Rapid implementation mapping to identify implementation determinants and strategies for cervical cancer control in Nigeria

BackgroundCervical cancer constitutes a huge burden among women in Nigeria, particularly HIV-infected women. However, the provision and uptake of cervical cancer screening and treatment is limited in Nigeria. Understanding implementation determinants is essential for the effective translation of such evidence-based interventions into practice, particularly in low-resource settings. COVID-19 pandemic necessitated online collaboration making implementation mapping challenging in some ways, while providing streamlining opportunities. In this study, we describe the use of a virtual online approach for implementation mapping (steps 1–3) to identify implementation determinants, mechanisms, and strategies to implement evidence-based cervical cancer screening and treatment in existing HIV infrastructure in Nigeria.MethodsThis study used a mixed methods study design with a virtual modified nominal group technique (NGT) process aligning with Implementation Mapping steps 1–3. Eleven stakeholders (six program staff and five healthcare providers and administrators) participated in a virtual NGT process which occurred in two phases. The first phase utilized online surveys, and the second phase utilized an NGT and implementation mapping process. The Exploration, Preparation, Implementation and Sustainment (EPIS) framework was used to elicit discussion around determinants and strategies from the outer context (i.e., country and regions), inner organizational context of existing HIV infrastructure, bridging factors that relate to bi-directional influences, and the health innovation to be implemented (in this case cervical cancer screening and treatment). During the NGT, the group ranked implementation barriers and voted on implementation strategies using Mentimeter.ResultsEighteen determinants to integrating cervical cancer screening and treatment into existing comprehensive HIV programs were related to human resources capacity, access to cervical cancer services, logistics management, clinic, and client-related factors. The top 3 determinants included gaps in human resources capacity, poor access to cervical cancer services, and lack of demand for services resulting from lack of awareness about the disease and servicesA set of six core implementation strategies and two enhanced implementation strategies were identified.ConclusionsRapid Implementation Mapping is a feasible and acceptable approach for identifying and articulating implementation determinants, mechanisms, and strategies for complex healthcare interventions in LMICs

From Fighting Wasting to Shedding Excess: An Explanatory Sequential Mixed-Method Study of Obesity Among People Living With HIV in Nigeria

The human immunodeficiency virus (HIV) infection is a global epidemic, with initial high mortality rates since the first diagnosis over three and a half decades ago. However, the use of antiretroviral therapy (ART) has led to longer, healthier lives for many people living with HIV (PLHIV). Accordingly, aging comes with associated co-morbidities like obesity, diabetes, and cardiovascular diseases. The purpose of this mixed-methods study was to further understand the emergent phenomenon of obesity and overweight among PLHIV who are on treatment with ART, using Nigeria as a case study. An explanatory sequential mixed-method design was used that involved the analysis of de-identified, quantitative, secondary data from two states in southeastern Nigeria in the first phase, followed by 16 key informant interviews (KIIs) of healthcare providers (HCPs) in the second phase. The quantitative and qualitative strands were integrated at three critical points – in the design, methods, and results presentation phases. The quantitative study included 3530 participants. The median age at ART commencement was 34 years (IQR: 28.0, 41.0), about 68% were female, and the median BMI at baseline was 21.8 kg/m2 (IQR: 19.4, 24.5). After 24 months on ART, the number of participants who were obese increased by 186%, while those underweight decreased by 59%. The median BMI was 23.6 kg/m2 (IQR: 21.1, 26.6) after 24 months. Overall, the BMI increased in 74.7% of the participants. Further analysis showed that age at ART commencement (p In conclusion, HCPs should keep in mind the likelihood of excess weight gain among PLHIV and the associated cardio-metabolic effects and have a plan to address it, especially with the universal roll-out of ART for PLHIV. The findings from this study will help HCPs develop services that will aid PLHIV to achieve the highest possible quality of life

Evaluating the design and implementation fidelity of an adapted Plan-Do-Study-Act approach to improve health system performance in a Nigerian state

Background: The Plan-Do-Study-Act (PDSA) cycle is fundamental to many quality improvement (QI) models. For the approach to be effective in the real-world, variants must align with standard elements of the PDSA. This study evaluates the alignment between theory, design and implementation fidelity of a PDSA variant adapted for Nigeria's health system performance improvement. Methods: An iterative consensus building approach was used to develop a scorecard evaluating new conceptual indices of design and implementation fidelity of QI interventions (design and implementation index, defects and gaps) based on Taylor's theoretical framework. Results: Design (adaptation) scores were optimal across all standard features indicating that design was well adapted to the typical PDSA. Conversely, implementation fidelity scores were only optimal with two standard features: prediction-based test of change and the use of data over time. The other features, use of multiple iterative cycles and documentation had implementation gaps of 17 % and 50 % respectively. Conclusion: This study demonstrates how both adaptation and implementation fidelity are important for success of QI interventions. It also presents an approach for evaluating other QI models using Taylor's PDSA assessment framework as a guide, which might serve to strengthen the theory behind future QI models and provide guidance on their appropriate use

Appraising and addressing design and implementation failure in global health: a pragmatic framework

There have been recent concerns about the failure of several global health interventions. Interventions are considered to have failed when they are unable to achieve the intended results. Failure may be linked to how the intervention was designed (design failure) or how it was implemented (implementation failure). Recently, substantial efforts have been employed to improve the outcomes of health interventions. These efforts have led to the development of several theories, models, and frameworks in implementation science to improve the quality of implementation, bridging the divide between evidence and practice. But significant gaps still exist. Whereas much work has been done to develop frameworks and approaches to improve implementation fidelity, not as much effort has been done to guide the adherence of interventions to program theory during the design of the programs. Further, there have been concerns about the applicability of these frameworks in the real-world. This article uses examples to illustrate these gaps and further proposes a pragmatic framework to address identified gaps, thus aiding evidence-informed program design and implementation. The proposed Theory-Design-Implementation (TyDI) framework will support policymakers, program planners and implementers to address potential design and implementation failure, thus improving the fidelity of interventions

Targeted HIV testing for male partners of HIV-positive pregnant women in a high prevalence setting in Nigeria.

BACKGROUND:Partner HIV testing during pregnancy has remained abysmally low in sub-Saharan Africa, particularly in Nigeria. Males rarely attend antenatal clinics with their female partners, limiting the few opportunities available to offer them HIV testing. In this study, we evaluated the scale-up of the Healthy Beginning Initiative (HBI), a community-driven evidenced-based intervention to increase HIV testing among pregnant women and their male partners. Our objectives were to determine the: (1) male partner participation rate; (2) prevalence of HIV among male partners of pregnant women; (3) factors associated with HIV positivity among male partners of HIV-positive pregnant women. METHODS:We reviewed program data of expectant parents enrolled in HBI in Benue State, north-central Nigeria. During HBI, trained lay health workers provided educational and counseling sessions, and offered free onsite integrated testing for HIV, hepatitis B virus and sickle cell genotype to pregnant women and their male partners who participated in incentivized, church-organized baby showers. Each participant completed an interviewer-administered questionnaire on demographics, lifestyle habits, and HIV testing history. Chi-square test was used to compare the characteristics of HIV-positive and HIV-negative male partners. Simple and multivariable logistic regression models were used to determine the association between participants' characteristics and HIV positivity among male partners of HIV-positive women. RESULTS:Male partner participation rate was 57% (5264/9231). Overall HIV prevalence was 6.1% (891/14495) with significantly higher rates in women (7.4%, 681/9231) compared to men (4.0%, 210/5264). Among the 681 HIV-positive women, 289 male partners received HIV testing; 37.7% (109/289) were found to be HIV-positive. In multivariate analysis, older age (adjusted odds ratio [aOR]: 2.45, 95% confidence interval [CI]: 1.27-4.72 for age 30-39 years vs. <30 years; aOR: 2.39, CI: 1.18-4.82 for age ≥40 years vs. <30 years) and self-reported daily alcohol intake (vs. never (aOR: 0.35, CI: 0.13-0.96)) were associated with HIV positivity in male partners of HIV-positive women. CONCLUSION:The community-based congregational approach is a potential strategy to increase male partner HIV testing towards achieving the UNAIDS goal of 90% HIV screening. Targeting male partners of HIV-positive women for screening may provide a higher yield of HIV diagnosis and the opportunity to engage known positives in care in this population

Rapid implementation mapping to identify implementation determinants and strategies for cervical cancer control in Nigeria

BackgroundCervical cancer constitutes a huge burden among women in Nigeria, particularly HIV-infected women. However, the provision and uptake of cervical cancer screening and treatment is limited in Nigeria. Understanding implementation determinants is essential for the effective translation of such evidence-based interventions into practice, particularly in low-resource settings. COVID-19 pandemic necessitated online collaboration making implementation mapping challenging in some ways, while providing streamlining opportunities. In this study, we describe the use of a virtual online approach for implementation mapping (steps 1-3) to identify implementation determinants, mechanisms, and strategies to implement evidence-based cervical cancer screening and treatment in existing HIV infrastructure in Nigeria.MethodsThis study used a mixed methods study design with a virtual modified nominal group technique (NGT) process aligning with Implementation Mapping steps 1-3. Eleven stakeholders (six program staff and five healthcare providers and administrators) participated in a virtual NGT process which occurred in two phases. The first phase utilized online surveys, and the second phase utilized an NGT and implementation mapping process. The Exploration, Preparation, Implementation and Sustainment (EPIS) framework was used to elicit discussion around determinants and strategies from the outer context (i.e., country and regions), inner organizational context of existing HIV infrastructure, bridging factors that relate to bi-directional influences, and the health innovation to be implemented (in this case cervical cancer screening and treatment). During the NGT, the group ranked implementation barriers and voted on implementation strategies using Mentimeter.ResultsEighteen determinants to integrating cervical cancer screening and treatment into existing comprehensive HIV programs were related to human resources capacity, access to cervical cancer services, logistics management, clinic, and client-related factors. The top 3 determinants included gaps in human resources capacity, poor access to cervical cancer services, and lack of demand for services resulting from lack of awareness about the disease and servicesA set of six core implementation strategies and two enhanced implementation strategies were identified.ConclusionsRapid Implementation Mapping is a feasible and acceptable approach for identifying and articulating implementation determinants, mechanisms, and strategies for complex healthcare interventions in LMICs

Acceptability and user experiences of a patient-held smart card for antenatal services in Nigeria: a qualitative study

BACKGROUND: Poor maternal, newborn and child health outcomes remain a major public health challenge in Nigeria. Mobile health (mHealth) interventions such as patient-held smart cards have been proposed as effective solutions to improve maternal health outcomes. Our objectives were to assess the acceptability and experiences of pregnant women with the use of a patient-held smartcard for antenatal services in Nigeria. METHODS: Using focus group discussions, qualitative data were obtained from 35 pregnant women attending antenatal services in four Local Government Areas (LGAs) in Benue State, Nigeria. The audio-recorded data were transcribed and analyzed using framework analysis techniques such as the PEN-3 cultural model as a guide. RESULTS: The participants were 18-44 years of age (median age: 24 years), all were married and the majority were farmers. Most of the participants had accepted and used the smartcards for antenatal services. The most common positive perceptions about the smartcards were their ability to be used across multiple health facilities, the preference for storage of the women\u27s medical information on the smartcards compared to the usual paper-based system, and shorter waiting times at the clinics. Notable facilitators to using the smartcards were its provision at the Baby showers which were already acceptable to the women, access to free medical screenings, and ease of storage and retrieval of health records from the cards. Costs associated with health services was reported as a major barrier to using the smartcards. Support from health workers, program staff and family members, particularly spouses, encouraged the participants to use the smartcards. CONCLUSION: These findings revealed that patient-held smart card for maternal health care services is acceptable by women utilizing antenatal services in Nigeria. Understanding perceptions, barriers, facilitators, and supportive systems that enhance the use of these smart cards may facilitate the development of lifesaving mobile health platforms that have the potential to achieve antenatal, delivery, and postnatal targets in a resource-limited setting

Male Partner Involvement on Initiation and Sustainment of Exclusive Breastfeeding Among HIV-infected Post-partum Women: Study Protocol for a Randomized Controlled Trial

Exclusive Breastfeeding (EBF) among human immunodeficiency virus (HIV)-infected mothers is known to be associated with a sustained and significant reduction in HIV transmission and has the potential to reduce infant and under-five mortality. Research shows that EBF is not common in many HIV-endemic, resource-limited settings despite recommendations by the World Health Organization. Although evidence abounds that male partner involvement increases HIV testing and uptake and retention of prevention of mother-to-child transmission interventions, few studies have evaluated the impact of male partners\u27 involvement and decision-making on initiation, maintenance, and sustainment of EBF. We propose a comparative effectiveness trial of Men\u27s Club as intervention group compared to the control group on initiation and sustainment of EBF. Men\u27s Club will provide male partners of HIV-infected pregnant women one 5-hr interactive educational intervention to increase knowledge on EBF and explore barriers and facilitators of EBF and support. Additionally, participating male partners in the Men\u27s Club as intervention group will receive weekly text message reminders during the first 6-week post-natal period to improve initiation and sustainment of EBF. Participants in the Men\u27s Club as control group will receive only educational pamphlets. Primary outcomes are the differences in the rates of initiation and sustainment of EBF at 6 months between the two groups. Secondary outcomes are differences in male partner knowledge of infant feeding options and the intent to support EBF in the two groups. Understanding the role and impact of male partners on the EBF decision-making process will inform the development of effective and sustainable evidence-based interventions to support the initiation and sustainment of EBF

Table_2_Rapid implementation mapping to identify implementation determinants and strategies for cervical cancer control in Nigeria.docx

BackgroundCervical cancer constitutes a huge burden among women in Nigeria, particularly HIV-infected women. However, the provision and uptake of cervical cancer screening and treatment is limited in Nigeria. Understanding implementation determinants is essential for the effective translation of such evidence-based interventions into practice, particularly in low-resource settings. COVID-19 pandemic necessitated online collaboration making implementation mapping challenging in some ways, while providing streamlining opportunities. In this study, we describe the use of a virtual online approach for implementation mapping (steps 1–3) to identify implementation determinants, mechanisms, and strategies to implement evidence-based cervical cancer screening and treatment in existing HIV infrastructure in Nigeria.MethodsThis study used a mixed methods study design with a virtual modified nominal group technique (NGT) process aligning with Implementation Mapping steps 1–3. Eleven stakeholders (six program staff and five healthcare providers and administrators) participated in a virtual NGT process which occurred in two phases. The first phase utilized online surveys, and the second phase utilized an NGT and implementation mapping process. The Exploration, Preparation, Implementation and Sustainment (EPIS) framework was used to elicit discussion around determinants and strategies from the outer context (i.e., country and regions), inner organizational context of existing HIV infrastructure, bridging factors that relate to bi-directional influences, and the health innovation to be implemented (in this case cervical cancer screening and treatment). During the NGT, the group ranked implementation barriers and voted on implementation strategies using Mentimeter.ResultsEighteen determinants to integrating cervical cancer screening and treatment into existing comprehensive HIV programs were related to human resources capacity, access to cervical cancer services, logistics management, clinic, and client-related factors. The top 3 determinants included gaps in human resources capacity, poor access to cervical cancer services, and lack of demand for services resulting from lack of awareness about the disease and servicesA set of six core implementation strategies and two enhanced implementation strategies were identified.ConclusionsRapid Implementation Mapping is a feasible and acceptable approach for identifying and articulating implementation determinants, mechanisms, and strategies for complex healthcare interventions in LMICs.</p