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Whidden C, Cissé AB, Cole F, Doumbia S, Guindo A, Karambé Y, Treleaven E, Liu J, Tolo O, Guindo L, Togola B, Chiu C, Tembely A, Keita Y, Greenwood B, Chandramohan D, Johnson A, Kayentao K, Webster J. Community case management to accelerate access to healthcare in Mali: a realist process evaluation nested within a cluster randomized trial. Health Policy Plan 2024; 39:864-877. [PMID: 39058651 PMCID: PMC11384120 DOI: 10.1093/heapol/czae066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 05/30/2024] [Accepted: 07/25/2024] [Indexed: 07/28/2024] Open
Abstract
The Proactive Community Case Management (ProCCM) trial in Mali reinforced the health system across both arms with user fee removal, professional community health workers (CHWs) and upgraded primary health centres (PHCs)-and randomized village-clusters to receive proactive home visits by CHWs (intervention) or fixed site-based services by passive CHWs (control). Across both arms, sick children's 24-hour treatment and pregnant women's four or more antenatal visits doubled, and under-5 mortality halved, over 3 years compared with baseline. In the intervention arm, proactive CHW home visits had modest effects on children's curative and women's antenatal care utilization, but no effect on under-5 mortality, compared with the control arm. We aimed to explain these results by examining implementation, mechanisms and context in both arms We conducted a process evaluation with a mixed method convergent design that included 79 in-depth interviews with providers and participants over two time-points, surveys with 195 providers and secondary analyses of clinical data. We embedded realist approaches in novel ways to test, refine and consolidate theories about how ProCCM worked, generating three context-intervention-actor-mechanism-outcome nodes that unfolded in a cascade. First, removing user fees and deploying professional CHWs in every cluster enabled participants to seek health sector care promptly and created a context of facilitated access. Second, health systems support to all CHWs and PHCs enabled equitable, respectful, quality healthcare, which motivated increased, rapid utilization. Third, proactive CHW home visits facilitated CHWs and participants to deliver and seek care, and build relationships, trust and expectations, but these mechanisms were also activated in both arms. Addressing multiple structural barriers to care, user fee removal, professional CHWs and upgraded clinics interacted with providers' and patients' agency to achieve rapid care and child survival in both arms. Proactive home visits expedited or compounded mechanisms that were activated and changed the context across arms.
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Affiliation(s)
- Caroline Whidden
- Department of Disease Control, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, United Kingdom
- Department of Research, Monitoring & Evaluation, Muso, SEMA Route de 501 Logements, Bamako H3M8+VJC, Mali
| | | | - Faith Cole
- Department of Anthropology, University of California, 375 Portola Plaza, Los Angeles, CA 90095, United States
- Institute for Social Research, University of Michigan, 426 Thompson Street, Ann Arbor, MI 48103, United States
| | - Saibou Doumbia
- Department of Research, Monitoring & Evaluation, Muso, SEMA Route de 501 Logements, Bamako H3M8+VJC, Mali
| | - Abdoulaye Guindo
- Faculté des Sciences de l'Éducation et des Sciences Humaines, Université des Lettres et des Sciences Humaines de Bamako, Rue 627 Porte 83, Bamako BP E 2528, Mali
| | - Youssouf Karambé
- Institut National de la Jeunesse et des Sports, Bamako J35J+CJF, Mali
| | - Emily Treleaven
- Institute for Social Research, University of Michigan, 426 Thompson Street, Ann Arbor, MI 48103, United States
| | - Jenny Liu
- Institute for Health & Aging, University of California, 490 Illinois Street, San Francisco, CA 94158, United States
| | - Oumar Tolo
- Muso, SEMA Route de 501 Logements, Bamako H3M8+VJC, Mali
| | - Lamine Guindo
- Department of Research, Monitoring & Evaluation, Muso, SEMA Route de 501 Logements, Bamako H3M8+VJC, Mali
| | - Bréhima Togola
- Department of Research, Monitoring & Evaluation, Muso, SEMA Route de 501 Logements, Bamako H3M8+VJC, Mali
| | - Calvin Chiu
- School of Public Health, University of California, 2121 Berkeley Way, Berkeley, CA 94704, United States
| | - Aly Tembely
- Ministère de la Santé et du Développement Social, Cité Administrative, Bamako JXGR+R48, Mali
| | - Youssouf Keita
- Muso, SEMA Route de 501 Logements, Bamako H3M8+VJC, Mali
| | - Brian Greenwood
- Department of Disease Control, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, United Kingdom
| | - Daniel Chandramohan
- Department of Disease Control, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, United Kingdom
| | - Ari Johnson
- Muso, SEMA Route de 501 Logements, Bamako H3M8+VJC, Mali
- Institute for Global Health Sciences, University of California, 550 16th Street, San Francisco, CA 94110, United States
| | - Kassoum Kayentao
- Department of Research, Monitoring & Evaluation, Muso, SEMA Route de 501 Logements, Bamako H3M8+VJC, Mali
- Malaria Research & Training Centre, Université des Sciences, des Techniques et des Technologies de Bamako, Bamako PO Box 1805, Mali
| | - Jayne Webster
- Department of Disease Control, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, United Kingdom
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Hargreaves JR, Baptiste S, Bhattacharjee P, Cowan FM, Herce ME, Lauer K, Sikazwe I, Geng E. Programme science methodologies and practices that address "FURRIE" challenges: examples from the field. J Int AIDS Soc 2024; 27 Suppl 2:e26283. [PMID: 38988041 PMCID: PMC11236905 DOI: 10.1002/jia2.26283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 05/13/2024] [Indexed: 07/12/2024] Open
Abstract
INTRODUCTION "Programme science" deploys scientific methods to address questions that are a priority to support the impact of public health programmes. As such, programme science responds to the challenges of making such studies: (1) feasible to undertake, (2) useful, (3) rigorous, (4) real-world-relevant, (5) informative, and undertaken by (6) equitable partnerships. The acronym "FURRIE" is proposed to describe this set of six challenges. This paper discusses selected HIV/STI (sexually transmitted infection) programme science case studies to illustrate how programme science rises to the FURRIE challenges. DISCUSSION One way in which programme science is made more feasible is through the analysis and interpretation of data collected through service delivery. For some questions, these data can be augmented through methods that reach potential clients of services who have not accessed services or been lost to follow-up. Process evaluation can enhance the usefulness of programme science by studying implementation processes, programme-client interactions and contextual factors. Ensuring rigour by limiting bias and confounding in the real-world context of programme science studies requires methodological innovation. Striving for scientific rigour can also have the unintended consequence of creating a gap between what happens in a study, and what happens in the "real-world." Community-led monitoring is one approach to grounding data collection in the real-world experience of clients. Evaluating complex, context-specific strategies to strengthen health outcomes in a way that is informative for other settings requires clear specification of the intervention packages that are planned and delivered in practice. Programme science provides a model for equitable partnership through co-leadership between programmes, researchers and the communities they serve. CONCLUSIONS Programme science addresses the FURRIE challenges, thereby improving programme impact and ultimately health outcomes and health equity. The adoption and adaptation of the types of novel programme science approaches showcased here should be promoted within and beyond the HIV/STI field.
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Affiliation(s)
- James R Hargreaves
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Solange Baptiste
- International Treatment Preparedness Coalition, Johannesburg, South Africa
| | - Parinita Bhattacharjee
- Institute for Global Public Health, University of Manitoba, Winnipeg, Manitoba, Canada
- Partners for Health and Development in Africa, Nairobi, Kenya
| | - Frances M Cowan
- CeSHHAR, Harare, Zimbabwe
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - Michael E Herce
- CIDRZ, Lusaka, Zambia
- Institute for Global Health and Infectious Diseases, University of North Carolina, Chapel Hill, USA
| | - Krista Lauer
- International Treatment Preparedness Coalition, Johannesburg, South Africa
| | | | - Elvin Geng
- Division of Infectious Diseases and Center for Dissemination and Implementation, Washington University in St. Lous, St. Louis, Missouri, USA
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Kilbourne AM, Geng E, Eshun-Wilson I, Sweeney S, Shelley D, Cohen DJ, Kirchner JE, Fernandez ME, Parchman ML. How does facilitation in healthcare work? Using mechanism mapping to illuminate the black box of a meta-implementation strategy. Implement Sci Commun 2023; 4:53. [PMID: 37194084 PMCID: PMC10190070 DOI: 10.1186/s43058-023-00435-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 05/06/2023] [Indexed: 05/18/2023] Open
Abstract
BACKGROUND Healthcare facilitation, an implementation strategy designed to improve the uptake of effective clinical innovations in routine practice, has produced promising yet mixed results in randomized implementation trials and has not been fully researched across different contexts. OBJECTIVE Using mechanism mapping, which applies directed acyclic graphs that decompose an effect of interest into hypothesized causal steps and mechanisms, we propose a more concrete description of how healthcare facilitation works to inform its further study as a meta-implementation strategy. METHODS Using a modified Delphi consensus process, co-authors developed the mechanistic map based on a three-step process. First, they developed an initial logic model by collectively reviewing the literature and identifying the most relevant studies of healthcare facilitation components and mechanisms to date. Second, they applied the logic model to write vignettes describing how facilitation worked (or did not) based on recent empirical trials that were selected via consensus for inclusion and diversity in contextual settings (US, international sites). Finally, the mechanistic map was created based on the collective findings from the vignettes. FINDINGS Theory-based healthcare facilitation components informing the mechanistic map included staff engagement, role clarification, coalition-building through peer experiences and identifying champions, capacity-building through problem solving barriers, and organizational ownership of the implementation process. Across the vignettes, engagement of leaders and practitioners led to increased socialization of the facilitator's role in the organization. This in turn led to clarifying of roles and responsibilities among practitioners and identifying peer experiences led to increased coherence and sense-making of the value of adopting effective innovations. Increased trust develops across leadership and practitioners through expanded capacity in adoption of the effective innovation by identifying opportunities that mitigated barriers to practice change. Finally, these mechanisms led to eventual normalization and ownership of the effective innovation and healthcare facilitation process. IMPACT Mapping methodology provides a novel perspective of mechanisms of healthcare facilitation, notably how sensemaking, trust, and normalization contribute to quality improvement. This method may also enable more efficient and impactful hypothesis-testing and application of complex implementation strategies, with high relevance for lower-resourced settings, to inform effective innovation uptake.
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Affiliation(s)
- Amy M. Kilbourne
- Health Services Research & Development, VA Office of Research and Development, US Department of Veterans Affairs and University of Michigan, 810 Vermont Ave, NW, Washington, D.C., 20420 USA
| | - Elvin Geng
- Washington University at St. Louis, St. Louis, MO USA
| | | | | | - Donna Shelley
- New York University School of Global Public Health, New York, New York USA
| | | | - JoAnn E. Kirchner
- Central Arkansas VA Healthcare System and University of Arkansas for Medical Sciences, North Little Rock, AR USA
| | - Maria E. Fernandez
- University of Texas Health Science Center at Houston, School of Public Health, Houston, TX USA
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Garner BR, Burrus O, Ortiz A, Tueller SJ, Peinado S, Hedrick H, Harshbarger C, Galindo C, Courtenay-Quirk C, Lewis MA. A Longitudinal Mixed-Methods Examination of Positive Health Check: Implementation Results From a Type 1 Effectiveness-Implementation Hybrid Trial. J Acquir Immune Defic Syndr 2022; 91:47-57. [PMID: 35583962 PMCID: PMC9377502 DOI: 10.1097/qai.0000000000003018] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 04/25/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Positive Health Check is an evidence-based video doctor intervention developed for improving the medication adherence, retention in care, and viral load suppression of people with HIV receiving clinical care. SETTING Four HIV primary care clinics within the United States. METHODS As part of a type 1 hybrid trial, a mixed-methods approach was used to longitudinally assess the following 3 key implementation constructs over a 23-month period: innovation-values fit (ie, the extent to which staff perceive innovation use will foster the fulfillment of their values), organizational readiness for change (ie, the extent to which organizational members are psychologically and behaviorally prepared to implement organizational change), and implementation climate (ie, the extent to which implementation is expected, supported, and rewarded). Quantitative mixed-effects regression analyses were conducted to assess changes over time in these constructs. Qualitative analyses were integrated to help provide validation and understanding. RESULTS Innovation-values fit and organizational readiness for change were found to be high and relatively stable. However, significant curvilinear change over time was found for implementation climate. Based on the qualitative data, implementation climate declined toward the end of implementation because of decreased engagement from clinic champions and differences in priorities between research and clinic staff. CONCLUSIONS The Positive Health Check intervention was found to fit within HIV primary care service settings, but there were some logistical challenges that needed to be addressed. Additionally, even within the context of an effectiveness trial, significant and nonlinear change in implementation climate should be expected over time.
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Affiliation(s)
| | | | - Alexa Ortiz
- RTI International, Research Triangle Park, NC; and
| | | | | | | | - Camilla Harshbarger
- Centers for Disease Control and Prevention, Division of HIV Prevention, Atlanta, GA
| | - Carla Galindo
- Centers for Disease Control and Prevention, Division of HIV Prevention, Atlanta, GA
| | - Cari Courtenay-Quirk
- Centers for Disease Control and Prevention, Division of HIV Prevention, Atlanta, GA
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Garner BR, Knudsen HK, Zulkiewicz BA, Tueller SJ, Gotham HJ, Martin EG, Donohoe T, Toro AK, Loyd K, Gordon T. The Setting-Intervention Fit of Nine Evidence-Based Interventions for Substance Use Disorders Within HIV Service Organizations Across the United States: Results of a National Stakeholder-Engaged Real-Time Delphi Study. J Acquir Immune Defic Syndr 2022; 90:S206-S214. [PMID: 35703773 PMCID: PMC9204782 DOI: 10.1097/qai.0000000000002981] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Given substance use disorders (SUDs) among people with HIV are highly prevalent, integrating SUD services within HIV service settings is needed to help end the HIV epidemic. In this study, we assessed the setting-intervention fit (SIF) of 9 evidence-based SUD interventions: acamprosate, disulfiram, oral naltrexone, injectable naltrexone, oral buprenorphine, injectable buprenorphine, contingency management, motivational interviewing, and cognitive behavioral therapy (CBT). SETTING Clinical and nonclinical HIV service organizations (HSOs) in the United States. METHODS In May 2020, a stakeholder-engaged real-time Delphi was completed with 202 HSOs. HSO respondents rated the extent to which each SUD intervention was fundable, implementable, retainable, sustainable, scalable, and timely for their HSO, and these 6 items were summed into an SIF score (possible range of 0-18). RESULTS Motivational interviewing had the highest average SIF score (11.42), with SIF scores above the midpoint (9.5) for clinical (11.51) and nonclinical HSOs (11.36). For nonclinical HSOs, none of the other interventions were above the midpoint. For clinical HSOs, the average SIF scores were above the midpoint for CBT (10.97) and oral buprenorphine (9.51). Multivariate regression analyses, which controlled for characteristics of the HSO respondent, revealed geographic region of the United States and whether the HSO currently offered any substance use services as 2 of the best predictors of SIF scores. CONCLUSIONS Notwithstanding the need to improve the SIF for the other evidence-based SUD interventions, motivational interviewing, CBT, and oral buprenorphine are currently the evidence-based SUD interventions with greatest perceived fit for integration within HSOs in the United States.
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Affiliation(s)
| | | | | | | | | | - Erika G Martin
- Rockefeller College of Public Affairs and Policy at the University at Albany, Both Part of the State University of New York, Albany
| | - Tom Donohoe
- University of California Los Angeles, Pacific AIDS Education and Training Center, Los Angeles, CA 90024 and
| | | | - Katie Loyd
- RTI International, Research Triangle Park, NC
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