The integration of harm reduction services in the Veterans Health Administration (VHA): a qualitative analysis of barriers and facilitators

Abstract

Background

Substance use is common among U.S. military veterans and veterans are at high risk for negative consequences associated with substance use, such as injection-related infections and overdose. Although harm reduction services (HRS) are highly evidence-based, implementation in traditional healthcare settings has been limited. This formative, qualitative study sought to identify barriers and facilitators to the integration of HRS and identify appropriate implementation strategies to support the optimized integration of a comprehensive bundle of HRS in the Veterans Health Administration (VHA).

Methods

Semi-structured interviews explored how harm reduction is currently understood by VHA providers and elicited input on perceived facilitators and barriers to implementation. Data were analyzed using a directed content analysis and the Practical, Robust Implementation and Sustainability Model (PRISM) implementation framework was used to organize findings. Results were then mapped to relevant implementation strategies using the Consolidated Framework for Implementation Research - Expert Recommendations for Implementing Change (CFIR – ERIC) tool.

Results

15 interviews with VHA providers were conducted across 5 sites. Respondents reported that current HRS are fragmented and dependent on the knowledge, time, and comfort level of individual providers. Stigma around substance use at the patient, provider, and institutional levels was noted to be a key barrier to HRS adoption. Based on identified barriers and facilitators, strategies that may be effective for increasing adoption of HRS include engagement of champions, communication and educational strategies, and adaptation of existing infrastructure.

Conclusions

Many of the barriers identified in this formative study may be addressed using evidence-based implementation strategies. Additional research is needed to identify implementation strategies that are effective for addressing stigma, which is perceived to be a persistent challenge to the provision of integrated harm reduction services.

Keywords:

• Harm reduction
• qualitative research
• implementation strategies
• CFIR – ERIC

Acknowledgments

The authors wish to thank the interviewees for their participation.

Authors’ contributions

LH coded, analyzed, and interpreted the data and was a major contributor in writing the manuscript. SS, KF, and JH also coded, analyzed, and interpreted the data and assisted with the manuscript. JH and WBE conceptualized the study, recruited study subjects, and assisted with the manuscript. JB and AG assisted with study conception and manuscript revision. All authors read and approved the final manuscript.

Availability of data and materials

The datasets analyzed during the current study are available from the corresponding author on request.

Ethics approval and consent to participate

Activities were determined to not to be human subjects research by the Institutional Review Board at the two lead medical centers and were approved and monitored by the sites’ Research and Development Committees. Study subjects provided full consent for participation.

Additional information

Funding

This study was funded by VA HSRD Innovations grant (INV 20-099, WBE and JH, Co-PI). WBE was supported by NHLBI 1K12HL138049-01. LH was supported by the Boston University Clinical HIV/AIDS Research Training (BU-CHART) Program (NIAID; T32 AI052074) and the Research in Addiction Medicine Scholars (RAMS) Program (NIDA; R25DA033211).