This study employed the Exploration, Preparation, Implementation, and Sustainment (EPIS) Framework [28]. The framework was specifically selected by the research team because the four phases interact dynamically with the inner (intra-organizational and individual adopter characteristics) and outer (service-, inter-organizational-, and advocacy environments) contexts that influence the success or failure of the implementation process. Figure 1 shows how the EPIS Framework was used in the study. The researchers operationalized the framework by beginning with sustainment in mind and adapting outer and inner contexts, strategies as well as evidence-based practices of the implementation process.
Setting
The study was conducted at Africa University, a tertiary education institution 18 km north of the eastern border city of Mutare, Zimbabwe. The target population was 1690 university students from 29 African countries and enrolment statistics at the time showed that 53% of the students were females, and 32% were international students. About 65% of the students lived on campus and 25% were housed in University-recommended hostels in Mutare City. The university is a small and geographically isolated community outside town and away from other health facilities and it had one clinic which was manned by four registered nurses who were trained to offer HTS.
Study design and sample
This was an exploratory sequential mixed method study and data were collected in three phases. The first phase was divided into two steps namely the exploration and preparation steps while the second phase involved the implementation and the final phase was the sustainment. Findings from the first phase guided implementation strategy selection. Survey tools used in both phase 1 (formative evaluation) and phase 3 (summative evaluation) were developed from previously used and published literature that assessed the acceptability and feasibility of HIVST. The data extraction tools were pre-tested at a technical college in Mutare City and its corresponding health facility for clarification, reliability, and validity. Before pretesting, the survey questionnaires were reviewed for face validity by the HTS experts from the MoHCC, and two local non-governmental organizations (NGOs) offering HTS to adolescents and young adults. This was done to ensure that the statements were clearly understood by participants and the questions were appropriate for the age group. To achieve effective translation of data extraction tools and add methodological rigor, forward and backward translation was done using four blinded multilingual experts from Africa University.
All enrolled university students were eligible to participate in both the formative and summative evaluation surveys and the age range of the participants was 18 to 34 years. Students who were on attachment away from campus and those who were aware of their HIV-positive status were excluded from the study.
Ethical clearance was issued by the Medical Research Council of Zimbabwe and the Africa University Research Ethics Committee. Permission to carry out the study was granted by the Provincial Medical Director of Manicaland and the Africa University administration. Written informed consent was obtained from all study participants. Due to the sensitive nature and stigma associated with HIV/AIDS, a distress protocol was developed to manage possible adverse emotional reactions especially in cases of unexpected reactive post-test results. The participants were informed about the protocol and were encouraged to seek in-person or anonymous support from the counseling team led by MM via a 24-h helpline service.
Phase 1
Step 1: Exploration (January to March 2018)
A campus-wide formative evaluation survey that employed quantitative methods was conducted to assess the implementation readiness of the inner context and innovation factors (e.g. prospective implementation barriers and facilitators) using a structured, pretested interviewer-administered questionnaire with 17 open- and closed-ended questions. The secondary aim was to ascertain the program implementation determinant (i.e. barriers and enables) as well as acceptability and feasibility pre-implementation as a benchmark against which the results of the summative evaluation were later compared with. The survey was conducted from 5 February to 9 March 2018.
Structured in-depth interviews were also used among purposively selected eight key informants from NGO representatives, government HTS focal persons at district and provincial levels, and university administrators to ascertain the outer context factors (e.g. organizational culture, climate, and work attitudes) that would influence the implementation of the intervention. The MoHCC and local HIV/AIDS-related NGOs were consulted since they were the custodian and agencies of the national HTS program, respectively.
The research team did a rapid scoping of literature underpinning the area of HIVST to ascertain strategies used by other researchers, identify knowledge gaps, challenges encountered, and the suggested solutions from the lessons learned as well as clarification of concepts. HIVST-related article search was done in electronic databases (e.g. MEDLINE, EMBASE, PubMed, and Scopus), reference lists, hand-searched journals, and existing networks using the framework proposed by Arksey and O’Marley (2005) [29] with the assistance of the institutional librarian.
Step 2: Preparation (February to August 2018)
During the exploration phase, a multidisciplinary team comprising of FMM (Public Health Physician), MT (Research Administrator), TM (Nurse Manager), and EC (Public Health Nurse) converged twice during the month of February 2018 for brainstorming and program planning meetings. For the duration of the meetings, the team assessed the outer context (e.g. national policies on HIV testing, possible inter-organizational networks) and the inner context (e.g. the absorptive capacity at AU, characteristics of target population). They also discussed the key program elements, such as (1) the stakeholders to be consulted, (2) materials to be procured, (3) strategies to be implemented, and (4) outlined individual responsibilities.
CU and QM (MoHCC Provincial HIV/STI/TB Focal persons) were contracted as program trainers who developed the HIVST Project Training of Trainers Facilitators Manual Hand Book (Additional file 1) and Training Evaluation Forms for participants (Additional file 2). FMM, MT, TM, and EC led the research team, procurement team, implementing team, and community engagement team, respectively. Figure 2 shows how the four teams collaborated towards the success of the SAYS Initiative.
The team leaders met for implementation strategy selection by way of interpreting the findings of the formative evaluation survey, selecting goals, develop tools and guidelines using the nominal group technique. The implementing team organized two community dialogue sessions which were held on campus and the audio recorded sessions were attended by 83 participants who were purposively selected according to their roles on campus and in HTS programming. These sessions aimed to introduce the SAYS Initiative and identify potential barriers and enablers of implementing the intervention. Volunteers from the university’s Peer Educators Club were selected to become the SAYS Initiative Champions.
As a way of capacity building, improving provider knowledge, and understanding organizational context barriers, 13 (2 males and 11 females) purposively selected staff members with backgrounds in medical, nursing, and laboratory sciences underwent a 5-day training in May 2018. A second training session was conducted for the three health providers from the university clinic, 26 Peer Educators (11 were females). The Peer Educators were students who were later responsible for providing pre-and post-testing psychosocial and emotional support to other students within the institutional environment. However, it was emphasized that complex cases would be referred to official university student counselors and the psychotherapists who were part of the implementation team. The Peer Educators were equipped with information on self-awareness and its role in counseling as participants were mentored on counseling principles, techniques, and processes through presentations, group discussions, and peer counseling role-plays To cater to the culturally and linguistically diverse pan-African environment at the university, the Peer Educators were from different nationalities and while they were all fluent in English (the language of instruction at the institution), a third of them were also fluent in either French or Portuguese languages.
The workshops also adopted and adapted validated and piloted HIVST materials [22] to develop program messages and materials that were to be printed on flyers and banners. The resulting information, education, and communication (IEC) materials were submitted to the Provincial Health Education and Promotion Office for appraisal before printing.
The implementing team engaged the community by scheduling a meeting with 17 local adolescents and young adults (16 to 27 years) who were not university students. The group was made up of Community Adolescent Treatment Support (CATS) members (68% of them were living with HIV), five hospital nurses working in the Opportunistic Infection Clinics in Mutasa District, six members of the Africa University Peer Network Club, and their patron (TM). The aim was to discuss pertinent issues related to HIV/AIDS screening/testing methods and experiences from young people already diagnosed and living with HIV.
Phase 2
Implementation (September 2018 – February 2019)
With the guidance of TM, the Peer Educators broadcasted the HIVST IEC materials. The HIVST video was shared via university clubs’ WhatsApp groups and the university Facebook page. Emails were sent out to students through the Registrar’s desk to advertise the program and Peer Educators received program t-shirts and hats to promote visibility. By way of consensus, the Peer Educators drafted a roaster and visited busy spots like the university dining hall, sporting and games arena, and hostels during lunch hours and weekends. All students were invited to an evening health fair that was held in August 2018 to launch the SAYS Initiative.
Intervention
The SAYS Initiative was a new intervention at the university and the name was derived from how the intervention was delivered. Upon receiving pre-test counseling which lasted for 15–20 min from a Peer Educator or a health provider, the participant was given a free HIV oral test kit (OraSure® Technologies, Bethlehem, PA, USA) and offered the option of self-testing in a private room at the clinic or take the test kit to their hostel/home. The HIVST kit package contained a pamphlet of instructions written in English, Shona, French and Portuguese languages to accommodate the language diversity among students at the university. Images displaying the testing steps were also added to complement the text and enhance understanding. Clearly labeled protected bins were placed in the testing rooms and strategic points at the hostels for disposal. While facilitating infection prevention and control, this effort also provided estimated insights into the use of kits as the bins were collected for physical counts of the used kits. The intervention was implemented over 6 months from 2 September 2018 to 28 February 2019.
Kit disbursement and supervision
HIVST kits were kept at the university laboratory for quality assurance and providers collected the kits based on demand. The MoHCC HIV testing and counseling manuals were adopted for the pre-and post-test counseling. Kit Disbursement Registers were used to anonymously capture socio-demographic data and mobile contact of participants.. Follow-up phone text messages were sent by the nurses to participants within 24 to 48 h of collecting the kit to check how the student was coping and enquire if they required any post-test services.
The university clinic was the central point of HIVST kit distribution. This was done to minimize ‘double-dipping’, ensure health provider support and supervision as well as fidelity monitoring. During the kit disbursement period, Peer Educators developed a rotational duty roaster. Peer Educators briefed the nurses on challenges and potential program adaptations during their daily and monthly meetings. Adaptations were integrated into the program by way of consensus.
Phase 3
Sustainment (March – April 2019)
A structured interviewer-administered questionnaire composed of 20 questions was used for the summative evaluation survey. The study participants were asked about the acceptability, potential concerns, perceived effectiveness of implementation and recommendations for adoption as well as sustainability of the intervention using semi-structured self-administered questionnaires. Accessibility was assessed using self-report measures, which included satisfaction, attitudes, perceptions, as well as experiences both pre-and post-intervention implementation. Evaluation findings were used as reinforcement to augment program sustainability and feed into possible scaling-up of program activities. In-depth interviews of nurses and Peer Educators, as well as record reviews were conducted 6 months post-implementation.
Data collection and analysis
The research team collected data during the formative evaluation survey with the assistance of Peer Educators. WM (Research Data Manager) and MT conducted in-depth interviews. FMM, PTM (Public Health Officer), SNT (Monitoring and Evaluation Officer), and WM were responsible for data entry and analysis. Audio recorded qualitative data were transcribed verbatim while field notes from dialogue sessions and open-ended survey questions were entered into NVivo 12, and segments were coded before thematic analysis was done by comparing grouped responses that emerged from the data. Quantitative data was imported into Epi Info version 7.2.1.0 (CDC, USA) for bivariate and multivariable logistic regression analysis at 95% confidence interval and 5% level of significance. The dependent variables were the intention to self-test for HIV for the formative evaluation survey and having self-tested for HIV for the summative evaluation survey. For both surveys, the independent variables constituted participants’ socio-demographic characteristics as well as knowledge, attitudes, perceptions, and experiences during the HIVST.