BACKGROUND:Alcohol-related cirrhosis is an important indication for liver transplantation (LTX) in Germany and worldwide. In Europe, the USA, and Canada patients with alcohol-related cirrhosis often have to maintain at least six months of abstinence and demonstrate treatment adherence before being listed for transplantation. Nevertheless, country-specific exception policies may allow earlier liver transplantation in selected cases. These requirements, combined with the severity of the disease, create challenges for patients, their relatives and the healthcare system. This study aimed to examine the roles and functions of family members in supporting adherence to therapy and maintaining abstinence in patients with alcohol-related cirrhosis prior to LTX listing. METHODS:A total of 35 interviews were conducted, including narrative interviews with 10 relatives, 11 patients, and 3 former patients, as well as semi-structured interviews with 11 healthcare professionals from different LTX centers across Germany. Interviews were audio-recorded, transcribed, and analyzed using qualitative content analysis. RESULTS:Relatives played a central role in supporting therapy adherence and abstinence, particularly by actively assisting with the implementation of treatment recommendations. They also assumed significant responsibility for acquiring and applying health literacy. Additionally, family members provided critical emotional support, yet their own psychosocial needs were often overlooked, leaving them without sufficient resources to cope with the associated burdens. CONCLUSIONS:Building on our findings, we propose a family-centered integrated model for patient-centered care in advanced liver disease and LTX. This model emphasizes the recognition and support of family members in clinical practice, aiming to improve both patient outcomes and the well-being of relatives involved in the care process.

INTRODUCTION:Tobacco and nicotine use in pregnancy poses risks to maternal and fetal health, from both traditional cigarettes (TCs) and e-cigarettes (ECs). This study examines the extent to which health-care professionals in pregnancy care address TC and EC use, provide counseling, and how factors such as risk perception and professional training influence these practices. METHODS:This exploratory cross-sectional online survey among gynecologists, midwives, and social workers (N = 347) evaluated differences in risk perception, assessment, and counseling on TC smoking and EC use in pregnancy. Analyses included Pearson correlations, and Wilcoxon tests corrected for multiple testing, as well as a Multivariate Analysis of Variance (MANOVA) with pairwise comparisons. RESULTS:TC use was considered significantly more risky compared to EC, with larger differences regarding maternal health (η2 = 0.196) compared to fetal health (η2 = 0.137). Nevertheless, EC use was significantly less frequently assessed (η2 = 0.368) and counseled for (η2 = 0.386) compared to TC smoking. More extensive knowledge on TC and EC was associated with higher risk perceptions, more frequent assessment, and more frequent counseling (ρ = 0.19-0.40). Assessment and counseling for TC were less frequent with higher self-rated training need on TC (ρ = -0.25 to -0.30). Social workers reported less assessment and counseling, respectively, as well as less knowledge both for TC and EC (p < .00001) compared to other professions. CONCLUSIONS:Findings reveal TC is perceived as slightly more harmful than EC but addressed notably less often. Greater knowledge was linked to higher risk perception and more frequent assessment and counseling. IMPLICATIONS:Given the central role of knowledge and training for clinically relevant outcomes, targeted training programs seem appropriate to increase assessment and counseling frequency. They may need to be tailored to specific professional groups and should enhance health-care professionals' confidence in addressing both TC and EC equally. Improved translation of clinical guidelines into practice, combined with evidence-based education can support consistent risk communication and cessation counseling, ensuring equitable care during pregnancy.

Background:Stigmatization of individuals with substance use disorders (SUDs) by healthcare professionals (HCPs) is a recognized problem, but its direct impact on patient treatment choices has not been systematically quantified. We aimed to provide first robust, quantitative metrics of non-disclosure, treatment avoidance, and treatment discontinuation for any medical treatment directly attributable to HCP stigma and to explore the lived experiences underpinning these behaviors. Methods:We conducted a prospective mixed-methods study with 119 adult inpatients with SUDs at a German university hospital (2021-2024). A self-developed questionnaire assessed stigma-related behaviors and their association with self-stigmatization. Qualitative data were analyzed using reflexive thematic analysis (RTA). A person with lived experiences contributed to writing up the manuscript. Findings:49.6% (95% CI 40.3-58.9; n = 59/119) reported non-disclosure of substance use, 36.1% (95% CI 27.5-45.5; n = 43/119) avoided necessary medical treatment, and 29.4% (95% CI 21.4-38.5; n = 35/119) discontinued treatment due to stigma. Internalized stigma significantly predicted all three outcomes (aORs 1.055-1.075, p ≤ .001). RTA identified "Institutional Stigma" (addiction as a "moral failing"), "Barriers to Care" (obstacles to respectful treatment), and "Cost of Disclosure" (negative consequences such as hostility after revealing substance use). Interpretation:Stigma from HCPs is a quantifiable contributor of treatment disengagement, representing a direct threat to patient safety and a major contributor to the SUD treatment gap. These findings underscore the urgent need for evidence-based interventions, including training HCPs across all specialties in non-stigmatizing communication, to improve healthcare engagement for this vulnerable population and narrow the substantial treatment gap. Funding:None.

Purpose Alcohol consumption during pregnancy is considered a preventable risk factor for fetal alcohol spectrum disorders (FASD). To enhance knowledge and communication skills among professionals (midwives, gynecologists, and staff working in counseling centers), an e-learning program was developed. The accompanying evaluation aimed to assess its utilization and gather user feedback on the content. Methods Questionnaires were administered before and after participation in the e-learning program. Additionally, usage data and user feedback were collected directly via the online platform. The analysis was conducted using descriptive statistics and inferential statistical methods. Results Among N=194 participants, 62.4% completed the e-learning program in full. The learning units were predominantly rated positively. However, free-text responses revealed profession-specific differences regarding practical applicability. Moreover, the 28-day completion period was often perceived as too short. Conclusion The e-learning program was generally well received and positively evaluated. Challenges arose due to the heterogeneous target group, indicating that stronger adaptation to the respective professional contexts would be beneficial. This also applies to structural conditions, such as the allotted completion period.

Background/Objectives: The legalization of recreational cannabis in Germany in 2024 has increased the relevance of cannabis use in maternal healthcare. Although prenatal cannabis exposure is associated with potential risks to fetal development, the topic remains underrepresented in midwifery research and education. Germany, midwives play a key role in prenatal care. This study investigates midwives’ self-rated knowledge, perceived risks, and the frequency of screening and counseling on cannabis use during pregnancy. Methods: This study presents a secondary analysis of cross-sectional survey data collected from midwives and physicians in Germany (N = 284) between May and October 2024. Statistical analyses included descriptive statistics, Wilcoxon signed-rank tests, chi-square tests, Spearman’s rank correlations, and multiple linear regression models. Results: Midwives rated their knowledge about cannabis-related risks during pregnancy as moderate. While most reported that substance use was addressed in initial training, only continuing education and older age were associated with higher self-rated knowledge. Knowledge was positively correlated with risk perception and communication frequency. Overall, risk perception was high—particularly regarding fetal outcomes—though cannabis was perceived as less harmful than alcohol and addressed less often. Fewer than half of the midwives routinely screened for cannabis use, and only 22% always provided counseling. Conclusions: To strengthen midwives’ preparedness, both the integration of cannabis-specific content into initial training and the expansion of continuing education may be beneficial. Clear, evidence-based, and non-stigmatizing communication strategies are essential to support maternal and fetal health in a changing legal and cultural landscape.

Alkoholkonsum in der Schwangerschaft gilt als vermeidbarer Risikofaktor für das Fetale Alkoholsyndrom. Zur Erweiterung des Wissens und der kommunikativen Kompetenzen von Fachkräften (Hebammen, Gynäkolog*innen und Personen, die in Beratungsstellen arbeiten) wurde ein E-Learning entwickelt. Ziel der begleitenden Evaluation ist es, dessen Inanspruchnahme sowie Rückmeldungen zu den Inhalten zu erfassen. Es erfolgten Fragebogenerhebungen vor und nach dem E-Learning sowie die Erhebung von Nutzungsdaten und Rückmeldungen von Nutzenden direkt über die Online-Plattform. Die Analyse erfolgte mittels deskriptiver Kennwerte und inferenzstatistischer Verfahren. Von N=194 Teilnehmenden schlossen 62,4% das E-Learning vollständig ab. Die Lerneinheiten wurden überwiegend positiv bewertet, wobei sich in den Freitextantworten berufsgruppenspezifische Unterschiede bezogen auf den Praxistransfer zeigten. Zudem wurde der Bearbeitungszeitraum von 28 Tagen häufig als zu kurz empfunden. Das E-Learning wurde insgesamt gut angenommen und bewertet. Herausforderungen zeigen sich durch die heterogene Zielgruppe, so dass eine stärkere Anpassung an die unterschiedlichen Arbeitskontexte sinnvoll wäre. Dies gilt auch für die Rahmenbedingungen wie den Bearbeitungszeitraum.

Objective The aim of this study was to record the current care and control structures in place for patients with ethyltoxic liver cirrhosis while being prepared for a liver transplant (LTX) at German transplant centers. In addition, it was also intended to analyze the associated barriers as well as the view of the practitioners on ways to improve care of this patient group.Methods In an exploratory descriptive qualitative design, 11 interviews with practitioners from 10 of the 22 German LTX centers were conducted and analyzed using qualitative content analysis.Results There were considerable differences in the care and control structures in place at the LTX centers. Addiction therapy counseling or treatment were not integrated into the treatment concept at all centers. Structural barriers arose from insufficient funding and staffing. Practitioners recommended expansion of treatment options as well as standardizing treatment concepts.Discussion The results of our study point to a need for action both in the area of the structures of the individual LTX centers and overall at the system level. Taking into account current standards of addiction medicine, our results could serve as a basis for the development of treatment concepts and recommendations for optimizing standard care before LTX.

INTRODUCTION:Injectable opioid agonist treatment (iOAT) with diacetylmorphine is an effective option for individuals previously considered non-responsive to opioid substitution treatment. Despite implementation in Canada and several European countries, relatively few eligible people choose to initiate iOAT. To better understand what encourages or deters prospective patients from initiating iOAT, the current study explores patients' perceptions on iOAT and how these influence therapy initiation in practice.METHODS:We conducted 34 semi-structured interviews with individuals currently in or eligible for iOAT in two German outpatient iOAT clinics. Transcripts were analysed following qualitative content analysis, with development of inductive categories and use of consensual coding. For member checking, we consulted individuals with lived experiences prior to data collection and publication.RESULTS:Participants based their choice to initiate iOAT on the perceived implications of the treatment on one's daily life and individual recovery. Participants were encouraged to initiate iOAT due to the therapy's perceived potential in reducing cravings and substance use, its positive health consequences, and due to the image of iOAT as a path towards abstinence. Regarding deterring perceptions, participants feared a profound impairment of daily life due to factors such as the daily visits to the clinic, were concerned about whether iOAT would sufficiently promote or even impede one's recovery, and described negative health effects.CONCLUSION:Perceptions found in this study profoundly influenced participants' decisions on iOAT enrolment and contextualize the previous literature. The study reveals the dynamic coexistence of different perceptions about iOAT and sheds light on the inner-group stigmatization of iOAT. Practitioners and future research should acknowledge the complexities found in the current study in order to exploit the full potential of effective treatment modalities such as iOAT.

BACKGROUND:Supervised injectable opioid treatment (SIOT) is a promising alternative for people living with opioid use disorder (OUD) who have not sufficiently benefitted from oral opioid substitution treatment. Yet, SIOT utilization remains limited in Germany. We propose that this is due to beliefs, or schemas, on SIOT among people living with OUD. Drawing from medical sociology and social psychology, this study explores the emergence and evolution of such schemas on SIOT. METHODS:We conducted semi-structured interviews with 34 individuals currently in or eligible for SIOT in two German outpatient treatment facilities and paralleled an inductive qualitative content analysis with the exploration of individual cases. RESULTS:The analysis revealed that peer-to-peer interaction and individuals' practical experiences in therapy are crucial in constructing and changing idiosyncratic and shared schemas of SIOT. When facing ambiguous information, cognitive strategies like subtyping served to mitigate uncertainty. CONCLUSION:This research has important practical implications for integrating experiential knowledge into clinical care and improve information sharing among people living with OUD. A nuanced understanding of the complex network of informal advice-seeking and -giving among people living with OUD is indispensable to adequately expand treatment modalities of proven effectiveness.

Zusammenfassung: Einführung: Patient_innen mit äthyltoxischer Leberzirrhose müssen 6 Monate Abstinenz nachweisen, ehe eine Listung für eine Lebertransplantation (LTX) erfolgen kann. Während die reguläre Versorgung von Patient_innen mit alkoholbezogenen Störungen heimatnah erfolgt, findet die regelmäßige Abstinenzkontrolle vor einer LTX, teilweise auch die suchtmedizinische Behandlung aktuell an 21 deutschen LTX-Zentren statt (Stand Februar 2024). Daraus können sich zusätzliche Herausforderungen an der Schnittstelle zwischen den LTX-Zentren und dem ambulanten Versorgungssystem ergeben. Diese Erhebung soll Barrieren in der Versorgung am Zentrum und in der Zusammenarbeit mit dem Suchthilfesystem erfassen. Methodik: Die Studie nutzte 11 semi-strukturierte Interviews mit Behandler_innen verschiedener LTX-Zentren als Datenquelle. Die Auswertung erfolgte mittels qualitativer Inhaltsanalyse. Ergebnisse: In den LTX-Zentren wurde die Vermittlung in ambulante Behandlung als Herausforderung identifiziert. Bezüglich des Suchthilfesystems wurden spezifische Barrieren wie fehlendes Verständnis für die somatische Komponente der Erkrankung bei Beratungsstellen und der Mangel an ambulanten Therapieplätzen und Versorgungsstrukturen für Patient_innen mit alkoholbezogenen Störungen und somatischen Erkrankungen benannt. Schlussfolgerung: Eine Vielzahl von Barrieren behindert die angemessene Weitervermittlung in passende suchtmedizinische Versorgungsangebote von Patient_innen mit einer äthyltoxischen Leberzirrhose in der Phase vor einer LTX. Diese sollten zur Verbesserung der Versorgung der genannten Zielgruppe adressiert werden.

Introduction: In Germany, patients with ethyltoxic liver cirrhosis must demonstrate 6 months of abstinence before listing for liver transplantation (LTX). While regular care for patients with alcohol-related disorders is provided close to home, regular abstinence monitoring prior to LTX, and in some cases addiction medicine treatment, takes place at one of the 21 German LTX centers (as of February 2024).This may result in additional challenges at the interface between LTX centers and the addiction care system.This exploratory qualitative survey aims to capture barriers to care at the center and in collaboration with the addiction care system. Methodology: The study used 11 semi-structured interviews with treatment providers from different LTX centers as data sources. Qualitative content analysis was used for analysis. Results: In the LTX centers, placement in outpatient treatment was identified as a particular challenge. With regard to the addiction support system, specific barriers such as a lack of understanding of the somatic component of the disease at counseling centers and, in particular, the lack of outpatient therapy places and care structures for patients with alcohol-related disorders and severe somatic diseases were named. Conclusion: Avariety of structural and professional barriers hinder the appropriate referral of patients with ethyltoxic liver cirrhosis in the phase before LTX to appropriate addiction care services. In order to overcome these barriers, appropriate specialist knowledge and barrier-free services should be created or expanded both at LTX centers and in the outpatient addiction support system.Theses barriers should be addressed to improve the care of the target group mentioned.

Background: In many countries, including Germany, it is recommended to abstain from alcohol during pregnancy to avoid harm to the baby. In this qualitative research study, analysis of online forums was conducted to explore women's perception of the German "zero alcohol during pregnancy" recommendation with regard to stigma and self-stigma. Methods: We used a grounded theory approach to analyze online forum discussions on alcohol use during pregnancy. Data consisted of 9 discussion threads from 5 different forums and blogs involving 115 participants in total. We used key concepts developed during analysis and the theory of stigma to interpret the posts. Results: We identified five key themes: (1) Low alcohol health literacy as a breeding ground for stigmatization; (2) The widespread assumption that maternal abstinence is a prerequisite for being considered a "good mother"; (3) Interpersonal role conflicts and a guilty conscience as a result of stigmatization or self-stigmatization; (4) Paying little attention to the role of psychosocial factors in alcohol consumption, especially regarding partner responsibility during pregnancy.; (5) Understanding the "zero alcohol during pregnancy" recommendation as a complete ban, associated with loss of autonomy. Conclusion: The current method of communicating the "zero alcohol during pregnancy" recommendation may have unintended consequences. Specifically, misconceptions about the harm associated with low alcohol consumption and setting high expectations of motherhood are factors that can contribute to stigma or self-stigma and potentially undermine self-efficacy, help-seeking behavior, and overcoming the barriers to alcohol health literacy.

Background Similar to many other countries, in Germany patients with alcohol-related liver disease are obliged to prove their abstinence before being accepted on a waitlist for liver transplantation. Health care professionals (HCPs) must both treat patients and ensure that patients have proven their abstinence. The aim of this exploratory study was to develop a deeper understanding of how HCPs deal with this dual role. Methods The study used semi-structured interviews as the source of data. 11 healthcare professionals from ten of the 22 German transplant centers were interviewed. After transcription, a qualitative content analysis was performed. Results We found that these HCPs faced an ethical dilemma, as they must balance the roles of being both a treatment provider (the therapist role) and an assessor (the monitoring role). To solve this dilemma, the strategy seems to be a tendency for the HCPs to take on one dominant role amongst these two roles. HCPs who prefer to take on the therapist role seem to feel burdened by the 6-month abstinence rule and the obligation to monitor their patients. HCPs who prefer to take on the monitoring role tend to have negative assumptions about the patients. HCPs also reported the impression that patients perceive HCPs as more involved in monitoring and less open to the therapeutic role. From this it can be deduced that current regulations and structures lead both to stress for HCPs and to suboptimal therapy for those affected. Conclusions The results showed that current transplantation guidelines can have a negative impact on both patient care and the burdens on the HCPs. From our point of view, there are various changes that could be made to the current clinical practice that would help solve this dilemma. For instance, integrating other assessment criteria that are more closely adapted to the health status trajectory and psychosocial background of the individual patient would be both possible and would lead to improvements in practice.

Zusammenfassung Ziel der Studie Ziel dieser Untersuchung war es, die derzeitigen Versorgungs- und Kontrollstrukturen für Patient*innen mit äthyltoxischer Leberzirrhose in der Vorbereitung auf eine Lebertransplantation (LTX) an deutschen Transplantationszentren zu erfassen. Es sollten zudem die damit einhergehenden Barrieren sowie die Sicht der Behandler*innen auf Verbesserungsmöglichkeiten für die Versorgung der Patient*innengruppe analysiert werden. Methodik In einem explorativen, deskriptiven, qualitativen Design wurden 11 Interviews mit Behandler*innen aus 10 der 22 deutschen LTX-Zentren geführt und inhaltsanalytisch ausgewertet. Ergebnisse Es zeigten sich deutliche Unterschiede in den Versorgungs- und Kontrollstrukturen der einzelnen Zentren. In das Behandlungskonzept integrierte suchttherapeutische Angebote gab es nicht an allen Zentren. Strukturelle Barrieren entstanden durch eine unzureichende Finanzierung und personelle Ausstattung. Behandler*innen wünschten sich erweiterte Behandlungsangebote sowie vereinheitlichte Behandlungskonzepte. Schlussfolgerungen Es zeigte sich Handlungsbedarf sowohl im Bereich der Strukturen der einzelnen LTX-Zentren als auch übergreifend auf Systemebene. Diese Ergebnisse könnten unter Berücksichtigung aktueller suchtmedizinischer Erkenntnisse als Grundlage zur Entwicklung von Behandlungskonzepten und -empfehlungen zur Optimierung der Versorgung vor LTX dienen.