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Hazim CE, Dobe I, Pope S, Ásbjörnsdóttir KH, Augusto O, Bruno FP, Chicumbe S, Lumbandali N, Mate I, Ofumhan E, Patel S, Rafik R, Sherr K, Tonwe V, Uetela O, Watkins D, Gimbel S, Mocumbi AO. Scaling-up and scaling-out the Systems Analysis and Improvement Approach to optimize the hypertension diagnosis and care cascade for HIV infected individuals (SCALE SAIA-HTN): a stepped-wedge cluster randomized trial. Implement Sci Commun 2024; 5:27. [PMID: 38509605 PMCID: PMC10953165 DOI: 10.1186/s43058-024-00564-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 03/06/2024] [Indexed: 03/22/2024] Open
Abstract
BACKGROUND Undiagnosed and untreated hypertension is a main driver of cardiovascular disease and disproportionately affects persons living with HIV (PLHIV) in low- and middle-income countries. Across sub-Saharan Africa, guideline application to screen and manage hypertension among PLHIV is inconsistent due to poor service readiness, low health worker motivation, and limited integration of hypertension screening and management within HIV care services. In Mozambique, where the adult HIV prevalence is over 13%, an estimated 39% of adults have hypertension. As the only scaled chronic care service in the county, the HIV treatment platform presents an opportunity to standardize and scale hypertension care services. Low-cost, multi-component systems-level strategies such as the Systems Analysis and Improvement Approach (SAIA) have been found effective at integrating hypertension and HIV services to improve the effectiveness of hypertension care delivery for PLHIV, reduce drop-offs in care, and improve service quality. To build off lessons learned from a recently completed cluster randomized trial (SAIA-HTN) and establish a robust evidence base on the effectiveness of SAIA at scale, we evaluated a scaled-delivery model of SAIA (SCALE SAIA-HTN) using existing district health management structures to facilitate SAIA across six districts of Maputo Province, Mozambique. METHODS This study employs a stepped-wedge design with randomization at the district level. The SAIA strategy will be "scaled up" with delivery by district health supervisors (rather than research staff) and will be "scaled out" via expansion to Southern Mozambique, to 18 facilities across six districts in Maputo Province. SCALE SAIA-HTN will be introduced over three, 9-month waves of intensive intervention, where technical support will be provided to facilities and district managers by study team members from the Mozambican National Institute of Health. Our evaluation of SCALE SAIA-HTN will be guided by the RE-AIM framework and will seek to estimate the budget impact from the payer's perspective. DISCUSSION SAIA packages user-friendly systems engineering tools to support decision-making by frontline health workers and to identify low-cost, contextually relevant improvement strategies. By integrating SAIA delivery into routine management structures, this pragmatic trial will determine an effective strategy for national scale-up and inform program planning. TRIAL REGISTRATION ClinicalTrials.gov NCT05002322 (registered 02/15/2023).
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Affiliation(s)
- Carmen E Hazim
- Department of Global Health, University of Washington, Seattle, WA, USA.
- Department of Child, Family, and Population Health Nursing, University of Washington, Seattle, WA, USA.
| | - Igor Dobe
- Instituto Nacional de Saúde, Vila de Marracuene, Província de Maputo, Mozambique
| | - Stephen Pope
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Kristjana H Ásbjörnsdóttir
- Centre of Public Health Sciences, University of Iceland, Reykjavík, Iceland
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Orvalho Augusto
- Department of Global Health, University of Washington, Seattle, WA, USA
- Faculty of Medicine, Universidade Eduardo Mondlane, Maputo, Mozambique
| | - Fernando Pereira Bruno
- Center for Translation Research and Implementation Science, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Washington D.C, USA
| | - Sergio Chicumbe
- Instituto Nacional de Saúde, Vila de Marracuene, Província de Maputo, Mozambique
| | - Norberto Lumbandali
- Instituto Nacional de Saúde, Vila de Marracuene, Província de Maputo, Mozambique
| | - Inocêncio Mate
- Instituto Nacional de Saúde, Vila de Marracuene, Província de Maputo, Mozambique
| | - Elso Ofumhan
- Mozambique Institute for Health Education and Research, Maputo, Mozambique
| | - Sam Patel
- Faculty of Medicine, Universidade Eduardo Mondlane, Maputo, Mozambique
| | - Riaze Rafik
- Mozambique Institute for Health Education and Research, Maputo, Mozambique
| | - Kenneth Sherr
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Department of Industrial & Systems Engineering, University of Washington, Seattle, WA, USA
| | - Veronica Tonwe
- Center for Translation Research and Implementation Science, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Washington D.C, USA
| | - Onei Uetela
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - David Watkins
- Department of Global Health, University of Washington, Seattle, WA, USA
- Division of General Internal Medicine, Harborview Medical Center, Seattle, WA, USA
| | - Sarah Gimbel
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Child, Family, and Population Health Nursing, University of Washington, Seattle, WA, USA
| | - Ana O Mocumbi
- Instituto Nacional de Saúde, Vila de Marracuene, Província de Maputo, Mozambique
- Faculty of Medicine, Universidade Eduardo Mondlane, Maputo, Mozambique
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Eastment MC, Wanje G, Richardson BA, Mwaringa E, Patta S, Sherr K, Barnabas RV, Mandaliya K, Jaoko W, Mcclelland RS. Results of a cluster randomized trial testing the Systems Analysis and Improvement Approach to increase cervical cancer screening in family planning clinics in Mombasa County, Kenya. Implement Sci 2023; 18:66. [PMID: 38012647 PMCID: PMC10680234 DOI: 10.1186/s13012-023-01322-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 11/14/2023] [Indexed: 11/29/2023] Open
Abstract
BACKGROUND Cervical cancer is the leading cause of cancer death in Kenyan women. Integrating cervical cancer screening into family planning (FP) clinics is a promising strategy to improve health for reproductive-aged women. The objective of this cluster randomized trial was to test the efficacy of an implementation strategy, the Systems Analysis and Improvement Approach (SAIA), as a tool to increase cervical cancer screening in FP clinics in Mombasa County, Kenya. METHODS Twenty FP clinics in Mombasa County were randomized 1:1 to SAIA versus usual procedures. SAIA has five steps: (1) cascade analysis tool to understand the cascade and identify inefficiencies, (2) sequential process flow mapping to identify bottlenecks, (3) develop and implement workflow modifications (micro-interventions) to address identified bottlenecks, (4) assess the micro-intervention in the cascade analysis tool, and (5) repeat the cycle. Prevalence ratios were calculated using Poisson regression with robust standard errors to compare the proportion of visits where women were screened for cervical cancer in SAIA clinics compared to control clinics. RESULTS In the primary intent-to-treat analysis in the last quarter of the trial, 2.5% (37/1507) of visits with eligible FP clients at intervention facilities included cervical cancer screening compared to 3.7% (66/1793) in control clinics (prevalence ratio [PR] 0.67, 95% CI 0.45-1.00). When adjusted for having at least one provider trained to perform cervical cancer screening at baseline, there was no significant difference between screening in intervention clinics compared to control clinics (adjusted PR 1.14, 95% CI 0.74-1.75). CONCLUSIONS The primary analysis did not show an effect on cervical cancer screening. However, the COVID-19 pandemic and a healthcare worker strike likely impacted SAIA's implementation with significant disruptions in FP care delivery during the trial. While SAIA's data-informed decision-making and clinic-derived solutions are likely important, future work should directly study the mechanisms through which SAIA operates and the influence of contextual factors on implementation. TRIAL REGISTRATION ClinicalTrials.gov, NCT03514459. Registered on April 19, 2018.
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Affiliation(s)
- McKenna C Eastment
- Departments of Medicine, University of Washington, Seattle, WA, 98104, USA.
| | - George Wanje
- Global Health, University of Washington, Seattle, WA, USA
| | - Barbra A Richardson
- Global Health, University of Washington, Seattle, WA, USA
- Biostatistics, University of Washington, Seattle, WA, USA
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | | | - Shem Patta
- Mombasa County Department of Health, Mombasa, Kenya
| | - Kenneth Sherr
- Global Health, University of Washington, Seattle, WA, USA
| | - Ruanne V Barnabas
- Departments of Medicine, University of Washington, Seattle, WA, 98104, USA
- Global Health, University of Washington, Seattle, WA, USA
- Epidemiology, University of Washington, Seattle, WA, USA
| | | | - Walter Jaoko
- Department of Medical Microbiology and Immunology, University of Nairobi, Nairobi, Kenya
| | - R Scott Mcclelland
- Departments of Medicine, University of Washington, Seattle, WA, 98104, USA
- Global Health, University of Washington, Seattle, WA, USA
- Epidemiology, University of Washington, Seattle, WA, USA
- Department of Medical Microbiology and Immunology, University of Nairobi, Nairobi, Kenya
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Vujcich D, Roberts M, Selway T, Nattabi B. The Application of Systems Thinking to the Prevention and Control of Sexually Transmissible Infections among Adolescents and Adults: A Scoping Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:ijerph20095708. [PMID: 37174226 PMCID: PMC10178699 DOI: 10.3390/ijerph20095708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 04/20/2023] [Accepted: 04/30/2023] [Indexed: 05/15/2023]
Abstract
Systems thinking is a mechanism for making sense of complex systems that challenge linear explanations of cause-and-effect. While the prevention and control of sexually transmissible infections (STIs) has been identified as an area that may benefit from systems-level analyses, no review on the subject currently exists. The aim of this study is to conduct a scoping review to identify literature in which systems thinking has been applied to the prevention and control of STIs among adolescent and adult populations. Joanna Briggs Institute guidelines for the conduct of scoping reviews were followed. Five databases were searched for English-language studies published after 2011. A total of n = 6102 studies were screened against inclusion criteria and n = 70 were included in the review. The majority of studies (n = 34) were conducted in African nations. Few studies focused on priority sub-populations, and 93% were focused on HIV (n = 65). The most commonly applied systems thinking method was system dynamics modelling (n = 28). The review highlights areas for future research, including the need for more STI systems thinking studies focused on: (1) migrant and Indigenous populations; (2) conditions such as syphilis; and (3) innovations such as pre-exposure prophylaxis and at-home testing for HIV. The need for conceptual clarity around 'systems thinking' is also highlighted.
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Affiliation(s)
- Daniel Vujcich
- Western Australian Sexual Health and Blood-Borne Virus Applied Research and Evaluation Network, School of Population Health, Curtin University, Perth, WA 6102, Australia
| | - Meagan Roberts
- Western Australian Sexual Health and Blood-Borne Virus Applied Research and Evaluation Network, School of Population Health, Curtin University, Perth, WA 6102, Australia
| | - Tyler Selway
- Western Australian Sexual Health and Blood-Borne Virus Applied Research and Evaluation Network, School of Population Health, Curtin University, Perth, WA 6102, Australia
| | - Barbara Nattabi
- School of Population and Global Health, University of Western Australia, Perth, WA 6009, Australia
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Abstract
In this Policy Forum, Anna Grimsrud and colleagues discuss the future of HIV testing in eastern and southern Africa, using insights gleaned from a 2021 expert consultation.
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Gimbel S, Ásbjörnsdóttir K, Banek K, Borges M, Crocker J, Coutinho J, Cumbe V, Dinis A, Eastment M, Gaitho D, Lambdin BH, Pope S, Uetela O, Hazim C, McClelland RS, Mocumbi AO, Muanido A, Nduati R, Njuguna IN, Wagenaar BH, Wagner A, Wanje G, Sherr K. The Systems Analysis and Improvement Approach: specifying core components of an implementation strategy to optimize care cascades in public health. Implement Sci Commun 2023; 4:15. [PMID: 36788577 PMCID: PMC9926643 DOI: 10.1186/s43058-023-00390-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 01/03/2023] [Indexed: 02/16/2023] Open
Abstract
BACKGROUND Healthcare systems in low-resource settings need simple, low-cost interventions to improve services and address gaps in care. Though routine data provide opportunities to guide these efforts, frontline providers are rarely engaged in analyzing them for facility-level decision making. The Systems Analysis and Improvement Approach (SAIA) is an evidence-based, multi-component implementation strategy that engages providers in use of facility-level data to promote systems-level thinking and quality improvement (QI) efforts within multi-step care cascades. SAIA was originally developed to address HIV care in resource-limited settings but has since been adapted to a variety of clinical care systems including cervical cancer screening, mental health treatment, and hypertension management, among others; and across a variety of settings in sub-Saharan Africa and the USA. We aimed to extend the growing body of SAIA research by defining the core elements of SAIA using established specification approaches and thus improve reproducibility, guide future adaptations, and lay the groundwork to define its mechanisms of action. METHODS Specification of the SAIA strategy was undertaken over 12 months by an expert panel of SAIA-researchers, implementing agents and stakeholders using a three-round, modified nominal group technique approach to match core SAIA components to the Expert Recommendations for Implementing Change (ERIC) list of distinct implementation strategies. Core implementation strategies were then specified according to Proctor's recommendations for specifying and reporting, followed by synthesis of data on related implementation outcomes linked to the SAIA strategy across projects. RESULTS Based on this review and clarification of the operational definitions of the components of the SAIA, the four components of SAIA were mapped to 13 ERIC strategies. SAIA strategy meetings encompassed external facilitation, organization of provider implementation meetings, and provision of ongoing consultation. Cascade analysis mapped to three ERIC strategies: facilitating relay of clinical data to providers, use of audit and feedback of routine data with healthcare teams, and modeling and simulation of change. Process mapping matched to local needs assessment, local consensus discussions and assessment of readiness and identification of barriers and facilitators. Finally, continuous quality improvement encompassed tailoring strategies, developing a formal implementation blueprint, cyclical tests of change, and purposefully re-examining the implementation process. CONCLUSIONS Specifying the components of SAIA provides improved conceptual clarity to enhance reproducibility for other researchers and practitioners interested in applying the SAIA across novel settings.
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Affiliation(s)
- Sarah Gimbel
- Department of Child, Family, and Population Health Nursing, University of Washington, Magnuson Health Science Bldg, Seattle, WA, USA.
- Department of Global Health, University of Washington, Seattle, WA, USA.
| | - Kristjana Ásbjörnsdóttir
- Department of Global Health, University of Washington, Seattle, WA, USA
- Center for Public Health Sciences, University of Iceland, Reykjavík, Iceland
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Kristin Banek
- Institute for Global Health and Infectious Diseases, University of North Carolina, Chapel Hill, NC, USA
| | - Madeline Borges
- Department of Child, Family, and Population Health Nursing, University of Washington, Magnuson Health Science Bldg, Seattle, WA, USA
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Jonny Crocker
- Department of Global Health, University of Washington, Seattle, WA, USA
| | | | - Vasco Cumbe
- Ministry of Health, Provincial Health Department, Sofala, Mozambique
| | - Aneth Dinis
- Department of Global Health, University of Washington, Seattle, WA, USA
- Ministry of Health, National Department of Public Health, Maputo, Mozambique
| | - McKenna Eastment
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Douglas Gaitho
- Network of AIDS Researchers of East and Southern Africa, Nairobi, Kenya
| | - Barrot H Lambdin
- Department of Global Health, University of Washington, Seattle, WA, USA
- RTI International, Berkeley, CA, USA
| | - Stephen Pope
- Department of Child, Family, and Population Health Nursing, University of Washington, Magnuson Health Science Bldg, Seattle, WA, USA
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Onei Uetela
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Carmen Hazim
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - R Scott McClelland
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Ana Olga Mocumbi
- Department of Global Health, University of Washington, Seattle, WA, USA
- Instituto Nacional de Saúde de Maputo, Maputo, Mozambique
- Universidade Eduardo Mondlane, Maputo, Mozambique
| | | | | | - Irene N Njuguna
- Department of Global Health, University of Washington, Seattle, WA, USA
- Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Bradley H Wagenaar
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Anjuli Wagner
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - George Wanje
- Department of Medical Microbiology, University of Nairobi, Nairobi, Kenya
| | - Kenneth Sherr
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
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Thomas D, Wanje G, Eastment MC, McClelland RS, Mwaringa E, Patta S, Jaoko W, Kinuthia J, Abubakar A, Sherr K, Barnabas RV. The cost of implementing the Systems Analysis and Improvement Approach for a cluster randomized trial integrating HIV testing into family planning services in Mombasa County, Kenya. BMC Health Serv Res 2022; 22:1480. [PMID: 36471311 PMCID: PMC9720937 DOI: 10.1186/s12913-022-08828-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 11/10/2022] [Indexed: 12/07/2022] Open
Abstract
BACKGROUND Although HIV testing in family planning (FP) clinics is a promising approach for engaging women in HIV treatment and prevention services, HIV testing rates are low in FP clinics in Kenya. In 2018, a cluster randomized trial was implemented in Mombasa, Kenya applying the Systems Analysis and Improvement Approach (SAIA) to integrate HIV testing into FP services (1K24HD088229-01). We estimated the incremental costs and explored cost drivers of the FP HIV SAIA implementation in Mombasa, Kenya. METHODS We conducted a costing evaluation from the payer perspective for the FP HIV SAIA randomized control trial. We identified relevant activities for the intervention including start-up, training, research and FP HIV SAIA. We estimated activity time burden using a time-and motion study. We derived unit costs through staff interviews and programmatic budgets. We present cost estimates for two different scenarios: as-implemented including research and projected costs for a Ministry of Health-supported intervention. All costs are reported in 2018 USD. RESULTS For an annual program output of 36,086 HIV tests administered to new FP clients, we estimated the total annual program cost to be $91,994 with an average cost per new FP client served of $2.55. Personnel and HIV rapid testing kits comprised 55% and 21% of programmatic costs, respectively. Assuming no changes to program outputs and with efficiency gains under the MOH scenario, the estimated cost per new FP client served decreased to $1.30 with a programmatic cost reduction of 49%. CONCLUSION FP HIV SAIA is a low-cost and flexible implementation strategy for facilitating integrated delivery of HIV testing alongside FP services. Although cost implications of the FP HIV SAIA intervention must continue to be evaluated over time, these findings provide context-specific cost data useful for budget planning and decision-making regarding intervention delivery and expansion. TRIAL REGISTRATION The trial was registered on December 15, 2016, with clinicaltrials.gov (NCT02994355).
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Affiliation(s)
- Dorothy Thomas
- Department of Global Health, University of Washington, Ninth and Jefferson Building, HMC 359927, 98104-2499, Seattle, USA.
| | - George Wanje
- Department of Global Health, University of Washington, Ninth and Jefferson Building, HMC 359927, 98104-2499, Seattle, USA
| | | | - R Scott McClelland
- Department of Global Health, University of Washington, Ninth and Jefferson Building, HMC 359927, 98104-2499, Seattle, USA
- Department of Medicine, University of Washington, Seattle, USA
- Department of Epidemiology, University of Washington, Seattle, USA
- Department of Medical Microbiology & Immunology, University of Nairobi, Nairobi, Kenya
| | - Emily Mwaringa
- Department of Health Services, County Government of Mombasa, Mombasa, Kenya
| | - Shem Patta
- Department of Health Services, County Government of Mombasa, Mombasa, Kenya
| | - Walter Jaoko
- Department of Medical Microbiology & Immunology, University of Nairobi, Nairobi, Kenya
| | - John Kinuthia
- Department of Global Health, University of Washington, Ninth and Jefferson Building, HMC 359927, 98104-2499, Seattle, USA
- Department of Research & Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Aisha Abubakar
- Department of Health Services, County Government of Mombasa, Mombasa, Kenya
| | - Kenneth Sherr
- Department of Global Health, University of Washington, Ninth and Jefferson Building, HMC 359927, 98104-2499, Seattle, USA
- Department of Epidemiology, University of Washington, Seattle, USA
- Department of Industrial & Systems Engineering, University of Washington, Seattle, USA
| | - Ruanne V Barnabas
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, USA
- Division of Infectious Diseases, Harvard Medical School, Boston, USA
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Long JE, Eastment MC, Wanje G, Richardson BA, Mwaringa E, Mohamed MA, Sherr K, Barnabas RV, Mandaliya K, Jaoko W, McClelland RS. Assessing the sustainability of the Systems Analysis and Improvement Approach to increase HIV testing in family planning clinics in Mombasa, Kenya: results of a cluster randomized trial. Implement Sci 2022; 17:70. [PMID: 36195890 PMCID: PMC9530422 DOI: 10.1186/s13012-022-01242-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 09/23/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In Kenya, HIV incidence is highest among reproductive-age women. A key HIV mitigation strategy is the integration of HIV testing and counseling (HTC) into family planning services, but successful integration remains problematic. We conducted a cluster-randomized trial using the Systems Analysis and Improvement Approach (SAIA) to identify and address bottlenecks in HTC integration in family planning clinics in Mombasa County, Kenya. This trial (1) assessed the efficacy of this approach and (2) examined if SAIA could be sustainably incorporated into the Department of Health Services (DOHS) programmatic activities. In Stage 1, SAIA was effective at increasing HTC uptake. Here, we present Stage 2, which assessed if SAIA delivery would be sustained when implemented by the Mombasa County DOHS and if high HTC performance would continue to be observed. METHODS Twenty-four family planning clinics in Mombasa County were randomized to either the SAIA implementation strategy or standard care. In Stage 1, the study staff conducted all study activities. In Stage 2, we transitioned SAIA implementation to DOHS staff and compared HTC in the intervention versus control clinics 1-year post-transition. Study staff provided training and minimal support to DOHS implementers and collected quarterly HTC outcome data. Interviews were conducted with family planning clinic staff to assess barriers and facilitators to sustaining HTC delivery. RESULTS Only 39% (56/144) of planned SAIA visits were completed, largely due to the COVID-19 pandemic and a prolonged healthcare worker strike. In the final study quarter, 81.6% (160/196) of new clients at intervention facilities received HIV counseling, compared to 22.4% (55/245) in control facilities (prevalence rate ratio [PRR]=3.64, 95% confidence interval [CI]=2.68-4.94). HIV testing was conducted with 60.5% (118/195) of new family planning clients in intervention clinics, compared to 18.8% (45/240) in control clinics (PRR=3.23, 95% CI=2.29-4.55). Interviews with family planning clinic staff suggested institutionalization contributed to sustained HTC delivery, facilitated by low implementation strategy complexity and continued oversight. CONCLUSIONS Intervention clinics demonstrated sustained improvement in HTC after SAIA was transitioned to DOHS leadership despite wide-scale healthcare disruptions and incomplete delivery of the implementation strategy. These findings suggest that system interventions may be sustained when integrated into DOHS programmatic activities. TRIAL REGISTRATION ClinicalTrials.gov (NCT02994355) registered on 16 December 2016.
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Affiliation(s)
- Jessica E Long
- Department of Epidemiology, University of Washington, 325 9th Avenue, Box 359909, Seattle, WA, 98104, USA. .,Present Address: Department of Medicine, University of Washington, Seattle, WA, USA.
| | - McKenna C Eastment
- Present Address: Department of Medicine, University of Washington, Seattle, WA, USA
| | - George Wanje
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Barbra A Richardson
- Department of Global Health, University of Washington, Seattle, WA, USA.,Department of Biostatistics, University of Washington, Seattle, WA, USA.,Fred Hutchinson Cancer Research Center, Vaccine and Infectious Disease Division, Seattle, WA, USA
| | | | | | - Kenneth Sherr
- Department of Epidemiology, University of Washington, 325 9th Avenue, Box 359909, Seattle, WA, 98104, USA.,Department of Global Health, University of Washington, Seattle, WA, USA.,Industrial & Systems Engineering, University of Washington, Seattle, WA, USA
| | - Ruanne V Barnabas
- Department of Epidemiology, University of Washington, 325 9th Avenue, Box 359909, Seattle, WA, 98104, USA.,Present Address: Department of Medicine, University of Washington, Seattle, WA, USA.,Department of Global Health, University of Washington, Seattle, WA, USA
| | | | - Walter Jaoko
- Medical Microbiology, University of Nairobi, Nairobi, Kenya
| | - R Scott McClelland
- Department of Epidemiology, University of Washington, 325 9th Avenue, Box 359909, Seattle, WA, 98104, USA.,Present Address: Department of Medicine, University of Washington, Seattle, WA, USA.,Department of Global Health, University of Washington, Seattle, WA, USA.,Medical Microbiology, University of Nairobi, Nairobi, Kenya
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8
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Eastment MC, Long JE, Wanje G, Richardson BA, Mwaringa E, Sherr K, Barnabas RV, Mandaliya K, Jaoko W, McClelland RS. Qualitative evaluation of the Systems Analysis and Improvement Approach as a strategy to increase HIV testing in family planning clinics using the Consolidated Framework for Implementation Research and the Implementation Outcomes Framework. Implement Sci Commun 2022; 3:97. [PMID: 36076250 PMCID: PMC9458310 DOI: 10.1186/s43058-022-00342-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 08/30/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Significant gaps remain in HIV testing and counseling (HTC) in family planning (FP) clinics. To address these gaps, our group tested an implementation strategy called the Systems Analysis and Improvement Approach (SAIA), an evidenced-based multi-component implementation strategy focused on improving entire care cascades. In a cluster randomized trial of 24 FP clinics in Mombasa County, Kenya, SAIA led to a significant increase in HTC in intervention clinics compared to control clinics. The objective of this manuscript was to evaluate SAIA using the Consolidated Framework for Implementation Research (CFIR) and assess the Implementation Outcomes Framework outcomes of acceptability, appropriateness, and feasibility. METHODS This qualitative assessment was nested within the cluster-randomized trial. Data collection included questionnaires to assess modifiable and non-modifiable health system factors related to HTC and in-depth interviews to query clinic norms, priorities, communication strategies, and readiness for change. The primary outcomes of interest were feasibility, appropriateness, and acceptability of SAIA. Data on inner setting and structural characteristics of FP clinics were collected to inform how context may impact outcomes. All interviews were recorded and analyzed using a rapid assessment approach. RESULTS Of the 12 intervention clinics, 6 (50%) were public facilities. Availability of resources varied by clinic. Most clinics had a positive implementation climate, engaged leadership, and access to resources and information. While not all clinics identified HTC as a clinic priority, most reported a strong culture of embracing change and recognition of the importance of HIV testing within FP clinics. Interviews highlighted very high acceptability, appropriateness, and feasibility of SAIA. The implementation strategy was not complicated and fit well into existing clinic processes. In particular, staff appreciated that SAIA allowed clinic staff to generate contextually relevant solutions that they implemented. CONCLUSIONS SAIA was implemented in FP clinics of varying sizes, capacity, and management support and was found to be acceptable, appropriate, and feasible. The agency that clinic staff felt in proposing and implementing their own solutions was likely part of SAIA's success. We anticipate this will continue to be a mechanism of SAIA's success when it is scaled up to more clinics in future trials. TRIAL REGISTRATION ClinicalTrials.gov (NCT02994355) registered 16 December 2016.
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Affiliation(s)
- McKenna C. Eastment
- Department of Medicine, University of Washington, 325 9th Avenue, Box 359909, Seattle, WA 98104 USA
| | - Jessica E. Long
- Department of Epidemiology, University of Washington, Seattle, WA USA
| | - George Wanje
- Department of Global Health, University of Washington, Seattle, WA USA
| | - Barbra A. Richardson
- Department of Global Health, University of Washington, Seattle, WA USA
- Department of Biostatistics, University of Washington, Seattle, WA USA
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA USA
| | | | - Kenneth Sherr
- Department of Epidemiology, University of Washington, Seattle, WA USA
- Department of Global Health, University of Washington, Seattle, WA USA
- Department of Industrial & Systems Engineering, University of Washington, Seattle, WA USA
| | - Ruanne V. Barnabas
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA USA
- Harvard Medical School, Boston, MA USA
| | | | - Walter Jaoko
- Department of Medical Microbiology and Immunology, University of Nairobi, Nairobi, Kenya
| | - R. Scott McClelland
- Department of Medicine, University of Washington, 325 9th Avenue, Box 359909, Seattle, WA 98104 USA
- Department of Epidemiology, University of Washington, Seattle, WA USA
- Department of Global Health, University of Washington, Seattle, WA USA
- Department of Industrial & Systems Engineering, University of Washington, Seattle, WA USA
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