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Piper KN, Anderson KM, Kokubun CW, Sheth AN, Sales J. Using qualitative comparative analysis to understand the conditions that produce successful PrEP implementation in family planning clinics. Implement Sci Commun 2023; 4:64. [PMID: 37296455 DOI: 10.1186/s43058-023-00450-2] [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: 06/08/2022] [Accepted: 06/03/2023] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND Title X-funded family planning clinics have been identified as optimal sites for delivery of pre-exposure prophylaxis (PrEP) for HIV prevention to U.S. women. However, PrEP has not been widely integrated into family planning services, especially in the Southern U.S., and data suggest there may be significant implementation challenges in this setting. METHODS To understand contextual factors that are key to successful PrEP implementation in family planning clinics, we conducted in-depth qualitative interviews with key informants from 38 family planning clinics (11 clinics prescribed PrEP and 27 did not). Interviews were guided by constructs from the Consolidated Framework for Implementation Research (CFIR), and qualitative comparative analysis (QCA) was used to uncover the configurations of CFIR factors that led to PrEP implementation. RESULTS We identified 3 distinct construct configurations, or pathways, that led to successful PrEP implementation: (1) high "Leadership Engagement" AND high "Available Resources"; OR (2) high "Leadership Engagement" AND NOT located in the Southeast region; OR (3) high "Access to Knowledge and Information" AND NOT located in the Southeast region. Additionally, there were 2 solution paths that led to absence of PrEP implementation: (1) low "Access to Knowledge and Information" AND low "Leadership Engagement"; OR (2) low "Available Resources" AND high "External Partnerships". DISCUSSION We identified the most salient combinations of co-occurring organizational barriers or facilitators associated with PrEP implementation across Title X clinics in the Southern U.S. We discuss implementation strategies to promote pathways that led to implementation success, as well as strategies to overcome pathways to implementation failure. Notably, we identified regional differences in the pathways that led to PrEP implementation, with Southeastern clinics facing the most obstacles to implementation, specifically substantial resource constraints. Identifying implementation pathways is an important first step for packaging multiple implementation strategies that could be employed by state-level Title X grantees to help scale up PrEP.
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Affiliation(s)
- Kaitlin N Piper
- Rollins School of Public Health, Emory University, Atlanta, GA, USA.
| | | | | | - Anandi N Sheth
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA
| | - Jessica Sales
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
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Newton-Levinson A, Regina R, Dys G, Higdon M, Sullivan S, Brooks MW, Kottke M, Hall KS, Blake SC. Implementation of Title X Family Planning Services in Primary Care: A Qualitative Study of a Primary Care Network in Georgia. Womens Health Issues 2023; 33:142-152. [PMID: 36473768 PMCID: PMC10010938 DOI: 10.1016/j.whi.2022.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 09/30/2022] [Accepted: 10/21/2022] [Indexed: 12/12/2022]
Abstract
CONTEXT There is increasing interest and value in integrating family planning services into primary care. Title X services provide an opportunity to expand low-cost access to these services. This study sought to identify and describe implementation factors that influenced the integration of a package of Title X services into a unique primary care setting within a Georgia primary care network whose community health center sites are primarily federally qualified health centers. METHODS We used an implementation science approach and were guided by the Consolidated Framework for Implementation Research. From December 2019 to September 2020, we conducted interviews with administrators and providers working at grantee and sub-grantee organizations about their experiences integrating Title X services into their existing practice. RESULTS Factors associated with the Inner Setting were especially important for integrating Title X in these settings. Participants identified specific needs related to resources such as electronic medical record (EMR) and reporting templates. Contextually specific clinical training for provision of long-acting reversible contraception and sexual health counseling, as well as administrative training for reporting and documentation efforts, was particularly needed. Grantee and sub-grantee organizations were able to leverage internal and external networks and adaptations to the intervention to successfully implement Title X services and to expand reach to new clients. CONCLUSIONS Integrating family planning into primary care may expand access to low-income and underserved populations. Approaches that incorporate flexibility and provide tailored resources for primary care settings such as EMR and reporting templates and trainings, and that leverage multiple forms of support and knowledge sharing, may be particularly important for helping to implement Title X services.
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Affiliation(s)
- Anna Newton-Levinson
- Center for Reproductive Health Research in the Southeast (RISE), Emory University, Atlanta, Georgia; Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, Georgia.
| | - Rachel Regina
- Center for Reproductive Health Research in the Southeast (RISE), Emory University, Atlanta, Georgia
| | - Gabrielle Dys
- Center for Reproductive Health Research in the Southeast (RISE), Emory University, Atlanta, Georgia
| | - Megan Higdon
- Center for Reproductive Health Research in the Southeast (RISE), Emory University, Atlanta, Georgia
| | - Sara Sullivan
- Georgia Family Planning System, The Family Health Centers of Georgia, Inc., Atlanta, Georgia
| | - Michael W Brooks
- Georgia Family Planning System, The Family Health Centers of Georgia, Inc., Atlanta, Georgia
| | - Melissa Kottke
- Center for Reproductive Health Research in the Southeast (RISE), Emory University, Atlanta, Georgia; Jane Fonda Center, Department of Gynecology and Obstetrics, School of Medicine, Emory University, Atlanta, Georgia
| | - Kelli S Hall
- Center for Reproductive Health Research in the Southeast (RISE), Emory University, Atlanta, Georgia; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia; Heilbrunn Department of Population & Family Health, Mailman School of Public Health, Columbia University, New York, New York
| | - Sarah C Blake
- Center for Reproductive Health Research in the Southeast (RISE), Emory University, Atlanta, Georgia; Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, Georgia
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Provision of HIV preexposure prophylaxis to female patients seeking family planning services in the United States. AIDS 2023; 37:137-148. [PMID: 36172845 DOI: 10.1097/qad.0000000000003398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE We conducted a scoping review to assess barriers to and facilitators of integrating HIV preexposure prophylaxis (PrEP) and family planning (FP) at the patient, provider, and implementation levels, and to identify gaps in knowledge. METHODS We conducted a search of five bibliographic databases from database inception to March 2022: PubMed, CINAHL, Embase, Web of Science and Scopus. Two reviewers screened abstracts and full texts to determine eligibility based on a priori inclusion and exclusion criteria. We categorized studies by their relevance to patient, provider, and implementation barriers, and extracted data based on prespecified elements. RESULTS Our initial search strategy yielded 1151 results, and 34 publications were included. Barriers to PrEP implementation in family planning settings included low PrEP knowledge among patients, hesitance to take PrEP due to perceived stigma, decreased willingness of providers unfamiliar with PrEP to prescribe PrEP, and limited financial and staffing resources that make prescribing and monitoring PrEP difficult. Facilitators included robust training for providers, stigma reduction efforts, leadership engagement, and increased resources specifically in settings with processes in place that ease the process of prescribing and monitoring PrEP. CONCLUSIONS Advances in implementation strategy development, stigma reduction, and drug development will be essential to reinforcing PrEP care in family planning settings and thereby reducing the incidence of HIV in women through highly effective pharmacologic HIV prevention methods.
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Carcone AI, Coyle K, Butame S, Harper GW, Aarons GA, Naar S. Using the Exploration-Preparation-Implementation-Sustainment (EPIS) Framework to prepare for the implementation of evidence-based practices into adolescent HIV settings. AIDS Behav 2022; 26:4093-4106. [PMID: 36066763 PMCID: PMC9643628 DOI: 10.1007/s10461-022-03735-0] [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] [Accepted: 05/26/2022] [Indexed: 11/01/2022]
Abstract
Despite advances in evidence-based practices (EBP) to support HIV prevention and treatment, youth ages 13-24 experience significant disparities in HIV risk and outcomes. An important factor in this disparity is poor EBP implementation, yet implementation research is limited, particularly in youth-serving settings. This study used the Exploration, Preparation, Implementation, Sustainment (EPIS) framework to guide the implementation of four Motivational Interviewing (MI) and MI-framed interventions into youth-serving HIV prevention and treatment settings. Key stakeholders (n = 153) across 13 sites completed pre-implementation interviews. Stakeholders' comments identified two critical factors for effective implementation: fit with the patient population and provider receptivity, including concerns about scope of practice, buy-in, and time. Stakeholders recommended strategies for structuring training, fidelity monitoring, and facilitating implementation including engaging informal leaders, collaboratively developing the implementation strategy, and site-wide implementation. Results highlight the importance of pre-implementation contextual assessment and strategic planning for identifying provider concerns and developing responsive implementation strategies.
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Affiliation(s)
- April Idalski Carcone
- Department of Family Medicine and Public Health Sciences, Wayne State University, Detroit, Michigan, United States
| | - Karin Coyle
- Education, Training, and Research (ETR), Scotts Valley, California, United States
| | - Seyram Butame
- Center for Translational Behavioral Science, Florida State University, Tallahassee, Florida, United States
| | - Gary W Harper
- Department of Health Behavior and Health Education, University of Michigan, Ann Arbor, Michigan, United States
| | - Gregory A Aarons
- ACTRI Dissemination and Implementation Science Center, University of California, San Diego, La Jolla, California, United States
| | - Sylvie Naar
- Center for Translational Behavioral Science, Florida State University, Tallahassee, Florida, United States
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Sonalkar S, McAllister A, Kete C, Fishman J, Frarey A, Short WR, Schreiber CA, Teitelman AM. Implementation of an HIV Pre-exposure Prophylaxis Strategy Into Abortion and Early Pregnancy Loss Care. J Acquir Immune Defic Syndr 2022; 90:S129-S133. [PMID: 35703764 PMCID: PMC9204783 DOI: 10.1097/qai.0000000000002972] [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] [Indexed: 11/26/2022]
Abstract
BACKGROUND Family planning and abortion clinics routinely address sexual health. We sought to evaluate implementation outcomes of an HIV pre-exposure prophylaxis (PrEP) care strategy for patients seeking management of induced abortion and pregnancy loss. SETTING Single-center, urban, academic, hospital-based family planning service. METHODS We used a multifaceted implementation strategy directed toward family planning providers comprised of educational sessions, an electronic medical record-prompted verbal assessment of HIV risk, electronic medical record shortcuts for PrEP prescription, and support of a PrEP navigator. We assessed penetration of the intervention by calculating the penetration of a PrEP offer, measured as the proportion of encounters in which PrEP was offered to PrEP-eligible individuals. We evaluated feasibility, acceptability, and appropriateness of the intervention using belief elicitation interviews with providers. RESULTS From November 2018 to April 2019, the proportion of PrEP eligible patients who were offered PrEP, was 87.9% (29/33). Providers found the intervention acceptable and appropriate, but reported barriers including time constraints, and disappointment if patients did not adhere to PrEP. Providers liked that PrEP provision in abortion care settings felt innovative, and that they could contribute to HIV prevention. CONCLUSION Family planning providers in an academic center found HIV risk assessment and PrEP provision to be feasible, acceptable, and appropriate. Further research should evaluate implementation outcomes of PrEP care strategies in additional abortion care contexts, including clinics offering reproductive health care outside of academia.
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Affiliation(s)
- Sarita Sonalkar
- Division of Family Planning, Perelman School of Medicine at the University of Pennsylvania, 3737 Market St, 12 Floor, Philadelphia, PA 19119, USA, 215-615-5234
| | - Arden McAllister
- Division of Family Planning, Perelman School of Medicine at the University of Pennsylvania, 3737 Market St, 12 Floor, Philadelphia, PA 19119, USA, 215-615-5234
| | - Corinne Kete
- Division of Family Planning, Perelman School of Medicine at the University of Pennsylvania, 3737 Market St, 12 Floor, Philadelphia, PA 19119, USA, 215-615-5234
| | - Jessica Fishman
- Department of Psychiatry, Perelman School of Medicine; Annenberg School for Communication, 3620 Walnut Street, Philadelphia, PA 19104; Leonard Davis Institute, University of Pennsylvania
| | - Alhambra Frarey
- Division of Family Planning, Perelman School of Medicine at the University of Pennsylvania, 3737 Market St, 12 Floor, Philadelphia, PA 19119, USA, 215-615-5234
| | - William R. Short
- Division of Infectious Diseases, Perelman School of Medicine at the University of Pennsylvania, 3801 Filbert Street, Suite 103, Philadelphia, PA 19104, 215-662-9908
| | - Courtney A. Schreiber
- Division of Family Planning, Perelman School of Medicine at the University of Pennsylvania, 3737 Market St, 12 Floor, Philadelphia, PA 19119, USA, 215-615-5234
| | - Anne M. Teitelman
- School of Nursing, University of Pennsylvania, Claire M. Fagin Hall, 418 Curie Blvd, Philadelphia, PA 19104
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Martinez-Cajas JL, Torres J, Mueses HF, Plazas PC, Arrivillaga M, Gomez SA, Galindo X, Buitrago EM, Llano BEA. Applying implementation science frameworks to identify factors that influence the intention of healthcare providers to offer PrEP care and advocate for PrEP in HIV clinics in Colombia: a cross-sectional study. Implement Sci Commun 2022; 3:31. [PMID: 35296369 PMCID: PMC8925047 DOI: 10.1186/s43058-022-00278-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 02/24/2022] [Indexed: 11/23/2022] Open
Abstract
Background Few studies have used implementation science frameworks to identify determinants of PrEP prescription by healthcare providers. In this work, we developed and psychometrically examined a questionnaire using the theoretical domains framework (TDF) and the consolidated framework for implementation research (CFIR). We used this questionnaire to investigate what factors influence the intention of healthcare providers to offer PrEP care and advocate for PrEP. Methods We conducted a cross-sectional study in 16 HIV healthcare organizations in Colombia. A 98-item questionnaire was administered online to 129 healthcare professionals. One hundred had complete data for this analysis. We used exploratory factor analysis to assess the psychometric properties of both frameworks, and multinomial regression analysis to evaluate the associations of the frameworks’ domains with two outcomes: (1) intention to offer PrEP care and (2) intention to advocate for PrEP impmentation. Results We found support for nine indices with good internal consistency, reflecting PrEP characteristics, attitudes towards population needs, concerns about the use of PrEP, concerns about the role of the healthcare systems, knowledge, beliefs about capabilities, professional role, social influence, and beliefs about consequences. Notably, only 57% of the participants were likely to have a plan to care for people in PrEP and 66.7% were likely to advocate for PrEP. The perception of the need for PrEP in populations, the value of PrEP as a practice, the influence of colleagues, and seeing PrEP care as a priority was related to being less likely to be unwilling to provide or advocate for PrEP care. Conclusion Our findings suggested the importance of multilevel strategies to increase the provision of PrEP care by healthcare providers including adquisition of new skills, training of PrEP champions, and strength the capacity of the health system. Supplementary Information The online version contains supplementary material available at 10.1186/s43058-022-00278-2.
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Affiliation(s)
- Jorge Luis Martinez-Cajas
- Division of Infectious Diseases, Department of Medicine, Queen's University, Kingston, ON, K7L 3 N6, Canada
| | - Julian Torres
- Montefiore Medical Center, Moses Division, Albert Einstein College of Medicine, The Oval Center at Montefiore, 3230 Bainbridge Ave, Bronx, NY, 10467, USA
| | | | | | - Marcela Arrivillaga
- Facultad de Ciencias de la Salud, Pontificia Universidad Javeriana Cali, Colombia, Calle, 18 118-250, Cali, Colombia
| | - Sheila Andrea Gomez
- Facultad de Ciencias de la Salud, Pontificia Universidad Javeriana Cali, Colombia, Calle, 18 118-250, Cali, Colombia
| | - Ximena Galindo
- Corporación de Lucha Contra el Sida, Carrera 56 2- 120, Cali, Colombia
| | - Ernesto Martinez Buitrago
- Departamento de Medicina Interna, Universidad del Valle, Calle 5 36-08 Hospital Universitario del Valle, Cali, Colombia
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Pyra M, Motley D, Bouris A. Moving toward equity: fostering transdisciplinary research between the social and behavioral sciences and implementation science to end the HIV epidemic. Curr Opin HIV AIDS 2022; 17:89-99. [PMID: 35225249 DOI: 10.1097/coh.0000000000000726] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Since the beginning of the HIV epidemic, social and behavioral scientists have developed interventions to stem the spread of the virus. The dissemination of these interventions has traditionally been a lengthy process; however, implementation science (IS) offers a route toward hastening delivery of effective interventions. A transdisciplinary approach, wherein IS informs and is informed by social and behavioral sciences (SBS) as well as community participation, offers a strategy for more efficiently moving toward health equity and ending the HIV epidemic. RECENT FINDINGS There has been considerable growth in HIV research utilizing IS theories, methods and frameworks. Many of these studies have been multi or interdisciplinary in nature, demonstrating the ways that IS and SBS can strengthen one another. We also find areas for continued progress toward transdisciplinarity. SUMMARY We review literature from 2020 to 2021, exploring the ways IS and SBS have been used in tandem to develop, evaluate and disseminate HIV interventions. We highlight the interplay between disciplines and make a case for moving toward transdisciplinarity, which would yield new, integrated frameworks that can improve prevention and treatment efforts, moving us closer to achieving health equity.
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Affiliation(s)
- Maria Pyra
- Chicago Center for HIV Elimination, Biological Sciences Division, University of Chicago
- Howard Brown Health Center
| | - Darnell Motley
- Chicago Center for HIV Elimination, Biological Sciences Division, University of Chicago
| | - Alida Bouris
- Chicago Center for HIV Elimination, Biological Sciences Division, University of Chicago
- Crown Family School of Social Work, Policy and Practice, University of Chicago, Chicago, IL, USA
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