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Implementation Science at UW

Keywords: Acceptability

✪ Human-Centered Design of an mHealth Tool for Optimizing HIV Index Testing in Wartime Ukraine: Formative Research Case Study

Authors:

Nancy Puttkammer, Elizabeth Dunbar, Myroslava Germanovych, Mariia Rosol, Matthew Golden, Anna Hubashova, Vladyslav Fedorchenko, Larisa Hetman, Liudmyla Legkostup, Jan Flowers, and Olena Nesterova

University of Washington affiliated authors are displayed in bold.

✪ Open Access

Published: January 2025

Read the full text in the open access journal JMIR Formative Research

Abstract:

Background

Assisted partner services (APSs; sometimes called index testing) are now being brought to scale as a high-yield HIV testing strategy in many nations. However, the success of APSs is often hampered by low levels of partner elicitation. The Computer-Assisted Self-Interview (CASI)–Plus study sought to develop and test a mobile health (mHealth) tool to increase the elicitation of sexual and needle-sharing partners among persons with newly diagnosed HIV. CASI-Plus provides client-facing information on APS methods and uses a standardized, self-guided questionnaire with nonjudgmental language for clients to list partners who would benefit from HIV testing. The tool also enables health care workers (HCWs) to see summarized data to facilitate partner tracking.

Objective

The formative research phase of the CASI-Plus study aimed to gather client and HCW input on the design of the CASI-Plus tool to ensure its acceptability, feasibility, and usability.

Methods

This study gathered input to prioritize features and tested the usability of CASI-Plus with HCWs and clients receiving HIV services in public health clinics in wartime Ukraine. The CASI-Plus study’s formative phase, carried out from May 2023 to July 2024, adapted human-centered design (HCD) methods grounded in principles of empathy, iteration, and creative ideation. The study involved 3 steps: formative HCD, including in-depth individual interviews with clients, such as men who have sex with men and people who inject drugs, and internet-based design workshops with HCWs from rural and urban HIV clinics in Chernihiv and Dnipro; software platform assessment and heuristic evaluation, including assessment of open-source mHealth platforms against CASI-Plus requirements, prototype development, and testing of the REDCap (Research Electronic Data Capture) prototype based on usability heuristics; and usability walk-throughs, including simulated cases with HCWs and clients.

Results:

The formative phase of the CASI-Plus study included in-depth individual interviews with 10 clients and 3 workshops with 22 HCWs. This study demonstrated how simplified HCD methods, adapted to the wartime context, gathered rich input on prioritized features and tool design. The CASI-Plus design reflected features that are both culturally sensitive and in alignment with the constraints of Ukraine’s wartime setting. Prioritized features included information about the benefits of HIV index testing; a nonjudgmental, self-guided questionnaire to report partners; client stories; and bright images to accompany the text. Two-way SMS text messaging between clients and HCWs was deemed impractical based on risks of privacy breaches, national patient privacy regulations, and HCW workload./p>

Conclusions

It was feasible to conduct HCD research in Ukraine in a wartime setting. The CASI-Plus mHealth tool was acceptable to both HCWs and clients. The next step for this research is a randomized clinical trial of the effect of the REDCap-based CASI-Plus tool on the number of partners named and the rate of partners completing HIV testing.

**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**

✪ Sustainability of an evidence-based intervention supporting transition to independent care for youth living with HIV in Kenya

Authors:

Alina Metje, Sarah Shaw, Cyrus Mugo, Mercy Awuor, Annabell Dollah, Hellen Moraa, Christine Kundu, Dalton Wamalwa, Grace John-Stewart, Kristin Beima-Sofie, and Irene Njuguna

University of Washington affiliated authors are displayed in bold.

✪ Open Access

Published: January 2025

Read the full text in the open access journal PLOS Global Public Health

Abstract:

Integrating and sustaining evidence-based interventions (EBIs) in routine care is crucial to improving HIV treatment outcomes among youth living with HIV (YLH). However, EBIs are often not sustained post clinical trial. An Adolescent Transition Package (ATP) delivered by health care workers (HCWs) and tested in Kenya in 2021 significantly improved YLH readiness to transition to independent care. Post-trial, participating clinics could continue using the ATP. We conducted 30 in-depth interviews with health care workers to evaluate determinants of continued ATP implementation one-year post-trial. Interviews used semi-structured guides, informed by the Consolidated Framework for Implementation Research version 2.0 (CFIR v2.0). Transcripts were analyzed thematically to identify key influences of ATP sustainment and fidelity post-trial. Effective training during and after the trial, and continued internal and external support for implementation, were crucial for sustained acceptability and feasibility. In contrast, staff shortages and high turnover, lack of integration into the existing electronic medical system, and maintaining staff motivation were barriers to ATP sustainment. Implementation fidelity was limited by workforce constraints and HCW beliefs about the importance of individualizing content and delivery to be responsive to individual client needs. ATP adaptability afforded optimization of delivery to overcome workforce constraints and meet client needs, increasing HCW perceptions of feasibility and motivating continued use. Alignment between observed impact and care provision goals further motivated ongoing ATP utilization. Strategies to ensure continued training and integration of tools into existing systems have the potential to further enhance ATP sustainability.

**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**

✪ A Team Coaching Intervention for Dementia Care: Acceptability and Feasibility Study in Care Communities

Authors:

Jessica Welsch, Boeun Kim, Lorna Prophater, Basia Belza, & Sam Fazio

University of Washington affiliated authors are displayed in bold.

✪ Open Access

Published: December 2024

Read the full text open access in the Journal of the American Medical Directors Association

Abstract:

Objectives

In 2018, the Alzheimer's Association published the Dementia Care Practice Recommendations (DCPR) to provide guidance on quality care for professionals. This study aimed to examine the feasibility and acceptability of a consultative coaching program to increase adoption of the DCPR.

Design

A single-group pre-post design was employed. A 6-month team coaching intervention was implemented to make organization-wide and measurable changes in the areas of (1) policies and procedures, (2) education and training, or (3) care practices to increase person-centered care practices.

Setting and Participants

A total of 36 care communities in Washington and Montana states were enrolled in this program.

Methods

Focus groups were conducted with participants to explore the acceptability and feasibility of the program. A 35-item employees satisfaction survey was administered both before and after the program.

Results

The findings offer preliminary evidence that implementing a coaching program is desired by care community staff and has a positive impact on staff job satisfaction and the use of person-centered care. The coaching model was received by staff as a supportive and affirming program.

Conclusions and Implications

The team coaching intervention, designed to improve person-centered care and employee satisfaction, is acceptable. However, its efficacy needs to be tested with a larger sample using a randomized controlled design.

**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**

✪ Acceptability of single-dose HPV vaccination schedule among health-care professionals in Kenya: a mixed-methods study

Authors:

Grace Umutesi, Bryan J Weiner, Lynda Oluoch, Elizabeth Bukusi, Maricianah Onono, Betty Njoroge, Lucy Mecca, Kenneth Ngure, Nelly R Mugo, Ruanne V Barnabas

University of Washington affiliated authors are displayed in bold.

✪ Open Access

Published: November 2024

Read the full text in the open access journal JNCI Monographs

Abstract:

Background

The World Health Organization recommends a single-dose human papillomavirus (HPV) vaccination schedule for girls and boys to accelerate progress toward cervical cancer elimination. We applied the Theoretical Framework of Acceptability (TFA) within the context of HPV vaccination to assess the acceptability of a single-dose schedule among health-care professionals in Kenya.

Methods

A REDCap survey was developed using relevant Theoretical Framework of Acceptability domains and validated with health-care professionals. Descriptive analyses and multivariate Poisson regression were conducted to assess factors associated with increased acceptability. Free-text responses were analyzed using a rapid qualitative approach, and findings were presented using a joint display.

Results

Among 385 responses, 74.2% of health-care professionals were female and 48.6% were nurses. On average, respondents had been in their position for 60 months, and one-third (33.2%) were based at level-4 facilities. The majority (75.84%) thought that giving a single-dose of the HPV vaccine to adolescent girls and young women was either acceptable or very acceptable. Qualitative findings highlighted that lack of information was the underlying reason for health-care professionals who were resistant, and most clinicians thought that a singled-dose schedule was less burdensome to clinicians and patients. Hospital directors had a non–statistically significantly lower acceptability likelihood than nurses (incident rate ratio = 0.93, 95% confidence interval = 0.45 to 1.71) and health-care professionals at urban facilities had a non–statistically significantly lower acceptability likelihood than clinicians in rural facilities (incident rate ratio = 0.97, 95% confidence interval = 0.83 to 1.13).

Conclusion

Although not statistically significant, predictors of increased acceptability provide information to tailor strategies to increase HPV vaccination coverage and accelerate progress toward cervical cancer elimination.

**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**

✪ Applying the Cognitive Walkthrough for Implementation Strategies methodology to inform the redesign of a selection-quality implementation toolkit for use in schools

Authors:

Kelsey S. Dickson, Olivia G. Michael, Amy Drahota, Aksheya Sridhar, Jessica E. Tschida, & Jill Locke

University of Washington affiliated authors are displayed in bold.

✪ Open Access

Published: November 2024

Read the full text in the open access journal Implementation Science Communications

Abstract:

Background

Implementation strategies are key to enhancing the translation of new innovations but there is a need to systematically design and tailor strategies to match the targeted implementation context and address determinants. There are increasing methods to inform the development and tailoring of implementation strategies to maximize their usability, feasibility, and appropriateness in new settings such as the Cognitive Walkthrough for Implementation Strategies (CWIS) approach. The aim of the current project is to apply the CWIS approach to inform the redesign of a multifaceted selection-quality implementation toolkit entitled Adoption of Curricular supports Toolkit: Systematic Measurement of Appropriateness and Readiness for Translation in Schools (ACT SMARTS) for use in middle and high schools.

Methods

We systematically applied CWIS as the second part of a community-partnered iterative redesign of ACT SMARTS for schools to evaluate the usability and inform further toolkit redesign areas. We conducted three CWIS user testing sessions with key end users of school district administrators (n = 3), school principals (n = 6), and educators (n = 6).

Results

Our CWIS application revealed that end users found ACT SMARTS acceptable and relevant but anticipate usability issues engaging in the ACT SMARTS process. Results informed the identification of eleven usability issues and corresponding redesign solutions to enhance the usability of ACT SMARTS for use in middle and high schools.

Conclusions

Results indicated the utility of CWIS in assessing implementation strategy usability in service of informing strategy modification as part of our broader redesign to improve alignment with end user, end recipient, and setting needs. Recommendations regarding the use of this participatory approach are discussed.

Contributions to the literature

  • The current case study adds to the nascent literature applying the Cognitive Walkthrough for Implementation Strategies (CWIS) method as part of a larger implementation project, including one of the first independent applications outside of the CWIS method developers.
  • The current case study illustrates the impact and utility of the CWIS method for designing and tailoring implementation strategies.
  • This case study provides further guidance and recommendations for the application of CWIS to future implementation projects.

**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**

Barriers and facilitators to implementing enteral resuscitation for major burn injuries: Reflections from Nepalese care providers

Authors:

Raslina Shrestha, Kajal Mehta, Aldina Mesic, Dinasha Dahanayake, Manish Yadav, Shankar Rai, Kiran Nakarmi, Pariwesh Bista, Tam Pham, & Barclay T Stewart

University of Washington affiliated authors are displayed in bold.

Subscription Required for Full Text Access

Published: October 2024

Read the full text in the subscription access journal Burns

✪ Acceptability of six-monthly PrEP dispensing supported with interim HIV self-testing to simplify PrEP delivery in Kenya: findings from qualitative research

Authors:

Nicholas Thuo, Ashley R. Bardon, Peter Mogere, Catherine Kiptinness, Edinah Casmir, Njeri Wairimu, Emmah Owidi, Phelix Okello, Nelly R. Mugo, Jared M. Baeten, Kenneth Ngure & Katrina F. Ortblad

University of Washington affiliated authors are displayed in bold.

✪ Open Access

Published: October 2024

Read the full text in the open access journal BMC Health Services Research

Abstract:

Background

In Africa, dispensing oral HIV pre-exposure prophylaxis (PrEP) within already strained public health facilities has led to prolonged waiting periods and suboptimal experiences for clients. We sought to explore the acceptability of dispensing PrEP semiannually with interim HIV self-testing (HIVST) versus quarterly PrEP dispensing with clinic-based HIV testing to optimize clinic-delivered PrEP services.

Methods

We conducted a qualitative study within a non-inferiority individual-level randomized controlled trial testing the effect of six-monthly PrEP dispensing with HIVST compared to the standard-of-care three-monthly PrEP dispensing on PrEP clinical outcomes in Kenya (ClinicalTrials.gov: NCT03593629). Eligible participants were ≥ 18 years, refilling PrEP for the first time, and either in an HIV serodifferent relationship (men and women) or singly enrolled (women only). A subset of participants in the intervention group completed serial in-depth interviews (IDIs) at enrollment, six months, and 12 months. We utilized stratified purposive sampling to ensure representation across participant groups. We analyzed our qualitative data thematically using a combination of inductive and deductive approaches, the latter guided by the Theoretical Framework of Acceptability (TFA).

Results

Between May 2018 and June 2021, we conducted 120 serial IDIs with 55 participants; 64% (35/55) were in a serodifferent relationship, 64% (35/55) were women, and the median age was 32 years (IQR 27–40). Overall, participants found this novel PrEP delivery model highly acceptable; it was well-liked, private (TFA construct: affective attitude), and less burdensome (TFA construct: burden) compared to standard PrEP delivery. Additionally, participants were confident in their ability to participate in the intervention (TFA construct: self-efficacy). Some participants, however, highlighted model disadvantages, including fewer opportunities for in-person counseling and potentially less accurate HIV testing (TFA construct: opportunity costs). Ultimately, most participants reported that the intervention allowed them to achieve their HIV prevention goals (TFA construct: perceived effectiveness) and that their confidence in at-home HIVST and PrEP continuation increased following each semiannual clinic visit.

Conclusions

Semiannual PrEP clinic visits supported with six-monthly drug dispensing and interim HIVST was acceptable among PrEP users who experienced the intervention in Kenya. More comprehensive pre-intervention counseling and training on HIVST may help alleviate the client concerns presented, which were often resolved over time with intervention experience.

**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**

✪ Usability of a Web-Based App for Increasing Adolescent Vaccination in Primary Care Settings: Think-Aloud and Survey Assessment

Authors:

Stephanie A S Staras, Justin Tauscher, Michelle Vinson, Lindsay A Thompson, Mary A Gerend & Elizabeth A Shenkman

University of Washington affiliated authors are displayed in bold.

✪ Open Access

Published: September 2024

Read the full text in the open access journal JMIR Formative Research

Abstract:

Background

In the United States, only 58% of teens receive the recommended 2 doses of the human papillomavirus vaccine by 15 years of age. Overcoming vaccine hesitancy often requires effective communication between clinicians and parents to address specific concerns. To support this, we developed ProtectMe4, a multilevel, theory-informed web-based intervention designed to address parents’ vaccine-related questions and assist clinicians in discussing vaccine concerns for 4 adolescent vaccines.

Objective

This study aims to evaluate the usability of ProtectMe4 in routine care settings across 3 pediatric primary care clinics. Specifically, the study aims to (1) observe the proposed workflow in practice, (2) identify usability issues experienced by parents and clinicians, and (3) assess the perceptions of both parents and clinicians regarding the app’s usability.

Methods

On designated days in 2020 and 2021, the study team recruited parents of 11- to 12-year-old patients attending appointments with participating clinicians. We conducted think-aloud assessments during routine care visits and administered a usability survey after participants used the app. For parents, we simultaneously video-recorded the app screens and audio-recorded their commentary. For clinicians, observational notes were taken regarding their actions and comments. Timings recorded within the app provided data on the length of use. We reviewed the recordings and notes to compile a list of identified issues and calculated the frequencies of survey responses.

Results

Out of 12 parents invited to use the app, 9 (75%) participated. Two parents who were invited outside of the planned workflow, after seeing the clinician, refused to participate. For the parents whose child’s vaccination record was identified by the app, the median time spent using the app was 9 (range 6-28) minutes. Think-aloud assessment results for parents were categorized into 2 themes: (1) troubleshooting vaccine record identification and (2) clarifying the app content and purpose. Among the 8 parents who completed the survey, at least 75% (6/8) agreed with each acceptability measure related to user satisfaction, perceived usefulness, and acceptance. These parents’ children were patients of 4 of the 7 participating clinicians. Consistent with the planned workflow, clinicians viewed the app before seeing the patient in 4 of 9 (44%) instances. The median time spent on the app per patient was 95 (range 5-240) seconds. Think-aloud assessment results for clinicians were grouped into 2 themes: (1) trust of app vaccine results and (2) clarifying the app content. On the survey, clinicians were unanimously positive about the app, with an average System Usability Scale score of 87.5 (SE 2.5).

Conclusion

This mixed methods evaluation demonstrated that ProtectMe4 was usable and acceptable to both parents and clinicians in real-world pediatric primary care. Improved coordination among clinic staff is needed to ensure the app is consistently offered to patients and reviewed by clinicians before seeing the patient.

**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**