Implementation of Evidence-Based Practices to Reduce Youth HIV Transmission and Improve Self-Management: A Survey of Key Stakeholder Perspectives

Using the Exploration-Preparation-Implementation-Sustainment (EPIS) Framework to prepare for the implementation of evidence-based practices into adolescent HIV settings

Despite advances in evidence-based practices (EBP) to support HIV prevention and treatment, youth ages 13-24 experience significant disparities in HIV risk and outcomes. An important factor in this disparity is poor EBP implementation, yet implementation research is limited, particularly in youth-serving settings. This study used the Exploration, Preparation, Implementation, Sustainment (EPIS) framework to guide the implementation of four Motivational Interviewing (MI) and MI-framed interventions into youth-serving HIV prevention and treatment settings. Key stakeholders (n = 153) across 13 sites completed pre-implementation interviews. Stakeholders' comments identified two critical factors for effective implementation: fit with the patient population and provider receptivity, including concerns about scope of practice, buy-in, and time. Stakeholders recommended strategies for structuring training, fidelity monitoring, and facilitating implementation including engaging informal leaders, collaboratively developing the implementation strategy, and site-wide implementation. Results highlight the importance of pre-implementation contextual assessment and strategic planning for identifying provider concerns and developing responsive implementation strategies.

Adapting the self-assessment of contextual fit scale for implementation of evidence-based practices in adolescent HIV settings

Background

Contextual fit is an important variable in the implementation of evidence-based programs (EBPs). The objectives of the current study were to examine the psychometric properties of the adapted Self-Assessment of Contextual Fit (SACF) measure for HIV clinical care settings (calling it SACF-HIV) and explore how perceptions of contextual fit varied across two different interventions (an intervention to scale up tailored motivational interviewing and an individually focused HIV prevention intervention) and 12 clinical sites.

Methods

We collected SACF-HIV data as part of a larger cross-project implementation science study (ATN 153). The study sample includes 128 clinicians, community health workers, interventionists, adherence counselors, and other members of the prevention and care team who engage in the implementation of EBPs at 12 HIV prevention and clinical care sites in the USA. We assessed the internal consistency of the SACF-HIV using Cronbach’s alpha and examined the sub-dimensionality of the scale with an exploratory factor analysis. To explore concurrent validity, we examined Pearson’s correlation coefficients between the adapted scale and fit-related sub-scale scores from the Evidence-Based Practice Attitudes Scale-50 (EBPAS-50). Variation in perceptions of fit by intervention was examined using descriptive statistics.

Results

Internal consistency of the adapted scale was strong (α=0.895). Factor analyses revealed two sub-scales—one capturing general insights regarding contextual fit, such as perceptions of skill, experience, and alignment with client needs (loadings ranging from .5 to .84), and a second centering perceptions regarding implementation support, such as resources and administrative support (loadings ranging from .89 to .97). Concurrent validity was supported by statistically significant correlations in the expected direction with EBPAS-50 fit-related sub-scales (r=.33–.35, p ≤ 0.05). SACF-HIV mean fit scores varied by intervention and the difference was statistically significant (2.78 vs. 2.53, p < 0.05).

Conclusions

There are relatively few tools assessing perceptions of contextual fit in HIV clinical settings. These results suggest the 12-item adapted SACF is a reliable, valid global assessment of perceptions of contextual fit and implementation support. The SACF-HIV can be used by practitioners and researchers interested in understanding an implementation context when planning to prepare and support EBP implementation.

Trial registration

TMI ClinicalTrials.gov NCT03681912; YMPH ClinicalTrials.gov NCT03488914

Training Providers in Motivational Interviewing to Promote Behavior Change

Motivational Interviewing (MI) is a highly specified behavior change communication approach to improve patient-provider relationships, provider communication, and patient health outcomes. Because MI is built on a foundation of patient autonomy support, a feature known to positively influence behavior change during adolescence and emerging adulthood, MI is an evidence-based framework that can inform interventions targeting improvements in health outcomes among youth. MI can be difficult to implement with adequate fidelity, because learning MI requires time and commitment from busy providers with competing priorities. This review addresses best practices for implementing MI within adolescent serving medical settings (eg, pediatrics, family practices, rural health clinics, community health organizations, and so forth), including an orientation to MI, examples of efficacious interventions that were developed leveraging MI, and consideration for the design of training programs that include ongoing support to maximize the likelihood of sustainment.