Uganda Archives - Implementation Science at UW

✪ A framework policy analysis of single-dose HPV vaccination adoption in East Africa: a rapid review

Abstract:

Cervical cancer is a global public health problem. While HPV vaccination effectively prevents cervical cancer, vaccination coverage remains low in low -and middle-income countries (LMICs) where around 94% of cervical cancer-related deaths occur. To improve coverage and accelerate progress toward achieving cervical cancer elimination, the World Health Organization (WHO) recommended that countries switch to a single-dose HPV vaccination schedule in 2022. Despite strong evidence of the health and economic benefits of a single-dose HPV vaccination schedule, its adoption has varied across countries.

We sought to rapidly review existing evidence to assess the “how” of policy reform on HPV vaccination, leveraging a policy analysis of single-dose HPV vaccination adoption in three East African countries. We used the Health Policy Triangle Framework (HPF) to compile key considerations that led to the adoption of single-dose HPV vaccination in Ethiopia, Uganda, and Tanzania. Relevant articles from peer-reviewed journals and grey literature published up to December 2024 were selected using pre-set inclusion and exclusion criteria. Data were extracted and summarized using a rapid qualitative analysis approach guided by the HPF. Twenty-four articles from academic and grey literature were examined.

Beyond context-specific aspects, a few common themes emerged across the three countries. Political will focused on addressing cervical cancer as a public health problem, and it was crucial to prioritize the revision of the HPV vaccination policy. The policy revision on the HPV vaccination schedule was undertaken, building on existing evidence and the WHO endorsement. Additionally, the availability of key evidence on the magnitude of this public health problem (eg: burden of the disease), the potential benefit of a single-dose schedule (efficacy, and the economic impact) played an important role in the policy revision process. At the national level, National Immunization Technical Advisory Groups (NITAGs) that provided evidence-based guidance to policy-makers were central to the single-dose decision-making process. Our findings highlighted key considerations for the policy revision process in three East African countries, which could inform strategic policy decisions in these countries and comparable settings.

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✪ Acceptability, feasibility, and factors affecting implementation of a gender-sensitivity training for HIV providers and staff in Uganda: a mixed methods, quasi-experimental controlled pilot trial

Abstract:

Background

Health workers play a critical role in providing gender-sensitive HIV care. However, without adequate training, they may inadvertently reinforce negative gender norms that hinder engagement in care. To improve ART services in sub-Saharan Africa, effective implementation strategies, including trainings, are essential.

Methods

This study evaluated the feasibility and acceptability of a novel 4-session, gender-sensitivity training for HIV health and lay workers in rural and peri-urban Uganda. We conducted a pilot quasi-experimental controlled trial in 2022–23, utilizing data from three sources: process data from 144 providers and 238 clients, qualitative post-intervention focus groups and interviews with 53 training attendees, and stakeholder interviews with 12 community leaders and facilitators. We employed thematic analysis guided by the Consolidated Framework for Implementation Research (CFIR).

Results

The training was highly rated by attendees via brief post-session surveys, with 99% of sessions deemed satisfactory. Qualitative feedback indicated that the sessions were perceived as appropriate for addressing providers’ gaps in delivering gender-sensitive care and as beneficial for participants. High feasibility was evidenced by 100% of intervention steps delivered (fidelity checklists), 86% attendance (attendance logs), and 98.6% and 94.8% recruitment of eligible providers and clients (study records), respectively. Through qualitative exit focus groups, factors that positively affected acceptability and feasibility included tactics to gain support from supervisors, the use of experienced facilitators and active learning approaches, and the consideration of the health system context in delivery (e.g., cadre mix, location). Suggested improvements encompassed addressing interpersonal and structural barriers to client-centered care, incorporating community sensitization, streamlining content, and enhancing mentorship follow-ups. Stakeholders recognized the training’s alignment with national health priorities and emphasized the need for clarity regarding its integration with existing training curricula and ongoing stakeholder engagement.

Conclusions

This study underscores the acceptability and feasibility of a gender-sensitivity training program for HIV providers; further evaluation of the program is warranted. Identified factors influencing implementation can inform enhancements to gender-focused training initiatives to improve the quality of HIV services and enhance client engagement and health outcomes.

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✪ Healthcare provider perspectives on integrating HIV care into cancer centers in Malawi, South Africa, Uganda, and Zimbabwe

Abstract:

Background

In East and Southern Africa, treatment of people with concomitant cancer and HIV is complicated by siloed service delivery pathways, which exacerbate barriers to care and impact clinical decision-making. Integrating HIV care into cancer treatment centers may improve service delivery and overall patient outcomes.

Methods

We administered a questionnaire to clinicians and support staff at tertiary cancer referral centers in Malawi, Zimbabwe, Uganda, and South Africa to assess level of concern about clinical management of people with HIV (PWH) and cancer, barriers to integrating HIV service delivery into cancer treatment delivery, and beliefs related to HIV, antiretroviral therapy (ART), and integrated care.

Results

Of 195 clinician and support staff participants, 165 (85 %) were direct providers of cancer-associated care. Over 50 % indicated that they held concerns about survival, treatment complications, co-morbidities, and drug-drug interactions in PWH compared to patients without HIV. Over 80 % agreed that knowing cancer patients’ HIV status, ART status, and ART regimen would facilitate better care and should be considered in cancer care decision-making. Overall, respondents were optimistic that HIV-related care could be easily integrated into cancer care provision. The most-frequently endorsed barriers to integrated care were workspace limitations, disruptions to workflow, availability of staff, and cost to the hospital and to patients.

Conclusions

Cancer clinicians and support staff report overall positive attitudes toward integrating HIV and cancer service delivery. Research to elucidate service delivery pathways and contextualize system-based barriers to integrating care are critical next steps to optimize linked HIV and cancer care delivery.

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✪ 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.

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✪ A pragmatic approach to identifying implementation barriers and facilitators for a novel pre-exposure prophylaxis (PrEP) delivery model at public facilities in urban Uganda

Abstract:

Background

Scalable HIV pre-exposure prophylaxis (PrEP) delivery models for resource-limited settings are critical for improving PrEP coverage and interrupting HIV transmission. This research uses technical assistance (TA) reports to evaluate implementation barriers and facilitators for a novel delivery model integrating PrEP and antiretroviral therapy (ART) delivery for HIV sero-different couples in public health facilities in Kampala, Uganda.

Methods

We used data from the Partners PrEP Program (PPP)—a stepped-wedge cluster randomized trial that is launching PrEP delivery through an integrated model of oral PrEP and antiretroviral therapy (ART) delivery for HIV sero-different couples at public health facilities in Kampala and Wakiso, Uganda (NCT03586128). Technical assistance teams, comprised of PPP program staff, conducted monthly TA visits to implementing facilities where they identified and addressed implementation challenges in collaboration with health facility staff. Findings were recorded in TA reports, a standardized form structured using the Consolidated Framework for Implementation Research (CFIR). We used a conceptual content analysis approach to evaluate TA reports completed from January to December 2019 and identify implementation barriers and facilitators.

Results

Among 39 reports from the 8 implementing facilities (~ 5 per facility), we identified 11 CFIR constructs. Key implementation facilitators included sensitizing and educating facility staff about PrEP (knowledge and beliefs about the innovation); establishing formal and informal feedback and accountability mechanisms (reflecting and evaluating); and empowering facility staff to address implementation challenges (self-efficacy). Key implementation barriers were related to ineffective recruitment and referral of sero-different couples to and from nearby facilities (cosmopolitanism) as well as stockouts of laboratory resources and testing supplies (available resources).

Conclusions

This analysis featured a robust implementation science framework to assess the relationship between early implementation determinants and outcomes of this innovative PrEP delivery model. Further, we have provided important descriptions of early implementation barriers and facilitators that will inform scale-up efforts for PrEP delivery within and beyond Uganda. Future work will refine the analysis of pragmatic program data, qualitatively investigate the identified key themes, and explore strategies for addressing implementation barriers.

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Identifying challenges and recommendations for advancing global mental health implementation research: A key informant study of the National Institute of Mental Health Scale-Up Hubs

Authors:

John A.Naslund, Jasmine Kalha, Juliana L. Restivo, Ishmael Amarreh, Tamora Callands, Hongtu Chen, Carlos Gomez-Restrepo, Hesham M. Hamoda, Arjun Kapoor, Sue Levkoff, Jones Masiye, Maria A. Oquendo, Vikram Patel, Inge Petersen, Ozge Sensoy Bahar, Laura Shields-Zeeman, Fred M. Ssewamala, Deepak Tugnawat, José Miguel Uribe-Restrepo, Lakshmi Vijayakumar, Bradley H. Wagenaar, Milton L.Wainberg, Larry Wissow, Haja Ramatulai Wurie, Chifundo Zimba, & Soumitra Pathare

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

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Published: January 2021

Read the full text in the subscription access journal Asian Journal of Psychiatry

✪ How to evaluate the implementation of complex health programmes in low-income settings: the approach of the Gavi Full Country Evaluations

Abstract:

Vaccination, like most other public health services, relies on a complex package of intervention components, functioning systems and committed actors to achieve universal coverage. Despite significant investment in immunization programmes, national coverage trends have slowed and equity gaps have grown. This paper describes the design and implementation of the Gavi Full Country Evaluations, a multi-country, prospective, mixed-methods approach whose goal was to monitor and evaluate processes, inputs, outputs and outcomes of immunization programmes in Bangladesh, Mozambique, Uganda and Zambia.

We implemented the Full Country Evaluations from 2013 to 2018 with the goal of identifying the drivers of immunization programme improvement to support programme implementation and increase equitable immunization coverage. The framework supported methodological and paradigmatic flexibility to respond to a broad range of evaluation and implementation research questions at global, national and cross-country levels, but was primarily underpinned by a focus on evaluating processes and identifying the root causes of implementation breakdowns. Process evaluation was driven by theories of change for each Gavi funding stream (e.g. Health Systems Strengthening) or activity, ranging from global policy development to district-level programme implementation.

Mixing of methods increased in relevance and rigour over time as we learned to build multiple methods into increasingly tailored evaluation questions. Evaluation teams in country-based research institutes increasingly strengthened their level of embeddedness with immunization programmes as the emphasis shifted over time to focus more heavily on the use of findings for programme learning and adaptation. Based on our experiences implementing this approach, we recommend it for the evaluation of other complex interventions, health programmes or development assistance.

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✪ Unintended uses, meanings, and consequences: HIV self-testing among female sex workers in urban Uganda

Abstract:

Female sex workers (FSWs) are at increased risk of HIV and face significant barriers to clinic-based HIV testing, including provider stigma and privacy constraints. HIV self-testing (HIVST) has been proven to significantly increase HIV testing among FSWs. Less is known, however, about how FSWs make meaning of oral-fluid HIV self-tests, and the unintended ways they use and understand this novel technology. From October 2016 to March 2017, we conducted 61 in-depth interviews with FSWs (n = 31) in Kampala, Uganda. Eligible participants were: female, ≥18 years, exchanged sex for money or goods, and had not recently tested for HIV. We used inductive coding to identify emerging themes and re-arranged these into an adapted framework. Unintended desirable ways FSWs described self-testing included as a means to test others, to bolster their reputation as a health-conscious sex worker, and to avoid bearing witness to suffering at health facilities. Unintended undesirable meanings ascribed to self-testing included misunderstandings about how HIV is transmitted (via saliva versus blood) and whether self-tests also test for other infections. HIVST can increase FSWs’ knowledge of their own HIV status and that of their sexual partners, but messaging and intervention design must address misunderstandings and misuses of self-testing.

Trial registration:

ClinicalTrials.gov identifier: NCT02846402

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✪ Situational analysis of breast health care systems: Why context matters

Abstract:

Background

Implementation of evidence‐based, resource‐appropriate guidelines for breast cancer control should be preceded by a baseline assessment or situational analysis to assess breast health infrastructure, workforce capacity, patient pathways, existing practices, accessibility, and costs.

Methods

To support the assessment of breast health care systems within the broader context in which they exist, the Breast Health Global Initiative (BHGI) developed, tested, and refined a set of situational analysis tools with which to guide the assessment of breast health care capacity, identify the relative strengths and weaknesses of the health system, and support stakeholders in prioritizing actionable items to advance breast cancer care using evidence‐based strategies tailored to their setting. The tools address 6 domains of breast health care delivery: 1) breast cancer early detection practices; 2) breast cancer awareness programs; 3) the availability of breast cancer surgery; 4) the availability of pathology; 5) the availability of radiotherapy, and 6) the availability of systemic therapy services. The current study also describes the more comprehensive International Atomic Energy Agency Programme of Action for Cancer Therapy (PACT) integrated missions for PACT (imPACT) review.

Results

As of 2020, 5 formal BHGI situational analyses have been performed in India, Brazil, Panama, Tanzania, and Uganda. As of August 2019, a total of 100 imPACT reviews have been conducted in 91 countries. These assessments can contribute to more informed policymaking.

Conclusions

Situational analyses are a prerequisite for the development of resource‐appropriate strategies with which to advance breast cancer control in any setting and should assess services across the entire breast health care continuum as well as the broader structural, sociocultural, personal, and financial contexts within which they operate.

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

✪ Implementation science and stigma reduction interventions in low- and middle-income countries: A systematic review

Abstract:

Background

Interventions to alleviate stigma are demonstrating effectiveness across a range of conditions, though few move beyond the pilot phase, especially in low- and middle-income countries (LMICs). Implementation science offers tools to study complex interventions, understand barriers to implementation, and generate evidence of affordability, scalability, and sustainability. Such evidence could be used to convince policy-makers and donors to invest in implementation. However, the utility of implementation research depends on its rigor and replicability. Our objectives were to systematically review implementation studies of health-related stigma reduction interventions in LMICs and critically assess the reporting of implementation outcomes and intervention descriptions.

Methods

PubMed, CINAHL, PsycINFO, and EMBASE were searched for evaluations of stigma reduction interventions in LMICs reporting at least one implementation outcome. Study- and intervention-level characteristics were abstracted. The quality of reporting of implementation outcomes was assessed using a five-item rubric, and the comprehensiveness of intervention description and specification was assessed using the 12-item Template for Intervention Description and Replication (TIDieR).

Results

A total of 35 eligible studies published between 2003 and 2017 were identified; of these, 20 (57%) used qualitative methods, 32 (91%) were type 1 hybrid effectiveness-implementation studies, and 29 (83%) were evaluations of once-off or pilot implementations. No studies adopted a formal theoretical framework for implementation research. Acceptability (20, 57%) and feasibility (14, 40%) were the most frequently reported implementation outcomes. The quality of reporting of implementation outcomes was low. The 35 studies evaluated 29 different interventions, of which 18 (62%) were implemented across sub-Saharan Africa, 20 (69%) focused on stigma related to HIV/AIDS, and 28 (97%) used information or education to reduce stigma. Intervention specification and description was uneven.

Conclusion

Implementation science could support the dissemination of stigma reduction interventions in LMICs, though usage to date has been limited. Theoretical frameworks and validated measures have not been used, key implementation outcomes like cost and sustainability have rarely been assessed, and intervention processes have not been presented in detail. Adapted frameworks, new measures, and increased LMIC-based implementation research capacity could promote the rigor of future stigma implementation research, helping the field deliver on the promise of stigma reduction interventions worldwide.

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