Kenya Archives - Page 2 of 8 - Implementation Science at UW

✪ Factors influencing community demand for assisted partner services for HIV in western Kenya: a multilevel qualitative analysis

Abstract:

Objectives

This study explores factors affecting community-level demand for assisted partner services (APS) and HIV testing services (HTS) in western Kenya.

Design

This is a multilevel qualitative analysis conducted as part of the APS Scale-up Study, a hybrid type 2 implementation-effectiveness study of APS integrated within routine HTS. For this analysis, in-depth phone interviews assessed demand for APS and factors influencing decisions to participate in APS.

Setting

Participants were recruited from eight healthcare facilities and (for APS stakeholders) from affiliated healthcare institutions in western Kenya (Kisumu and Homabay). Interviews were conducted by phone in 2019 and 2020.

Participants

67 participants were interviewed: 14 APS providers, 16 female index clients, 17 male sexual partners and 20 community members. Participants were recruited using criteria-based purposive sampling to represent different types of facilities and to include indexes who named different numbers of partners and stakeholders representing all Kenyan healthcare system levels.

Results

Collectively, participants perceived that demand and uptake of APS could be impacted by multiple stigmas related to HIV, sexual behaviours and identities; long clinical wait times; certain gender norms and expectations; and fear of relationship dissolution, loss of financial support and intimate partner violence. However, different stakeholder groups generally focused on different factors; women focused more on gender dynamics and family roles; male sexual partners on stigma and structural barriers; HTS providers focused on HIV testing accessibility; and community-level stakeholders focused on low community awareness of APS.

Conclusions

Stigma reduction, awareness about APS, creation of male entry points at the facility level and provision of social support mechanisms have the potential to increase demand for APS.

Data availability statement

Data are available upon reasonable request. The datasets generated and/or analysed during the current study are not publicly available because some interview transcripts may contain sensitive individual information; however, they can be made available from the corresponding author on reasonable request.

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

✪ Training and Support Practices and Insights in the Sustainability of mHealth Implementations in Sub-Saharan Africa

Abstract:

We conducted an interview-based study to understand the training and support practices and insights that influence sustainable implementations of mHealth projects of varying mHealth technologies. The qualitative assessment was inspired by the Consolidated Framework for Implementation Research adapted with the recommended questions for guiding the implementation of training programs. Participants in the study (N = 16) were both international and in-country researchers managing projects in sub-Saharan Africa. We chose to focus on training and support, as it is often the interface between international and in-country components of these projects. Participants agreed on the central role of training in the implementation of mHealth projects and are following best practices. There was often a division in the responsibility of training between international and in-country researchers reflecting the distinction between project management and local implementation adaptions. One of the main findings is the importance of individualized continuous retraining to make deployments robust with respect to changing conditions with technology and personnel, an aspect that has been managed a bit differently with varying mHealth technologies as presented in this article.

^{**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

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**}

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

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**}

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

✪ Digital communication between mothers and community health workers to support neonatal health (CHV-NEO): study protocol for a randomized controlled trial

Authors:

Keshet Ronen, Lincoln C. Pothan, Violet Apondi, Felix A. Otieno, Daniel Mwakanema, Felix O. Otieno, Lusi Osborn, Julia C. Dettinger, Priyanka Shrestha, Helena Manguerra, Ferdinand Mukumbang, Millicent Masinde, Evelyn Waweru, Mercy Amulele, Christine Were, Beatrice Wasunna, Grace John-Stewart, Bryan Weiner, Arianna Rubin Means, Barbra A. Richardson, Anna B. Hedstrom, Jennifer A. Unger & John Kinuthia

^{University of Washington affiliated authors are displayed in bold.}

✪ Open Access

Published: October 2024

Read the full text in the open access journal Trials

Abstract:

Background

Provision of essential newborn care at home, rapid identification of illness, and care-seeking by caregivers can prevent neonatal mortality. Mobile technology can connect caregivers with information and healthcare worker advice more rapidly and frequently than healthcare visits. Community health workers (CHWs) are well-suited to deliver such interventions. We developed an interactive short message service (SMS) intervention for neonatal health in Kenya, named CHV-NEO. CHV-NEO sends automated, theory-based, actionable, messages throughout the peripartum period that guide mothers to evaluate maternal and neonatal danger signs and facilitate real-time dialogue with a CHW via SMS. We integrated this intervention into Kenya’s national electronic community health information system (eCHIS), which is currently used at scale to support CHW workflow.

Methods

The effect of CHV-NEO on clinical and implementation outcomes will be evaluated through a non-blinded cluster randomized controlled trial. Twenty sites across Kisumu County in Western Kenya were randomized 1:1 to provide either the national eCHIS with integrated CHV-NEO messaging (intervention) or standard of care using eCHIS without CHV-NEO (control). We will compare neonatal mortality between arms based on abstracted eCHIS data from 7200 pregnant women. Secondary outcomes include self-reported provision of essential newborn care (appropriate cord care, thermal care, and timely initiation of breastfeeding), knowledge of neonatal danger signs, and care-seeking for neonatal illness, compared between arms based on questionnaires with a subgroup of 2000 women attending study visits at enrollment in pregnancy and 6 weeks postpartum. We will also determine CHV-NEO’s effect on CHW workflows and evaluate determinants of intervention acceptability, adoption, and fidelity of use through questionnaires, individual interviews, and messaging data.

Discussion

We hypothesize that the CHV-NEO direct-to-client communication strategy can be successfully integrated within existing CHW workflows and infrastructure, improve the provision of at-home essential newborn care, increase timely referral of neonatal illness to facilities, and reduce neonatal mortality. The intervention’s integration into the national eCHIS tool will facilitate rapid scale-up if it is clinically effective and successfully implemented.

Trial registration

ClinicalTrials.gov, NCT05187897. The CHV-NEO study was registered on January 12, 2022.

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

✪ Providing HIV-assisted partner services to partners of partners in western Kenya: an implementation science study

Abstract:

Introduction

Assisted partner services (APS), or exposure notification and HIV testing for sexual partners of persons diagnosed HIV positive (index clients), is recommended by the World Health Organization. Most APS literature focuses on outcomes among index clients and their partners. There is little data on the benefits of providing APS to partners of partners diagnosed with HIV.

Methods

We utilized data from a large-scale APS implementation project across 31 facilities in western Kenya from 2018 to 2022. Females testing HIV positive at facilities were offered APS; those who consented provided contact information for all male sexual partners in the last 3 years. Male partners were notified of their potential HIV exposure and offered HIV testing services (HTS). Males newly testing positive were also offered APS and asked to provide contact information for their female partners in the last 3 years. Female partners of male partners (FPPs) were provided exposure notification and HTS. All participants with HIV were followed up at 12 months post-enrolment to assess linkage-to antiretroviral treatment (ART) and viral suppression. We compared HIV positivity, demographics and linkage outcomes among female index clients and FPPs.

Results

Overall, 5708 FPPs were elicited from male partners, of whom 4951 received HTS through APS (87% coverage); 291 FPPs newly tested HIV positive (6% yield), an additional 1743 (35.2%) reported a prior HIV diagnosis, of whom 99% were on ART at baseline. At 12 months follow-up, most FPPs were taking ART (92%) with very few adverse events: <1% reported intimate partner violence or reported relationship dissolution. FPPs were more likely than female index clients to report HIV risk behaviours including no condom use at last sex (45% vs. 30%) and multiple partners (38% vs. 19%).

Conclusions

Providing HIV testing via APS to FPP is a safe and effective strategy to identify newly diagnosed females and achieve high linkage and retention to ART and can be an efficient means of identifying HIV cases in the era of declining HIV incidence. The high proportion of FPPs reporting HIV risk behaviours suggests APS may help interrupt community HIV transmission via increased knowledge of HIV status and linkage to treatment.

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

✪ Using FRAME to characterize provider-identified adaptations to a stepped care intervention for adolescents and youth living with HIV in Kenya: a mixed methods approach

Abstract:

Introduction

The Data-informed Stepped Care (DiSC) study is a cluster-randomized trial implemented in 24 HIV care clinics in Kenya, aimed at improving retention in care for adolescents and youth living with HIV (AYLHIV). DiSC is a multi-component intervention that assigns AYLHIV to different intensity (steps) of services according to risk. We used the Framework for Reporting Adaptations and Modifications-Expanded (FRAME) to characterize provider-identified adaptations to the implementation of DiSC to optimize uptake and delivery, and determine the influence on implementation outcomes.

Methods

Between May and December 2022, we conducted continuous quality improvement (CQI) meetings with providers to optimize DiSC implementation at 12 intervention sites. The meetings were guided by plan-do-study-act processes to identify challenges during early phase implementation and propose targeted adaptations. Meetings were audio-recorded and analysed using FRAME to categorize the level, context and content of planned adaptations and determine if adaptations were fidelity consistent. Providers completed surveys to quantify perceptions of DiSC acceptability, appropriateness and feasibility. Mixed effects linear regression models were used to evaluate these implementation outcomes over time.

Results

Providers participated in eight CQI meetings per facility over a 6-month period. A total of 65 adaptations were included in the analysis. The majority focused on optimizing the integration of DiSC within the clinic (83%, n = 54), and consisted of improving documentation, addressing scheduling challenges and improving clinic workflow. Primary reasons for adaptation were to align delivery with AYLHIV needs and preferences and to increase reach among AYLHIV: with reminder calls to AYLHIV, collaborating with schools to ensure AYLHIV attended clinic appointments and addressing transportation challenges. All adaptations to optimize DiSC implementation were fidelity-consistent. Provider perceptions of implementation were consistently high throughout the process, and on average, slightly improved each month for intervention acceptability (β = 0.011, 95% CI: 0.002, 0.020, p = 0.016), appropriateness (β = 0.012, 95% CI: 0.007, 0.027, p<0.001) and feasibility (β = 0.013, 95% CI: 0.004, 0.022, p = 0.005).

Conclusions

Provider-identified adaptations targeted improved integration into routine clinic practices and aimed to reduce barriers to service access unique to AYLHIV. Characterizing types of adaptations and adaptation rationale may enrich our understanding of the implementation context and improve abilities to tailor implementation strategies when scaling to new settings.

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

✪ “A problem shared is a problem solved:” integrating human-centered design and implementation science to optimize lay counselor supervision in Western Kenya

Abstract:

Implementation science and human-centered design (HCD) offer useful frameworks and methods for considering and designing for individuals' needs and preferences when implementing new interventions or technologies in global health. When used in tandem, the two approaches may blend creative and partnered research methods with a focus on the factors necessary to design, implement, and sustain interventions. However, research is needed that describes the process of blending these two approaches and explores the experiences of community partners. This study builds from a stepped-wedge cluster-randomized trial in Western Kenya, wherein teachers and community health volunteers have been trained to provide trauma-focused cognitive behavioral therapy (TF-CBT). Mobile phones emerged as a tool to supervise lay counselors from afar; however, their use was characterized by unique challenges. Informed by human-centered design and implementation science, we first engaged lay counselors (n = 24) and supervisors (n = 3) in individual semi-structured interviews then hosted an in-person participatory workshop to “co-design” solutions to optimize the use of mobile phone supervision. Lay counselors participated in focus group discussions regarding their experiences in the workshop. Focus group transcripts were analyzed using thematic analysis. We describe our approach as well as focus group discussion results. Counselors felt the workshop was a valuable experience to learn new strategies from their colleagues, and they enjoyed the “collaborative spirit” that emerged as they worked together. Counselors felt that varying small and large group discussions fostered participation by creating opportunities for more people to engage and share their thoughts. Counselors suggested the approach be improved by providing more tangible materials (e.g., hand-outs) and more closely following a schedule of activities. It is important to also center stakeholders’ experiences as partners in the research process. Though counselors largely expressed positive sentiments, they also shared valuable suggestions for how to improve participatory research practices in the future.

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

✪ The Effect of Stigma on Family Planning and HIV Pre-exposure Prophylaxis Decisions of Young Women Accessing Post-Abortion Care in Kenya

Abstract:

Adolescent girls and young women (AGYW) in Eastern and Southern Africa face parallel epidemics of unintended pregnancy and HIV. Their sexual health decisions are often dominated by intersecting stigmas. In an implementation science project integrating delivery of daily, oral pre-exposure prophylaxis (PrEP) for HIV prevention into 14 post-abortion care (PAC) clinics in Kenya, we enrolled a subset of PrEP initiating AGYW (aged 15 to 30 years) into a research cohort. Utilizing log binomial models, we estimated the effect of PrEP stigma on PrEP continuation (measured via self-report and urine assay for tenofovir) and abortion stigma on contraceptive initiation. Between April 2022 and February 2023, 401 AGYW were enrolled after initiating PrEP through their PAC provider, of which 120 (29.9%) initiated highly-effective contraception. Overall, abortion and PrEP stigmas were high in this cohort. Abortion stigma was more prevalent among those that were adolescents, unmarried, and reported social harm. Among 114 AGYW returning for the month 1 follow-up visit, 83.5% reported continuing PrEP and 52.5% had tenofovir detected. In this subset, higher levels of PrEP stigma were significantly associated with greater likelihood of PrEP adherence, but not PrEP continuation. For abortion stigma, greater scores in the subdomain of isolation were significantly associated with greater likelihood of initiating a highly-effective contraception, while greater scores in the subdomain of community condemnation were significantly associated with reduced likelihood of initiating a highly-effective contraception. Given the burden of stigma documented by our work, PAC settings are a pivotal space to integrate stigma-informed counseling and to empower young women to optimize contraceptive and PrEP decisions.

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

Authors:

✪ Open Access

Read the full text in the open access journal BMJ Open

Abstract:

Objectives

Design

Setting

Participants

Results

Conclusions

Data availability statement

Authors:

✪ Open Access

Read the full text in the open access ACM Journal on Computing and Sustainable Societies

Abstract:

Authors:

✪ Open Access

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

Abstract:

Authors:

✪ Open Access

Read the full text in the open access journal JNCI Monographs

Abstract:

Background

Methods

Results

Conclusion

Authors:

✪ Open Access

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

Abstract:

Background

Methods

Results

Conclusions

Authors:

✪ Open Access

Read the full text in the open access journal Trials

Abstract:

Background

Methods

Discussion

Trial registration

Authors:

✪ Open Access

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

Abstract:

Introduction

Methods

Results

Conclusions

Authors:

✪ Open Access

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

Abstract:

Introduction

Methods

Results

Conclusions

Authors:

✪ Open Access

Read the full text in the open access journal Social Science and Medicine - Mental Health

Abstract:

Authors:

✪ Open Access

Read the full text in the open access journal AIDS and Behavior

Abstract: