Factors influencing initial implementation of an online community-based exercise intervention with adults living with HIV: a systems approach.

Introduction: Online community-based exercise (CBE) is a digital health intervention and rehabilitation strategy that promotes health among people living with HIV. Our aim was to describe the factors influencing initial implementation of a pilot online CBE intervention with adults living with HIV using a systems approach, as recommended by implementation science specialists. Methods: We piloted the implementation of a 6-month online CBE intervention and 6-month independent exercise follow up, in partnership with the YMCA in Toronto, Canada. We recruited adults living with HIV who identified themselves as safe to engage in exercise. The intervention phase included personalized exercise sessions online with a personal trainer; exercise equipment; access to online exercise classes; and a wireless physical activity monitor. Two researchers documented implementation factors articulated by participants and the implementation team during early implementation, defined as recruitment, screening, equipment distribution, technology orientation, and baseline assessments. Data sources included communication with participants; daily team communication; weekly team discussions; and in-person meetings. We documented implementation factors in meeting minutes, recruitment screening notes, and email communication; and analyzed the data using a qualitative descriptive approach using a systems engineering method called Cognitive Work Analysis. Results: Thirty-three adults living with HIV enrolled in the study (n = 33; median age: 52 years; cis-men: 22, cis-women: 10, non-binary: 1). Fifty-five factors influencing implementation, spanned five layers: (i) Natural, including weather and the COVID-19 virus; (ii) Societal, including COVID-19 impacts (e.g. public transit health risks impacting equipment pick-ups); (iii) Organizational, including information dissemination (e.g. tech support) and logistics (e.g. scheduling); (iv) Personal, including physical setting (e.g. space) and digital setting (e.g. device access); and (v) Human, including health (e.g. episodic illness) and disposition (e.g. motivation). The implementation team experienced heightened needs to respond rapidly; sustain engagement; and provide training and support. Additional organizational factors included a committed fitness training and research team with skills spanning administration and logistics, participant engagement, technology training, physical therapy, and research ethics. Conclusion: Fifty-five factors spanning multiple layers illustrate the complexities of online CBE with adults living with HIV. Initial implementation required a dedicated, rehabilitation-centred, multi-skilled, multi-stakeholder team to address a diverse set of factors.

Visualizing harm reduction: Methodological and ethical considerations.

The use of visual methods is becoming increasingly common and accepted in health research. This paper explores the opportunities and constraints of using photo-based methods in the context of a community-based participatory research study on how to engage people living with HIV in conversations about a hospital's recently introduced harm reduction policy. Using a blended approach of photovoice and photo-elicited interviews, we provided participants (n = 16) with cameras and asked them to take a series of photos that "show how you feel about or have experienced harm reduction as a Casey House client." We reflect on methodological insights from the study to think through the process of doing photo-based work on a stigmatized topic in a small hospital setting by foregrounding: 1) how the act of taking photos assisted participants in visualizing connections between space, harm reduction, and substance use; 2) expectations of participation and navigating daily health realities; and 3) issues of confidentiality, anonymity and stigma in clinical settings. These reflections provide a case study on the importance of critically examining the process of engaging with photo-based methods. We conclude the paper by re-thinking issues of context and photo-based methods. Rather than viewing context as a neutral backdrop to apply a method, context should be viewed as an active force in shaping what can or cannot be done or produced within the space. Photo-based methods may offer an effective community-engagement strategy but may require modification for use in a clinical setting when working on a stigmatized topic with individuals with complex health care needs. Given the potential of visual methods as a community engagement strategy, research teams are advised to understand the entire process as a data collection opportunity so that these methods can be further explored in a variety of contexts.

Living with addiction: the perspectives of drug using and non-using individuals about sharing space in a hospital setting.

Hospitals seem to be places where harm reduction approaches could have great benefit but few have responded to the needs of people who use drugs. Drawing on recent theoretical contributions to harm reduction from health geography, we examine how the implementation of harm reduction is shaped by space and contested understandings of place and health. We examine how drug use and harm reduction approaches pose challenges and offer opportunities in hospital-based care using interview data from people living with HIV and who were or had recently been admitted to a hospital with an innovative harm reduction policy. Our data reveal the contested spatial arrangements (and the related practices and corporeal relations) that occur due to the discordance between harm reduction and hospital regulatory policy. Rather than de-stigmatising drug use at Casey House Hospital, the adoption of the harm reduction policy sparked inter-client conflict, reproduced dominant discourses about health and drug users, and highlights the challenges of sharing space when drug use is involved. The hospital setting produces particular ways of being for people who use and those who do not use drugs and the demarcation of space in a drug using context. Moving forward, harm reduction practice and research needs to consider more than just interactions between drug users and healthcare providers, or the role of administrative policies; it needs to position ethics at the forefront of understanding the collisions between people, drug use, place, and space. We raise questions about the relationship between subjectivity and spatial arrangements in mediating the success of harm reduction.