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Table 2 Qualitative summary of stakeholder interviews (n=6) by consolidated framework for implementation research domains and constructs

From: Using formative evaluation of a community-based opioid overdose prevention program to inform strategic communication for adoption, implementation, and sustainability

CFIR Domaina,b

Intervention Characteristics

Outer Setting

Inner Setting

Characteristics of Individuals

Process

Intervention Source

[…] is familiar that it [overdoses] is happening more often than they would like it to in the community.

[…] is aware of the response team dealing with the issues at hand, police department in general or outreach after it.

Relative Advantage

Did work for a while trying to outreach with the initial recovery coaches […] but felt Winthrop had a fair amount of resources so didn’t continue to provide support.

I like what they are trying to do but […] doesn’t necessarily agree with the model. […] I don’t see how people want to open their door to cops. “[Peer recovery coach] should also be a part of the door knock process – friendly face in plain clothes of ‘I’ve been there, done that,’ opens the door to bigger conversations.”

Adaptability

Clear gap is safe locations for people to use drugs. C.L.E.A.R. Program delivers naloxone. Gap would be working closer with folks who are abstinence-minded, very hard line about recovery, maybe some antiquated views about naloxone distribution to address abuse. It [naloxone use] just needs to be normalized.

Gaps that C.L.E.A.R. can provide: Ability to share data when overdoses occur, perform post-overdose outreach, being able to respond in 24-hour timeframe…

Evidence Strength & Quality

Amount of calls decreasing. They have a number of communities that have seen a decrease in opioid overdose, decrease in Narcan and patient touches have gone down. Some communities haven’t had an impact on the issue at all because they don’t have infrastructure.

Addicts are still using but there aren’t increases yet related to COVID. One concern with data is that one individual is counted for each instance even though same individual. If that individual passes away the data goes down the next month.

Complexity

History [pre-dates the current leadership team] that Winthrop doesn’t want to collaborate with outside agencies. Some of that is why agency doesn’t collaborate and some of it is due to COVID.

External Policy & Incentives

They say this [not enough female detox places] is because there aren’t beds. The way this was modeled it’s geared towards men. There is no trauma specific programming to females... the caretaker piece, women can’t find people to watch their kids and they don’t get tailored services so they leave or don’t show up.

Patient Needs & Resources

Winthrop has a much bigger alcohol abuse problem than it does opiates. There is a rise in cannabis overdoses across entire state as well… Think beyond the idea of opiates. Need the same infrastructure, opiates or not. The system and the process will be the same for any substance and the stakeholders are all the same.

“Are we doing anything with that person to be proactive, before a kid goes out and overdoses. What are we doing proactively and how are we doing reactively?”

Peer Pressure

[Other town] is a great example – any type of overdose they flag that call and send that report to a group of stakeholders – police, fire, mental health. They then take the report, identify the case, and make arrangements to door knock and track the individual. “This has been really effective to reduce rates [of overdose].”

Cosmopolitanism

[It’s important to talk to the leadership] for C.L.E.A.R. Program to see what info they want. If they want pre-hospital EMS report so they can get the complete report, inclusive of paramedics and EMS conversations. They can get more context other than just law enforcement reports. Not broached […] as an opportunity until recently.

[The current partners] “are a tight group [Winthrop Public Schools, Public Health, and Public Safety] so the confidentiality among us is very strong……pact between us that allows sharing of information.” Knowing each other separates us from the average town or city collaboration. We all live in the community so that’s another level of understanding [and passion].

“Winthrop is an island all to itself. They are very cut-off and secluded from everything else. And I think they [may] like it that way.”

Structural Characteristics

The goal is that there would be an entire unit led by [a trained officer] from each “house” to handle cases. Other officers are already in touch to replace [the primary officer] in situations where he’s busy, more often with a Behavioral Health (BH) incident and less likely in an overdose. This is informal, but the process could be formalized. In BH there is lots of recidivism (less paperwork).

Networks and Communications

We […] need to communicate more – we used to meet [regularly] and now we don’t. “How do we communicate more efficiently and effectively? Share the lows instead of keeping it all for ourselves?”

Personality and egos can be challenging – local government is a funny thing. Different agendas and different ideas/level of knowledge. It [can] impact the level of collaboration across the board. Collaboration with the program – “it doesn’t matter where you are from it makes more sense to build capacity across the board”. Staffing [can also make it] hard to collaborate.

Culture

[Certain people have] tried to break down the stigma a bit but I don’t know if the culture has shifted. “It’s a huge undertaking…it’s the town culture, not a department of public health culture”

Implementation Climate

I would love to collaborate with [other mental health-focused agencies] but I don’t [know if it] will happen. My [peer recovery] coaches used to be over there and there was a good relationship. But over time it’s waned.

Implementation Climate

It shouldn’t be always up to our harm reduction program to meet gaps because we lack resources or partners to meet them. [Other towns] have substantial funding and resources to tie and work closely together.

Readiness for Implementation

Each community has its own strategic plan… […] wants to look at all these overarching strategic programs across all communities. Their strategic plan may look different than what Winthrop has in place. Need to sit down and identify what are collective goals?

Self-efficacy

“If I lock someone up for 18 months, then the crime rate drops for 18 months. If we’re able to turn someone’s life around, then the crime rate drops for 30 years…”

Other Personal Attributes

[What outcomes matter most to you?] Wraparound piece and education of family. If someone is using, they are extremely unhealthy and that sends a ripple effect to everyone else. “What resources are out there and how is that affecting everyone else so you can protect yourself and the person you love?”

Individual Identification with Organization

[The program should] reach out to the people they need on board. [Message should be] we want to enhance the program we have now. We are doing a re-launch and we need your support and really looking to collaborate… “level of authenticity” things seem one way but are actually another. Own what you didn’t do – “We see a lot of smoke and mirrors in public health... it’s not a failure it’s a learning opportunity”.

Knowledge & Beliefs about

the Intervention

Right now Winthrop [to my knowledge] is the only one without a naloxone program (OEND program). So when overdose occurs it’s not just about providing access to recovery but looking at stages of change and meeting them where they are – if they want to use then [the program should] help them use in safety. Help [those in need] build up readiness to get to the next level. This is a big gap that law enforcement can’t do…

As it [The C.L.E.A.R. Program] evolved and went into different staffing it was a complicated process. “It’s a very new field in itself…not a lot of standards and best practices to implement and supervise coaches effectively…”. Went through number of trial and error and how to best supervise – supervisor coach. The supervision wasn’t working out.

Planning

Pursue larger opportunities for funding. [In order to do this] need to have institutional knowledge and infrastructure to pursue larger opportunities. Winthrop is an important partner – “need to have the relationship to feel confident so we can pursue [additional funding].”

Quarterly meeting would be great. Recovery support opening near Winthrop and co-occurring in-house that also borders. […] not sure if Winthrop knows about these resources. “If we met more often and could be on the same page it could be helpful and beneficial.”

Executing

What is happening with an individual 6 months from now? [There is a need for] Tracking individuals long-term to observe recidivism, identify gaps in programming

These [Ex. recovery support] are some things they could implement on a local level but would be better to also work with Winthrop to share and pool resources, shared goals, and then streamline data.

Engaging

Shared data is so important, but level of buy-in from leadership is more important for sustainability.

In person meeting with the goal of coming together and relaunching the program and re-establishing goals

Reflecting & Evaluating

Shared information system that is secure – the right people are receiving the right information and receiving the right access that’s really important…

“Some type of platform, that we can all go in and have access to… Success stories, where are they at”

  1. a Quotes are presented as stated unless edited to remove identifying information as indicated by […] in the quote. The use of brackets is also used to insert clarifying information not part of the response and/or quote
  2. b Some quotes were removed to protect stakeholder confidentiality and instead general themes are provided