Table 3 Coding framework (selected examples): from interview records to initial coding

Interviewer: So who injects you?

Steroid user: My mate does it. I got him to come here [in the service] with me. So I got him started on doing it, so we both came here and got them [service providers] to show how he should do it.

Users' injecting practices Available interventions

Conflicts in perspectives and practices (service providers recommended that users inject themselves)

Interviewer: When you go to the service, you're just asking for syringes and needles?

Steroid user: I don't think they know that much about the steroids in those sort of places. You could put a bit more information about certain things in them leaflets. I think they're limited in what they actually will tell you. It's all negative.

Users' viewpoints on harm reduction services

Negative viewpoints about conventional needle and syringe programmes

Interviewer: Where does your sense of responsibility [towards clients] come from?

Service provider: Because people associate it [steroid use] with health, because people are going to the gyms and they work out. So people think of it as being healthy, well it's not. It's like it's okay, because you are not injecting into a vein and costing us a lot of money.

Harms relating to steroid use

Perceived differences between steroid users and opioid users

Perceived need for services

Interviewer: What extra services do you provide?

Service provider: We do syringe exchange, safer injecting information, the nurse will give them hepatitis B vaccinations, complete blood count [to determine infection], liver function tests, cholesterol tests, dietary advice, blood pressure monitoring and safer drug use messages. Even smoking cessation, the nurse will look at that as well. We do, recently, chlamydia and gonorrhoea screening.

Interventions in steroid clinics

Scope of harm reduction

Interviewer: If you should sum up harm reduction, what is the definition you would give?

Service provider: What the tendency is: ‘What was the mistake I made? I must not have taken enough [amount of anabolic steroids], so next time I'll do it. I'll increase the dosage’, and they go through the same process, get more side effects. We try to educate people about the whole thing, the whole package, so that they are able to maximise the effects. If they are going to do it, then they should get the result [in physique] and maintain those results. The idea being that if they are happy with the results they get, they are less likely to then go on to higher doses or more cycles.

Dosage information

Offer information/interventions to limit usage

Development of specialised interventions

Notions of steroid clinics