Table 3 Key findings from co-production with target group representatives (service providers and people who inject drugs)

(i) Service providers

 Acceptability of intervention

All service providers were receptive to the aims of the intervention and expressed willingness to be involved in future research activities to test it with their clients as part of the study

 Professional judgements

Service providers frequently discussed with pride the importance of the relationships they had developed with their clients

Allow service providers autonomy and judgement to decide who and when the intervention is delivered to

Delivery of the intervention would require a judgement by the service provider as to whether the client would be receptive to the intervention

Clients may be aware that their injection practice differs from lower-risk practice. As such, time and appreciation of this, and an understanding that some may not wish to describe their injection practice in detail, is required by service providers

Relevance of intervention messages and changes to injecting practices / health seeking behaviour could be increased if delivered to the client at a time of crisis (e.g. presenting with wound site infection)

 Characteristics of target users

Some service providers perceived that an intervention of this type would be most relevant to clients with a shorter injecting history

Allow service providers autonomy and judgement to decide who and when the intervention is delivered to

Greater barriers to safer injecting practices among clients with less stable lifestyles, long injecting histories and complex social and health needs were noted

Openness of clients to discuss injecting practices appeared to differ geographically. Service providers who worked with clients in South Bristol commented that their job role and stigma prevented open discussions and uncertainty as to whether their clients injected or not. This appeared less of a barrier among service providers based in East and Central Bristol. However, it is possible that this is related to the role of the provider as these were not consistent between geographical areas

Develop guidance for service providers to overcome stigma around open discussion about injecting practices

 Intervention delivery and training needs

Some service providers had limited time to dedicate to intervention delivery (5–10 min). This could also be influenced by how receptive a client was during an encounter

The intervention should be deliverable in the length of time available to the service provider (5 min upwards)

All service providers could access a confidential space to deliver the intervention

Preferences for intervention training included both face-to-face and online modules

Develop training module that can be delivered face to face or online

(ii) People who inject drugs

 Structural barriers to change

Injecting outdoors presented most barriers to safer injecting practices—rushed, with more opportunities for contamination

Address structural barriers as part of the intervention

Lack of access to equipment like sterile water to prepare injections and post-injection swabs acted as barriers to safer injecting practices with some people reporting using a range of higher risk water options and either not swabbing or using pre-injection swabs after injecting

 Characteristics of target users

Challenging beliefs of people who have been using drugs long-term with entrenched behaviours is difficult—especially if no history of bacterial infections at wound sites

Encouraging clients to change one key aspect of their injecting practice is most realistic given habits which may have been formed over decades. Training should reinforce to service providers that this may be challenging for their clients

There was often scope for improving some aspect of the injecting practice. A wide range of different areas for harm reduction strategies were apparent

Given the complexity and range of injecting practices identified as part of the co-production activities, a ‘one size fits all’ approach is not appropriate. Service providers should tailor harm reduction advice specifically to areas identified as more risky following (open) discussion with the client

 Delivery of intervention and training needs

Clients may have good knowledge and report ‘best practice’ around injecting behaviours, although this may not always correspond with their history of wound site infections. Images being used as a 'talking point' can help encourage more open discussions, but these may not always be reflective of actual practice.

Service providers should be aware that social desirability bias may impact response from clients. Example questions to probe the client further could be provided as part of the training manual for service providers. Consider involving peers in delivering the intervention, where social desirability is likely to be reduced.

(iii) REACT steering group, academic and clinical experts

 Context to implementation

The main causes of bacterial infections must underpin targets for behaviour change, including: hygiene measures, vein damage, equipment reuse, sharing, not rotating sites, subcutaneous injection, use of water.

Stigma and shame are major barriers to overcome in this intervention.

Encouraging clients to change one key aspect of injecting practice is most realistic in light of habitual practice which may have developed over decades

Focus on safer injecting practices is required, incorporating reuse of equipment, use of acids, water and rotating sites.

Provide resources to promote better hygiene.

Service providers should tailor harm reduction advice specifically to areas identified as most risky following open discussion with client.

Provide guidance for service providers to overcome stigma around open discussion of injecting practices.

Universal messages about preventing infection should be include in the training manual

 Scope for supporting change

Attending to the immediate priorities of people who inject drugs, e.g. venous access and care, have the potential to (re)engage clients

Small, manageable changes are possible. Structural barriers can be addressed by supporting people to navigate existing structures differently, e.g. provide swabs as part of the intervention.

Providers outside of specialist drug treatment services need to be skilled in basic harm reduction practice. Those delivering the intervention need to be knowledgeable and non-judgemental

Frame the intervention around priorities of people who inject drugs.

Address some structural barriers, in part, through practical resources to enable safer injecting, e.g. hand sanitiser, swabs with instructions for correct use.

Training is required to support service providers to deliver the intervention

 Possible targets and strategies for intervention

Delivery to coincide with teachable moments may encourage engagement with the intervention.

Structural barriers must be addressed alongside individual-level influences on practice and risk.

Focus on one intervention (prevention or treatment) with a narrower focus.

Goal setting in this context is problematic as it has the potential for increasing existing stigma associated with drug use, implying blame and judgement on the individual, sense of failure and focuses on individual rather than structural barriers

Address structural barriers (as above.)

The focus of the intervention should be on primary prevention of bacterial infections.

Do not include goal setting, instead discuss ways to prevent bacterial skin infections, talk about past history and experiences of managing bacterial infections to see if there are any lessons to be learnt and harm reduced in the future.

 Presentation, format and framing of intervention

Use images and cards to support engagement, including a range of practices that people who inject drugs relate to and using cards flexibly to open conversations about pain, practices, self-care and seeking treatment.

Focus should be on supporting people to care for veins and avoid pain to reduce risk and enable people who inject drugs to prioritise earlier intervention, rather than including a ‘list of things you should do’ which could be stigmatising depending on the mode of delivery.

Avoid use of images of infections and focus on primary prevention rather than earlier intervention/ treatment

Develop information to be used alongside the intervention ‘cards’.

Frame intervention around vein care to focus on priorities of people who inject drugs