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Kim TV, Pham TND, Phan P, Le MHN, Le Q, Nguyen PT, Nguyen HT, Nguyen DX, Trang B, Cao C, Gurakar A, Hoffmann CJ, Dao DY. Effectiveness and implementation of decentralized, community- and primary care-based strategies in promoting hepatitis B testing uptake: a systematic review and meta-analysis. EClinicalMedicine 2024; 76:102818. [PMID: 39309722 PMCID: PMC11416547 DOI: 10.1016/j.eclinm.2024.102818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2024] [Revised: 08/20/2024] [Accepted: 08/21/2024] [Indexed: 09/25/2024] Open
Abstract
Background Expanding chronic hepatitis B (CHB) testing through effective implementation strategies in primary- and community-care setting is crucial for elimination. Our study aimed to determine the effectiveness of all available strategies in the literature and evaluate their specifications and implementation outcomes, thereby informing future programming and policymaking. Methods We conducted a systematic review and meta-analysis (PROSPERO CRD42023455781), searching Scopus, Embase, PubMed, and CINAHL databases up to June 05, 2024, for randomized controlled trials investigating primary- and community-care-based implementation strategies to promote CHB testing. Studies were screened against a priori eligibility criteria, and their data were extracted using a standardized protocol if included. ROB-2 was used to assess the risk of bias. Implementation strategies' components were characterized using the Behavior Change Wheel (BCW) framework. Random-effect models were applied to pool the effectiveness estimate by strategy. Mixed-effect meta-regression was employed to investigate if effectiveness varied by the number of strategy's BCW components. Findings 7146 unique records were identified. 25 studies were eligible for the review, contributing 130,598 participants. 19 studies were included in the meta-analysis. No studies were conducted in low-and-middle-income countries. Implementation outcomes were reported in only ten studies (40%). Community-based strategies included lay health workers-led education (Pooled Risk Difference = 27.9% [95% Confidence Interval = 3.4-52.4], I2 = 99.3%) or crowdsourced education on social media (3.1% [-2.2 to 8.4], 0.0%). Primary care-based strategies consisted of electronic alert system (8.4% [3.7-13.1], 95.0%) and healthcare providers-led education (HCPs, 62.5% [53.1-71.9], 27.5%). The number of BCW-framework-driven strategy components showed a significant dose-response relationship with effectiveness. Interpretation HCPs-led education stands out, and more enriched multicomponent strategies had better effectiveness. Future implementation strategies should consider critical contextual factors and policies to achieve a sustainable impact towards hepatitis B elimination targets. Funding Tran Dolch Post-Doctoral Fellowship in Hepatology, Johns Hopkins University School of Medicine, Baltimore MD, USA.
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Affiliation(s)
- Thanh Van Kim
- Center of Excellence for Liver Disease in Viet Nam, Johns Hopkins School of Medicine, Baltimore, MD, USA
- Department of Epidemiology, Pham Ngoc Thach University of Medicine, Viet Nam
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Trang Ngoc Doan Pham
- Center of Excellence for Liver Disease in Viet Nam, Johns Hopkins School of Medicine, Baltimore, MD, USA
- School of Public Health, University of Illinois at Chicago, Chicago, IL, USA
| | - Paul Phan
- Center of Excellence for Liver Disease in Viet Nam, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Minh Huu Nhat Le
- Center of Excellence for Liver Disease in Viet Nam, Johns Hopkins School of Medicine, Baltimore, MD, USA
- International Ph.D. Program in Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Research Center for Artificial Intelligence in Medicine, Taipei Medical University, Taipei, Taiwan
| | - Quan Le
- Center of Excellence for Liver Disease in Viet Nam, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Phuong Thi Nguyen
- University of Health Sciences, Vietnam National University Ho Chi Minh City (VNUHCM-UHS), Binh Duong, Viet Nam
| | - Ha Thi Nguyen
- University of Health Sciences, Vietnam National University Ho Chi Minh City (VNUHCM-UHS), Binh Duong, Viet Nam
| | - Dan Xuan Nguyen
- Center of Excellence for Liver Disease in Viet Nam, Johns Hopkins School of Medicine, Baltimore, MD, USA
- Boston University School of Public Health, Boston, MA, USA
| | - Binh Trang
- Center of Excellence for Liver Disease in Viet Nam, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Chelsea Cao
- Center of Excellence for Liver Disease in Viet Nam, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Ahmet Gurakar
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Christopher J. Hoffmann
- Center of Excellence for Liver Disease in Viet Nam, Johns Hopkins School of Medicine, Baltimore, MD, USA
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Doan Y Dao
- Center of Excellence for Liver Disease in Viet Nam, Johns Hopkins School of Medicine, Baltimore, MD, USA
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
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Tetteh EK, Effah W, de las Fuentes L, Steger-May K, Goss CW, Dowdy DW, Huffman MD, Williams MJ, Tonwe V, Bansal GP, Geng EH, Dávila-Román VG, Rice T, Schechtman KB. Dissemination and implementation research coordination and training to improve cardiovascular health in people living with HIV in sub-Saharan Africa: the research coordinating center of the HLB-SIMPLe Alliance. Implement Sci Commun 2024; 5:62. [PMID: 38845055 PMCID: PMC11155162 DOI: 10.1186/s43058-024-00599-4] [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: 01/24/2024] [Accepted: 05/28/2024] [Indexed: 06/09/2024] Open
Abstract
As global adoption of antiretroviral therapy extends the lifespan of People Living with HIV (PLHIV) through viral suppression, the risk of comorbid conditions such as hypertension has risen, creating a need for effective, scalable interventions to manage comorbidities in PLHIV. The Heart, Lung, and Blood Co-morbiditieS Implementation Models in People Living with HIV (HLB-SIMPLe) Alliance has been funded by the National Heart, Lung, and Blood Institute (NHLBI) and the Fogarty International Center (FIC) since September 2020. The Alliance was created to conduct late-stage implementation research to contextualize, implement, and evaluate evidence-based strategies to integrate the diagnosis, treatment, and control of cardiovascular diseases, particularly hypertension, in PLHIV in low- and middle-income countries (LMICs).The Alliance consists of six individually-funded clinical trial cooperative agreement research projects based in Botswana, Mozambique, Nigeria, South Africa, Uganda, and Zambia; the Research Coordinating Center; and personnel from NIH, NHLBI, and FIC (the Federal Team). The Federal Team works together with the members of the seven cooperative agreements which comprise the alliance. The Federal Team includes program officials, project scientists, grant management officials and clinical trial specialists. This Alliance of research scientists, trainees, and administrators works collaboratively to provide and support venues for ongoing information sharing within and across the clinical trials, training and capacity building in research methods, publications, data harmonization, and community engagement. The goal is to leverage shared learning to achieve collective success, where the resulting science and training are greater with an Alliance structure rather than what would be expected from isolated and unconnected individual research projects.In this manuscript, we describe how the Research Coordinating Center performs the role of providing organizational efficiencies, scientific technical assistance, research capacity building, operational coordination, and leadership to support research and training activities in this multi-project cooperative research Alliance. We outline challenges and opportunities during the initial phases of coordinating research and training in the HLB-SIMPLe Alliance, including those most relevant to dissemination and implementation researchers.
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Affiliation(s)
- Emmanuel K Tetteh
- Institute for Informatics, Data Science and Biostatistics, Washington University School of Medicine, St. Louis, MO, USA.
- Center for Public Health Systems Science, Brown School, Washington University in St. Louis, St. Louis, MO, 63130, USA.
| | - William Effah
- Institute for Informatics, Data Science and Biostatistics, Washington University School of Medicine, St. Louis, MO, USA
| | - Lisa de las Fuentes
- Institute for Informatics, Data Science and Biostatistics, Washington University School of Medicine, St. Louis, MO, USA
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Karen Steger-May
- Institute for Informatics, Data Science and Biostatistics, Washington University School of Medicine, St. Louis, MO, USA
| | - Charles W Goss
- Institute for Informatics, Data Science and Biostatistics, Washington University School of Medicine, St. Louis, MO, USA
| | - David W Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Mark D Huffman
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Makeda J Williams
- Center for Translation Research and Implementation Science, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Veronica Tonwe
- Center for Translation Research and Implementation Science, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Geetha P Bansal
- John E Fogarty International Center, National Institutes of Health, Bethesda, MD, USA
| | - Elvin H Geng
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Victor G Dávila-Román
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Treva Rice
- Institute for Informatics, Data Science and Biostatistics, Washington University School of Medicine, St. Louis, MO, USA
| | - Kenneth B Schechtman
- Institute for Informatics, Data Science and Biostatistics, Washington University School of Medicine, St. Louis, MO, USA
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Cordoba E, Garofalo R, Kuhns LM, Pearson C, Scott Batey D, Janulis P, Jia H, Bruce J, Hidalgo MA, Hirshfield S, Radix A, Belkind U, Duncan DT, Kim B, Schnall R. Neighborhood-level characteristics as effect modifiers on the efficacy of the MyPEEPS mobile intervention in same-sex attracted adolescent men. Prev Med Rep 2024; 42:102726. [PMID: 38689890 PMCID: PMC11059328 DOI: 10.1016/j.pmedr.2024.102726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 04/09/2024] [Accepted: 04/11/2024] [Indexed: 05/02/2024] Open
Abstract
To estimate the effect of neighborhood-level modification on the efficacy of the MyPEEPS Mobile intervention on the reduction of condomless anal sex acts among same-sex attracted adolescent men. A series of generalized linear mixed model was used to examine if the effect of the MyPEEPS Mobile intervention on condomless anal sex acts was moderated by neighborhood-level factors using data from the 2019 American Community Survey US Census Bureau. "The magnitudes of intervention were significantly smaller at both 6- and 9-month follow-up among adolescents living in neighborhood with high proportions of Hispanic or Latino residents (IRR6M = 1.02, 95 % CI: 1.01, 1.02; IRR9M = 1.03, 95 % CI: 1.01, 1.05) and high proportions of families with income below the poverty level (IRR6M = 1.07, 95 % CI: 1.01, 1.12; IRR9M = 1.05, 95 % CI: 1.01, 1.10), which indicated that living in communities with a higher concentration of residents living under poverty or of Hispanic/and Latino ethnicity significantly modified the effective of program intervention on condomless sex among adolescent MSM. Understanding how neighborhood characteristics modify the effect of HIV prevention interventions may be useful in better targeting delivery and tailoring content of interventions based on neighborhood level characteristics such as the ones identified in this study.
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Affiliation(s)
- Evette Cordoba
- School of Nursing, Columbia University, New York, NY 10032, USA
| | - Robert Garofalo
- Division of Adolescent & Young Adult Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, 225 East Chicago Avenue, Chicago, IL 60611, USA
- Department of Pediatrics, Northwestern University, Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Lisa M. Kuhns
- Division of Adolescent & Young Adult Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, 225 East Chicago Avenue, Chicago, IL 60611, USA
- Department of Pediatrics, Northwestern University, Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Cynthia Pearson
- Indigenous Wellness Research Institute, School of Social Work, University of Washington, 4101 15 Avenue Northeast, Seattle, WA, 98105, USA
| | - D. Scott Batey
- School of Social Work, Tulane University, 127 Elk Place, New Orleans, LA 70112, USA
| | - Patrick Janulis
- Department of Sociomedical Sciences, Northwestern University, Chicago, IL 60611, USA
| | - Haomiao Jia
- School of Nursing, Columbia University, New York, NY 10032, USA
| | - Josh Bruce
- Birmingham AIDS Outreach, 205 32 Street, Birmingham, AL 35233, USA
| | - Marco A. Hidalgo
- Division of Internal Medicine-Pediatrics and Preventive Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, 911 Broxton Avenue, Los Angeles, CA 90024, USA
| | - Sabina Hirshfield
- STAR Program, Department of Medicine, SUNY Downstate Health Sciences University, 450 Clarkson Avenue, MSC 1240, Brooklyn, NY 11203, USA
| | - Asa Radix
- Callen-Lorde Community Health Center, 356 West 18 Street, New York, NY, 10011, USA
- Columbia University, Mailman School of Public Health, Department of Epidemiology, New York, NY 10032, USA
| | - Uri Belkind
- Callen-Lorde Community Health Center, 356 West 18 Street, New York, NY, 10011, USA
| | - Dustin T. Duncan
- Columbia University, Mailman School of Public Health, Department of Epidemiology, New York, NY 10032, USA
| | - Byoungjun Kim
- Department of Surgery, New York University, New York, NY, 10016, USA & Department of Population Health, New York University, New York, NY 10016, USA
| | - Rebecca Schnall
- School of Nursing, Columbia University, New York, NY 10032, USA
- Columbia University, Mailman School of Public Health, Department of Population and Family Health, New York, NY, 10032, USA
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Jhaveri TA, Jhaveri D, Galivanche A, Lubeck-Schricker M, Voehler D, Chung M, Thekkur P, Chadha V, Nathavitharana R, Kumar AMV, Shewade HD, Powers K, Mayer KH, Haberer JE, Bain P, Pai M, Satyanarayana S, Subbaraman R. Barriers to engagement in the care cascade for tuberculosis disease in India: A systematic review of quantitative studies. PLoS Med 2024; 21:e1004409. [PMID: 38805509 PMCID: PMC11166313 DOI: 10.1371/journal.pmed.1004409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 06/11/2024] [Accepted: 04/29/2024] [Indexed: 05/30/2024] Open
Abstract
BACKGROUND India accounts for about one-quarter of people contracting tuberculosis (TB) disease annually and nearly one-third of TB deaths globally. Many Indians do not navigate all care cascade stages to receive TB treatment and achieve recurrence-free survival. Guided by a population/exposure/comparison/outcomes (PECO) framework, we report findings of a systematic review to identify factors contributing to unfavorable outcomes across each care cascade gap for TB disease in India. METHODS AND FINDINGS We defined care cascade gaps as comprising people with confirmed or presumptive TB who did not: start the TB diagnostic workup (Gap 1), complete the workup (Gap 2), start treatment (Gap 3), achieve treatment success (Gap 4), or achieve TB recurrence-free survival (Gap 5). Three systematic searches of PubMed, Embase, and Web of Science from January 1, 2000 to August 14, 2023 were conducted. We identified articles evaluating factors associated with unfavorable outcomes for each gap (reported as adjusted odds, relative risk, or hazard ratios) and, among people experiencing unfavorable outcomes, reasons for these outcomes (reported as proportions), with specific quality or risk of bias criteria for each gap. Findings were organized into person-, family-, and society-, or health system-related factors, using a social-ecological framework. Factors associated with unfavorable outcomes across multiple cascade stages included: male sex, older age, poverty-related factors, lower symptom severity or duration, undernutrition, alcohol use, smoking, and distrust of (or dissatisfaction with) health services. People previously treated for TB were more likely to seek care and engage in the diagnostic workup (Gaps 1 and 2) but more likely to suffer pretreatment loss to follow-up (Gap 3) and unfavorable treatment outcomes (Gap 4), especially those who were lost to follow-up during their prior treatment. For individual care cascade gaps, multiple studies highlighted lack of TB knowledge and structural barriers (e.g., transportation challenges) as contributing to lack of care-seeking for TB symptoms (Gap 1, 14 studies); lack of access to diagnostics (e.g., X-ray), non-identification of eligible people for testing, and failure of providers to communicate concern for TB as contributing to non-completion of the diagnostic workup (Gap 2, 17 studies); stigma, poor recording of patient contact information by providers, and early death from diagnostic delays as contributing to pretreatment loss to follow-up (Gap 3, 15 studies); and lack of TB knowledge, stigma, depression, and medication adverse effects as contributing to unfavorable treatment outcomes (Gap 4, 86 studies). Medication nonadherence contributed to unfavorable treatment outcomes (Gap 4) and TB recurrence (Gap 5, 14 studies). Limitations include lack of meta-analyses due to the heterogeneity of findings and limited generalizability to some Indian regions, given the country's diverse population. CONCLUSIONS This systematic review illuminates common patterns of risk that shape outcomes for Indians with TB, while highlighting knowledge gaps-particularly regarding TB care for children or in the private sector-to guide future research. Findings may inform targeting of support services to people with TB who have higher risk of poor outcomes and inform multicomponent interventions to close gaps in the care cascade.
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Affiliation(s)
- Tulip A. Jhaveri
- Division of Infectious Diseases, University of Mississippi Medical Center, Jackson, Mississippi, United States of America
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, Massachusetts, United States of America
| | - Disha Jhaveri
- Department of Public Health and Community Medicine and Center for Global Public Health, Tufts University School of Medicine, Boston, Massachusetts, United States of America
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Amith Galivanche
- Department of Public Health and Community Medicine and Center for Global Public Health, Tufts University School of Medicine, Boston, Massachusetts, United States of America
| | - Maya Lubeck-Schricker
- Department of Public Health and Community Medicine and Center for Global Public Health, Tufts University School of Medicine, Boston, Massachusetts, United States of America
| | - Dominic Voehler
- Department of Public Health and Community Medicine and Center for Global Public Health, Tufts University School of Medicine, Boston, Massachusetts, United States of America
| | - Mei Chung
- Department of Public Health and Community Medicine and Center for Global Public Health, Tufts University School of Medicine, Boston, Massachusetts, United States of America
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, Massachusetts, United States of America
| | - Pruthu Thekkur
- Centre for Operational Research, International Union Against Tuberculosis and Lung Disease (The Union), Paris, France
- South-East Asia Office, International Union Against Tuberculosis and Lung Disease (The Union), New Delhi, India
| | | | - Ruvandhi Nathavitharana
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, United States of America
| | - Ajay M. V. Kumar
- Centre for Operational Research, International Union Against Tuberculosis and Lung Disease (The Union), Paris, France
- South-East Asia Office, International Union Against Tuberculosis and Lung Disease (The Union), New Delhi, India
- Department of Community Medicine, Yenepoya Medical College, Yenepoya (deemed to be university), Mangalore, India
| | - Hemant Deepak Shewade
- Division of Health Systems Research, ICMR-National Institute of Epidemiology, Chennai, India
| | - Katherine Powers
- Department of Public Health and Community Medicine and Center for Global Public Health, Tufts University School of Medicine, Boston, Massachusetts, United States of America
| | - Kenneth H. Mayer
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, United States of America
- The Fenway Institute, Boston, Massachusetts, United States of America
| | - Jessica E. Haberer
- Center for Global Health, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, United States of America
| | - Paul Bain
- Countway Library of Medicine, Boston, Massachusetts, United States of America
| | - Madhukar Pai
- Department of Global and Public Health and McGill International TB Centre, McGill University, Montreal, Canada
| | - Srinath Satyanarayana
- Centre for Operational Research, International Union Against Tuberculosis and Lung Disease (The Union), Paris, France
- South-East Asia Office, International Union Against Tuberculosis and Lung Disease (The Union), New Delhi, India
| | - Ramnath Subbaraman
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, Massachusetts, United States of America
- Department of Public Health and Community Medicine and Center for Global Public Health, Tufts University School of Medicine, Boston, Massachusetts, United States of America
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Mody A, Filiatreau LM, Goss CW, Powell BJ, Geng EH. Instrumental variables for implementation science: exploring context-dependent causal pathways between implementation strategies and evidence-based interventions. Implement Sci Commun 2023; 4:157. [PMID: 38124203 PMCID: PMC10731809 DOI: 10.1186/s43058-023-00536-x] [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: 12/03/2022] [Accepted: 12/05/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND The impact of both implementation strategies (IS) and evidence-based interventions (EBI) can vary across contexts, and a better understanding of how and why this occurs presents fundamental but challenging questions that implementation science as a field will need to grapple with. We use causal epidemiologic methods to explore the mechanisms of why sharp distinctions between implementation strategies (IS) and efficacy of an evidence-based intervention (EBI) may fail to recognize that the effect of an EBI can be deeply intertwined and dependent on the context of the IS leading to its uptake. METHODS We explore the use of instrumental variable (IV) analyses as a critical tool for implementation science methods to isolate three relevant quantities within the same intervention context when exposure to an implementation strategy is random: (1) the effect of an IS on implementation outcomes (e.g., uptake), (2) effect of EBI uptake on patient outcomes, and (3) overall effectiveness of the IS (i.e., ~ implementation*efficacy). We discuss the mechanisms by which an implementation strategy can alter the context, and therefore effect, of an EBI using the underlying IV assumptions. We illustrate these concepts using examples of the implementation of new ART initiation guidelines in Zambia and community-based masking programs in Bangladesh. RESULTS Causal questions relevant to implementation science are answered at each stage of an IV analysis. The first stage assesses the effect of the IS (e.g., new guidelines) on EBI uptake (e.g., same-day treatment initiation). The second stage leverages the IS as an IV to estimate the complier average causal effect (CACE) of the EBI on patient outcomes (e.g., effect of same-day treatment initiation on viral suppression). The underlying assumptions of CACE formalize that the causal effect of EBI may differ in the context of a different IS because (1) the mechanisms by which individuals uptake an intervention may differ and (2) the subgroup of individuals who take up an EBI may differ. IV methods thus provide a conceptual framework for how IS and EBIs are linked and that the IS itself needs to be considered a critical contextual determinant. Moreover, it also provides rigorous methodologic tools to isolate the effect of an IS, EBI, and combined effect of the IS and EBI. DISCUSSION Leveraging IV methods when exposure to an implementation strategy is random helps to conceptualize the context-dependent nature of implementation strategies, EBIs, and patient outcomes. IV methods formalize that the causal effect of an EBI may be specific to the context of the implementation strategy used to promote uptake. This integration of implementation science concepts and theory with rigorous causal epidemiologic methods yields novel insights and provides important tools for exploring the next generation of questions related to mechanisms and context in implementation science.
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Affiliation(s)
- Aaloke Mody
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, Campus Box 8051, 4523 Clayton Avenue, St. Louis, MO, 63110, USA.
| | - Lindsey M Filiatreau
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, Campus Box 8051, 4523 Clayton Avenue, St. Louis, MO, 63110, USA
| | - Charles W Goss
- Division of Biostatistics, Washington University School of Medicine, St. Louis, MO, USA
| | - Byron J Powell
- Brown School of Social Work, Washington University in St. Louis, St. Louis, MO, USA
| | - Elvin H Geng
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, Campus Box 8051, 4523 Clayton Avenue, St. Louis, MO, 63110, USA
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Guilamo-Ramos V, Johnson C, Thimm-Kaiser M, Benzekri A. Nurse-led approaches to address social determinants of health and advance health equity: A new framework and its implications. Nurs Outlook 2023; 71:101996. [PMID: 37349232 DOI: 10.1016/j.outlook.2023.101996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 05/19/2023] [Accepted: 05/23/2023] [Indexed: 06/24/2023]
Abstract
BACKGROUND The U.S. health care system is burdened by inefficiencies, longstanding health inequities, and unstainable costs. Within the nursing profession and the broader health care sector, there is growing recognition of the need for a paradigm shift that addresses persistent structural problems and advances health equity. PURPOSE Despite evidence of the importance of the social determinants of health (SDOH) in shaping inequitable health outcomes, practical tools for applying SDOH theory in the development of effective nurse-led programs to mitigate harmful SDOH remain scarce. METHODS We synthesize extant SDOH literature into a heuristic framework for conceptualizing core SDOH mechanisms, constructs, and principles. FINDINGS To illustrate how nurse scientists can use the framework to guide the development of programs for SDOH mitigation, we outline a three-step exemplar application to the U.S. Latino HIV epidemic. DISCUSSION Our framework can inform a paradigm shift toward nurse-led, multi-level SDOH mitigation across practice, education, and research.
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Affiliation(s)
- Vincent Guilamo-Ramos
- Center for Latino Adolescent and Family Health, Duke University, Durham, NC; School of Nursing, Duke University, Durham, NC; School of Medicine, Department of Family Medicine and Community Health, Department of Infectious Diseases, Duke University, Durham, NC; Presidential Advisory Council on HIV/AIDS, US Department of Health and Human Services, Washington, DC.
| | - Celia Johnson
- Center for Latino Adolescent and Family Health, Duke University, Durham, NC; School of Nursing, Duke University, Durham, NC
| | - Marco Thimm-Kaiser
- Center for Latino Adolescent and Family Health, Duke University, Durham, NC; School of Nursing, Duke University, Durham, NC
| | - Adam Benzekri
- Center for Latino Adolescent and Family Health, Duke University, Durham, NC; School of Nursing, Duke University, Durham, NC
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Eshun-Wilson I, Ford N, Mody A, Beres L, Schwartz S, Baral S, Geng EH. Strengthening implementation guidelines for HIV service delivery: Considerations for future evidence generation and synthesis. PLoS Med 2023; 20:e1004168. [PMID: 36877738 PMCID: PMC10027212 DOI: 10.1371/journal.pmed.1004168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Revised: 03/20/2023] [Indexed: 03/07/2023] Open
Abstract
Ingrid Eshun-Wilson and colleagues summarize gaps in primary HIV implementation research methods and reporting, and propose areas for future methodological development.
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Affiliation(s)
- Ingrid Eshun-Wilson
- Division of Infectious Diseases, School of Medicine, Washington University in Saint Louis, Saint Louis, Missouri, United States of America
- Department of Global Health, Stellenbosch University, Cape Town, South Africa
| | - Nathan Ford
- Department of HIV, Viral Hepatitis and Sexually Transmitted Infectionss, World Health Organization, Geneva, Switzerland
| | - Aaloke Mody
- Division of Infectious Diseases, School of Medicine, Washington University in Saint Louis, Saint Louis, Missouri, United States of America
| | - Laura Beres
- Department of International Health, John Hopkins School of Public Health, Baltimore, Maryland, United States of America
| | - Sheree Schwartz
- Department of Epidemiology, John Hopkins School of Public Health, Baltimore, Maryland, United States of America
| | - Stefan Baral
- Department of Epidemiology, John Hopkins School of Public Health, Baltimore, Maryland, United States of America
| | - Elvin H. Geng
- Division of Infectious Diseases, School of Medicine, Washington University in Saint Louis, Saint Louis, Missouri, United States of America
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Rojas-Saunero LP, Labrecque JA, Swanson SA. Invited Commentary: Conducting and Emulating Trials to Study Effects of Social Interventions. Am J Epidemiol 2022; 191:1453-1456. [PMID: 35445692 PMCID: PMC9347019 DOI: 10.1093/aje/kwac066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 01/24/2022] [Accepted: 03/15/2022] [Indexed: 01/28/2023] Open
Abstract
All else being equal, if we had 1 causal effect we wished to estimate, we would conduct a randomized trial with a protocol that mapped onto that causal question, or we would attempt to emulate that target trial with observational data. However, studying the social determinants of health often means there are not just 1 but several causal contrasts of simultaneous interest and importance, and each of these related but distinct causal questions may have varying degrees of feasibility in conducting trials. With this in mind, we discuss challenges and opportunities that arise when conducting and emulating such trials. We describe designing trials with the simultaneous goals of estimating the intention-to-treat effect, the per-protocol effect, effects of alternative protocols or joint interventions, effects within subgroups, and effects under interference, and we describe ways to make the most of all feasible randomized trials and emulated trials using observational data. Our comments are grounded in the study results of Courtin et al. (Am J Epidemiol. 2022;191(8):1444-1452).
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Affiliation(s)
| | | | - Sonja A Swanson
- Correspondence to Dr. Sonja A. Swanson, Department of Epidemiology, School of Public Health, University of Pittsburgh, 130 De Soto Street, Pittsburgh, PA 15261 (e-mail: )
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Mannoh I, Amundsen D, Turpin G, Lyons CE, Viswasam N, Hahn E, Ryan S, Baral S, Hansoti B. A Systematic Review of HIV Testing Implementation Strategies in Sub-Saharan African Countries. AIDS Behav 2022; 26:1660-1671. [PMID: 34797449 PMCID: PMC9426653 DOI: 10.1007/s10461-021-03518-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/23/2021] [Indexed: 11/25/2022]
Abstract
HIV/AIDS remains a looming presence in public health across the world, particularly in Sub-Saharan Africa. The HIV Care Cascade hinges on testing and knowledge of HIV status. Though significant advances have been made in diagnosing people living with HIV (PLHIV), limitations in understanding which strategies are best suited to certain regions or populations have contributed to the uneven distribution in the success of various HIV testing strategies. Here, we present a conceptual framework that outlines effective HIV testing strategies for four target groups. This framework is based on a systematic literature review of articles published from January 1st, 2008, to December 31st, 2019. The effectiveness of HIV testing strategies depends on various factors including the setting, type of test and service providers. Multiple strategies are needed to reach the UNAIDS target of 95% of individuals knowing their HIV status. Expansion of community-based approaches, self-testing and HIV testing services in antenatal care will further improve the state of HIV testing in Sub-Saharan Africa.
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Affiliation(s)
- Ivy Mannoh
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Gnilane Turpin
- Department of Epidemiology, Center for Public Health and Human Rights, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Carrie E Lyons
- Department of Epidemiology, Center for Public Health and Human Rights, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Nikita Viswasam
- Department of Epidemiology, Center for Public Health and Human Rights, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Elizabeth Hahn
- Department of Epidemiology, Center for Public Health and Human Rights, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Sofia Ryan
- Department of Epidemiology, Center for Public Health and Human Rights, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Stefan Baral
- Department of Epidemiology, Center for Public Health and Human Rights, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Bhakti Hansoti
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Medicine Suite 200, 5801 Smith Avenue, Baltimore, MD, 21209, USA.
- Department of International Health, Bloomberg School of Public Health, Baltimore, MD, USA.
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Brownson RC, Shelton RC, Geng EH, Glasgow RE. Revisiting concepts of evidence in implementation science. Implement Sci 2022; 17:26. [PMID: 35413917 PMCID: PMC9004065 DOI: 10.1186/s13012-022-01201-y] [Citation(s) in RCA: 51] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Accepted: 04/04/2022] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Evidence, in multiple forms, is a foundation of implementation science. For public health and clinical practice, evidence includes the following: type 1 evidence on etiology and burden; type 2 evidence on effectiveness of interventions; and type 3: evidence on dissemination and implementation (D&I) within context. To support a vision for development and use of evidence in D&I science that is more comprehensive and equitable (particularly for type 3 evidence), this article aims to clarify concepts of evidence, summarize ongoing debates about evidence, and provide a set of recommendations and tools/resources for addressing the "how-to" in filling evidence gaps most critical to advancing implementation science. MAIN TEXT Because current conceptualizations of evidence have been relatively narrow and insufficiently characterized in our opinion, we identify and discuss challenges and debates about the uses, usefulness, and gaps in evidence for implementation science. A set of questions is proposed to assist in determining when evidence is sufficient for dissemination and implementation. Intersecting gaps include the need to (1) reconsider how the evidence base is determined, (2) improve understanding of contextual effects on implementation, (3) sharpen the focus on health equity in how we approach and build the evidence-base, (4) conduct more policy implementation research and evaluation, and (5) learn from audience and stakeholder perspectives. We offer 15 recommendations to assist in filling these gaps and describe a set of tools for enhancing the evidence most needed in implementation science. CONCLUSIONS To address our recommendations, we see capacity as a necessary ingredient to shift the field's approach to evidence. Capacity includes the "push" for implementation science where researchers are trained to develop and evaluate evidence which should be useful and feasible for implementers and reflect community or stakeholder priorities. Equally important, there has been inadequate training and too little emphasis on the "pull" for implementation science (e.g., training implementers, practice-based research). We suggest that funders and reviewers of research should adopt and support a more robust definition of evidence. By critically examining the evolving nature of evidence, implementation science can better fulfill its vision of facilitating widespread and equitable adoption, delivery, and sustainment of scientific advances.
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Affiliation(s)
- Ross C. Brownson
- Prevention Research Center, Brown School at Washington University in St. Louis, One Brookings Drive, Campus, Box 1196, St. Louis, MO 63130 USA
- Department of Surgery, Division of Public Health Sciences, and Alvin J. Siteman Cancer Center, Washington University School of Medicine, Washington University in St. Louis, St. Louis, MO 63130 USA
| | - Rachel C. Shelton
- Department of Sociomedical Sciences, Columbia University Mailman School of Public Health, New York, NY 10032 USA
| | - Elvin H. Geng
- Division of Infectious Diseases, Department of Medicine and Center for Dissemination and Implementation in the Institute for Public Health, Washington University School of Medicine, Washington University in St. Louis, St. Louis, MO 63110 USA
| | - Russell E. Glasgow
- Department of Family Medicine and Adult & Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO 80045 USA
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Abstract
Elvin Hsing Geng and colleagues discuss mechanism mapping and its utility in conceptualizing and understanding how implementation strategies produce desired effects.
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Affiliation(s)
- Elvin H. Geng
- Center for Dissemination and Implementation, Institute for Public Health and Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, United States of America
- * E-mail:
| | - Ana A. Baumann
- Division of Prevention Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, United States of America
| | - Byron J. Powell
- Center for Dissemination and Implementation, Institute for Public Health and Brown School, Washington University, St. Louis, Missouri, United States of America
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Hontelez JAC, Bulstra CA, Yakusik A, Lamontagne E, Bärnighausen TW, Atun R. Evidence-based policymaking when evidence is incomplete: The case of HIV programme integration. PLoS Med 2021; 18:e1003835. [PMID: 34752470 PMCID: PMC8577724 DOI: 10.1371/journal.pmed.1003835] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Jan Hontelez and co-authors discuss the use of different types of evidence to inform HIV program integration.
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Affiliation(s)
- Jan A. C. Hontelez
- Heidelberg Institute of Global Health (HIGH), Heidelberg University Medical Center, Heidelberg, Germany
- Department of Public Health, Erasmus MC, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Caroline A. Bulstra
- Heidelberg Institute of Global Health (HIGH), Heidelberg University Medical Center, Heidelberg, Germany
- Department of Public Health, Erasmus MC, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Anna Yakusik
- The Joint United Nations Programme on HIV/AIDS (UNAIDS), Geneva, Switzerland
| | - Erik Lamontagne
- The Joint United Nations Programme on HIV/AIDS (UNAIDS), Geneva, Switzerland
- Aix-Marseille School of Economics, CNRS, EHESS, Centrale Marseille, Aix-Marseille University, Les Milles, France
| | - Till W. Bärnighausen
- Heidelberg Institute of Global Health (HIGH), Heidelberg University Medical Center, Heidelberg, Germany
- Africa Health Research Institute (AHRI), Mtubatuba, South Africa
- Harvard Center for Population and Development Studies, Harvard University, Cambridge, Massachusetts, United States of America
| | - Rifat Atun
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
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Implementing Implementation Research: Teaching Implementation Research to HIV Researchers. Curr HIV/AIDS Rep 2021; 18:186-197. [PMID: 33709323 DOI: 10.1007/s11904-021-00551-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2021] [Indexed: 02/01/2023]
Abstract
PURPOSE OF REVIEW Given the growth in HIV-related implementation research, there is a need to expand the workforce and rigor through implementation science (IS) training and mentorship. Our objective is to review IS training opportunities for HIV-focused researchers and describe the approach and lessons learned from a recent HIV-related implementation research training initiative. RECENT FINDINGS IS training opportunities range from degree programs to short- and longer-term professional development institutes and community-focused institutional trainings. Until recently, there have not been extensive dedicated opportunities for implementation research training for HIV-focused investigators. To meet this gap, an inter-Center for AIDS Research IS Fellowship for early-stage investigators was launched in 2019, building on lessons learned from dissemination and implementation training programs. Key components of the HIV-focused IS fellowship include didactic training, mentorship, grant-writing, and development of HIV-IS collaborative networks. Fellows to-date were two-thirds junior faculty and one-third post-doctoral fellows, the majority (69%) with prior public health training. Perceived value of the program was high, with a median rating of 9 [IQR 8-9] on a 10-point scale. Overall, 22/27 (81%) Fellows from the first cohort submitted IS-related grants within 12 months of Fellowship completion, and by 1 year 13 grants had been funded among 10 investigators, 37% overall among Fellows. Mentors identified framing of IS questions as the top-ranked training priority for HIV-investigators. Increasing knowledge of the utility of IS may support more grants focused on optimal implementation of HIV treatment and prevention strategies. Experiences from mentors and trainees engaged in an IS-focused fellowship for HIV investigators demonstrate the demand and value of a dedicated training program and reinforce the importance of mentorship.
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Improving Care Outcomes for PLWH Experiencing Homelessness and Unstable Housing: a Synthetic Review of Clinic-Based Strategies. Curr HIV/AIDS Rep 2020; 17:259-267. [PMID: 32382919 DOI: 10.1007/s11904-020-00488-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW Singular interventions targeting vulnerable populations of people living with HIV (PLWH) are necessary for reducing new infections and optimizing individual-level outcomes, but extant literature for PLWH who experience homelessness and unstable housing (HUH) has not been compiled. To inform implementation of clinic-based programs that improve care outcomes in this population, we present a synthetic review of key studies examining clinic-based interventions, specifically case management, patient navigation, financial incentives, and the use of mobile technology. RECENT FINDINGS Results from unimodal interventions are mixed or descriptive, are limited by inability to address related multi-modal barriers to care, and do not address major challenges to implementation. Multi-component interventions are needed, but gaps in our knowledge base may limit widespread uptake of such interventions before further data are compiled. Future research evaluating interventions for PLWH experiencing HUH should include implementation outcomes in order to facilitate adaptation across diverse clinical settings.
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