Provider perceptions of deimplementation in OAT provision during COVID-19: considering social inequity in health

Author: Anna Conway, Alison D Marshall, Sione Crawford, Jeremy Hayllar, Jason Grebely, Carla Treloar

Theme: Social Science & Policy Research Year: 2023

Deimplementation, the removal or reduction of potentially hazardous approaches to care, is key to progressing social equity in healthcare. During the COVID-19 pandemic, opioid agonist treatment services deimplemented aspects of provision which had long been central to treatment in Australia; supervised dosing, urine drug screening, and frequent in-person attendance for review. This study examined how providers considered social inequity in the health of patients in relation to deimplementation.

Between August and December 2020, semi-structured interviews were conducted with 29 OAT providers in Australia. The social determinants of client retention in OAT were coded and clustered according to how providers considered deimplementation. Normalisation Process Theory was then used to analyse the clusters in relation to how providers understood their work during the COVID-19 pandemic as responding to systemic issues that condition OAT access.

We applied Normalisation Process Theory to explore four overarching themes: adaptive execution, cognitive participation, normative restructuring, and sustainment. Accounts of adaptive execution demonstrated tensions between providers’ conceptions of equity and patient autonomy. Cognitive participation and normative restructuring were integral to the workability of rapid and drastic changes within the OAT services. Key transformative actors included communities of practice and “thought leaders” who had long supported deimplementation for more humane care. Looking to the post-pandemic period, several providers expressed discomfort at operating with “evidence-enough” and called for narrowly defined types of data on adverse events (e.g., overdose) and expert consensus on takeaway doses.

The possibilities for achieving social equity in health are limited by the divergent treatment goals of providers and people receiving OAT. Working towards deimplementation of restrictive OAT provision requires co-created treatment goals, patient-centred monitoring and evaluation, and access to a supportive community of practice for providers.

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