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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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Akiba CF, Patel SV, Wenger LD, Morgan-Lopez A, Zarkin GA, Orme S, Davidson PJ, Kral AH, Lambdin BH. Systems analysis and improvement approach to improve naloxone distribution within syringe service programs: study protocol of a randomized controlled trial. Implement Sci 2023; 18:33. [PMID: 37537665 PMCID: PMC10398915 DOI: 10.1186/s13012-023-01288-x] [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: 06/05/2023] [Accepted: 07/24/2023] [Indexed: 08/05/2023] Open
Abstract
BACKGROUND More than half a million Americans died of an opioid-related overdose between 1999 and 2020, the majority occurring between 2015 and 2020. The opioid overdose mortality epidemic disproportionately impacts Black, Indigenous, and people of color (BIPOC): since 2015, overdose mortality rates have increased substantially more among Black (114%) and Latinx (97%) populations compared with White populations (32%). This is in part due to disparities in access to naloxone, an opioid antagonist that can effectively reverse opioid overdose to prevent death. Our recent pilot work determined that many barriers to naloxone access can be identified and addressed by syringe service programs (SSPs) using the Systems Analysis and Improvement Approach to Naloxone distribution (SAIA-Naloxone). This randomized controlled trial will test SAIA-Naloxone's ability to improve naloxone distribution in general and among BIPOC specifically. METHODS We will conduct a trial with 32 SSPs across California, randomly assigning 16 to the SAIA-Naloxone arm and 16 to receive implementation as usual. SAIA-Naloxone is a multifaceted, multilevel implementation strategy through which trained facilitators work closely with SSPs to (1) assess organization-level barriers, (2) prioritize barriers for improvement, and (3) test solutions through iterative change cycles until achieving and sustaining improvements. SSPs receiving SAIA-Naloxone will work with a trained facilitator for a period of 12 months. We will test SAIA-Naloxone's ability to improve SSPs' naloxone distribution using an interrupted time series approach. Data collection will take place during a 3-month lead-in period, the 12-month active period, and for an additional 6 months afterward to determine whether impacts are sustained. We will use a structured approach to specify SAIA-Naloxone to ensure strategy activities are clearly defined and to assess SAIA-Naloxone fidelity to aid in interpreting study results. We will also assess the costs associated with SAIA-Naloxone and its cost-effectiveness. DISCUSSION This trial takes a novel approach to improving equitable distribution of naloxone amid the ongoing epidemic and associated racial disparities. If successful, SAIA-Naloxone represents an important organizational-level solution to the multifaceted and multilevel barriers to equitable naloxone distribution.
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Affiliation(s)
- Christopher F Akiba
- RTI International, 3040 E Cornwallis Rd, Research Triangle, Research Triangle Park, NC, 27709, USA.
| | - Sheila V Patel
- RTI International, 3040 E Cornwallis Rd, Research Triangle, Research Triangle Park, NC, 27709, USA
| | - Lynn D Wenger
- RTI International, 3040 E Cornwallis Rd, Research Triangle, Research Triangle Park, NC, 27709, USA
| | - Antonio Morgan-Lopez
- RTI International, 3040 E Cornwallis Rd, Research Triangle, Research Triangle Park, NC, 27709, USA
| | - Gary A Zarkin
- RTI International, 3040 E Cornwallis Rd, Research Triangle, Research Triangle Park, NC, 27709, USA
| | - Stephen Orme
- RTI International, 3040 E Cornwallis Rd, Research Triangle, Research Triangle Park, NC, 27709, USA
| | - Peter J Davidson
- Department of Medicine, Division Global Public Health, UCSD, 9500 Gilman Dr, La Jolla, CA, 92093, USA
| | - Alex H Kral
- RTI International, 3040 E Cornwallis Rd, Research Triangle, Research Triangle Park, NC, 27709, USA
| | - Barrot H Lambdin
- RTI International, 3040 E Cornwallis Rd, Research Triangle, Research Triangle Park, NC, 27709, USA
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Inguane C, Gimbel S, Soi C, Tavede E, Murgorgo F, Isidoro X, Sidat Y, Nassiaca R, Coutinho J, Cruz M, Agostinho M, Amaral F, Dinis A, Ábsjörnsdóttir K, Crocker J, Manaca N, Ramiro I, Pfeiffer J, de Fátima Cuembelo M, Sherr K. Assessing drivers of implementing "Scaling-up the Systems Analysis and Improvement Approach" for Prevention of Mother-to-Child HIV Transmission in Mozambique (SAIA-SCALE) over implementation waves. Implement Sci Commun 2023; 4:84. [PMID: 37488632 PMCID: PMC10364357 DOI: 10.1186/s43058-023-00422-6] [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: 07/15/2022] [Accepted: 04/01/2023] [Indexed: 07/26/2023] Open
Abstract
BACKGROUND The Systems Analysis and Improvement Approach (SAIA) is an evidence-based package of systems engineering tools originally designed to improve patient flow through the prevention of Mother-to-Child transmission of HIV (PMTCT) cascade. SAIA is a potentially scalable model for maximizing the benefits of universal antiretroviral therapy (ART) for mothers and their babies. SAIA-SCALE was a stepped wedge trial implemented in Manica Province, Mozambique, to evaluate SAIA's effectiveness when led by district health managers, rather than by study nurses. We present the results of a qualitative assessment of implementation determinants of the SAIA-SCALE strategy during two intensive and one maintenance phases. METHODS We used an extended case study design that embedded the Consolidated Framework for Implementation Research (CFIR) to guide data collection, analysis, and interpretation. From March 2019 to April 2020, we conducted in-depth individual interviews (IDIs) and focus group discussions (FGDs) with district managers, health facility maternal and child health (MCH) managers, and frontline nurses at 21 health facilities and seven districts of Manica Province (Chimoio, Báruè, Gondola, Macate, Manica, Sussundenga, and Vanduzi). RESULTS We included 85 participants: 50 through IDIs and 35 from three FGDs. Most study participants were women (98%), frontline nurses (49.4%), and MCH health facility managers (32.5%). An identified facilitator of successful intervention implementation (regardless of intervention phase) was related to SAIA's compatibility with organizational structures, processes, and priorities of Mozambique's health system at the district and health facility levels. Identified barriers to successful implementation included (a) inadequate health facility and road infrastructure preventing mothers from accessing MCH/PMTCT services at study health facilities and preventing nurses from dedicating time to improving service provision, and (b) challenges in managing intervention funds. CONCLUSIONS The SAIA-SCALE qualitative evaluation suggests that the scalability of SAIA for PMTCT is enhanced by its fit within organizational structures, processes, and priorities at the primary level of healthcare delivery and health system management in Mozambique. Barriers to implementation that impact the scalability of SAIA include district-level financial management capabilities and lack of infrastructure at the health facility level. SAIA cannot be successfully scaled up to adequately address PMTCT needs without leveraging central-level resources and priorities. TRIAL REGISTRATION ClinicalTrials.gov, NCT03425136 . Registered on 02/06/2018.
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Affiliation(s)
- Celso Inguane
- Department of Global Health, University of Washington, Seattle, WA, USA.
- Hans Rosling Center for Population Health, 700D.4, University of Washington, Box 351620, 3980 15Th Ave. NE, Seattle, WA, 98105, USA.
- Cooperativa de Ideias e Pesquisa em Saúde - CO-IDEAS, Maputo City, Mozambique.
| | - 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
| | - Caroline Soi
- Department of Global Health, University of Washington, Seattle, WA, USA
| | | | | | | | - Yaesh Sidat
- Manica Province Health Directorate, Chimoio, Mozambique
| | | | - Joana Coutinho
- Comité Para a Saúde de Moçambique, Maputo City, Mozambique
| | - Maria Cruz
- Comité Para a Saúde de Moçambique, Maputo City, Mozambique
| | - Mery Agostinho
- Comité Para a Saúde de Moçambique, Maputo City, Mozambique
| | | | - Aneth Dinis
- Department of Global Health, University of Washington, Seattle, WA, USA
- National Department of Public Health, Ministry of Health, Maputo City, Mozambique
| | - Kristjana Ábsjörnsdóttir
- Center for Public Health Sciences, University of Iceland, Reykjavik, Iceland
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Jonny Crocker
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Nélia Manaca
- Health Alliance International, Beira, Mozambique
| | - Isaias Ramiro
- Comité Para a Saúde de Moçambique, Maputo City, Mozambique
| | - James Pfeiffer
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Anthropology, University of Washington, Seattle, WA, USA
| | - Maria de Fátima Cuembelo
- Department of Community Health, Faculty of Medicine, Universidade Eduardo Mondlane, Maputo City, 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
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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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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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Beima-Sofie K, Wagner AD, Soi C, Liu W, Tollefson D, Njuguna IN, Ogutu E, Gaitho D, Mburu N, Oluoch G, Mwaura P, Cherutich P, Oyiengo L, John-Stewart GC, Nduati R, Sherr K, Gimbel S. Providing "a beam of light to see the gaps": determinants of implementation of the Systems Analysis and Improvement Approach applied to the pediatric and adolescent HIV cascade in Kenya. Implement Sci Commun 2022; 3:73. [PMID: 35842734 PMCID: PMC9287987 DOI: 10.1186/s43058-022-00304-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 05/04/2022] [Indexed: 11/10/2022] Open
Abstract
Background Children and adolescents living with HIV have poorer rates of HIV testing, treatment, and virologic suppression than adults. Strategies that use a systems approach to optimize these multiple, linked steps simultaneously are critical to close these gaps. Methods The Systems Analysis and Improvement Approach (SAIA) was adapted and piloted for the pediatric and adolescent HIV care and treatment cascade (SAIA-PEDS) at 6 facilities in Kenya. SAIA-PEDS includes three tools: continuous quality improvement (CQI), flow mapping, and pediatric cascade analysis (PedCAT). A predominately qualitative evaluation utilizing focus group discussions (N = 6) and in-depth interviews (N = 19) was conducted with healthcare workers after implementation to identify determinants of implementation. Data collection and analysis were grounded in the Consolidated Framework for Implementation Research (CFIR). Results Overall, the adapted SAIA-PEDS strategy was acceptable, and the three tools complemented one another and provided a relative advantage over existing processes. The flow mapping and CQI tools were compatible with existing workflows and resonated with team priorities and goals while providing a structure for group problem solving that transcended a single department’s focus. The PedCAT was overly complex, making it difficult to use. Leadership and hierarchy were complex determinants. All teams reported supportive leadership, with some describing in detail how their leadership was engaged and enthusiastic about the SAIA-PEDS process, by providing recognition, time, and resources. Hierarchy was similarly complex: in some facilities, leadership stifled rapid innovation by insisting on approving each change, while at other facilities, leadership had strong and supportive oversight of processes, checking on the progress frequently and empowering teams to test innovative ideas. Conclusion CQI and flow mapping were core components of SAIA-PEDS, with high acceptability and consistent use, but the PedCAT was too complex. Leadership and hierarchy had a nuanced role in implementation. Future SAIA-PEDS testing should address PedCAT complexity and further explore the modifiability of leadership engagement to maximize implementation. Supplementary Information The online version contains supplementary material available at 10.1186/s43058-022-00304-3.
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Affiliation(s)
| | - Anjuli D Wagner
- Department of Global Health, University of Washington, Seattle, USA.
| | - Caroline Soi
- Department of Global Health, University of Washington, Seattle, USA
| | - Wenjia Liu
- Department of Child, Family & Population Health Nursing, University of Washington, Seattle, USA
| | - Deanna Tollefson
- Department of Global Health, University of Washington, Seattle, USA
| | - Irene N Njuguna
- Department of Global Health, University of Washington, Seattle, USA.,Research & Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Emily Ogutu
- Gangarosa Department of Environmental Health, Emory University, Atlanta, USA
| | - Douglas Gaitho
- Network of AIDS Researchers in Eastern and Southern Africa, Nairobi, Kenya
| | - Nancy Mburu
- Network of AIDS Researchers in Eastern and Southern Africa, Nairobi, Kenya
| | - Geoffrey Oluoch
- Network of AIDS Researchers in Eastern and Southern Africa, Nairobi, Kenya
| | - Peter Mwaura
- Network of AIDS Researchers in Eastern and Southern Africa, Nairobi, Kenya
| | | | | | - Grace C John-Stewart
- Department of Global Health, University of Washington, Seattle, USA.,Department of Epidemiology, University of Washington, Seattle, USA.,Department of Pediatrics, School of Medicine, Seattle, USA.,Department of Medicine, University of Washington, Seattle, USA
| | - Ruth Nduati
- Network of AIDS Researchers in Eastern and Southern Africa, Nairobi, Kenya.,Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Kenneth Sherr
- Department of Global Health, University of Washington, Seattle, USA.,Department of Epidemiology, University of Washington, Seattle, USA.,Department of Industrial & Systems Engineering, University of Washington, Seattle, USA
| | - Sarah Gimbel
- Department of Global Health, University of Washington, Seattle, USA.,Department of Child, Family & Population Health Nursing, University of Washington, Seattle, USA
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