Research paper
Using nominal group technique among clinical providers to identify barriers and prioritize solutions to scaling up opioid agonist therapies in Ukraine

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Abstract

Background

Opioid agonist therapies (OAT) like methadone and buprenorphine maintenance treatment remain markedly under-scaled in Ukraine despite adequate funding. Clinicians and administrators were assembled as part of an implementation science strategy to scale-up OAT using the Network for Improvement of Addiction Treatment (NIATx) approach.

Methods

Nominal Group Technique (NGT), a key ingredient of the NIATx toolkit, was directed by three trained coaches within a learning collaborative of 18 OAT clinicians and administrators to identify barriers to increase OAT capacity at the regional “oblast” level, develop solutions, and prioritize local change projects. NGT findings were supplemented from detailed notes collected during the NGT discussion.

Results

The top three identified barriers included: (1) Strict regulations and inflexible policies dictating distribution and dispensing of OAT; (2) No systematic approach to assessing OAT needs on regional or local level; and (3) Limited funding and financing mechanisms combined with a lack of local/regional control over funding for OAT treatment services.

Conclusions

NGT provides a rapid strategy for individuals at multiple levels to work collaboratively to identify and address structural barriers to OAT scale-up. This technique creates a transparent process to address and prioritize complex issues. Targeting these priorities allowed leaders at the regional and national level to advocate collectively for approaches to minimize obstacles and create policies to improve OAT services.

Section snippets

Background

Ukraine has the highest HIV prevalence in Europe, primarily concentrated in people who inject drugs (PWID) (Joint United Nations Programme on HIV/AIDS (UNAIDS), 2016). Expanding opioid agonist therapies (OAT) with methadone or buprenorphine is the most cost-effective, evidence-based strategy for reducing HIV transmission in Ukraine (Alistar, Owens, & Brandeau, 2011). Buprenorphine was introduced in Ukraine in 2004 (Bruce, Dvoryak, Sylla, & Altice, 2007), followed by methadone in 2008 (Lawrinson

Methods

The current implementation science strategy used in this study is central to the Promoting Action on Research Implementation (PARiHS) framework (Stetler, Damschroder, Helfrich, & Hagedorn, 2011), which focuses on an understanding of the available evidence (i.e., opioid agonist therapies are the most effective treatment for opioid use disorders and very effective HIV prevention strategies), context (i.e., the key ingredient addressed during this NGT activity) and facilitation (i.e., the process

Results

Table 1 presents the entire list of barriers identified by each team and the voting results by team members. Table 2 presents the thematic breakdown and total scores of the top barriers hindering OAT expansion on the regional level in Ukraine. The top barriers for each group were limited to three since the fourth highest ranking barrier had markedly fewer votes than the first three.

The top three barriers to increasing OAT capacity on the regional level identified by the regional change Teams

Discussion

During the NGT process, participants highlighted that the most salient barriers to OAT scale-up in Ukraine are structural factors, such as government policies, that are believed to limit OAT program capacity and flexibility, thereby creating barriers to entry and retention of OAT clients. Specifically, participants stressed the need for reforms at the government level, especially in the Ukrainian MoH, where changes in legislation and policies governing OAT medication procurement and

Conclusions

Scale-up efforts of OAT have been thwarted by many structural barriers on both national and local levels. The use of NGT with OAT stakeholders was an important tool to collaboratively identify and prioritize stakeholder beliefs regarding the multiple complex structural factors that affect OAT expansion in Ukraine. In the context of a learning collaborative focused on improving OAT quality, NGT identified rigid regulatory requirements, inflexible mechanisms for medication distribution, financial

Conflict of interest

None.

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    Both authors contributed equally to the manuscript as first authors.

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