Developing a theory informed pathway for primary care-initiated hepatitis c virus treatment in Scotland

Author: David Whiteley Elizabeth Speakman Lawrie Elliott Katherine Davidson Helen Jarvis Michael Quinn Paul Flowers

Theme: Social Science and Policy Research Year: 2021

Background: Increasing hepatitis C virus (HCV) treatment uptake among people who inject drugs (PWID) demands the development of novel pathways. Successful implementation of such pathways will necessitate changes in individual and collective behaviours, and pathway development should be enhanced by evidence and theory. This qualitative study utilised the Theoretical Domains Framework (TDF) and Behaviour Change Wheel (BCW) to develop a primary care-initiated HCV treatment pathway in Scotland. Methods: We conducted semi-structured interviews with 38 stakeholders, including PWID living with HCV, GPs, HCV specialists, community pharmacists and support workers from third sector agencies. Analysis was three-stage. First, thematic analysis shaped the broad pathway structure, which was then refined by behavioural mapping of the key sequential steps. Second, data were aligned to these steps, and significant barriers and enablers identified. Third, we employed the TDF and BCW to suggest ways to enhance pathway implementation at key stages, which stakeholders then appraised and refined. Results: The recommended pathway lessened the burden on primary care prescribers (PCPs) by proposing post-treatment fibrosis assessment. It contained a minimum of three service user appointments (excluding drug collection) encompassing 18 individual behavioural steps (figure 1). Key barriers to pathway implementation included PCP capacity, confidence and belief in skills, and tenuous professional relationships between some stakeholders. Enablers included clear lines of communication, reduced social stigma and detailed protocols. Following stakeholder consultation, recommendations to enhance pathway implementation included training and educational resources for PCPs; fostering inter-professional networks; strategies for building therapeutic relationships remotely, and targeted publicity and messaging to PWID. Conclusion: The pathway and associated recommendations provide a theory-informed template for localised implementation of PCP-initiated HCV treatment. This pathway complements an eclectic assembly of community-based models of HCV care in Scotland, but is unique, and contentious, in proposing HCV treatment initiation prior to specialist assessment and formal liver fibrosis staging. Disclosure of Interest Statement: This study was funded by the Chief Scientist Office of the Scottish Government Health Directorates (HIPS/18/49). No pharmaceutical grants were received in the development of this study. Figure 1: Proposed treatment pathway (behavioral steps)

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