UW Articles Archive - Page 6 of 60 - Implementation Science at UW

✪ 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.

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

✪ Community/patient group champion team retrospective look at engage for equity PLUS: Results from a post-intervention champion team focus group

Abstract:

Community/patient voice has long been stifled in favor of the priorities of powerful health organizations that set the agenda for institutional practices and policies shaping health equity research. Academic Health Centers (AHC) and Clinical Translational Science Centers (CTSC) promote missions that are often unaligned with the realities of community and patient experiences when interacting with researchers and representatives from these institutions. Implementation science has increasingly adopted collaborative and participatory approaches to the design and implementation of health interventions co-created with community/patient group members as equal participants within community-academic partnerships. Community-based participatory research/community-engaged research are widely recognized as approaches to health intervention research that offers the potential for community-patient voice to be heard when the principles of authentic participatory research are adhered to throughout all aspects of the project. For AHC’s and CTSC’s to be fully engaged, the populations they serve must have access to institutional leadership and influence over decision-making about the organizational resources allocated to community/patient groups beyond efforts to cultivate a positive public image. The E2 community/patient champion team focus groups provide unique perspectives on how equitable institutional transformation can be accomplished in a retrospective assessment of the E2 PLUS Intervention.

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✪ Enhancing provider adoption of patient-reported outcome measures (PROMs) through implementation science: insights from two international workshops

Abstract:

Background

Although the use of patient-reported outcome measures (PROMs) in practice is increasing, successful implementation is contingent on engaging healthcare providers (HCPs). Using Implementation Science (IS), we present the content of two workshops hosted at the International Society for Quality-of-Life annual conferences for individuals seeking to implement PROMs collection and use in their settings. Our goals were to provide workshop participants with knowledge, tools, and resources to prepare HCPs for PROM adoption and to demonstrate tailored strategies to meet context-specific needs.

Methods

An interdisciplinary team with diverse expertise in PROMs implementation delivered two workshops guided by the Capability, Opportunity, Motivation – Behavior (COM-B) model and the Theoretical Domains Framework (TDF). Using dotmocracy, participants were asked to consider, for their local context, the factors most important for changing HCPs’ behaviors to adopt PROMs in daily practice.

Results

The workshops incorporated IS theories, models, and frameworks (TMFs) to identify barriers faced by HCPs, support behavior change, and apply tailored theory-informed implementation strategies to prepare HCPs for PROM integration and evaluate adoption success. The factors rated the most important by workshop participants (n = 53) were woven into the discussions to illustrate the most common barriers encountered by HCPs adopting PROMs. Presenters drew on real-world practice and research experiences to identify promising implementation strategies, including education, training, behavioral modeling, persuasion, environmental restructuring, enablement, and audit and feedback to increase the capability, opportunity, and motivation of HCPs.

Conclusion

Given the increasing evidence base supporting the role of PROMs in patient-centered care, it is imperative to understand the mechanisms and best practices for increasing provider adoption of PROMs. This work offers a roadmap for understanding determinants more important to HCPs and systematically selecting theory-informed implementation strategies that may increase the likelihood of HCP adoption of PROMs. Offering tailored HCP training/education programs and implementation strategies can prepare HCPs for timely and effective PROM implementation.

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

“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

✪ Evaluating behavioral intervention technologies: Integrating human-centered design and implementation science outcomes

Abstract:

Background

Behavioral intervention technologies (BITs) offer scalable, cost-effective healthcare solutions but often show reduced impacts in community settings and are rarely sustained. Human-centered design (HCD) enhances usability by tailoring BITs to stakeholder needs, while implementation science (IS) identifies contextual barriers and strategies to promote uptake and sustainability. Both HCD and IS aim to improve BIT usability and implementation through iterative, user-focused processes but are rarely integrated.

Objective

We introduced the user-centered and sustainable implementation science (USIS) model, a novel and systematic framework that combines HCD and IS principles to enhance BIT effectiveness and sustainability. We aimed to (1) synthesize the HCD and IS outcomes and integrate them into a USIS framework; (2) apply USIS to a case study: the sleep shared-management intervention for children with juvenile idiopathic arthritis and their parents (SLEEPSMART).

Methods

We conducted a narrative literature review on HCD and IS outcomes for BITs from the PubMed, CINAHL, and Web of Science databases. Articles were selected based on their focus on usability, implementation outcomes, and evidence-based healthcare practices. This synthesis informed the development of the USIS model.

Results

The USIS model incorporates five domains: (1) user-centeredness (empathy, engagement, and equity), (2) efficiency (cost, timeliness, and rapidity), (3) feasibility (learnability, memorability, error reduction, and low cognitive load), (4) satisfaction (acceptability and appropriateness), and (5) fidelity (adoption, penetration, and sustainability). We applied the USIS model to evaluate the SLEEPSMART project to demonstrate the application of the USIS model in guiding BIT design and refinement. Insights from the review informed the design principles applied during the development and testing stages of SLEEPSMART.

Conclusion

The USIS model serves as a practical and theoretical guide to improve BIT design and evaluation. By emphasizing implementation considerations early and centering user needs, USIS provides a pathway to bridge HCD and IS approaches to enhance the real-world impact and sustainability of digital health innovations.

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

✪ When evidence is not enough: A qualitative exploration of healthcare workers’ perspectives on expansion of two-way texting (2wT) for post- circumcision follow-up in South Africa

Abstract:

As per South African national guidelines, in-person follow-up visits after voluntary medical male circumcision (VMMC) are required but may be unnecessary. Two-way texting (2wT), an mHealth platform, engages clients in post-operative care and triages those with complications to in-person review. 2wT was found to be safe, effective, and efficient. In South Africa, to understand provider perspectives on 2wT and potential for expansion, 20 key informant interviews were conducted with management, clinicians, data officials and support staff involved in 2wT scale-up. Interviews were analyzed using rapid qualitative methods and informed by two implementation science frameworks: the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework and the Pragmatic, Robust, Implementation and Sustainability Model (PRISM). Participants shared mixed and multi-faceted feedback, including that 2wT improves monitoring and evaluation of clients and clinical outcomes while also reducing follow-up visits. Challenges included duplicative routine and 2wT reporting systems and perceptions that 2wT increased workload. To improve the likelihood of successful 2wT scale-up in routine VMMC settings, participants suggested: further 2wT sensitization to ensure clinician and support staff buy-in; a dedicated clinician or nurse to manage telehealth clients; improved dashboards to better visualize 2wT client data; mobilizing 2wT champions at facilities to garner support for 2wT as routine care; and updating VMMC guidelines to support VMMC telehealth. As attendance at follow-up visits may not be as high as reported, implementing 2wT may require more effort but also brings added benefits of client verification and documented follow-up. The transition from research to routine practice is challenging, but use of RE-AIM and PRISM indicate that it is not impossible. As VMMC funding is decreasing, more effort to share the evidence base for 2wT as a safe, cost-effective, high-quality approach for VMMC follow-up is needed to encourage widespread uptake and adoption.

Author summary

South Africa has a high prevalence of HIV, and voluntary medical male circumcision is a prevention method recommended by the World Health Organization. Two-way texting (2wT) is a digital health intervention that allows males to receive educational messages after circumcision about healing and send messages directly to a provider via SMS or WhatsApp. This system detects as many complications as routine follow-up care, though is more efficient. As we scale up to new locations in South Africa, we wanted to ensure the approach is well-adapted for health workers. Through 20 interviews with health workers, we found that it saves clients in-person visits and helps with data collection. However, more effort is needed to introduce the intervention to clinicians, including providing better training and appointing champions to help motivate clinicians. Funding for HIV and VMMC programs is decreasing, so it is important to find tools such as digital health to reduce the burden on facilities while maintaining quality client care.

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

✪ Building the Plane as We Fly: Considerations for Scaling Out Coordinated Specialty Care for Early Psychosis in the Rural United States

Abstract:

Coordinated specialty care (CSC) programs for early psychosis have expanded rapidly in the United States in recent years due to evidence supporting early intervention and subsequent federal funding. The majority of CSC programs are located in major urban and surrounding suburban areas, although many states are expanding or planning to expand CSC services to rural and remote areas. Despite ongoing implementation efforts, little is known about effective implementation of CSC in rural and remote communities. The present article uses the “scale out” model as a guiding framework to consider how CSC can be implemented in rural areas and describes considerations relevant to infrastructure for rural CSC: defining rurality, priority population, workforce, financing, telehealth, strengths of rural communities, culture, and social determinants of health. We then discuss two overarching challenges of (a) integrating alternative bottom-up, community partnership approaches, such as community-based participatory research, into the scale out model and (b) using the scale out model for an implementation effort that is already underway. We argue that successful rural CSC implementation will involve integrating the scale out model with rigorous community-based participatory research to incorporate theory with real-world needs and learn in real-time from ongoing implementation efforts.

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

✪ 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.

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

✪ Getting to Implementation for HIV Pre-Exposure Prophylaxis (GTI-PrEP): A data-driven approach to PrEP prescribing

Abstract:

Background

Pre-Exposure Prophylaxis (PrEP) dramatically reduces the likelihood of acquiring human immunodeficiency virus (HIV), yet it remains under-prescribed, particularly for people in communities with high HIV incidence. While implementation science and health services researchers aim to address disparities in care, few interventions have proven effective in doing so. We aimed to identify implementation strategies associated with higher PrEP prescribing rates and pilot test a tailored intervention as a proof-of-concept in a single Veterans Health Administration (VA) facility.

Methods

VA clinicians were surveyed using an instrument derived from the Evidence-based Recommendations for Implementing Change taxonomy to assess the use of various strategies for PrEP in fiscal years 2019–2021. Correlational analyses identified the strategies associated with the frequency of PrEP prescribing and semi-structured interviews with personnel from 11 VA medical facilities with high PrEP prescribing refined and manualized these strategies into the Getting to Implementation (GTI)-PrEP playbook. The playbook was subsequently pilot tested in a VA facility with high new HIV diagnosis rates and low PrEP prescribing rates.

Results

The clinician survey collected 157 responses from 95 unique VA facilities on implementation strategy use. Analysis identified eight strategies significantly associated with PrEP prescribing, including: networking, clinician education, clinical support tools, dashboard utilization, telehealth, pharmacist involvement, direct patient engagement, and enhanced sexual health history taking. In the pilot study, the site completed the GTI-PrEP Playbook with high fidelity and newly implemented seven of the eight strategies, achieving a 363% increase in PrEP prescribing rates among Black Veterans over the one-year period.

Conclusions

This multi-year national evaluation identified a core subset of effective implementation strategies for increasing PrEP prescribing. The process of empirically specifying these strategies and pilot testing them through the GTI-PrEP playbook demonstrates a promising, data-driven approach to improve PrEP prescribing rates and reduce racial disparities in HIV prevention.

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

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