This study explores frontline support workers’ perspectives on how mothers’ needs and children’s rights are balanced in harm reduction programs in an urban centre in Alberta, Canada. Interviews were conducted with five (5) workers employed at harm reduction programs supporting mothers and/or children facing circumstances related to substance use, domestic violence, mental health, poverty, homelessness, and criminal justice system involvement. The interviews, along with content from publicly available (web-based) program descriptions, were analyzed through a theoretical framework that mobilizes theories of intersectional stigma (both on symbolic/interactional and structural levels). Participants revealed that intersectional stigma emerges from an abstinence-based child welfare system (namely, Children’s Services (CS) in Alberta), which constitutes a major barrier to ensuring the best interests of both mothers and children. Such stigma manifests based on the intersecting identities that women hold as mothers, as substance users, as partners who face violence, as criminalized persons, and more. Experiences of these barriers disproportionately impact mothers who do not meet idealized standards of mothering—standards which seem to be upheld and reproduced by the medicalization of motherhood. These families are more vulnerable to interventions including child apprehensions, which have severe impacts for both mothers and their children. The perspectives of the frontline support workers point to the importance of a harm reduction approach as an alternative to the current harm elimination one, but identified tensions between harm reduction and harm elimination remain a barrier to balancing the best interests of both mothers and children. Despite these tensions, the participants discuss their own practices of self-awareness and reflection and point to relationship building, non-judgment, and client-centering as essential to the role of the frontline worker who adopts a harm reduction approach.

Background: The use of health data from sources such as administrative and medical records to examine efficacy of health interventions is becoming increasingly common. Addressing selection bias inherent in these data is important; treatments are allocated according to clinical need and resource availability rather than delivered under experimental conditions. Propensity score (PS) methods are widely used to address selection bias due to observed confounding. This project used PS methods with observational cohort data relating to individuals who had attended an Emergency Department (ED) following self-harm (including self-poisoning and self-injury). This group is at greatly increased risks of further self-harm, suicide and all-cause mortality compared to the general population. However, it is not clear how hospital management affects risks of these adverse outcomes. Methods: A systematic review of PS methods with record-based mental health care data was used to determine the most appropriate methodological approach to estimate treatment effects following presentation to ED following self-harm. Following this review, PS stratification and PS matching methods were used with observational self-harm data to address observed baseline differences between patients receiving different types of clinical management following their hospital presentation (specialist psychosocial assessment, medical admission, referral to outpatient mental health services and psychiatric admission). Effects on repeat attendance for self-harm, suicide and all-cause mortality within 12 months were estimated. Advice on the interpretation and dissemination of results was sought from service users. Results: The systematic review resulted in 32 studies. The quality of the implementation and reporting of methods was mixed. Sensitivity analysis of the potential impacts of unobserved confounding was largely absent from the studies. Results from analysis of the self-harm cohorts showed that, broadly, prior to PS adjustment, individuals receiving each of the four categories of hospital management had higher risks of repeat attendance for self-harm, suicide and all-cause mortality than those not receiving that management. The use of PS methods resulted in attenuation of most of these increased risks. Psychosocial assessment appeared to be associated with reduced risk of repeat attendance for self-harm (risk ratio 0.87, 95% CI 0.80 to 0.95). Three advisors attended a group meeting and a further two provided responses by email. As a result of advisors' recommendations, an information sheet is being developed containing information about what patients can expect when attending hospital following self-harm and how treatment might influence future risk. Conclusions: Propensity score methods are a promising development in evaluating routine care for individuals who have self-harmed. There is now more robust evidence that specialist psychosocial assessment is beneficial in reducing risk of further attendances for self-harm. Advisors offered different perspectives to the researchers, leading to novel suggestions for dissemination.

Introduction. Recent studies have suggested a secular increase in the prevalence of self-harm, suicidal ideation and depression in young people. This study aims to report the changes in prevalence of psychological disturbance over time in a clinic population. Method: Data on the prevalence of psychological symptoms was measured by the Youth Self-Report (YSR) and Child Behaviour Checklist (CBCL), in a 21-year clinic cohort of adolescents aged from 12 to 17. This data was analysed to investigate secular changes and predictors of disorder. Results: Significant secular increases were demonstrated in parent reports of self-harm and suicidal ideation, of 5percent and 4percent per cohort year respectively, but there was no significant change in the anxious/depressed sub-scale. There were no changes demonstrated in self-reports of self-harm, suicidal ideation or anxiety/depression. Self-harm and suicidal ideation, both parent reported and self-reported, significantly increased with increasing age, female gender, drug use, anxiety/depression and other clinically significant scores on the YSR and CBCL sub-scales. The YSR was a more accurate predictor of both self-harm and suicidal ideation than the CBCL. Conclusions: The results of this study suggest that there has not been a significant increase in psychological disorder in this population. There was, however, an apparent increase due to increasing parental awareness of some symptoms, particularly self-harm and suicidal ideation. While parents have a higher rate of reporting disorder, young people's self-reports remain a more accurate predictor of specific symptoms, including self-harm and suicidal ideation.

Nurses who work with people who use drugs in the Downtown Eastside of Vancouver (DTES), British Columbia are on the forefront in advancing a harm reduction framework in very controversial, cutting-edge practice environments. The purpose of this study was to explore how these nurses, using the framework of harm reduction, make sense of their nursing practice. It is hoped that the results of this study may advance adopting a harm reduction framework in nursing practice, education and policy development and serve as the foundation for further nursing research. This study utilized a qualitative interpretive descriptive methodology to gather data from eight nurses who work with people who use drugs in harm reduction practice environments. The nurses were divided into two focus groups and data was collected through a semi-structured focus group interview. Following initial data analysis, each focus group was reconvened and a second semi-structured group interview was held to clarify and to further discuss the emerging themes. The data analysis proceeded simultaneously with the interviews utilizing a process of constant comparative analysis. I completed the thematic analysis as I moved between the transcripts and identified commonalties and variations within the emerging themes. Ultimately, I described one overarching theme, which encapsulated the range of experiences described by the nurses. The theme that I identified was: meeting people where they are at. The importance to the nurses of both the therapeutic nurse-client relationship and a commitment to praxis were apparent. In conclusion, the value the nurses placed on "meeting people where they are at" was integral in gaining an understanding of how they make sense of their nursing work.

Despite thirty published evaluation reports citing the effectiveness of Vancouver’s safe injection site (Small 2008), the Canadian federal government refuses to endorse safe injection sites as a health service option available to injection drug users (IDUs). Insite’ s evaluation results are undergoing debate, because two communicative spheres of knowledge, each with a unique authoritative language, are conflicting as each is attempting to gain moral authority over the right to recontextualize drug users. Drawing on a literature review of two harm reduction programs in Vancouver, Insite and Sheway, and expert interviews with evaluators, I show that what constitutes “evidence” is in fact subjective, determined by spheres of communicability that are built upon social, professional and political contexts. To confront the problematic nature of this issue, I suggest that evaluators and overseers need to treat program evaluation as a process of negotiation, best approached in a fluid manner. By obscuring multiple user experiences in the evaluation of harm reduction programs, evaluators and overseers risk imposing their communicative ideologies on what it means to be a drug user.

Nurses who work with people who use drugs in the Downtown Eastside of Vancouver (DTES), British Columbia are on the forefront in advancing a harm reduction framework in very controversial, cutting-edge practice environments. The purpose of this study was to explore how these nurses, using the framework of harm reduction, make sense of their nursing practice. It is hoped that the results of this study may advance adopting a harm reduction framework in nursing practice, education and policy development and serve as the foundation for further nursing research. This study utilized a qualitative interpretive descriptive methodology to gather data from eight nurses who work with people who use drugs in harm reduction practice environments. The nurses were divided into two focus groups and data was collected through a semi-structured focus group interview. Following initial data analysis, each focus group was reconvened and a second semi-structured group interview was held to clarify and to further discuss the emerging themes. The data analysis proceeded simultaneously with the interviews utilizing a process of constant comparative analysis. I completed the thematic analysis as I moved between the transcripts and identified commonalties and variations within the emerging themes. Ultimately, I described one overarching theme, which encapsulated the range of experiences described by the nurses. The theme that I identified was: meeting people where they are at. The importance to the nurses of both the therapeutic nurse-client relationship and a commitment to praxis were apparent. In conclusion, the value the nurses placed on "meeting people where they are at" was integral in gaining an understanding of how they make sense of their nursing work.

Despite thirty published evaluation reports citing the effectiveness of Vancouver’s safe injection site (Small 2008), the Canadian federal government refuses to endorse safe injection sites as a health service option available to injection drug users (IDUs). Insite’ s evaluation results are undergoing debate, because two communicative spheres of knowledge, each with a unique authoritative language, are conflicting as each is attempting to gain moral authority over the right to recontextualize drug users. Drawing on a literature review of two harm reduction programs in Vancouver, Insite and Sheway, and expert interviews with evaluators, I show that what constitutes “evidence” is in fact subjective, determined by spheres of communicability that are built upon social, professional and political contexts. To confront the problematic nature of this issue, I suggest that evaluators and overseers need to treat program evaluation as a process of negotiation, best approached in a fluid manner. By obscuring multiple user experiences in the evaluation of harm reduction programs, evaluators and overseers risk imposing their communicative ideologies on what it means to be a drug user.

Introduction. Recent studies have suggested a secular increase in the prevalence of self-harm, suicidal ideation and depression in young people. This study aims to report the changes in prevalence of psychological disturbance over time in a clinic population. Method: Data on the prevalence of psychological symptoms was measured by the Youth Self-Report (YSR) and Child Behaviour Checklist (CBCL), in a 21-year clinic cohort of adolescents aged from 12 to 17. This data was analysed to investigate secular changes and predictors of disorder. Results: Significant secular increases were demonstrated in parent reports of self-harm and suicidal ideation, of 5percent and 4percent per cohort year respectively, but there was no significant change in the anxious/depressed sub-scale. There were no changes demonstrated in self-reports of self-harm, suicidal ideation or anxiety/depression. Self-harm and suicidal ideation, both parent reported and self-reported, significantly increased with increasing age, female gender, drug use, anxiety/depression and other clinically significant scores on the YSR and CBCL sub-scales. The YSR was a more accurate predictor of both self-harm and suicidal ideation than the CBCL. Conclusions: The results of this study suggest that there has not been a significant increase in psychological disorder in this population. There was, however, an apparent increase due to increasing parental awareness of some symptoms, particularly self-harm and suicidal ideation. While parents have a higher rate of reporting disorder, young people's self-reports remain a more accurate predictor of specific symptoms, including self-harm and suicidal ideation.

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