Complexity of implementing harm reduction services in community hospitals A two-phase qualitative study ,2021

1 Original Article Thai Journal of Pharmaceutical Sciences 1
2 2
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5 Complexity of implementing harm 5
6 reduction services in community 6
7 hospitals: A two-phase qualitative study 7
8 8
9 9
10 10
11 11
12 11A32Q2
13  ???

14  ??? 1A4Q3
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AQ148 Corresponding Author: ABSTRACT 18
 ??? 19
19 Objective: Regardless of effective harm reduction services (HRS) in Thanyarak Hospital, 20
20 Received: June 15, 2021 difficulties exist while implementing them in community hospitals. This study aimed to 21
21 Accepted: October 13, 2021 investigate the complexities of HRS implementation in two community hospitals in Mae Hong 22
22 Published: August 26, 2022 Son. Methods: Phase 1, in-depth interviews were conducted with 21 participants to investigate 23
23 the complexity of HRS dissemination. An interview guide was developed from the seven domains 24
24 of the Non-adoption, Abandonment, Scale-up, Spread, and Sustainability framework, and 25
25 thematic analysis was used. Phase 2 involved two rounds of a Delphi technique with 17 experts to 26
26 evaluate the HRS’s complexity level (complex, complicated, simple). Results: Although patients 27
27 were highly satisfied with HRS, implementing it in community hospitals was complex. Complex 28
28 issues included: complexity in opioid addiction caused by a variety of factors; understanding 29
29 social contexts and cooperating of communities and agencies outside required health sectors; and 30
30 emerging of unintended consequences. Complicated issues included resources and specialized 31
31 knowledge required; concerns of staff’s competencies and readiness in re-arranging regular 32
32 services for HRS. Conclusion: The HRS operators should understand that they are working on 33
33 complex issues. Engaging a broader system and preparing for unexpected events will boost the 34
34 likelihood of success in the transfer of HRS to other settings. 35
35
36 36
37 Keywords: Community hospital, Complexity, Harm reduction services, NASSS framework, Technology transfer 37

38 38
39 39
40 40
F41 INTRODUCTION Pharmacists play a major role in setting up and running 41
42 or centuries, drug addiction has been a major global the HRS by managing drug systems for MMT. Overdose 42
43 and national issue. It also affects families, social monitoring and prevention by ensuring availability of naloxone 43
44 groups, and public health.[1-5] A 10% rise in injectable for methadone antidote, and supportive care in the early phase 44
45 drug use has resulted in 6471 new HIV transmissions in of methadone dose adjustment with NSAIDs, benzodiazepines, 45
46 Thailand[5-6] and sharing syringes also raise hepatitis B and C and other psychiatric medicines are included in MMT services. 46
47 risks.[7] Consequently, Thailand’s drug policy has been updated These services are organized by pharmacists to increase 47
48 to reflect current worldwide trends, viewing drug abuse as multidisciplinary teamwork in methadone patient care.[10-12] 48
49 a public health issue requiring universal harm reduction While these roles are common in pharmacies abroad,[13-16] they 49
50 treatments.[2] are only found in drug-specialized hospitals and some tertiary 50
51 care hospitals in Thailand. The lack of supportive policies and 51
52 Harm reduction services (HRSs) apply a person-centered the societal environment of stigmatizing drug addicts are to 52
53 care model for individuals using drugs. It is a flexible solution blame.[17] 53

54 for individuals who cannot quit. HRSs aim to prevent or reduce Thanyarak Mae Hong Son Hospital, a specialized hospital 54
55 the negative health effects of drug and alcohol abuse, as well in Mae Hong Son Province, has effectively implemented HRS. In 55
56 as losses to people, communities, and societies.[8-9] In Thailand, 2017, only two of Mae Hong Son’s seven community hospitals 56
57 HRSs comprise 16 services, including pharmacologic, medical, offered HRS, with Thanyarak Mae Hong Son Hospital leading 57
58 and social functions. HRSs also offer methadone maintenance the way. Despite following HRS requirements, limitations and 58
59 therapy (MMT). Because HRSs offer individualized care, delays were encountered due to a lack of resources and the 59
60 hospitals must provide a variety of resources to support such authorities’ refusal to accept such services.[18-19] Scaling up 60
61 operations.[5] new health-care technologies like HRS is typical, especially 61

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1 in complex health-care interventions. The outcomes may not hospitals in Mae Hong Son Province, Pang Mapha and Mae La 1
2 be as successful as the original model due to difficulties in Noi Hospitals, both of which adopted the policy of organizing 2
3 codification and replication.[20-24] HRS. During Phase 2, the researchers used the NASSS 3
4 framework to summarize and classify the HRS implementation 4
5 Many models have been developed to describe the conditions from Phase 1.[26] Then, 17 experts used the Delphi 5
6 complexity of health innovation, including diffusion of technique to agree on the level of complexity. The NASSS 6
7 innovation[21] and the Non-adoption, Abandonment, Scale-up, framework was used as an analytical framework in this study 7
8 Spread, and Sustainability (NASSS) framework.[25,26] The because it focuses on systems thinking and the challenges of 8
9 NASSS framework was created in 2019. This framework spreading healthcare technology throughout the complexity of 9
10 explains the relationship between personal factors, and healthcare systems. 10
11 external corporate and social contexts in expanding health 11
12 innovation, which involves a complex adaptive system Between February and June 2020, data were collected. 12
13 including nonliving components such as budgets, tools, The study was approved by the Princess Mother National 13
14 and regulations, as well as living components such as Institute on Drug Abuse Treatment Research Ethics Review 14
15 administrators, academics, planners, support staff, patients, Committee (No. 021/2020). 15
16 and the general public, so the properties of complexity 16
17 vary.[27,28] Greenhalgh et al. used the NASSS framework to Phase 1: Situation of Implementing HRS 17
18 predict and assess the effectiveness of health innovation in Community Hospitals 18
19 programs. They discovered that some health advances are 19
20 difficult to implement, and that most healthcare innovations Study design 20
21 failed to be implemented.[24] Before expanding the program, 21
22 the NASSS framework can be used to assess the complexity The study employed a qualitative study design using in-depth 22
interviews with key informants. 23
23 of health innovation. This framework can be used to plan 24
24 and improve policy implementation and learn from program Participants 25
25 failures.[24-29] 26
26 To the best of our knowledge, no studies have been The researcher purposively selected 21 key informants from 27
27 conducted to investigate the challenges and complexity stakeholders involved in establishing HRS in Pang Mapha 28
28 of implementing HRS in community hospitals, nor have and Mae La Noi Hospitals aiming to reach the saturation of 29
29 any study been conducted to apply the NASSS framework information for each study theme.[46] The key informants 30
30 to implement HRS. Most international studies related to represented four major groups: (1) Seven “innovators” 31
31 consisting of personnel and administrators from Thanyarak 32
32 HRS implementation mainly focused on providing services Mae Hong Son Hospital, Princess Mother National Institute 33
33 in pharmacies[14-16,30] and many focused only on personal on Drug Abuse Treatment, and Mae Hong Son Provincial 34
34 factors that influenced service success, such as pharmacists’ Public Health Office, (2) nine community hospital staff as 35
35 attitudes.[13,31,32] the adopters of HRS, (3) four patients in the service area of 36
two community hospitals, and (4) one civil society member 37
36 Related HRS studies in Thailand have focused on coverage working with patients with drug addiction. No one refused to 38
37 of needle and syringe exchange or calls for services,[33-37] factors participate or dropped out during the study. Table 1 shows the 39
38 related to the use of services,[38] developing behavioral change characteristics of the key informants. 40
39 interventions,[39] retaining services,[40] expanding service at the 41
40 national level,[37,41-43] and legal aspects of related services.[37,44] Study instruments 42
41 A few related studies concerning implementing HRS in Thai 43
42 hospitals solely employed program theory and performance This study used an in-depth interviewing guide based on 44
43 monitoring workshops to identify hurdles and plan for broader relevant literature reviews[21,23-26] to investigate participants’ 45
44 community hospital implementation.[18-45] opinions regarding the complexity of HRS. The primary 46
45 questions were adapted from seven domains of the NASSS 47
46 This study aimed to investigate the complexity of framework:[26] Condition/illness of opioid addiction, 48
47 implementing HRS in community hospitals in Mae Hong technology or HRS, adopter systems, value propositions, 49
48 Son Province, where Thanyarak Mae Hong Son Hospital was health-care organizations, the wider system, and embedding 50
49 only able to assist two of the seven community hospitals in and adaptation over time [Appendix 1]. The content validity 51
50 establishing such services. In this case, the HRS was viewed of the interview guide was evaluated by three experts: Two 52
51 as an innovation, which constituted a new service introduced specialized doctors who served as team leaders and adopters, 53
52 to community hospitals (the adopter) by a pharmacist in the and a complex adaptive systems specialist. Following the 54
53 project leading team from Thanyarak Mae Hong Son Hospital experts’ advice, the interview guide was justified and then 55
54 (the innovator). Results of this study will help codify and evaluated using three medical professionals to guarantee ease 56
55 implement HRS in other community hospitals, as well as of use and understandability by the responders. 57
56 improve access to drug treatment for Thai patients. 58
The interviewer (KN, PharmD, female) had worked 59
57 METHODS as a pharmacist in a hospital specializing in drugs and 60
58 substance abuse for the past 5 years, and had been involved 61
59 The study comprised two phases: During Phase 1, in-depth in establishing HRS in both Pang Mapha and Mae La Noi
60 interviews were conducted to gather information concerning Hospitals since the beginning (2017–2019). This provided a
61 the situation of implementing HRS in two community thorough comprehension of the situation and a positive rapport
with the participants. Before collecting data, the interviewer

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1 Table 1: Characteristics of Phase 1 participants (n = 21) 1
2 Characteristics 2
3 Innovators (7) Adopters Wider system (1) 3
4 Patient and Caregiver (4) 4
Staff (9)

5 Sex 5
6 Male ‑6
7 24 4 7
8 8
9 Female 55 ‑ 1
Career
9
10 Physician 12 ‑ ‑ 10

11 Pharmacist ‑2 ‑ ‑ 11
12 22 ‑ 12
13 Nurse ‑ 13

14 Public health technical officer 2‑ ‑ ‑ 14

15 Psychologist 11 ‑ ‑ 15
16 16
17 Finance officer 12 ‑ ‑ 17
18 Farmer ‑‑ 4 ‑ 18

19 NGO ‑‑ ‑ 1 19

20 Duration of service or treatment duration 20
21 21
22 <1 year 11 ‑ ‑ 22

23 1–5 years ‑1 1 1 23

24 6–10 years 24 2 ‑ 24

25 >10 years 43 1 ‑ 25
26 26
27 27
28 underwent qualitative research training and practiced with the Participants 28
29 research team members and three non-participants. 29
30 A total of 17 experts were purposefully chosen to ensure a 30
31 Data collection consistent level of average discrepancy in expert responses.[47] 31
These included addiction experts, academics working on drugs, 32
32 The researcher (KN) interviewed the key informants in person experts on the health system’s complexity, and people with 33
33 and by phone at a time and place that suited them. The expertise in drug operations in Mae Hong Son Province (three 34
34 interviews were conducted in a quiet area of the interviewee’s individuals were the same as in Phase 1). Table 2 shows the 35
35 workplace without non-participants present. Research details experts’ characteristics. 36
36 were explained to the key informants using a participant
37 information sheet. An audio recording was requested ahead Study instruments 37
38 of time and field notes were taken during the interview. No 38
39 follow-up interviews were conducted in any situation. Before A report summarizing the description and level 39
40 thanking the key informants and closing the session, the of complexity in seven domains of implementing HRS 40
41 researcher reviewed the main points of the discussion and resulted from the analysis of Phase 1 interviews. The level 41
42 requested them to confirm the information. Interviews lasted of complexity for each domain was classified as simple, 42
43 45–90 min depending on data saturation. complicated, or complex by the researcher according to the 43

44 Data analysis NASSS framework,[26] as shown in Table 3. 44
45 45
46 Data triangulation was used to examine the A round 1 Expert Assessment Form for Experts was used 46
47 trustworthiness of data acquired from multiple sources. The to rate their agreement on the level of complexity of each 47
48 information was obtained from observation, interviewing HRS implementing domains as specified in the report. The 48
49 (doctors, pharmacists, nurses, and the HRS clinical support agreements were graded on a 5-point Likert scale from most 49
50 staff team in a community hospital), and documentation study. agreeable (5) to least agreeable (1). 50

51 The audio tape was transcribed verbatim without consulting A round 2 Expert Evaluation Form for the same group of 51
52 the participants. Based on the theoretical study framework, experts was used to reconsider their agreement on the level of 52
53 content analysis was used to analyze the data. complexity based on all experts in round 1. For each domain, 53
54 the form provided median, interquartile range (IQR), and 54
55 Phase 2: Complexity of Implementing HRS frequency of responses, as well as a 5-point Likert scale to 55
56 in Community Hospitals assess agreement. 56
57 Data collection 57
58 Study design 58

59 Following the completion of Phase 1 analysis, a qualitative The complexity of implementing HRS in community hospitals 59
60 study using the Delphi method was conducted to obtain expert was assessed using the Delphi technique. The invited experts 60
61 consensus. received an invitation letter, acceptance form, participant 61

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1 Table 2: Characteristics of Phase 2 participants (n = 17) Princess Mother National Institute on Drug Abuse Treatment. 1
2 Expert The adopter group consisted of community hospital staff as 2
3 group Institute Position (n) well as patients and caregivers. Only one coordinator staff 3
from the Thai Drug User Network (TDN), an NGO in Chiang 4
4 Addiction Princess Mother National Physician (1), nurse Mai, served as a representative for the wider system. 5
5 experts Institute on Drug Abuse (1), pharmacist (1) 6
6 Treatment An analysis of the NASSS framework[25,26] revealed seven 7
7 domains of innovation implementation in community hospitals, 8
Narcotics Control Office Narcotics control each with a different level of complexity but interconnected. 9
8 Region 5 (Chiang Mai, officer (1) One domain changed another, as shown in Figure 1. “Complex 10
9 Thailand) domains” included the condition (opioid dependence), the 11
wider system, and embedding and adaptability through time. 12
10 Academics Thanyarak Mae Hong Public health “Complicated domains” included HRS, adopter systems, and 13
working Son Hospital, Thanyarak technical officer (3)a healthcare organizations. A value proposition was considered 14
11 on drugs Chiang Mai Hospital, Mae a “simple domain.” The next section describes each domain in 15
12 addiction Hong Son Provincial Public detail. 16
13 Health Office 17
14 Experts Condition, Illness 18
15 Pang Mapha Hospital Physician (1)a, nurse 19
16 in drug (1) Addiction is a more complex problem than physical symptoms 20
17 operations Mae La Noi Hospital Nurse (1), Pharmacist because the condition is tied to social and cultural issues 21
in Mae Hong (1)a 22
Son Province Being addicted to opioids causes the patient to be in a 23
18 Thanyarak Mae Hong Son Psychologist (Case condition of drug dependence and unable to live without 24
19 Hospital manager) (1) them. Opioid substitution maintenance therapy is required for 25
long-term treatment. When the patient returns to the same 26
20 former environment, it would be very easy for them to return 27
21 Thai Drug User Network Staff (1) to drug use. Moreover, many circumstances can contribute to 28
22 (TDN), Chiang Mai addiction, such as living in a rural location with limited access 29
23 to public health care forcing them to self-medicate with drugs, 30
24 experiencing economic problems producing living hardship, or 31
25 possessing a desire to experiment. 32
26 Experts on Auditors of Public Health Physician (2), nurse 33
27 the health Region 1.1 (2) Drug use has a wide range of consequences, including 34
28 system family issues, psychiatric diseases, crime, and unlawful 35
29 complexity activities. Although treating physical problems of drug 36
30 addiction may not be more difficult than treating general 37
aIncluding one person from Phase 1 patients, dealing with the sociocultural implications of drug 38
addiction necessitates a sophisticated body of knowledge and 39
31 information sheet, and research consent form. A round 1 supervision by a multidisciplinary team. 40
32 Expert Assessment Form was then emailed to participants, 41
33 requesting them to agree on the level of complexity for each “It has a very complex body of knowledge concerning drug 42
34 dependence and can be quite difficult for any general practitioner 43
35 domain and answer within 14 days. The data were summarized to focus on other matters and physical ailments. So many times, 44
36 using descriptive statistics (frequency, median, and IQR). when we encounter patients with a drug addiction, we tend to 45
37 refer them to a specialized hospital, but we will return to continue 46
38 To assess their opinions after hearing the group answers, taking care of them later.” (Adopter, Staff 209). 47
39 experts were given a round 2 Expert Evaluation Form to 48
40 respond to within 14 days. The results were evaluated again Wider System 49
41 using descriptive statistics to assess group agreement. The data 50
42 collection would continue until the group members agreed. Incompatibility of social context and Thai law concerning HRS 51
43 The experts reached an agreement during the second Delphi 52
44 round. The Thai society’s attitude toward HRS makes it difficult 53
to administer the service. Methadone patients are still seen 54
45 Data analysis as potentially dangerous drug users rather than patients 55
46 undergoing treatment. Methadone has been perceived by the 56
47 Descriptive statistics including frequency, median, and IQR community as promoting illegal assembly or a new addiction. 57
48 were used. Criteria for the experts’ consensus were determined Furthermore, HRS rules continue to be in conflict with those of 58
49 by an IQR not more than 1.5 and a median not <4.5. other agencies, particularly the Needle and Syringe Program 59
(NSP). 60
50 RESULTS 61
51 “Asked whether the policy permits this, in practice it’s quite
52 opposite. Thanyarak Mae Hong Son Hospital staff, for example,
53 Phase 1: Situation of Implementing HRS wondered whether they could really provide all 16 service
54 in Community Hospitals packages? A meeting of the Ministries of Public Health and the

55 Phase 1 interviews were conducted with 21 key informants
56 having a stake in setting up services at two community hospitals,
57 Pang Mapha and Mae La Noi Hospitals. Table 1 shows the key
58 informants’ characteristics. The innovator group consisted of a
59 team leader and support staff from Thanyarak Mae Hong Son
60 Hospital, public health technical officers from the Provincial
61 Public Health Office, and Harm Reduction Committee from the

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1 Table 3: Agreement of the second round Delphi in Phase 2 1
2 Domain and characteristic 2
3 Level of complexity Level of experts’ agreement 3
4 proposed by researcher Median (IQR) Agreement 4

5 Condition, illness Complex 5 (0) Complex 5

6 The essence of drug addiction is that the benefits of treatment vary from 6
7 patient to patient and are unpredictable. Drug addiction can be caused 7
8 by a variety of circumstances, and its cure or prevention requires the 8
9 cooperation of several authorities. 9
10 10
Wider system Complex 5 (0) Complex 11
12
11 Although evidence supports the efficacy and effectiveness of methadone 13
12 maintenance therapy in the treatment of addiction, the operation is 14
13 inconsistent with the social context and operations with other departments. 15
14 16
Embedding and adaptation over time Complex 5 (1) Complex

15 Many domains are involved in implementing HRS, many of which are
16 complex and subject to change over time. Thus, community hospitals must
plan to deal with the changes that will occur before and while implementing
17 HRS. This includes working with communities or local independent agencies 17
18 to ensure that Harm Reduction initiatives are understood consistently. 18

19 Technology Complicated 5 (1) Complicated 19

20 HRS demands a wide variety of sources; however, these resources can be 20
21 handled with proper planning and training. 21
22 Adopter system 22
23 Complicated 5 (1) Complicated 23
24 24
HRS is convenient for patients to obtain, and the services may be adjusted 25
to fit existing work. However, hospital staff still encounters operational 26
25 problems, and the operation requires collaboration with many stakeholders
26 both inside and outside the organization.

27 Healthcare organization Complicated 5 (0) Complicated 27

28 Because community hospitals lack sufficient operating resources, their 28
29 services must be tailored to the hospital’s unique circumstances, and they 29
30 must collaborate with external agencies to gain the resources they require. 30

31 Value proposition Simple 5 (0) Simple 31

32 The HRS benefits both hospital staff and patients because it promotes 32
33 community health. 33
34 IQR=Interquartile range=Q3‑Q1 34
35 35
36 free needles and syringes, prompting practitioners to ponder 36
37 1. Addiction is a more complex whether or not to provide the service. The operation and the 37
38 problem than physical symptoms legislation are incompatible.” (Innovator 104). 38
39 because the condition is tied to 39
Embedding and Adaptation Over Time 40
social and cultural issues 41
Adaptation of community hospitals to the emergence 42
40 2. Incompatibility of social
41 context and Thai law
42 concerning HRS 3. Adaptation of community
hospitals to the emergence

43 Complex HRS in community hospitals has been modified from 43
44 the Ministry of Public Health’s initial guidelines and manuals 44
45 4. HRS that is adjusted to be used in local community hospitals. As a result of staff 45
46 according allocation and shortages, a system for consulting specialized 46
47 Complicated to the local context: hospitals as well as personnel planning specifically for drug 47

48 5. Diverse perspectives about 6. Limited readiness of community addiction has been developed. 48
49 HRS of community hospital hospitals for drug operations 49
50 operators and patients with “Actually, I believe the community hospital will be able to 50
51 drug addiction handle it. It does not have to be a specialized hospital because 51
52 when we, the community hospital staff, are unsure, we can 52
53 Simple simply seek guidance from a specialized hospital. A new intern 53
54 doctor may be nervous, but when someone can offer help or when 54
55 7. The multi-dimensional value of guidelines are accessible, we will be able to treat patients with 55
56 HRS in a neighboring hospital addiction as if they were regular patients.” (Adopter, Staff 201). 56

57 Figure 1: The complexity of the implementing of harm reduction Technology 57
58 services in community hospitals based on the research findings 58
59 HRS that is adjusted according to the local context 59
60 60
61 Interior was held, and they discovered that the police, as law HRS requires drug specialists and interprofessional personnel 61
enforcement officers, directly opposed the practice of providing from several departments to care for patients, and HRS services

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1 must be integrated with other community hospital duties. It’s a complicated problem that can’t yet be quantified.” 1
2 Consequently, constraints on resources affect HRS supplies, (Innovator 101). 2
3 such as a shortage of psychologists in community hospitals, a 3
4 lack of personnel with specialized expertise in drug addiction, Phase 2: Level of Complexity of 4
5 and varying MMT criteria based on hospital context. Implementing HRS to Community 5
6 Hospitals 6
7 “The Methadone Clinic requires that trained or experienced 7
8 doctors be present before opening, but this is nearly impossible The researchers used data from Phase 1 interviews to classify 8
9 to achieve in practice. Furthermore, once the clinic was created, the complexity of implementing HRS in community hospitals 9
10 that doctor abruptly moved and was replaced by a new doctor using the NASSS framework and then employing the Delphi 10
11 without prior training in this field. We don’t have a choice; we’ll technique with 17 experts to formalize the consensus. Table 2 11
12 just have to cope with it as is.” (Innovator 101). shows the expert’s characteristics. Table 3 summarizes each 12
HRS domain from Phase 1, the researchers’ proposed degree 13
13 Adopter System of complexity, and the experts’ agreed level of complexity, 14
14 represented as median and IQR. After the second round of 15
15 Delphi, all experts agreed on the description and level of 16
16 Diverse perspectives about HRS of community hospital operators complexity for each HRS domain. The findings revealed 17
17 and patients with drug addiction varying levels of complexity in each domain, from simple, to 18
complicated, to complex. Value proposition constitutes a simple 19
18 Patients appreciated the HRS in community hospitals. They domain. Technology (HRS), adopter system, and health-care 20
19 learned to identify withdrawal and overdose symptoms and organization are all complicated domains. The illness (drug 21
20 consult with their doctor. On the other hand, community addiction), the wider system, embedding, and adaptation over 22
21 hospital staffs are worried about their abilities, personal safety, time are all part of the complex domain [Table 3 and Figure 1]. 23
22 and the possibility of methadone being supplied locally. 24
23 DISCUSSION 25
24 “Before working in therapy, I was frightened of being hurt. 26
25 However, we realized that they are just like any other person with This study examined the situation of implementing HRS in 27
26 a physical disease. So far, there have been no incidents of hurting community hospitals regarding seven domains, and ranking 28
27 authority, threatening us, or making us feel uneasy.” (Adopter, the complexity level of each domain using the NASSS 29
28 framework[26] and the principle of complexity theory.[24] Three 30
Staff 207). levels of complexity were noted: Simple, complicated, and 31
complex. The results showed that each domain exhibited a 32
29 Health-care Organization different level of complexity. Understanding the context of 33
30 complex domains helped prepare for unexpected occurrences 34
31 Limited readiness of community hospitals for drug operations that may arise during implementation. 35
32 36
33 Because establishing HRS requires significant operational The HRS value proposition domain constitutes a “simple” 37
34 resources, community hospitals service expansion remains domain because it could clearly observe the advantages it 38
35 limited. Service continuity and discontinuity also depend on obtained. HRS could help reduce the negative effects of drug 39
use. As a result, patients were satisfied with HRS and able to 40
36 provincial cooperation, hospital director leadership, and staff adjust to therapy, as shown in related research.[9,48] 41
37 turnover. 42
38 Technology, adopter system, and health-care organizations 43
39 “Having a patient in the region is the first step in setting were among the “complicated” domains because they entailed 44
40 up HRS. It requires large amounts of resources, including the many elements, the linkage was not always straightforward, 45
41 collaboration of a doctor, pharmacist, and nurse who are likely and problems developed frequently while implementing. For 46
42 to provide counseling, as well as other elements such as preparing example, HRS requires a site, tools, specialist knowledge, 47
43 and stocking drugs, a massive amount of paperwork for the HRS employees, and information systems.[2] Consequently, each 48
44 establishment process, and a thorough understanding of legal hospital had unique services based on their resources and 49
45 regulations.” (Innovator 101). employees. The main HRS treatment is MMT, but the lack of 50
holistic care may cause some patients to relapse, making it 51
46 Value Proposition difficult to overcome opioid addiction.[18,49] Furthermore, lack 52
47 of dedicated money, human resources, or specialized training 53
48 The multidimensional value of HRS in a neighboring hospital can hamper implementing HRS in community hospitals. 54
49 Even in developed high-income countries, insufficient service 55
50 The value proposition viewed by both patients and providers investment is common.[50] 56
51 is the most straightforward domain in administering HRS. 57
52 Patients, their families, and the community all immediately The program’s complexity influenced HRS acceptability by 58
53 benefit from the services. Patients can resume normal lives and community hospital staff. Support staffs were concerned about 59
54 duties to their families and communities. The hospital sees the their safety as well as their ability to provide services because 60
55 activity as a way to increase money, empower personnel, and drug users can be violent and aggressive at times.[51,52] Other 61
56 broaden patient services access, all of which benefit communal health-care providers seemed to share these sentiments.[13,32,51]
57 well-being. Regular staff training and modest support systems, such a

58 “The establishment of the HRS leads to a sense of well-
59 being in the community, because some of the patient’s conditions
60 improve, allowing them to care for themselves or their ailing
61 parents, resulting in fewer sick parents visiting the hospital.

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1 standardized document template, could help staff members accelerate scaling up and solving difficulties of adopting new 1
2 work more comfortably with drug users.[53] technology. Stabilizing the system in high-risk conditions, like 2
3 the COVID-19 pandemic, remains challenging.[59] However, 3
4 Because health care is a complex adaptive system, it would understanding how complex innovation works in complex 4
5 be necessary to be prepared for unexpected events.[28] Changes health systems is the first step toward helping providers 5
6 in operating policies and shifting clinic staff are examples of improve services. 6
7 emerging events identified in HRS. The province HRS network 7
8 should prepare for this situation by providing human resources Pharmacists play a special role in HRS. In other countries, 8
9 and maintaining professional training, as well as developing a HRS is widely available in pharmacies, and pharmacists play 9
10 system for remote consultation with specialized hospitals. a larger role in improving service quality and, most critically, 10
assuring drug safety.[10,13-16,60] In Thailand, pharmacists lead 11
11 Illness, wider system, embedding, and adaptation over a team tasked with installing and scaling up HRS. Their 12
12 time are “complex” domains. They are unpredictable, dynamic, awareness of HRS complexities might help them improve 13
13 and may interact with other subunits, causing context shifts their performance in HRS operations and other services, as 14
14 for other subunits. For example, relapse is a possibility because innovators or adopters. Embracing complexity allows for more 15
15 the illness (drug addiction) has unpredictable effects differing complete planning, implementation, and evaluation of service 16
16 from patient to patient.[54] The causes of drug use have been expansion. These constitute important input for policymakers 17
17 related to social, economic, and cultural factors; however, seeking to scale up effective service delivery systems. These 18
18 drug addiction can also contribute to these issues. Therefore, would also increase pharmacists’ public health roles.[61,62] 19
19 providing comprehensive care and addressing other issues for 20
20 drug users require cross-departmental teamwork.[2,5] This study encountered two significant limitations that 21
21 could be addressed in future research. First, only one Thai 22
22 However, as related studies have shown,[18,52,55] the Drug User Network member represented civil society. In a 23
23 operation in Mae Hong Son Province is still socially well-planned system, like that in Europe, civil society could 24
24 incompatible. Some people objected to HRS being held at a help scale up services or even help supervise them.[63] Thus, 25
25 hospital because they thought that it encouraged new drug future studies may include more civil society members, such as 26
26 use, mingling, and illegal methadone sales. Furthermore, community leaders and other agency personnel in the patient’s 27
27 providing NSPs are still illegal, making them difficult to community, to better grasp the social context complexities. 28
28 execute in hospitals. To minimize operational disagreements, Second, in Mae Hong Son Province, HRS is only accessible at 29
29 community hospitals have adapted their service models to one specialized hospital. In places like Chiang Mai Province, 30
30 avoid such services. This helped integrate HRS activities within which has implemented HRS in multiple districts, community 31
31 the social context and ensured their long-term sustainability. hospitals’ readiness, support staff, and patient acceptance 32
32 Because drug use criminalization negatively impacts treatment may vary. Studying more provinces will help grasp difficulties 33
33 outcomes, many studies have proposed legal reform or implementing services. 34
34 alternative policy frameworks based on public health and 35
35 human rights principles.[56,57] CONCLUSION 36
37
36 Addiction and treatment are complex issues. This is the Many factors made implementing HRS in community hospitals 38
37 first study to use the NASSS framework to investigate the difficult. Using the NASSS framework, this study discovered 39
38 complexity of implementing HRS in community hospitals. One complex domains included addiction and the wider system. 40
39 of the few related research studies, concerning implementing Community hospitals may have encountered new challenges 41
40 HRS and scaling up in Thai hospitals, used Program Theory to when implementing HRS, demanding long-term planning. 42
41 identify constraints.[18] Their findings were similar to ours in Complicated domains included the adopter’s system and 43
42 terms of patient value and HRS discrepancies with the social the health-care organization’s preparedness. As a result, 44
43 environment, but other dimensions such as illness nature, Thanyarak Hospital must plan and help in creating community 45
44 technology, adopter acceptance, and community hospital hospital readiness before implementing HRS. 46
45 readiness were not provided. 47
46 Further Steps Included 48
47 Compared with other concepts such as the WHO’s health 49
48 systems framework,[58] we found that the NASSS framework First, communicating the HRS operational concepts to the 50
49 could better describe the relationship between individual public sector, civil society, and government personnel through 51
50 factors, context outside the organization, and society that major entities such as the Provincial Health Office’s Working 52
Group on Harm Reduction Measures and the Thanyarak 53
51 may affect the broader implementation of complex health Hospital. The communication would enhance the operator’s 54
52 innovations. Therefore, analyzing the operations in vulnerable attitude and lead to acceptance of drug users’ identities, 55
53 groups such as drug addicts was appropriate, where the making work easier for community hospital staff while also 56
54 planning of an operation must consider the social context, allowing them to conform within the societal context. Second, 57
55 motivation, values, and professional norms of the operating appropriate authorities such as the Provincial Public Health 58
56 staff. Office and Thanyarak Hospital should provide funding, 59
57 This study used the NASSS framework, retrospectively, resources, staff, and knowledge to make the community 60
58 to explain and gather lessons learnt from the delayed HRS hospital more readily available to begin HRS. Third, 61
59 implementation. The NASSS framework could help implement Thanyarak Hospital coordinated with local stakeholders such
60 HRS teams understand the context and difficulties that may
61 arise before, during, and after service installation. It could

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1 as community leaders and municipalities to build core services to Support Successful Uptake of Innovations and Improvements 1
2 that worked well in community hospitals. This should simplify in Health Care. London: The Health Foundation; 2018. 2
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50
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38 52
39 53
40 Author Queries??? 54
41 AQ1: Kindly provide running title 55
42 AQ2: Kindly provide author name 56
43 AQ3: Kindly provide author affiliation 57
44 AQ4: Kindly provide corresponding author details and email id 58
45 59
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1 APPENDIX 1: PHASE 1 INTERVIEW QUESTIONS 1
22
3 3
4 Appendix 1: Phase 1 interview questions 4

5 Domain Innovator Adopter Adopter (patient Wider system 5
6 (staff) and career) 6

7 1. Condition/illness of opioid addiction 7
8 1A: What is the nature of opioid In your opinion, what is the nature of opioid How do you understand about addiction? Can it be 8
9 addiction or patients with addiction or patients with opioid addiction? treated? How does drug addiction differ from other 9
10 opioid addiction? illness? 10

11 1B: W hat sociocultural factors In your opinion, are any comorbidities Since using drugs, Have you ever seen a patient 11
are associated with opioid associated with opioid addiction? How can it what diseases do you using drugs and developing
12 addiction? be caused by any social or cultural factor? have? What are the another disease? What are the 12
13 possible causes, in your possible causes? 13
14 opinion? 14

15 2. Technology or the harm reduction services 15
16 16
17 2A: W hat are the key features How do you participate in working at the Please explain about Have you ever heard of the 17
18 of the technology? clinic? How difficult is the operation? the procedure at the harm reduction services? Can 18
19 clinic, how do you you tell me what that was 19
How difficult is the operation? feel about it? (easy or like? 20
difficult) What needs to
20 be improved? 21
21 22
22 2B: W hat kind of knowledge What results or indicators do you think will What advice did the ‑
does the technology bring occur after the clinic operation? How can the clinic staff give you
23 into play? patient’s change be measured? and how did you put 23
24 that knowledge into 24
25 2C: W hat knowledge and/or What knowledge or What kind of practice? 25
26 support is required to use support do you think is support do How did you prepare yourself before receiving the 26
27 the technology? required to run the clinic? you need in service? 27

28 operating the 28
29 clinic? 29

30 2D: Is the harm reduction Is the harm reduction service format suitable Have you heard of the harm reduction services or are 30
31 service format appropriate for operation in a community hospital or not? you familiar with them? Do you think a clinic should be 31
for operation in the How can it be operated sustainably? established in a nearby community hospital?
32 community hospital? 32
33 What is the likelihood that the 33
34 clinic will later close? 34
35 3. Adopters system 35
36 36
37 3A: What changes in staff roles, ‑ When providing ‑ ‑ 37
practices and identities are the harm
38 implied? reduction 38
39 service, do you 39
40 think that your 40
role, duties and
41 behaviors have 41
42 changed from 42
43 your previous 43
job? How?

44 3B: Is this technology ‑ ‑ If you go to your local hospital, how do you adjust from 44
45 achievable by, and 45
acceptable to patient/ your previous practice?
caregiver?
46 46
47 3C: D o you need help from ‑ ‑ Who or what other Have you ever provided any 47
48 a caregiver and how to agencies can you trust assistance to patients? 48
49 receive it? besides yourself? 49
50 (Relatives, friends, 50
51 neighbors, village 51
52 leaders, health 52
centers, subdistrict
53 administrators) 53

54 4. Value proposition 54
55 55
56 4A: What is the value or benefit How do you think establishing this drug harm ‑ ‑ 56
to community hospitals reduction clinic will benefit your hospital? (in
57 of establishing a harm terms of revenue/performance/overview of 57
58 reduction clinic? (value on drugs in Mae Hong Son Province) 58
59 supply side)? 59
60
60 (Contd...)

61 61

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1 Appendix 1: (Continued) 1
2 Domain 2
3 Innovator Adopter Adopter (patient Wider system 3
(staff) and career) 4
4 5
5 4B: What is the opinion of ‑ ‑ What benefits have What benefits do you think 6
patients on desirability, you received from the patients will receive from 7
6 efficacy, safety, and cost clinic? How useful do attending the clinic? 8
7 effectiveness of the harm you think the clinic is 9
reduction clinic? (value on for you? 10
8 the demand side)? 11
9 5. Healthcare organization 12
10 13
11 5A: W hat is the capacity of the How do you think your hospital is capable of managing the clinic (e.g., human resources, knowledge, 14
organization to establish budget, and other resources)? 15
12 the harm reduction 16
13 services? 17
14 5B: H ow is the readiness of the Do you think the community hospitals are ready to operate the clinic? How much? 18
15 organization to establish the 19
16 harm reduction services? 20
21
17 5C: What about budgetary ‑ How does the ‑ ‑ 22
18 readiness? How is it hospital plan to 23
planned? prepare for the 24
19 budget? 25
20 5D: W hat changes will 26
21 be required in team ‑ What changes ‑ ‑ 27
22 interactions and routines? have you made 28
to the previous 29
23 procedures 30
while running 31
24 the clinic? 32
25 5E: H ow is an assessment of the How will you evaluate the establishment of ‑ 33
26 establishment of the harm the harm reduction services? ‑ 34
27 reduction services? 35
36
28 6. Wider system 37
29 6A: What is the political, 38
30 economic, regulatory, What is your opinion on the operation of the harm reduction clinic? 39
31 professional (e.g., 40
32 medicolegal), and Does the operation of the harm reduction clinic contrast with any professional ethics or the sociocultural 41
sociocultural context for context? 42
43
33 program rollout? 44
34 7. Embedding and adaptation over time 45
35 46
36 7A: What about adapting/ ‑ How have you ‑ ‑ 47
changing health innovations developed/ 48
37 (harm reduction services), improved/ 49
38 adopters or treatment changed the 50
39 processes? service? 51
40 52
7B: H ow resilient is the How have you helped solve What problems did you encounter in the service? 53
organization in dealing problems in the operation 54
41 with critical events and of the community hospital? How did you solve them, and how do you plan to deal with them in the 55
adapting to unforeseen future? 56
42 circumstances? 57
43 58
44 59
45 60
46 61
47
48
49
50
51
52
53
54
55
56
57
58
59
60
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