Qualitative Research Archives - Page 2 of 10 - Implementation Science at UW

✪ “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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“It makes all the sense in the world”: A qualitative evaluation of patient perspectives on implementation outcomes of a peer-facilitated integrated infectious disease and substance use care model

✪ 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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✪ “If he returns, receive him because he has realized that he needs assistance”: A qualitative study exploring preferences for retention on antiretroviral therapy support in Malawi among Lighthouse Clinic clients

Abstract:

Introduction

Retention of people living with HIV (PLHIV) on antiretroviral therapy (ART) is critical. Retention is not static: clients cycle in and out of care over the course of treatment. Retention support is also evolving, with interventions like mobile health (mHealth) gaining traction. We aimed to explore ART clients’ perspectives and recommend strategies for improved retention support including a two-way-texting (2wT) mHealth intervention in two clinics in Malawi.

Materials and methods

We conducted focus group discussions (FGDs) with PLHIV on ART receiving 2wT or standard of care (SoC) retention support to understand client perspectives. FGDs were audio-recorded in Chichewa, translated and transcribed into English. We used the RE-AIM implementation science framework to report findings on the reach, effectiveness, adoption, implementation, and maintenance potential of retention interventions considering individual, clinic/organization, and community factors. Through rapid qualitative analysis, we identified key themes and subthemes.

Results

Ten FGDs were conducted with 89 ART clients (aged ≥18 years; 55% female): four FGDs among 2wT participants and six among SoC participants. Few differences were observed between 2wT and SoC clients. All clients appreciated accessing at least one form of support and recommended continuous assistance, regardless of age, sex, or duration on ART. Clients wished to be encouraged by other PLHIV to allay common fears. Groups discussed the need for intensified support to retain young clients or those out of care longer. Individual responsibility was identified as necessary, but insufficient, to improve retention: respondents desired a more positive clinic environment to encourage persistence in care. Fear of stigma, unintended status disclosure, and negative interactions with clinic staff prevent some clients from returning to care.

Conclusion

PLHIV want differentiated, continuous retention support from other PLHIV coupled with a positive clinic environment to promote retention and reengagement in care. As differentiated retention support is expensive, consideration of cost, feasibility, and sustainability is needed.

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✪ Determinants of implementation of a stepped care intervention for adolescents and youth living with HIV in Kenya: a qualitative evaluation

Abstract:

Background

Differentiation of HIV services, a client-centered strategy, may improve care outcomes among adolescents and youth living with HIV (AYLHIV). Understanding health provider perceptions of barriers and facilitators that influence implementation can optimize adoption and sustainment of health systems interventions.

Methods

The Data-informed Stepped Care (DiSC) study was a cluster randomized controlled trial of a stepped care intervention in 24 HIV care facilities in Kenya. At each visit, providers used an assessment tool to allocate AYLHIV to services according to level of need. Stable clients were allocated to differentiated service delivery (DSD) with less frequent visits. Intensified services, including behavioral counseling, were provided for those with greater likelihood of loss to follow-up, mental health issues, or viral non-suppression. We conducted focus group discussions (FGDs) with providers across 12 intervention sites between January-February 2023. FGDs used a semi-structured interview guide, grounded in the Consolidated Framework for Implementation Research, which were audio-recorded and transcribed. Transcripts were analyzed using a team-based rapid turnaround approach to characterize key determinants influencing adoption, reach, and fidelity.

Results

Providers were enthusiastic about, and quick to adopt, the DiSC intervention. They found the DiSC tool easy to use and felt it provided a relative advantage by improving service delivery efficiency and prioritizing time with higher need AYLHIV. Providers noted the importance of tool flexibility to align with changing national guidelines. They expressed concerns about compatibility with existing workflows at facilities exclusively using electronic medical record (EMR) systems, suggesting EMR integration will be needed for intervention sustainment. AYLHIV eligible for DSD benefited from clinic visit intervals that aligned with the school calendar, which posed a challenge for reaching AYLHIV in more intensive steps. Provider collective efficacy was important in consistent implementation of DiSC and was facilitated by continuous quality improvement meetings, access to knowledge and information, and perceived intervention effectiveness. Supportive leadership was an important driver of implementation success, through availing space for mental health counseling sessions and time for client-provider interactions outside standard operating hours.

Conclusions

Consideration of alignment with national policy, integration into clinic workflows, school schedules, and leadership engagement, will be important for sustained use of differentiated care interventions.

Trial registration

ClinicalTrials.gov, NCT05007717. Registration date: July 13, 2021.

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✪ Advancing implementation of single session interventions in schools: a protocol for a qualitative study

Abstract:

Background

Schools are one of the most common settings in which youth seek mental health services, yet existing school-based mental health interventions are often difficult to implement due to time, cost, and staffing limitations. Digital, self-administered Single Session Interventions (SSIs) are evidence-based supports that are intentionally structured to deliver a clinically-meaningful dosage of evidence-based content within one session. Although multiple studies have demonstrated the clinical effectiveness of school-based SSIs, there have been no systemic efforts to understand how SSIs can be practically implemented in schools. The goal of this project is to partner with students, parents, and school staff to identify factors that impact the implementation of SSIs and understand how SSIs can be sustainably integrated as mental health supports into school mental health infrastructure.

Methods

We will conduct focus groups (five groups, total n = 35–45) among community members (i.e., students, parents/caregivers, teachers, school administrators, and school mental health providers) to assess perceived facilitators and barriers to the effective implementation of evidence-based SSIs in schools (Aim 1). We will then work in partnership with community members (n = 10–15) to co-design multi-level implementation strategies (i.e., student-directed, staff-directed, system-directed) for increasing uptake and promoting sustainability of school-based SSIs (Aim 2). We will use inductive coding to thematically analyze qualitative data from group sessions. This study is being conducted within the Lake Washington School District in the Seattle, Washington region.

Discussion

The proposed project will be the first to investigate facilitators and barriers to real-world implementation of SSIs in schools and strategies to improve implementation. Future studies may test the effectiveness of the generated implementation strategies on outcomes such as SSI uptake over time.

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✪ Finding the balance between rigour and relevance: implementing adaptations to the implementation of a pragmatic randomised controlled trial of a two-way texting intervention for voluntary medical male circumcision in South Africa

Abstract:

Objectives

To document adaptations that were made to the implementation of the two-way texting (2wT) randomised controlled trial (RCT) for voluntary medical male circumcision (VMMC) in South Africa and to provide a nuanced discussion on the differences between adaptations and fidelity in this context.

Design

We conducted a qualitative study using the Framework for Reporting Adaptations and Modifications in Evidence-based Implementation Strategies (FRAME-IS) to examine 2wT adaptations. We reported adaptations to the 2wT intervention using two steps. First, we categorised adaptations in a shared study-specific Google Docs that documented participant engagement with the 2wT system, tracked daily RCT implementation notes, reported software bugs and noted reminder emails about adaptations for the research team. Second, we conducted a qualitative assessment of the influence of adaptations on project outcomes via 10 periodic reflection meetings with VMMC implementers. Reflection documentation included notes from field observations, meeting minutes and informal partner check-ins to complete adaptation documentation. Using the FRAME-IS as a codebook, adaptations were categorised.

Settings

The RCT was conducted in rural and urban VMMC clinics in the North West and Gauteng districts of South Africa.

Participants

Implementation scientists and VMMC implementers who implemented the 2wT pragmatic randomised controlled trial (pRCT) were participants for the adaptation study.

Primary and secondary outcome measures

The primary outcome measure was the adaptations that were made during the implementation of the 2wT pRCT. The secondary outcome measures were fidelity and rigour of implementing adaptations to the 2wT pRCT.

Results

Between June 2021 and February 2022, 13 adaptations were identified in three phases during the implementation of the 2wT pRCT. The first phase of adaptations aimed to augment study recruitment, including conducting weekend VMMC recruitment camps, using mobile outreach services in the rural site, adding two urban sites to increase recruitment, using weekly WhatsApp calls for updates with all implementing teams, using virtual meetings to implement the 2wT strategy remotely during COVID-19 restrictions and allocating one clinician to work outside of normal working hours. The second phase of adaptations further enhanced enrolments, including adding two local language translations in the usability survey for 2wT men and contributing a portion towards the salary of the implementing staff by the research partner. The third phase included the exclusion of two rural clinics as recruitment sites due to inconsistent mobile phone networks, adding another layer of data quality checks to ensure data quality, training non-clinical counsellors to help with enrolling clients, retraining of staff in the rural site with high staff turnover and using both primary and alternative phone numbers for enrolment to reduce loss to follow-up.

Conclusions

This study made adaptations to the 2wT pRCT without compromising the fidelity of the study. The 2wT pRCT balances rigour (fidelity) and relevance (adaptation). Adaptations should not be confined by rigour but should also not go unchallenged or unverified. We conclude that fidelity can be maintained with adaptations that are implemented to close the gap between research in the laboratory and practice.

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✪ Lessons learnt from the 2021 Pacific Northwest heat dome: a qualitative study of western Washington’s healthcare community response

Abstract:

Objective

The 2021 Pacific Northwest heat dome was Washington state’s deadliest recorded weather event and presented unprecedented response challenges to the state’s health sector. Understanding the impacts of this extreme heat event (EHE) on the sector as well as the barriers to and facilitators of implementing effective heat response is critical to preparing for future events, which are happening more frequently in the region due to climate change.

Design

Guided by an implementation science framework, we convened listening sessions and focus groups of the health sector in western Washington to reflect on regional response efforts.

Setting

Health sector organisations in 15 counties in western Washington State, USA: Clallam, Grays Harbor, Island, Jefferson, King, Kitsap, Lewis, Mason, Pacific, Pierce, San Juan, Skagit, Snohomish, Thurston and Whatcom.

Participants

A convenience sample of 109 listening group participants was recruited through the professional networks of the Northwest Healthcare Response Network, a regional healthcare coalition. 27 of the health sector professionals were recruited using purposive sampling to participate in seven focus groups organised by organisation type.

Results

The co-presence of the COVID-19 pandemic, limited staff capacity, resource acquisition challenges and inadequate regional collaboration emerged as key barriers, while advanced planning, indoor cooling capabilities, adapting strategies to local needs, robust internal relationships and strong external partnerships were reported to facilitate effective response. Establishing centralised coordination ahead of heat events, making improvements to the cooling capabilities of the built environment, developing plans and policies for EHEs that have co-benefits for other events, adopting evidence-informed response strategies, institutionalising the knowledge and relationships developed through prior events and improving evaluative processes (such as developing real-time monitoring capacity) will enable more effective response to future EHEs.

Conclusions

Western Washington’s health sector implemented EHE response activities that enabled essential service continuity, despite limited resources, unfamiliarity with EHEs and other systemic challenges. The recency of the heat dome presents an opportunity to incorporate lessons learnt into practice, policies, plans and built environment; these are necessary improvements ahead of future large-scale events the region may experience in the coming decades.

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✪ 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**}

✪ Development of a method for qualitative data integration to advance implementation science within research consortia

Abstract:

Background

Methods of integrating qualitative data across diverse studies and within multi-site research consortia are less developed than those for integrating quantitative data. The development ofsuchmethods is essential to support the data exchange needed for cross-study qualitative inquiry and given the increasing emphasis on data sharing and open science. We describe methods for qualitative data integration within the National Cancer Institute’s Improving the Management of symPtoms During And following Cancer Treatment (IMPACT) Consortium funded by the Cancer MoonshotSM. Data collection and analysis were guided by the Consolidated Framework for Implementation Research (CFIR). Our case study highlights potential solutions for unique challenges faced when integrating qualitative data across multiple settings in a research consortium.

Methods

The IMPACT consortium is comprised of three research centers (RCs) each conducting pragmatic trials examining the effectiveness of routine symptom management on patient-centered outcomes. After reaching consensus on use of CFIR as the common implementation determinant framework, RCs developed a semi-structured interview guide and tailored it to features of their healthcare setting and symptom management interventions. RCs conducted interviews/focus groups with healthcare system partners to examine contextual factors impacting implementation. RCs exchanged 1–2 transcripts (n = 5 total) for purposes of pilot testing the methodology.

Results

Given the heterogeneity of study settings and contexts, it was challenging to simultaneously assign codes at both domain and construct levels and the process was resource intensive. Recommendations include employing a common framework for data collection and analyses from the outset, coding at domain level first and then incorporating construct codes, and centralizing processes via a coordinating center (or similar entity) and combining coded transcripts using qualitative software. We also generated an iteratively refined codebook that employed the CFIR schema and incorporated CFIR 2.0 to provide detailed guidance for coders conducting cross-study qualitative inquiry.

Conclusions

Limited guidance exists on how to support qualitative data integration, data exchange, and sharing across multiple studies. This paper describes a systematic method for employing an implementation determinant framework-guided approach to foster data integration. This methodology can be adopted by other research consortia to support qualitative data integration, cross-site qualitative inquiry, and generate improved understanding of evidence-based intervention implementation.

Contributions to the literature

Few standard practices exist for integrating qualitative data across different studies to conduct cross-study qualitative inquiry. Developing data integration procedures is critical to generating insights about practice improvement across settings and achieving goals of open science.
This report describes a method for integrating qualitative data using the Consolidated Framework for Implementation Research illustrated within the context of NCI’s Improving the Management of symPtoms During And following Cancer Treatment (IMPACT) Consortium.
The method describedcan be applied within research consortia and across multi-site studies to support qualitative data integration, thereby producing valuable insights to improve implementation of evidence-based interventions.

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

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

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

Abstract:

Background