Subtheme 1.1: Knowledge about HCV testing |
Offering HCV testing/treatment will improve the health and quality of life of individuals (Enabler) | 8 | “I’m going to [offer HCV testing] for sure because the earlier you get treated, the fewer the complications […] The faster it happens, the better it happens, the better the chance to re-affiliate people to society, to the healthcare system, and to be able to offer a treatment team and move on.” – HC14 | Knowledge; Beliefs about consequences | |
I have the knowledge base to explain HCV tests, including the difference between Ab and RNA testing (Enabler) | 7 | “Well, one tests whether you have antibodies and the other one will test whether the virus is active in your body.” – HC21 | Knowledge | |
Offering HCV testing/treatment will contribute to elimination by increasing testing, reducing transmission (Enabler) | 6 | “If we want to stop the epidemic of hepatitis C, are there many solutions? Hepatitis C isn’t going to be stopped by your prayer beads, it’s about screening, and awareness and treatment… Leveling things out.” – HC08 | Knowledge; Beliefs about consequences | |
I don’t know much about HCV testing (e.g., difference between Ab and RNA testing) (Barrier) | 5 | “Especially in people who use drugs or are homeless, I don’t know if you are supposed to do that, the RNA test right after – I don’t understand exactly what the test entails, let’s say you need to do a second test, a second meeting.” – HC25 | Knowledge | |
Offering HCV testing/treatment will lead to economic and societal benefits (Enabler) | 4 | “Obviously for society, the more people we treat, the cheaper it gets for society. I like when my taxes are used properly, so obviously for society, I try to mention that.” – HC14 | Knowledge; Beliefs about consequences | |
I don’t know much about HCV rapid point-of-care tests (Barrier) | 2 | “I know that at one time there were rapid tests. At the end of a finger but is it efficient or not?” – HC30 | Knowledge | |
Subtheme 1.2: Essential skills for HCV testing and linkage to care |
Lack of skills to effectively integrate the offer of HCV testing in workflows (Barrier) | 8 | “It would be nice to organize training under the angle of dialogue between the nurses and the workers, as we have very close day-to-day practices, […] I think, as I said, it would facilitate that discussion and those exchanges and experience-based knowledge, which are very important.” – HC10 “I think [we need specific training on] approaches based on ethnocultural relationships, trans people, intersex people, queer people, people with disabilities.” – HC25 | Beliefs about capabilities; Skills | |
I feel comfortable in offering HCV testing (Enabler) | 6 | “I have the tools – I’m lucky, no, I worked for it, I educated myself […] it’s easy for me to de-dramatize and explain the process, I feel I have the tools to answer those questions. And yes, there is always something beyond my abilities, but I have a phone, I can call [name], I can go get the information, I’m not going to leave that person alone, so they are really going to get the information quickly and accessibly.” – HC14 | Beliefs about capabilities; Skills | |
Problem-solving skills to provide tailored support throughout all stages of the testing process (Enabler) | 5 | “We’ll look, with them, at all the places where they offer [HCV testing], the resources, depending on what their connections are already with resources or the hospital system. Do they have follow-ups in certain places? So, we’ll look at what is more suitable for them. What is more practical in their situation.” – HC28 | Skills | |
Effective pre- and post-test counseling skills are essential for engaging individuals in care and delivering HCV test results with empathy and support (Enabler) | 5 | “I think you have to be comfortable with the announcement of the results. […] Will you be able to support the person and direct them? Because you are opening a door but you need to close it properly because you can’t say it’s 5 PM and I’m done working and you are positive, bye! [...] But I think we really need to support the person, also be able to support a person in crisis, because a crisis is not just screaming and crying, you can also have a silent crisis – they are the worse by the way – so knowing the psychological state of the person. I’ve often given people results, and the people were completely disorganized, and they were just like “I’m just going to throw myself in front of a car”.” – HC15 | Skills | |
Empathy and relational skills are essential to develop a trusting relationship (Enabler) | 4 | “It’s always better to know the person on a minimum level to start [talking about HCV testing], which does involve a certain intimacy – we are close enough to their intimacy when it comes to injecting and fixed sites, so I think it’s important to have a connection [...] I would say, undeniably, the relationship with the person.” – HC10 | Skills | |
Motivational skills are essential to motivate individuals to get tested and follow through with treatment (Enabler) | 4 | “The biggest quality is accepting the person as they are and where they want to go. I have zero expectations and 100% hope. If I have no expectations toward someone then I am never disappointed and when you are never disappointed, the other isn’t in a place to have to perform, to make you happy, to do good, to get their stickers; they are who they are, with what they can be.” – HC08 | Skills | |
Communication skills are essential to de-dramatize HCV and use positive framing of HCV testing (Enabler) | 3 | “I’ve said “I think you might have caught a little something that needs to be treated quickly so that you don’t give it to somebody else, apparently it’s not a gift”, [...] We have to de-dramatize and accompany them because they are afraid [...] You have to level it out, because otherwise hepatitis C is scary, what does it do? My liver is done for! I’m going to have cirrhosis! [...] I offer it based on who has a girlfriend, who wants one, a boyfriend or whatever, a lover; can we get a tune-up before we go further?” – HC08 | Skills | |
Theme 2: Navigating professional roles and leveraging lived experience in HCV care |
Subtheme 2.1: Role clarity and task sharing |
Offering HCV testing and support individuals for testing is part of my role as a harm reduction worker (Enabler) | 9 | “It’s part of my job. In fact, as I was saying, since I’ve been here, my main objective has always been prevention and treatment of STBBIs. [...] Testing is the reason we are here, basically. The rest is a lever or a method of prevention.” – HC23 | Social/Professional role and identity | |
HCV is a priority, and my main objective is prevention and treatment of STBBIs (Enabler) | 5 | “My main objective has always been prevention and treatment of STBBIs.” – HC23 | Goals | |
There is a need for task sharing between professionals and clarity in roles (Barrier) | 5 | “We cannot make appointments for HCV testing as a [harm reduction] worker, each time we have to transfer to the nurses.” – HC10 | Social/Professional role and identity | |
HCV is one priority amongst many competing priorities (Mixed) | 5 | “I’m motivated when the person is motivated to hear about [HCV testing]. Often there’s an interest for that. But often there are other issues. There are other things that are a priority for them. They’re positive but sometimes, that’s it, it will be put off to when other things will be stabilized. When they are out of certain problems in their lives or certain periods more problematic.” – HC28 | Goals | |
Empowering and developing the skills of workers in harm reduction (Enabler) | 4 | “That’s an advantage for me, but also a question of gratification, so for me, taking up a new practice or having the ability to take part in that screening process, is something very positive I think” – HC10 | Beliefs about consequences | |
Offering HCV testing and support individuals for testing is not part of my job description (Barrier) | 3 | “I find it important to master hepatitis C but at the same time, I don’t think that it’s my role at [organization]. Besides directing people, it’s delicate as a subject because I don’t want, it’s delicate, the approach is delicate I don’t want to lecture. I don’t want…they get stoned to forget, eh? To not be in touch with…they abandon themselves. They destroy themselves. They don’t like themselves. So, to encourage them in that, it’s confronting for them. That’s my experience. It’s that, to stop playing savior. It’s to build and organize according to their needs, their requests.” – HC24 | Social/Professional role and identity | |
HCV is more of a priority for some individuals (e.g., pregnant women, mental health issues, coinfections) (Enabler) | 3 | “All people with mental health conditions, mental disability problems, that is a priority for them because the ability to make a decision is difficult […] you need accompaniment to get people to go through the process.” – HC08 | Goals | |
HCV is not my priority (Barrier) | 2 | “In theory, I’m very motivated. In practice, we are drowning in our daily tasks that unfortunately, it’s not my priority. My priority will be to maintain the service offering, its continuity and all that, you know.” – HC29 | Goals | |
Subtheme 2.2: Leveraging lived experience to intervene |
I use my lived experience of drug use, homelessness, or HCV to intervene with individuals about HCV (Enabler) | 8 | “That’s the whole point, it’s to use my experience and my life to intervene with people. I use it as a work tool, ensuring that interventions are best adapted to people’s realities. […] Just the fact I understand, intimately, the daily life of someone in that situation and being able to share experiences or having a better contact with the street and being able to communicate the information. Of course, it has a great influence – as much for, I don’t know, an appointment, someone who uses opiates by injection, if you give them an appointment in two weeks at 8 AM, they will never be there. For example. Of course, it can be to help bridge communications between them and professionals or people they are trying to communicate with.” – HC21 | Social/Professional role and identity | |
Theme 3: Resource availability and service integration in HCV care |
Subtheme 3.1: Availability of staff and healthcare providers |
There is a lack of staff and a lot of turnover (Barrier) | 9 | “There’s a big turnover of staff. It’s hard. […] I can’t either forget the budget, all the story of human resources, the difficulty of human resources. To keep, to retain staff. You know, it’s systemic. The general manager asked for grants to the government, to society focused on that theme, that social issue.” – HC24 | Environmental context and resources | |
Lack of dedicated/permanent healthcare provider onsite (Barrier) | 5 | “We should have nurses who are available at all times, on-site […] you are ready now, it needs to be now! If it’s not now, unfortunately it will not happen. Again, the notion of time is very different, reality is so different when you live in the streets or in survival mode or using or whatever.” – HC21 | Environmental context and resources | |
Nurses at the supervised injection site are available to offer HCV testing (Enabler) | 3 | “There are nurses at the Supervise Injection Site – if I know for a fact that the person uses drugs, I send them there, but if I don’t think the person uses drugs, then I’m not going to send them there, which has nothing to do with their world.” – HC25 | Environmental context and resources | |
Subtheme 3.2: Organizational processes and resources |
Easy communication with and favourable influence of decision-makers (Enabler) | 7 | “I can speak directly to the Director, he has knowledge about drugs and pharmaceuticals, and when I have questions about that, whether it’s anything, I can make an appointment with my Director and we can chat about that and I will use what he knows.” – HC14 | Environmental context and resources; Social influences | |
Lack of rapid point-of-care testing (Barrier) | 7 | “I think it’s important to offer [HCV testing] that is easy, quick and accessible because then it’s much easier: you have a positive result, okay, go, don’t panic, don’t freak out, we need a confirmation – but at least you can offer a fast answer” – HC14 | Environmental context and resources | |
Lack of service stability (Barrier) | 7 | “[The major barrier] is the lack of service stability. […] that the main problem is going to occur when things are not done immediately. We have trouble scheduling appointments.” – HC23 “There is not always a nurse who is available. There is not always a clinical nurse who has the possibility to take blood. So, for several years now, I find that the offer has deteriorated at the supervised injection site. Therefore, we are more to reference and orientation elsewhere. Because we can’t seem to provide that service, that we should provide.” – HC29 | Environmental context and resources | |
Lack of organizational processes/guidelines for HCV testing (Barrier) | 6 | “It’s something we talk about sometimes in team meetings but there is no protocol, no…it’s just case studies, by interventions that we did or situations that we experienced. But otherwise, no, there are no guidelines.” – HC28 | Environmental context and resources | |
Lack of appropriate space to ensure confidentiality of HCV testing (Barrier) | 5 | “What would facilitate things is to have somewhere confidential to conduct the tests. […] We have one of the biggest teams and we are stuck in a Harry Potter closet – there is no room.” – HC25 | Environmental context and resources | |
HCV testing often requires a Medicare card, which makes it really difficult for some people (Barrier) | 5 | “We have a nurse who comes to Cactus once a week for testing – she comes from a private clinic, but you need the Medicare card in that case, so depending on the situation…” – HC21 | Environmental context and resources | |
Theme 4: Social and emotional influences on HCV testing |
Influence of the relationship with the individual is significant (Mixed) | 7 | “I think a lot of it is about the relationship of trust you have with the person, which will make a difference. […] It depends on the relationship you have with the person and their needs. In some cases, there are kids who – I did not wait long enough to create that relationship of trust – so there was no result, it did not have a negative impact, but it just did not work because there was not that relationship of trust” – HC21 | Social influences | |
Offering HCV testing might negatively impact my relationship with clients (Barrier) | 7 | “Could [offering HCV testing] have negative impacts?” “Maybe people will find me annoying, but I don’t think it would get to the point of breaking the relationship.” – HC21 | Social influences; Beliefs about consequences | |
It is often difficult to engage with clients about HCV testing/we don’t have control over what happens to people (Barrier) | 6 | “Getting in touch with them [is difficult]. You do the first test, and then you don’t see them for six months. Today, one of them had a test, he was positive, and he went to prison for four months. We know he is in prison, but we are like…” – HC08 | Beliefs about capability; Social influences | |
Favourable peer influence and support about HCV (Enabler) | 6 | “I helped my colleague for her “Hepatitis C Day,” I made flyers, I have some knowledge which meant that I often worked as a partner, or we talked about it because the people I was close to were in it. Obviously, this influenced me, but I also know that when you work as a team, you often have one person who is a master, a specialist, we all have our strengths and weaknesses” – HC14 | Social influences | |
Emotional and psychological impacts on workers (Barrier) | 6 | “Giving a positive diagnostic information to someone about a virus which is relatively destructive, it’s not easy. It a psychological mental burden [for us] on top of that.” – HC29 | Emotion; Beliefs about consequences | |
Behavioral, psychosocial and communication challenges (Barrier) | 3 | “Sometimes there’s something with people, you are not comfortable, we have more and more aggressive people, verbally, I’ve never been hit or anything, but sometimes they yell.” – HC15 | Social influences | |
Success with HCV testing can bring us positive emotions (Enabler) | 4 | “Excited. Positive. Excited to be able to do something more, excited about helping my community, excited about learning something new. Positive because I think it’s going to be positive to be able to offer a service and at the same time empowering because I will be able to empower my community by helping them so they can be screened more comfortably.” – HC25 | Emotion | |
Theme 5: Behavioral regulation and incentives for HCV testing |
Having a network of contacts for HCV testing is helpful (Enabler) | 4 | “It’s always the personalized referral, so if I tell them to go to this hospital, they won’t go. You have to go see [this person], at this hospital, third floor, and I call her and she’s waiting for you. [...] The way we work here is we know who high risk users are, and we start talking “do you know [this worker]?”, Everybody knows [this worker]. “She is in a hepatitis C program, let me call her for you to see if she’s available, because it’s nice to get it done again”, and then she comes down as fast, and then we get started.” – HC08 | Behavioural regulation | |
Financial compensation for individuals get screened, getting their results, being linked to care (Enabler) | 4 | “Depending on where we come from, paying people to offer them a service may seem a little bit disconnected, but on a greater scale, it is much cheaper to pay people 20 bucks to get tested, rather than them not knowing and giving it to other people, and then we have to pay for the treatment for all those people.” – HC21 | Behavioural regulation | |
Bundling HCV testing with interventions addressing other needs (Enabler) | 3 | “If you tell me you are looking for a place to stay right now, I’m going to ask you if you had hepatitis C testing and I may have a potential place to offer. […]I will use hepatitis C for anything that will benefit me managing more than one thing. I would say it’s always part of a combination.” – HC14 | Behavioural regulation | |
Rewards and/or objects to promote screening (e.g., lighter, hygiene kits, backpacks, coffee, pastries) (Enabler) | 2 | “I think this was for hepatitis C, there were lighters with logos and information on them. There were calling cards with information about screening and hepatitis C – we still have some, and we still print them. Generally, that is helpful, every time, even if the person hasn’t discussed it with me at all, but “it’s possible that you might talk to a woman who will tell you about hepatitis C, please know that she will give you all the information about screening and the phone number is on the card”. That’s an alternative way of discussing it. Tools like that work well.” – HC21 | Behavioural regulation | |
Using opportunities/healthcare needs are a window of opportunity to offer screening (Enabler) | 1 | “Now I have a guy with a big abscess, so if he’s got an abscess this big, […] it means he injects in less than favourable conditions, so he is at high risk. […] That is my lever that is going to make me go, okay, you have an abscess, so it’s on his left hand so he can have myocarditis, and because you have an abscess, you may have got other things, so then we do the funnel, so I go through it, this is eliminated, we can eliminate hepatitis C, we are going to do a hepatitis C test, we are going to do a checkup, so we can check that off, so I go through it as if hepatitis C is not dangerous, as though it’s just part of STIs.” – HC08 | Behavioural regulation | |