# Barriers and facilitators of implementation of liver screening in an outreach-based care pathway for people experiencing homelessness and substance use disorders: a qualitative study of clinicians’ and stakeholders’ perspectives

## TL;DR

This study explores the challenges and enablers of using a non-invasive liver screening method in outreach services for homeless individuals with substance use disorders.

## Contribution

The study provides new insights into implementing liver screening in outreach care for homeless populations through qualitative analysis of clinician and stakeholder perspectives.

## Key findings

- Barriers included training costs, limited hepatology capacity, and funding uncertainties.
- Facilitators included VCTE's immediate feedback, targeted funding, and motivated staff.
- Strong interagency collaboration and workforce development are needed for successful implementation.

## Abstract

People experiencing homelessness face disproportionate rates of liver disease, yet are often excluded from mainstream healthcare services. Vibration-Controlled Transient Elastography (VCTE) is a non-invasive method for liver screening increasingly used in community settings. However, evidence on implementing such screening pathways in outreach services remains limited. This study explored the views of clinicians and stakeholders on the barriers and facilitators to implementing a VCTE liver screening pathway within an assertive outreach drug and alcohol service in North West England.

A qualitative design involving semi-structured interviews was used to explore the implementation of the pathway. Twenty participants, including frontline clinicians and stakeholders involved in service design, commissioning, and delivery, were interviewed. Data were analysed using Framework Analysis guided by the Consolidated Framework for Implementation Research (CFIR). Both deductive coding using CFIR domains and inductive coding were applied.

Key barriers included training costs, capacity within hepatology services, patients’ difficulties in accessing healthcare, and uncertainties around continuity of funding. Facilitators included the immediate feedback provided by VCTE supporting harm reduction advice, targeted initial funding for services supporting people experiencing homelessness, a strong team culture of person-centred care, staff motivation, and the flexibility of the outreach delivery model. Challenges around interpreting results and navigating referral processes highlighted the need for stronger cross-sector collaboration and workforce development.

Integrating liver screening into outreach-based drug and alcohol services was considered acceptable by staff and stakeholders when supported by interagency partnerships, targeted funding, and motivated staff. Future implementation efforts should prioritise keyworker training and enhanced communication between drug and alcohol and hepatology services.