign on problem gambling, revealing a low exposure rate of 8% among adult residents of Indiana . Aside fWe advocate for a gestalt view on persuasive messaging, emphasising the significance of theoretical developments in the growing field of RG research. There have been a considerable number of survey studies on gambling that have applied the Theory of Planned Behaviours (TPB) to examine gamblers’ intentions and empirically test the correlations between TPB parameters. Notably, strong correlations have been found between gamblers’ gambling practice and their intentions, and also between problem gamblers’ perceived behavioural control and their level of engagement in gambling ,30,31,32https://www.ncpg.org.sg/resources/advertisements, accessed on 13 October 2023) that vividly depict the challenging circumstances of problem gamblers and seek to provide them with channels for assistance, reflecting the use of Model B, which portrays the severe consequences of uncontrolled gambling. NCPG endeavours to maintain a high level of vigilance regarding problem gambling and has implemented a comprehensive system to monitor and reduce visits of problem gamblers to betting venues , showcasing a tangible response to pathological gambling identified in Model B, and employing a robust and effective system. Given their significant practical value in safeguarding problem gamblers, the functionality of response systems to problem gambling deserves focused research attention. Since the slogans collected in this study had a limited scope and were exploratory in nature, it is important to note that its findings on the models of persuasion and the attitudes towards gambling should not be viewed as representative of broader trends or characteristics of the locations where the slogans were produced and used. In fact, we can observe that different models of persuasion are often employed concurrently by various campaigners promoting RG in the same area. For example, in Singapore, the Responsible Gambling Forum (RGF), a partner of the National Council on Problem Gambling (NCPG), utilised the slogan ‘playing smart’, which exemplifies Model A and emphasises sustainable gambling practices. On the other hand, NCPG has released more than ten advertisements (This research has investigated the theoretical constructs underlying the messages conveyed by slogans that promote RG. Two representative models have been identified—one encouraging ‘grounded’ gambling with self-control, and the other dissuading players from gambling by highlighting its devastating ‘harms’. The two models demonstrate sharply different stances on gambling in terms of players’ financial well-being, social lives, and self-control. Each model utilises unique conceptual metaphors or distinct mapping principles to strengthen its message, while the models further contrast with each other in terms of the frame of gains/losses expressed. The first model fosters gamblers’ risk-averting behaviour to maintain enjoyable, sustainable, and recreational gambling by exercising self-control, promoting smartness, reason, and a well-managed life. By contrast, the second model appeals to gamblers’ sense of responsibility towards their families and their desire to protect themselves from grave financial losses due to gambling. However, the frame of losses expressed in the second model may potentially provoke risk-taking behaviours in problem gamblers, according to Prospect Theory . There i


Hepatitis C is curable with direct-acting antivirals (DAAs). However, treatment uptake remains low among marginalized populations such as people who inject drugs. We sought to understand challenges to treatment uptake with DAAs among people living with hepatitis C and compare treatment experiences between people who do and do not inject prescription and/or unregulated drugs.We conducted a qualitative study using focus groups with 23 adults aged 18 years and over who completed DAA treatment or were about to begin such treatment at the time of the study. Participants were recruited from hepatitis C treatment clinics across Toronto, Ontario. We drew upon stigma theory to interpret participants’ accounts.Following analysis and interpretation, we generated five theoretically-informed themes characterizing the experiences of individuals accessing DAAs: “being ‘worthy’ of the cure”, “spatially enacted stigma”, “countering social and structural vulnerability: the importance of peers”, “identity disruption and contagion: attaining a ‘social cure’” and “challenging stigma with population-based screening”. Overall, our findings suggest that structural stigma generated and reproduced through healthcare encounters limits access to DAAs among people who inject drugs. Peer-based programs and population-based screening were proposed by participants as mechanisms for countering stigma within health care settings and ‘normalizing’ hepatitis C among the general population.Despite the availability of curative therapies, access to such treatment for people who inject drugs is limited by stigma enacted in and structured within healthcare encounters. Developing novel, low-threshold delivery programs that remove power differentials and attend to the social and structural determinants of health and reinfection are needed to facilitate further scale up of DAAs and support the goal of eradicating hepatitis C as a public health threat. Chronic hepatitis C viral (HCV) infection is a significant global public health concern, affecting an estimated 71 million people worldwide –7 with aFortunately, chronic hepatitis C is now curable in almost every infected person with direct-acting antivirals (DAAs) , 16. UnlYet, despite the individual and public health benefits of curative treatment with DAAs, uptake of treatment remains low in Canada, particularly among people who inject drugs , 27, 28.Our study was conducted in Toronto, Ontario, Canada. Ontario is Canada’s most populous province and is home to over 40% of Canadians living with hepatitis C . AlthougIn qualitative research, sampling is not conducted for the purpose of probabilistic generalizability to a larger population . InsteadWe conducted four focus groups with 23 adults aged 18 years and over. Because we were concerned that people who inject drugs could experience inadvertent harm or stigma in groups that included people who did not inject drugs, two focus groups were comprised exclusively of participants with a current or past history of injection drug use. The remaining focus groups were comprised of individuals who did not inject drugs, although a small number reported a past history of injection drug use. Although the optimum number of focus groups for research stratified by specific participant characteristics is unknown, a minimum of two focus groups per stratum with ongoing assessment of response saturation is considered sufficient , 40. AllWe developed a semi-structured focus group guide to elicit participants’ hepatitis C related diagnostic and therapeutic experiences and to understand how they became aware of and accessed DAA therapy. Probing questions captured participants’ perspectives regarding the social and structural factors that promote and hinder access to DAAs and the delivery of hepatitis C related care. While we used the interview guide to address key areas of interest and to stimulate discussion, we allowed participants to steer the discussion toward aspects of their experience that they felt to be most relevant and appropriate. Focus groups lasted between 96 and 145 min and were audio taped and professionally transcribed, with transcripts undergoing a quality check to ensure accuracy.Immediately following each focus group, two researchers (CP and TA) debriefed to reflect on the nature of topics discussed, the tone of the group interaction, identify notable exchanges among participants, and compare and contrast emerging insights among the different focus groups. Debriefing notes were summarized with field notes as memos and together with the transcripts, comprised the data corpus available for subsequent analysis and interpretation.We used constructionist grounded theory to analyze our data . As a fiWe obtained written informed consent from all participants. This study was approved by the Research Ethics Board of St. Michael’s Hospital (REB# 18–142).Overall, the median age of study participants was 57 years , and most  were born in Canada. Participants who did not use drugs were older  than those who did use drugs . Similarly, years since diagnosis was longer among participants who did not use drugs  relative to participants who did use drugs .We generated five concepts characterizing the experiences of individuals accessing HCV treatment: “being ‘worthy’ of the cure”, “spatially enacted stigma”, “countering social and structural vulnerability: the importance of peers”, “identity disruption and contagion: attaining a ‘social cure’” and “challenging stigma with population-based screening”.Access to hepatitis C treatment is an obvious prerequisite to becoming cured and achieving elimination of the disease. However, the accounts of participants describe vastly differing experiences in their ability to secure such access, with participants who did not use drugs describing a fairly uncomplicated pathway to curative care. Conversely, participants who did use drugs and/or were perceived by healthcare providers to have a substance use disorder described a haphazard process that reproduced the felt stigma of the ‘irresponsible drug user’ inculcated through previous encounters with the health care system.P: My family doctor told me, as soon as he said there was that diagnosis, and he said ‘There’s a cure’. To me, that was (laugh) all I wanted to hear. And of course, he referred me to the specialist. And, the rest is, is history, I guess, as it were. So, when I got the diagnosis, I was, he told me there was a cure for it. There was treatment. Um, I referred to Dr. Google, (laugh) for more information, till I came here. And so to me, there wasn’t, and there isn’t a stigma in my case, only because I don’t tell anybody. I don’t feel any urge to tell, except my wife, obviously. But, beyond that, I feel no compunction.For participants who did not use drugs, access to curative therapy was described as a logical extension of their diagnosis, with no qualifying conditions for care.P: Yeah. I know. (name), and when I first, I came here, Dr. (name) and everybody gave me their hands. That was a good sign that they didn’t afraid of my disease. Of course, they knew I got um, hep C. They had my profile. And that was a good sign, for me. I was calm, calm calmer. And I think what felt great, Dr. (name) did two or three blood tests; they confirmed that I have hep C. They did liver scan. And, they were so informative.Moreover, once in care, participants who did not use drugs described the various measures taken by clinic staff to ensure an organized treatment experience, from providing the necessary requisitions for bloodwork, assistance with drug coverage, and phone ‘check-ins’ as reassurance and reminders of upcoming appointments. Importantly, these individuals described being ‘made comfortable’ through the orderly process and interactions with the clinic staff that dispelled perceptions of stigma around a diagnosis of hepatitis C.P: But, they didn’t once, when I left the hospital, did they ever tell me where to go, for treatment.P: That’s right, yeah.P: Never, not once. Not once did they say to me, ‘Here’s where you can go, for possible treatment for your hep C.‘ Not once, in any hospital I was in.I: Right.P: Lack of education.P: They just keep telling me I have it. But I just told them I had it, cause I write it down on that form. So they’d reconfirm to me, what I already told them.P: Yeah. Back and forth, back and forth.P: But they never steered me to a place where I could actually get help. And that’s the truth.In contrast, participants who used drugs framed treatment with DAAs as an exception rather than an extension of their diagnosis. Specifically, these individuals recounted missed opportunities to be referred to or informed of curative therapy despite abundant interactions with health care providers who were aware of their diagnosis.According to participants, the lack of information from health care providers regarding curative therapies has fostered an environment where the belief that treatment for hepatitis C entails a protracted course of therapy with interferon persists, deterring people who use drugs and alcohol from actively seeking help. In the absence of referrals and information from health care providers, participants recounted the importance of peers as their gateway to learning about and accessing modern curative therapy.P: Yeah, I found out through peers, and like -.P: Word of mouth.P: I go to the injection site as well, and like, and then, we’d all be talking, we became friends with, so we just, yeah.P: Kind of like word of mouth.P: Just like, word of mouth, yeah.P: Just like how they found out from this. Like, you know what I mean, word of mouth.P: Mmm-hmm.P: So I wish there was better information out there –.P: Okay? And I was going to try and get treatment. And the doctor said, ‘Unless you quit drinking alcohol, we’re not going to waste - ' they’re not going waste their resources on me. This is when I first started out. So every time I went to see them, he said ‘Have you been drinking?‘ And I said ‘Well,’, ‘No, we can’t do you.‘ So they tried to make me quit for so long, before they would start me on the liver treatment. And I said ‘Well, that’s going to be impossible. Because I’m an alcoholic. I’ve been drinking for forty years.‘ So they wouldn’t treat me for my hepatitis because of my alcoholism. But yet, I was on a methadone program for fourteen years. So, I wanted to get rid of my hepatitis C, but because I couldn’t quit drinking, I didn’t qualify. Cause that’s the way it was, eh, (name), when I first started -P: Yeah.P: You had to prove yourself, that you were kind of worthy of –P: Worthy. Yeah.However, even after becoming aware of treatment and securing referrals to specialists, participants recounted how access to treatment was not straightforward. Instead, individuals described being subjected to various practices that reinforced felt and internalized stigma of people who use drugs as being ‘irresponsible’, ‘chaotic’ and ‘unreliable’ that had been instilled within them through prior encounters with the health care system. One way these perceptions were reproduced was through interactions with health care providers in which conditions were placed on the receipt of curative therapy. In this manner, participants recounted having to demonstrate their ‘worthiness’ for treatment by first abstaining from drugs or alcohol or providing evidence of ‘stability’ in their lives.P: ‘You got one chance at this and one chance only.‘ But she said, even before I started, ‘I’m making sure that you’re making a commitment to us. Cause, it’s going to benefit you, right?‘P: You’re wasting the -.P: you’re wasting money, and you’re fucked. Like, you -.P: Yeah.P: And you won’t get it again.The notion of proving oneself ‘worthy’ for treatment was intimately tied to the production of DAAs as costly interventions subject to rationing among those individuals who could satisfactorily ‘qualify’ for treatment. It was not uncommon for individuals to perceive being “looked down upon” while being told the costs of treatment and how, accordingly, they had “one chance” at the cure contingent on proving themselves reliable and deserving of the resources that would be expended for a course of DAAs.P: She was concerned about me and my hepatitis C. She didn’t care about, you know, what I did to self-medicate.The acts of placing conditions on curative therapy and re/producing a discourse of deservedness were deterrents to care for participants who use drugs, recounting how they “just gave up” on pursuing treatment and resigning themselves to “dying with hep C”. Participants contrasted these experiences with the care they subsequently received at clinics integrating peer-led treatment programs and harm reduction services with HCV care, where accessing treatment was not situated within narratives and practices that reproduced feelings of worthlessness among clients.P: Even walking in the building, if they see you walking around that area, that building, we know what that building’s about.I: Right.P: Yeah.P: We know what that building’s about. That’s harm reduction. That’s drug addicts. That’s people that are infected there.Participants who use drugs also recounted how seeking care in settings known to provide services for individuals who use drugs can undermine efforts at achieving disease eradication among vulnerable populations by deterring engagement with these sites. Specifically, while participants who did not use drugs accessed specialty services in an otherwise non-descript building lacking in physical markings identifying it as a space offering treatment for hepatitis C, those who did use drugs highlighted the potential for inadvertent disclosure of drug use and hepatitis C status if they are seen entering settings known for the provision of services catering to individuals living with this condition.P: And then see my friend waiting there to see their doctor, and then they’re going to see me going into the hep C nurse. (laugh)P: Yeah. (laugh)P: It says right there [on the nurse’s door].P: It’s like putting a label right on your forehead.In addition, participants who use drugs identified how stigma can be enacted within health care settings by physical layouts clearly demarcating spaces as being for those with hepatitis C.Importantly, participants described themselves as being unable to effect change when potentially problematic signage or layouts were identified to staff. These interactions are exemplars of Link and Phelan’s notion that power differentials can inadvertently produce conditions in which labelling can occur, with the end result being a propagation of stigma that affected individuals are powerless to counter .P: It’s in the waiting room, the first door, and it says ‘Hep C’.P: Has she changed it yet? (laugh)P: Yeah, I asked her to change it. She just said ‘No, it’s policy.‘P: You know, a lot of people just don’t. And make them aware, ‘Listen, you are responsible. We’re all responsible.‘ And I think that’s a little bit heavy message, but it, in the same way, it is a message, even for the people who are under the influence of, you know, that they are aware of that you are also very responsible. ‘Okay, you made a choice. You’re going to live that kind of a life. But at least be responsible so that you do not transfer the disease.‘ It could be the hep C. It could be the, ah, any other disease as well. It’s not just hep C. Right? So, yeah, I think if we all think of it that way, a little bit of responsibility starts from me and you and you and you. And somehow, if there is a way of letting the people know, over there, who are homeless: it’s their responsibility too.Central to the accounts of conditional access and establishing one’s ‘worthiness’ for treatment is a neo-liberal discourse emphasizing health as an individual responsibility and substance use as a personal choice, thereby constructing people who use drugs as lacking in self-control and without a sense of collective responsibility for interrupting the transmission of HCV –49. ThisP: Yeah. You see, here’s where that logic is flawed. I worked with the parole system for years. And I got, I had to read a lot of case files of these people. And a lot of these people who are in the prison system, they’ve been marginalized, either socioeconomically, racially, and they’re, plus there’s the fact that a lot of them are emotionally, sexually and physically abused. I think that of the people that I had to deal with, the inmates I had to deal with, I think eighty percent of them are physically, mentally or sexually abused as children –P: That’s right.P: by a caregiver. They all had demons to deal with. Nobody was there to help them. Nobody was there to help them. They end up on the street as kids, cause there’s nowhere else for them to go. And what do they do? Where do they get their warm hug? They get it from heroin.However, the emphasis on individual responsibility was also challenged by participants who did and did not use drugs who felt that such perceptions ignored the structural forces underlying substance use and which influence the health of people who use drugs, including housing instability, criminalization of drug use and past traumas –7, 47.P:P: People would go ‘Wow, I’m not just grabbing a bag and getting looked at dirty.’ I’m getting treated by someone that uses, that’s actually willing to help me.Consequently, participants who use drugs recounted the importance of integrating hepatitis C treatment with programming and support services required to mitigate their structural vulnerability to adverse health outcomes and optimize the likelihood of achieving a cure. In the absence of such services, therapy was perceived as futile given the need to attend to competing priorities, lack of a means to attend clinic appointments and limited access to safe injection supplies to prevent reinfection. Examples of supports deemed necessary by participants included on-site harm reduction services with hours of operation that align with those during which drug use occurs, financial support to offset the costs of attending clinic appointments, and assistance with food and housing insecurity. Participants stressed the fundamental necessity of involving people who use drugs and people living with HCV in the design and delivery of treatment and supportive programs to ensure that services were rooted in the tacit expertise of people with lived experience as opposed to the knowledge of “someone that’s just read it from a book”. Because of a shared sense of identity, participants explained how they would be more honest with and trusting of peers relative to other health care providers, and how receiving treatment from peers provided a counterpoint to the discrimination experienced in past encounters with the health care system.In addition to involving peers in the provision of material supports and treatment, accounts of participants who use drugs were replete with references to the importance of peer support groups in optimizing access to curative therapies and successfully completing treatment programs. Specifically, peer support groups were described in terms of “having a place to go” and “being in the same boat”, generating a sense of being at ease and acceptance that stood in contrast to past experiences of proving one’s worth for treatment. Furthermore, participants recounted how the act of providing and receiving peer support served as an antidote to the stigma and shame structured within spaces initially perceived as potentially unsafe.P: But once you’re in the group, you feel like you, we’re all together sort of.P: Yeah, exactly.I: Okay.P: Um, I don’t care that people see me go through (name) door anymore.P: No.P: Me neither.P: All right. Yeah. It’s been, ah, it’s been eye opening, educational, you know, everything. I brought a ton of people through that group now. I’ve worked with that group; I work for that group. So, yeah. It’s life changing, going through those groups.In addition to serving as sources of camaraderie and care that is perceived as non-judgemental, peer-led treatment programs and groups provided opportunities for personal transformation through employment as peer workers and individuals with expertise in the science and treatment of hepatitis C. In this way, some participants became galvanized to counter systemic deficiencies in the lack of access to curative therapies among people who use drugs.P: Right? Like, there’s a lot of good people out there fighting, like, (cites names) and all them, right? They’re pushing through it and trying to get big change in the system. Like, we’ve gone through marches downtown Toronto, down to the Ministry of Health and asked for certain criterias to be changed and stuff, but you know? And because society looks at it as, you know, ‘You have hep C. How’d you get hep C? You’re a drug user. Shame on you.‘ Now, they have safe injection sites, which are, you know, they’ll stop quite a bit of the hep C, right? Because the safe injection site now has the tools for people that transmit those – so hopefully, they get the word out.Participants who use drugs also described how involvement in peer-led activities provided the impetus for larger mobilization efforts aimed at removing disease-based qualifying criteria for DAAs imposed at the time these therapies were first made available and ensuring that the harm reduction services required to prevent reinfection and support safe drug use while undergoing HCV treatment were in place. In this manner, participants seek to challenge upstream determinants shaping access to care and treatment success among people who use drugs.The need for ancillary services and peer support was less explicitly evident in the narratives of participants who did not use drugs, who typically shared information regarding their diagnosis with close family only. However, as noted earlier, these participants described interactions with clinic staff as caring and non-stigmatizing, such that a need for additional support beyond that received by the treating physicians and nurses was not required.P: Just everything. Because, like, I felt like a human, treated like a human being.P: It’s like one-stop shopping, isn’t’ it? (laugh) You come here, and everything gets done for you.Although participants who did not use drugs did not express a need for services addressing the stigma and structural causes underlying the acquisition of hepatitis C, these participants recounted their appreciation for a streamlined treatment experience wherein all necessary paperwork and approvals were completed with the assistance of clinic staff and the availability of allied health support staff  ensured uninterrupted access to treatment and information. For these participants, delivering these efficiencies within a climate of compassion was key to ensuring treatment success.Participants who did and did not use drugs expressed a range of concerns when learning of their diagnosis with hepatitis C, such as feeling shame, being ostracized by others and losing employment. In many cases, these concerns were rooted within a discourse of HCV as being especially contagious and readily transmittable through routine daily practices , 48. ImpP: Not letting anybody use your knife, your fork, your plates, your spoons, your cups -.P: Oh yeah, yeah.P: Right? You can’t let them wear your sweaters, your clothes, your socks.P: ‘You’re sick. You’re – get away from me. Don’t smoke a cigarette of mine. Don’t touch - ‘P: ‘my fucking plate.‘ You know what I mean?P: ‘Don’t even come close to me.‘P: Yeah.P: Yeah. ‘Don’t come close to me. Don’t kiss me. Don’t hug me.‘Moreover, participants described ignorance about the transmissibility of hepatitis C among their social networks, resulting in actions that reinforced the notion of the ‘dirty’ individual who is a vector of illness and amplified feelings of shame and fears of abandonment.P: I’ve been through it. I didn’t like it, but now I’m cured. I don’t have to worry about infecting my friends’ children, or my friends, or anybody around me. I don’t have to worry that I’m a walking disease.Because of fears of ostracization and transmission to others, it was not uncommon for participants to frame the cure in terms of both viral clearance and the opportunities to ‘cure’ oneself of the problematic imputations associated with the virus. For participants who did not use drugs in particular, a successful cure was defined in terms of a return to a time when life was ‘normal’ and unencumbered by the weight of being a potential source of infection to others and the various forms of stigma associated with this condition.In contrast, such restitution appeared out of reach for participants who use drugs. For these individuals, a virologic cure does not automatically translate into a successful ‘social cure’, with claims of being cured being challenged in interactions with health care providers. Consequently, people who inject drugs resign themselves to having to continually ‘prove’ that they are cured, being perceived as being an ongoing source of infection, and living with the label of being infected with HCV.P: Yeah. I’m going to live with it forever, even though I’m cured.P: Yeah.P: I’m still going to live with it, forever and ever and ever.P: Yeah. I’m going to have it forever.P: Yeah. All of us will.P: Like, everybody that knows that I got, I had hep C, in their mind, I have it forever.P: If you go in there, and you’re middle class, and you look like you’re okay, they don’t assume that you might have something like hep C, whereby if somebody goes in there looking like a drug addict, they would assume that. And I spent many, many, many years, doing drugs, like, decades doing drugs. And not until I finally told the doctor, I, when I started using harm reduction, when I lost my home, and I went through university doing drugs; I went through working, you know, and all these years, and yet, no one knew. No one even thought, you know, that I was doing that. You know?Participants described a lack of visibility of hepatitis C in the public domain, with little information available to the general public regarding how the virus is acquired and, importantly, the availability of a cure. According to participants, this lack of public awareness allows stigma to persist and undermines efforts to eradicate hepatitis C. Moreover, participants recounted how the persistent conflation of hepatitis C with injection drug use and the manner in which such information can be managed by patients during health care encounters influences who gets tested and ultimately treated for hepatitis C.P: There may be a certain age group of people, I don’t know, that might be, I don’t know. But to me, it’s kind of interesting all of us are older.Given the limitations of a risk-based approach to screening and their own experiences of having no symptoms attributable to hepatitis C, participants described the importance of considering broader population-based screening strategies for identifying asymptomatic individuals otherwise perceived as being at minimal risk for hepatitis C. Notably, through their participation in the focus groups, participants identified older adults as being one potential group that could benefit from enhanced screening programs, an observation that is consistent with birth-cohort screening strategies endorsed as a means of identifying undiagnosed individuals , 51.P: TP: Well, because, like, (name) was saying, the stigma. You know, I’m kind of in awe today, of that. A lot of people might have it and not even know it. So just a brochure that goes out in the mail, to every, whoever, that, that comes in the mail. You know, that there is free testing, and hepatitis seems to be growing. You know? That it’s important, just a flyer that it’s important to be tested through the Ministry of Health or somebody so that everybody gets a thing that, to bring up awareness that it’s not the stigma of drug addiction and all that. You know? And I’m sure just by being here today, there’s a ton of people out there that have it that don’t even know.Participants described several avenues to facilitate population-based screening, such as testing during annual physical examinations and integrating hepatitis C screening with existing breast and colorectal cancer screening programs , 53. In In our qualitative study, we found important differences in how HCV treatment was experienced by people who do and do not use drugs. Overall, our findings illustrate how structural stigma generated and reproduced through healthcare encounters limit access to DAAs among people who inject drugs.Our findings have important implications for hepatitis C treatment delivery. Specifically, eliminating hepatitis C as a public health threat is predicated on equitable and low-threshold provision of DAA treatment to all individuals living with this condition , 54, 55.In contrast to participants who inject drugs, participants who did not inject drugs did not endorse experiencing stigma though healthcare encounters. Instead, these participants generally recounted how interactions with healthcare staff provided respite from the felt stigma and identity disruption associated with hepatitis C. Further, referral to therapy was described as a logical extension of diagnosis, with extensive supports in place to facilitate adherence, follow-up testing and financial coverage for DAAs. Although one area of overlap between people who did and did not inject drugs was the embodiment of stigma as hygienic practices that would not be expected to interrupt HCV transmission, participants who did not inject drugs experienced ‘the cure’ as both virologic and social clearance, in that they felt liberated from the identity of the ‘dirty’ individual who is a peril to others. Conversely, this benefit was not perceived as attainable by people who inject drugs, who instead describe having their claims of being cured challenged by healthcare providers. This finding is an illustration of Goffman’s concept of ‘identity engulfment’, wherein people who inject drugs remain subject to expressions of labelling and stigma because hepatitis C remains central to how they are defined by others who have the power to do so, notably healthcare providers . MoreoveOur study has some limitations. First, our sample includes only participants who were engaged in hepatitis C care, precluding us from making inferences about those with less engagement. However, we were interested in understanding the experiences of individuals who had received treatment and draw comparisons between people who did and did not inject drugs to explore the different dimensions of stigma and how these influence access to DAAs. Second, our study was conducted in a large urban centre, and may not reflect experiences of people with hepatitis C in rural and remote settings. However, our goal was to understand factors that limit DAA uptake in settings where hepatitis C treatment is otherwise not limited by the availability of specialists, treatment programs and harm reduction services. Third, we did not consider the perspectives of clinicians and policymakers. However, we elected to characterize the experiences of people with hepatitis C in the DAA era as few such studies have been conducted and the need for such research has been raised . FinallyIn conclusion, our work demonstrates how various dimensions of hepatitis C related stigma limit access to curative DAA therapy for people who inject drugs. Developing and ensuring unfettered access to novel HCV treatment delivery programs that attend to the social and structural determinants of stigma are needed to facilitate further scale up of DAAs in this population and support goals of eradicating hepatitis C as a public health threat.