Table 2 Guidance for future drug alert design (co-design findings mapped onto CFIR domains)

Outer setting (needs and resources, access to information, contextual factors)

CFIR constructs not examinable from study data, but recommended for future formative evaluations: Cosmopolitanism; Peer pressure; External policies & incentives

Results from needs-analysis and key contextual factors that will influence successful implementation of alerts

Workforce needs

Broader context for drug alerts

Alert objectives

Drug market intelligence is important for informing clinical and community practice, but many health and community workers report limited access to timely drug market information (information currently accessed through secondary sources and often unreliable or unverifiable)

Desire for receiving high-risk single-substance and drug trend alerts is strong

Limited knowledge of emerging drug market information impacts credibility with clients/patients/consumers (AOD workers) and capacity for delivering effective clinical responses (UC practitioners). Alerts provide opportunity for building trust, credibility and rapport with people who use drugs and necessary information exchange

Health and community workers have varied experience, knowledge and information needs regarding emerging drug market information (e.g. drug literacy; clinical management experience; and harm reduction knowledge)

People who use drugs and public audiences have equally diverse substance-use experience, drug literacy/knowledge, and information needs

Alert objectives should be clear and targeted:

1. Promote awareness of emerging market trends & reported harms (all audiences);

2. Improve clinical responses (health & community workers);

3. Information exchange & education (professionals, PWUD, public) to:

a. Support informed decision-making (e.g. PWUD engagement with harm reduction/preventative action)

b. Reduce incidence/impact of drug-related harm (professional & public)

NB: Alert objectives should also include building trust, credibility and engagement with harm reduction services and reducing stigma for people who use drugs

Individuals receiving and delivering the intervention (knowledge and beliefs, attributes)

CFIR constructs not examinable from study data, but recommended for future formative evaluations: self-efficacy; individual stage of change; individual identification with organization

Key characteristics of people receiving and delivering alert information (alert audiences) that will influence successful alert implementation

Alert audiences^a

Beliefs and attitudes

Knowledge and experience

Other attributes

Audiences extend beyond the health and community services professional setting to people who use drugs and public audiences (friends, families, carers, etc.)

Health and community practitioners are committed to reducing drug-related harms but responsibilities for preventing/reducing harm and perception of what this entails varies within and across sectors and roles (e.g. some UC workers prioritise clinical management of acute harm over providing harm reduction advice; some AOD workers are not harm reduction focused)

Workers view themselves as ‘conduits’ for sharing information and education within and outside professional settings (colleagues, clients/patients/service users). They may access alert systems in multiple contexts

Health and community practitioners are time-poor, often away from a desk for extended periods of time and can be hard to reach with a single platform/mode of communication

Intervention characteristics (design, source, adaptability, relative advantage)

CFIR constructs not examinable from study data, but recommended for future formative evaluations: Cost; Complexity; Trialability; Evidence strength and quality

Key features of the drug alert that will influence successful implementation

Information source (credibility)

Alert design: features, content, framing/messaging/tone, layout

Relevance to stakeholders

Adaptability

Advantage of alerts

Information should be credible (evidence-based), realistic and relatable. The alert source must be trusted and have credible authority to issue alerts to facilitate engagement with recommended actions

People who use drugs may be sceptical of healthcare providers with limited understanding of dynamic drug markets and distrusting of authorities that promote rhetoric about the ‘dangerousness of drugs’ in a prohibition world. Agendas must not appear alarmist

Shareable outside a professional setting (e.g. ‘packaged alerts’ suitable for sharing with multiple audiences and settings who are not health and community workers) to minimise need for repurposing/translating/misinterpreting alert information

Concise information but comprehensive inclusion of critical information/content (avoid withholding information or assuming hierarchy of knowledge among audiences)

Language should be accessible to all audiences (consider communities with diverse literacy, physical and cognitive abilities, education, and cultural backgrounds)

Messaging must be clear, engaging, and ‘strike the right tone’ (not sensationalised/hyperbolic, condescending, or stigmatising). Avoid unintended outcomes (e.g. stigmatising people who use drugs, sensationalising risk, promoting drug-seeking behaviour and/or unrealistic outcomes)

Design should be attention-grabbing, professional, recognisable and ‘obviously an alert’. Uniformity of branding/design and prominent severity indicators promote alert identification and action. ‘Professional’ designs lend to credibility (but public audiences of people who use drugs may favour less-formal designs). Unnecessary logos and branding should be avoided

Layout should flow logically to minimise cognitive load required when filtering through information (easy to read, clear actionable headings/ cascading information with key information at the top, information segmented for utility and relevance to multiple audiences)

Tailored for multiple audiences (workers, people who use drugs, public). Each alert must be adapted to ensure contextually and situationally relevant content, messaging, recommendations and advice

Alerts increase exposure to emerging drug market information and help to verify anecdotal reports about local drug markets and facilitate more efficient and reliable communication within and across health and community settings. Alerts are valuable tools for building trust and rapport with clients and patients; prompting conversations and sharing credible, evidence-based information to promote risk perception, encourage individual behaviour change/responsive action. More broadly, they may also help to reduce inadvertent stigma, and potentially irrelevant hyperbole about the ‘dangerousness of drugs’

Process of implementation (planning, engaging, executing, champions)

CFIR constructs not examinable from study data, but recommended for future formative evaluations: Executing; Leadership; Reflecting & evaluating

Key features of alert dissemination that will influence successful implementation

Alert format/dissemination mechanisms

Timing and frequency

Consultation

Trust in alert system

Alert champions

Alerts must be disseminated on multiple platforms and in various formats (electronic and printable materials)

Email, SMS, smart phone applications and social media are preferred tools for receiving alert notifications. Systems should consider technical limitations of each platform and consider broad communication strategies for providing alerts on platforms relevant to a range of different stakeholder groups (e.g. SMS has limited information; bulk emails with attachments can be blocked; paper & electronic formats are preferred for different scenarios)

All alert formats should include access to more detailed, contextual information when available. A closed information loop should provide access to further information at all points where someone might engage with the alert

Alerts must be timely and relevant (ideally issued within 2 weeks of an event happening), and alerts should be sent as soon as information becomes available. Processes should not delay publication and dissemination of time-critical emerging drug market information

Prominent risk severity indicators (tiered notification systems) can highlight situational urgency, facilitate prompt responses and help to minimise ‘alert fatigue’

Websites (centrally managed, dynamic online alert repositories/archives) are critical adjunct to alert systems and should segment information into categories of relevance for different audiences so individuals can opt into the type and level of information required

Trust in alert systems can be established with consistent and reliable branding, relevant and relatable messaging, evidence-based verifiable information, engagement of key stakeholders, and transparency about source of alert information

The alert system should consult with key stakeholders (e.g. health and community service professionals, peer support organisations, and community) to build trust in the alert source

Alert ‘champions’ may facilitate communication networks and more efficient information exchange

Inner setting (structural characteristics, networks and communications)

CFIR constructs not examinable from study data, but recommended for future formative evaluations: Culture; Implementation climate (e.g. leadership, available resources, readiness for implementation); Structural characteristics

Key characteristics of the service/system delivering alerts that will influence successful implementation

Alert source (single, centrally managed structure)

Communication networks

Information should be centrally managed and disseminated by a single information source to minimise the need for filtering through multiple resources/notifications

Health and community service professional networks and organisations have varied information-sharing systems and procedures for communicating drug market intelligence (e.g. workplace communication systems between AOD services and local law enforcement or emergency services are highly variable). Alerts may help to support improved information sharing across and within networks

Systems must consider processes to facilitate information flow within and across networks, organisations and community settings (beyond the alert system)

Alert systems require networks of multiple information sources to triangulate and verify alert information