Kenya Archives - Implementation Science at UW

✪ Strengthening primary care facility management: a systematic review of management interventions, implementation strategies, and outcomes in six sub-Saharan African countries

Abstract:

Background

Although primary health care (PHC) is central to health system performance, effective facility-level management is a critical determinant of service quality, resource use, and improved health outcomes. We conducted a systematic review to synthesize evidence on interventions, implementation strategies, and outcomes aimed at strengthening PHC facility management in Sub-Saharan Africa (SSA).

Methods

We conducted a systematic review using thematic synthesis. Eight electronic databases were searched for peer-reviewed studies and grey literature published between 2012 and 2022, focusing on interventions targeting PHC facility management in SSA. Implementation strategies were mapped to the thematic cluster areas of the Expert Recommendations for Implementing Change (ERIC) framework. Implementation outcomes were classified using Proctor’s Implementation Outcome Framework, and management effectiveness domains were identified through thematic analysis.

Results

Of 3,752 studies screened, nine met the inclusion criteria. These studies represented six SSA countries: Botswana, Ethiopia, Kenya, South Africa, Tanzania, and Zambia. Four categories of intervention were identified: (1) training and capacity building programs, (2) peer-to-peer learning, (3) audit and feedback-based quality management systems, and (4) supportive supervision. These interventions were delivered through multiple implementation strategies, including training and education, coaching and mentoring, learning collaboratives, interactive continuous learning, and routine data monitoring. Acceptability was the most consistently reported implementation outcome. Improvements in management effectiveness were identified across four domains: financial management, organizational climate and culture, resource management and utilization, and human resource management. Five studies also reported intermediate service-level outcomes including improvements in maternal and child health indicators.

Conclusion

Interventions aimed at strengthening PHC facility management in SSA primarily emphasize skill development, collaboration, and ongoing managerial support, typically delivered through multiple strategies. However, few studies have evaluated these interventions using rigorous experimental or pragmatic study designs. More robust implementation research is needed to identify effective strategies for strengthening PHC facility management and supporting the consistent implementation of national PHC guidelines.

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✪ Reciprocal innovation in implementation science and global health: reflections from the EXTRA-CVD (extending the HIV treatment cascade for cardiovascular disease prevention) study

Abstract:

Reciprocal innovation, a model of sustained, multidirectional exchange in which health strategies are adapted, revisited, and refined across contexts, offers a compelling framework to rethink how implementation science can support global health equity by enabling dynamic, multidirectional learning across different contexts. Drawing on the EXTRA-CVD trial, a nurse-led cardiovascular disease prevention intervention designed to extend the HIV treatment cascade in United States (U.S.) HIV clinics, which adapted strategies informed by implementation research in Kenya and the U.S. Veterans Affairs health system, this perspective examines how reciprocal innovation can begin to emerge within existing research structures, as well as where opportunities for deeper exchange remain limited. We identify four operational domains of reciprocal innovation: care delivery strategies, end-user engagement, research methodologies, and research leadership and partnership. Across these domains, we describe how cross-context learning shaped intervention adaptation and site-level implementation in EXTRA-CVD, as well as missed opportunities where more intentional feedback, shared leadership, and methodological exchange could have strengthened multidirectional learning. Taken together, this work highlights both the potential and the practical challenges of reciprocal innovation in implementation research, emphasizing its role in moving beyond unidirectional knowledge transfer toward iterative, context-responsive learning. By embedding structures for iterative feedback, equity-centered governance, and multidirectional learning systems within research and implementation systems, future global partnerships can foster more inclusive, responsive, and sustainable health interventions.

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✪ Identifying Community-Sourced Implementation Strategies for Delivering a Task-Shared Mental Health Intervention for Fathers in Kenya

Abstract:

Background

To design accessible interventions, understanding how best to implement them in context is essential. Strategies that reflect community perspectives may be most relevant and impactful. This study aimed to identify and specify community-sourced implementation strategies for delivering a mental health and alcohol use intervention for fathers in Kenya and to map them to the Expert Recommendations for Implementing Change (ERIC) taxonomy.

Method

In Eldoret, Kenya, focus groups (seven groups; 31 participants) and key informant interviews (n = 18) were conducted with hospital leaders, policymakers, mental health providers, community leaders, fathers, lay providers, patients, and men currently experiencing mental health and alcohol use challenges. Data were analyzed using the framework method to generate high-level codes, followed by a second phase to extract, specify, and review implementation strategies.

Results

Community members identified lay providers recruited from the community as a promising delivery approach, with professional providers contributing to linkage to care and support for more acute needs. Engagement of community leaders and leveraging existing infrastructure were seen as key to enhancing implementation and reach, particularly among men. Multiple delivery settings (e.g., church, hospital, school) were considered acceptable depending on patient preference. A total of 25 unique community-sourced strategies were identified: three directly matched ERIC strategies, 19 were adapted, and two were unique to the community context.

Conclusions

This study identified locally grounded implementation strategies to guide early-stage intervention delivery for fathers in Kenya. Findings contribute to the growing body of implementation science in non-Western contexts and highlight a participatory approach for identifying and specifying strategies relevant to local systems and populations.

Plain Language Summary

This study explored how to deliver mental health and alcohol use treatment to Kenyan fathers based on community and father input. Key strategies included using local helpers, familiar spaces, and engaging leaders. Findings emphasize co-design and context-based delivery to make interventions more accessible, relevant, and ready for testing.

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✪ “Though there are some challenges, we try our best to follow the guidelines”: a qualitative study exploring determinants of providing guideline-adherent care to hospitalized children in Kenya

Abstract:

Background

Clinical treatment guidelines are designed to improve quality of care by offering clear recommendations for health workers; however, across many settings, implementing guidelines is a challenge. For over 20 years, comprehensive World Health Organization guidelines for care of hospitalized children have provided guidance for treating the primary causes of childhood death. These recommendations were adapted in Kenya and codified in the Basic Paediatric Protocol; however, adherence to these evidence-based interventions remains suboptimal.

Methods

This qualitative study identified the barriers and facilitators of providing guideline-adherent care to children admitted to two hospitals in Kenya. The semi-structured question guide was informed by the Theoretical Domains Framework (TDF). Three focus group discussions and 16 in-depth interviews were conducted with 35 health workers. Participants were nurses, doctors, clinical officers, or nutritionists (including in-charges and clinical supervisors). Interviews were audio recorded and transcribed. Transcripts were coded using a TDF-based codebook, validated, and analyzed for themes.

Results

TDF domains with the greatest influence on the thematic findings were environmental context and resources, social influences, beliefs about consequences, and beliefs about capabilities. Health workers were knowledgeable about guidelines and felt strongly that adherence to them was beneficial; however, they also faced barriers implementing them. Challenges related to the environmental context were pervasive, including shortages of staff and supplies. Participants praised the simplicity of guidelines but also noted that simplified diagnostic criteria don’t align with complex patient presentations. While guidelines empowered some nurses to make clinical decisions, respondents reported that strict professional roles sometimes delayed diagnosis and treatment. Further, health workers reported some deviations were intentional (ex. when guidelines were not aligned to their beliefs) and other times they were unintentional (ex. when complex patient presentations make guideline adherence difficult).

Conclusions

Knowledge of guidelines and motivation to use them were not major determinants in this analysis. Rather, human and material resource shortages presented the greatest barrier to guideline adherence in this setting. Improving guidelines by involving health workers in participatory development of guidelines would improve both clarity and feasibility. Health workers are well-versed in guideline recommendations, so educational strategies should focus on knowledge gaps or changes in the latest version of guidelines.

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✪ Improving fever management of hospitalized children with cancer: barriers, facilitators, and proposed interventions from healthcare providers in Kenya

Abstract:

Children with cancer in lower-middle-income countries (LMICs) are at increased risk of dying from infections. Prompt treatment of fever episodes improves outcomes, yet poorly described challenges impair management. This qualitative study explored healthcare provider perspectives on barriers to and facilitators of inpatient fever management in children with cancer at a public tertiary referral children’s hospital in Kenya. Healthcare providers involved in fever management were recruited. Semi-structured interviews were audio-recorded, transcribed verbatim, and entered into NVivo software. Coding was informed by a theoretical fever framework and the Consolidated Framework for Implementation Research. Thematic analysis and mind mapping identified recurrent themes and subthemes. Strategies were mapped to identified barriers. The sixteen participants included nurses (n = 2), clinicians (n = 6), pharmacists (n = 2), phlebotomists (n = 2), and microbiology laboratory staff (n = 4). We identified three overarching themes: empowerment of healthcare providers and caregivers, the importance of timely management, and teamwork/human resource availability. Healthcare provider attributes served as facilitators: motivation to improve care, eagerness to learn, willingness to change practice, and need for treatment guidance. Factors within the hospital system were barriers, with subthemes including poor communication between cadres, delays in laboratory results, and staffing shortages. Participants suggested knowledge sharing, a treatment guideline, task shifting, and hiring additional healthcare providers as potential interventions. Managing fever episodes in children with cancer is complex, requiring multiple cadres of healthcare providers and caregiver participation. The proposed interventions may overcome barriers, but future studies are needed to assess the effectiveness of these strategies in improving fever management.

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✪ Evaluating the effectiveness of a One-Stop PrEP Care model to enhance HIV prevention: a protocol for a cluster-randomised trial in Kisumu County, Kenya

Abstract:

Introduction

Oral HIV pre-exposure prophylaxis (PrEP) is a highly effective biomedical intervention for HIV prevention, but its access and utilisation are challenging, especially in high-burden settings such as Kenya. For potential PrEP users, long delays and repeated consultations with several providers are obstacles to both PrEP uptake and continuation. The One-Stop PrEP Care project aims to promote the use of PrEP among clients in the health system and enhance client satisfaction by reducing the waiting time.

Methods and analysis

We are conducting a 1:1 cluster-randomised trial to evaluate whether One-Stop PrEP Care achieves equivalent or better PrEP outcomes compared with the standard of care model in 12 high-volume HIV clinics in Kisumu County, Kenya. In the One-Stop model, all core PrEP components, including HIV risk evaluation, HIV testing and PrEP dispensing, are provided by one provider in a single consultation room. Programme data from ≥2400 new PrEP clients will be abstracted for 12 months each to obtain primary endpoints of PrEP initiation and continuation. Adherence will be assessed via blood drug level testing. A nested cohort of up to 300 PrEP clients will be enrolled and followed every 3 months to provide in-depth data on individual HIV prevention behaviour, risk perception and how they align PrEP use with perceived risk. We will also evaluate programme costs.

Ethics and dissemination

Ethical approval was obtained from the University of Washington Institutional Review Board (IRB) on 8 July 2022 (IRB ID: STUDY00015873) and the Kenya Medical Research Institute Scientific and Ethics Review Unit (SERU) with a letter dated 4 May 2023 (Ref: 4697). Project findings will be shared with stakeholders, including the Ministry of Health, County health officials and participants. Results will be disseminated through manuscripts, policy briefs and health meetings.

Protocol amendments

Plans for communicating important protocol modifications include timely notifications to all study team members and training on the changes, and updates to relevant stakeholders, including the two IRBs, through protocol amendment submissions.

Protocol version V. 2.0 dated 21 May 2024.

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✪ High acceptability, feasibility and sustainability of a direct-to-pharmacy differentiated PrEP delivery model in public health HIV clinics in Kenya: perspectives of PrEP clients and healthcare providers

Abstract:

Introduction

High client opportunity costs and a burdened healthcare system limit oral pre-exposure prophylaxis (PrEP) delivery in Kenyan public HIV clinics. We conducted a qualitative study among PrEP clients and providers to understand the acceptability, feasibility and willingness to implement a client-centred, differentiated direct-to-pharmacy (DTP) PrEP refill visits intervention aimed at improving the efficiency of PrEP implementation in real-world clinics.

Methods

From March 2021 to March 2022, we conducted in-depth interviews with clients and healthcare providers participating in an individual facility pharmacy-based PrEP delivery model for PrEP refills among clients in the continuation phase at two public HIV clinics in central Kenya. The core components of the DTP model included directed-to-PrEP pharmacy refill visits conducted by facility pharmacy staff and client HIV self-testing (HIVST) while waiting for services at the pharmacy. We used semi-structured interview guides informed by the Consolidated Framework for Implementation Research (CFIR). We analysed data using thematic content analysis and organised findings by CFIR constructs.

Results

We interviewed 20 PrEP clients and 20 healthcare providers. PrEP clients included 15 females and had a median age of 39 years (interquartile range [IQR]: 33–48). Providers included 13 females, had a median age of 32 years (IQR: 30–41), and included 10 HIV counsellors, 5 pharmacy and 3 clinical providers. Both providers and clients reported high satisfaction with DTP PrEP refill visits derived from improved clinic flow and quality of service. Among clients, shorter waiting times and less movement between multiple clinic rooms reduced delays, improved privacy and reduced stigma associated with visiting HIV clinics. Furthermore, shorter waiting times and infrequent clinic visits reduced loss of working hours and income among clients, motivating PrEP continuation. Providers reported improved clinic flow, reduced work burden among non-pharmacy providers, improved knowledge and ease of implementing DTP refill visits. However, providers expressed concerns about the potential loss of roles among HIV counsellors and the shifting of workload burden to pharmacy providers.

Conclusions

Differentiated DTP refill visits with HIVST were highly acceptable and feasible among PrEP clients and providers. Context-specific modifications and scale-up of the intervention could improve the efficiency of PrEP delivery within public HIV clinics in Kenya and similar settings.

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✪ “When he is around, I’ll take the PrEP, but when he is not, I will not take PrEP”: key influences on PrEP use decisions among women attending family planning clinics in Kenya

Abstract:

Background

Women of childbearing age in sub-Saharan Africa (SSA) face a disproportionately high risk of HIV acquisition. Although oral PrEP has been universally scaled up for individuals at significant risk of HIV, its uptake and sustained use remain suboptimal. Understanding PrEP use decisions offers insights into context-specific barriers and facilitators to its utilization.

Methods

From September to November 2023, we conducted a qualitative study nested in a larger prospective, open-label clinical trial (FP-Plus). We conducted in-depth interviews (IDIs) with younger women (ages 15–24) and older women (ages ≥25) who declined, delayed, discontinued, or restarted PrEP during the study. IDIs were conducted at two FP clinics by trained Kenyan social scientists and were audio recorded, translated, and transcribed. We analyzed data using inductive and deductive thematic analysis through the lens of the theory of planned behavior (TPB) to explore experiences, beliefs, and rationale among women who made various PrEP decisions.

Results

We interviewed 64 women, including 40 younger women and 24 older women, all of whom declined, delayed, discontinued, or restarted PrEP (n = 16 women/category). The median age of these women was 24 years (IQR, 23–30). The majority of participants (86%, 55/64) were using family planning methods, primarily injectables (42%, 23/64). PrEP discontinuation or restart was primarily influenced by changes in HIV risk dynamics. Agency and perceived HIV risk were pivotal factors in PrEP use decisions, shaping participants’ ability to practice effective prevention adherence (TPB: perceived behavioral control). Women who declined PrEP cited a lack of autonomy, partner influence, and insufficient information (TPB: social and subjective norms). Low self-efficacy influenced decisions to delay or decline PrEP (TPB: behavioral beliefs and attitudes). In addition, challenges with PrEP pill size, taste, and texture were perceived as barriers to swallowing pills among all groups of women. Participants expressed a preference for alternative PrEP formulations, such as injectable PrEP, due to perceived ease of use, privacy, and potential to support adherence.

Conclusions

PrEP discontinuation and restart cycles largely reflected changes in HIV risk. Women who decline or delay PrEP may benefit from personalized support to improve their autonomy, recognizing that HIV risk persists during periods of PrEP delay.

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✪ What do women want in pharmacy-based HIV prevention services during pregnancy? Developing attributes and levels for a discrete choice experiment in Western Kenya

Abstract:

Background

The delivery of HIV prevention services (e.g., HIV testing, pre-exposure prophylaxis (PrEP) initiation and refills, and STI testing) in community pharmacies could address clinic barriers faced by pregnant women such as extended travel and wait times. We conducted a qualitative study in Western Kenya to select and prioritize attributes and levels for a discrete choice experiment (DCE) to design pharmacy-based HIV prevention services for pregnant women.

Methods

We began by identifying a comprehensive list of attributes and levels relevant to women considering HIV prevention during pregnancy. This list was informed by recommended HIV prevention interventions for pregnant women, our objective to design services for pharmacy settings, and attributes identified in the literature as important for other populations when choosing HIV and pharmacy-based services. From March to November 2022, we recruited participants using stratified purposeful sampling and collected qualitative data through seven focus group discussions with women, four with health providers, and eight individual interviews with technical experts. Interviews were audio-recorded, translated, transcribed, and summarized in debrief reports. We conducted debriefing meetings and analyzed these reports to identify and refine the essential attributes that would influence decisions to access HIV prevention services from a pharmacy during pregnancy.

Results

We initially identified twelve potential attributes that were evaluated during the focus groups. Five attributes were eliminated based on ranking exercises with women and health providers. Additional attributes suggested during the focus groups were ranked low by participants or not mentioned frequently enough and, therefore, not included. We finalized and refined levels for each attribute using insights from the literature, participant feedback, and design considerations. The study identified seven attributes: service location, type of HIV test, STI testing availability, partner HIV testing availability, PrEP availability, service access methods (e.g., appointment versus walk-ins), and service fee.

Conclusions

This study was the first step in data collection toward defining attributes and levels for a DCE survey and successfully identified seven preliminary attributes and levels. Pre-testing and pilot testing activities further explored the feasibility and understanding of the attributes and levels.

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✪ Impact of a stakeholder selected implementation strategy package – fast tracking, provider re-training, and co-location – on PrEP implementation for pregnant women in antenatal care clinics in western Kenya

Abstract:

Background

Pre-exposure prophylaxis (PrEP) is recommended for HIV prevention in pregnant and postpartum women at substantial ongoing risk for HIV. In resource-limited settings, there exist gaps in the integration of PrEP into antenatal care.

Methods

We conducted a difference-in-differences analytic approach (3 months pre- and 3 months post) between January 2022 and July 2022 in 8 facilities (4 intervention and 4 comparison) in western Kenya. During the 6-month period, we tested a combination of 2 stakeholder selected implementation strategies – retraining health providers and fast tracking PrEP clients– to improve PrEP delivery. All study facilities dispensed PrEP in the Maternal and Child health clinics (MCH). We evaluated absolute changes in: PrEP penetration, PrEP fidelity, client PrEP knowledge, client satisfaction, and client waiting and service times as outcomes specified a priori while PrEP offer and HIV testing were outcomes specified post hoc. We measured acceptability and appropriateness by providers of the implementation strategies using AIM and IAM respectively.

Results

We observed statistically significant improvements in PrEP penetration and PrEP offer (p < 0.05) and non-significant improvements in fidelity. PrEP penetration increased 6 percent points (p = 0.002), PrEP offer increased nearly 6 percentage points (p = 0.002), and PrEP fidelity increased 4 percentage points (p = 0.202) in intervention vs comparison facilities. Client PrEP knowledge increased 0.45 out of 7 total points (p < 0.001) and PrEP screening increased 13 percentage points (p = 0.001). We observed no significant changes in service time (0.13-min increase; p = 0.249), waiting time (0.03-min decrease; p = 0.796), or client satisfaction (0.04/24 total point decrease; p = 0.849) in intervention vs comparison facilities. HIV testing did not significantly change (7 percentage point decrease, p = 0.305). The implementation strategy bundle was deemed appropriate and acceptable by the providers (appropriateness: 18.5/20; acceptability: 18.5/20). Overall, the implementation strategy bundle was associated with larger increases in implementation outcomes among women receiving a visit other than their first ANC visit, as well as among sites without stockouts of HIV test kits.

Conclusions

A stakeholder-selected implementation strategy bundle that included retraining healthcare workers, fast tracking PrEP clients to reduce waiting time, and PrEP dispensing in MCH improved several implementation outcomes without significantly affecting waiting time or reducing service time.

Contributions to the literature

Evidence is sparse on effective implementation strategies that focus on structural- and provider-level barriers to enhance delivery of integrated care in resource-limited settings.
Stakeholder-selected strategies are hypothesized to have a better fit to local context and potentially be more effective than externally selected strategies.
We tested a package of two stakeholder-selected implementation strategies – retraining health providers, fast tracking PrEP clients in a difference-in-differences study in 8 clinics in Kenya.
The package was associated with significant improvements in PrEP penetration, PrEP offer, PrEP knowledge, and PrEP screening. It was not associated with significant changes in PrEP fidelity, HIV testing, service time, waiting time, or client satisfaction.
The improvement associated with the package was most pronounced among clinics that did not experience substantial stockouts of supplies, suggesting that implementation strategies are not sufficient to overcome gaps in basic resourcing in the presence of critical events.

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Authors:

✪ Open Access

Read the full text in the open access journal BMC Primary Care

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Background

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Authors:

✪ Open Access

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

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✪ Open Access

Read the full text in the open access journal Implementation Research and Practice

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Plain Language Summary

Authors:

✪ Open Access

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

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Authors:

✪ Open Access

Read the full text in the open access journal Frontiers in Oncology

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Authors:

✪ Open Access

Read the full text in the open access journal BMJ Open

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Introduction

Methods and analysis

Ethics and dissemination

Protocol amendments

Authors:

✪ Open Access

Read the full text in the open access journal Journal of the International AIDS Society

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Authors:

✪ Open Access

Read the full text in the open access journal Frontiers in Medicine

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Authors:

✪ Open Access

Read the full text in the open access journal AIDS Research and Therapy

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Authors:

✪ Open Access

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

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Contributions to the literature