Improving Retention in Care for Adolescents and Young Adults in Kenya: Implementation Science to Support Adaptation and Integration of a Stepped Care Intervention

Abstract

Adolescents and young adults represent a diverse population. Globally, more than five million are living with HIV. This dissertation comprises three aims with the overall objective to evaluate implementation outcomes of a cluster randomized controlled trial, Data-informed Stepped Care (DiSC) to Improve Adolescent HIV Outcomes (UG3/UH3 HD096906; PIs: Kohler, John-Stewart), that tested a Stepped Care intervention across 24 health facilities to improve retention among adolescents and youth living with HIV (AYLHIV) in western Kenya. We use an implementation science approach to understand how to optimize stepped care and provide valuable information about the context necessary for successful scale-up of stepped care interventions for adolescents and young adults within Kenya or scale out to other global settings. We applied three implementation science frameworks to accomplish our overall objective. In Aim 1, the Framework for Reporting Adaptations and Modifications to Evidence-based interventions (FRAME) was applied to characterize provider-identified adaptations that were made to improve DiSC stepped care intervention fit with context. Providers participated in continuous quality improvement (CQI) meetings using plan-do-study-act processes to optimize uptake and delivery of the intervention. During the CQI meetings, providers completed surveys to quantify their perceptions of adaptation influence on implementation outcomes of acceptability, appropriateness, and feasibility. A total of 65 adaptations were made, with the majority focused on optimizing the integration of DiSC within the clinic. Primary reasons for adaptations were to increase reach and engagement with AYLHIV and align delivery with their needs and preferences. All adaptations were considered fidelity consistent. Provider perceptions of implementation were consistently high throughout, but on average, slightly improved each month for intervention acceptability (β = 0.011, 95% CI: 0.002, 0.020, p = 0.016), appropriateness (β = 0.012, 95% CI: 0.007, 0.027, p<0.001) and feasibility (β = 0.013, 95% CI: 0.004, 0.022, p = 0.005). In Aim 2, the Consolidated Framework for Implementation Research (CFIR) was used to understand key barriers and facilitators that influenced implementation outcomes of adoption, reach, and fidelity of the DiSC stepped care intervention. In this qualitative assessment, focus group discussions (FGDs) were conducted with providers across 12 intervention sites using a semi-structured interview guide grounded in relevant CFIR constructs across five domains, including novel constructs relevant in low- and middle-income country settings. A Sort and Sift, Think and Shift rapid qualitative analysis approach was used to identify key determinants of implementation. A total of 43 health providers participated in 12 FGDs. Overall, providers described a general positive experience engaging with the DiSC intervention and were enthusiastic about it and quick to adopt. They found the DiSC tool easy to use and felt it provided a relative advantage by improving service delivery efficiency and prioritizing time with higher need AYLHIV. Providers perceived that the DiSC intervention facilitated individualized care to better meet adolescent needs and believed that the design quality and packaging of DiSC supported AYLHIV reach and engagement. Provider collective efficacy was important in consistent implementation of DiSC and was facilitated by CQI meetings, access to knowledge and information, and perceived intervention effectiveness. Providers identified compatibility with workflows and changing guidelines as the most prominent challenges, and supportive leadership as an important driver of implementation success. As a result of their experiences, providers recommended scale up of the DiSC intervention so that others may benefit but highlighted specific considerations such as modifications to the DiSC tool to inform care and management, strategies to support DiSC integration into routine and workflows, and continued engagement with key stakeholders. In Aim 3, we use the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework to guide evaluation of DiSC intervention performance. We used a mixed methods convergent parallel design with data obtained from diverse sources including medical records, an end-of-trial survey, and in-depth interviews with providers (n=2/facility). Quantitative and qualitative data were compared for concordance. Of 933 AYLHIV screened, 895 were enrolled, representing 96% reach overall. There were no significant differences between intervention and control facilities in the primary effectiveness outcome measure defined as number of missed visits (8.5% versus 8.3% respectively; adjusted Relative Risk [aRR] = 1.04 (95% Confidence Interval [CI]: 0.89, 1.20). However, perceived intervention effectiveness, including improved retention and viral suppression among AYLHIV, motivated continued implementation throughout the study duration. Forty-nine providers were trained to deliver the DiSC intervention, representing 25% (49/199) of the total health facility workforce. All providers trained, adopted, and delivered the intervention. Implementation was facilitated by provider-identified adaptations to optimize contextual fit of the DiSC intervention within respective healthcare settings. All adaptations made by providers were fidelity consistent. Key determinants influencing implementation were provider collective efficacy, compatibility with clinic workflows, leadership engagement, and alignment with changing national guidelines. Post-trial, providers agreed that the DiSC intervention will be sustainable (maintenance) beyond the study period (72% agree/strongly agree) and believed it could be easily integrated into clinic operations (92% agree/strongly agree). Providers supported continued use of the DiSC intervention (maintenance), citing leadership support, training, and material and human resources as key influencers on future sustainment. This dissertation enriches our understanding of implementation contexts, outcomes, as well as barriers and facilitators, and adds to the knowledge base of evidence-based interventions to support retention in care for AYLHIV to improve their health outcomes. We used implementation science frameworks to close the know-do gap, the gap between what we know and what we do, in order to achieve maximum impact for populations who need it most.