Table 4 Implementation strategies used and determinants influenced, according to participants
ERIC strategy number | ERIC strategy name | CFIR determinant(s) influenced | Description | Illustrative quotes |
|---|---|---|---|---|
19 | Conduct ongoing training | + Knowledge and beliefs about intervention | POWER staff periodically held trainings to educate site staff about PrEP and encourage them to refer clients for PrEP services. | At first, I was like, “Why are they giving people ARVs before they are sick? They will form resistance and that will be an issue.” We [FP nurses] did not understand PrEP until they [POWER staff] gave us the CME [continuing medical education]. Then I learned that this thing actually protects people from getting HIV. … Once I learned what it was, I really embraced it. (Nurse, not employed by POWER, IDI 4) |
54 | Provide local technical assistance | + Access to knowledge and information | POWER study coordinator was available on-demand to answer providers’ questions and assist with complex cases. | [If I had questions,] I normally turned to the study coordinator. All my questions have always been answered, especially the technical ones, because we need an expert in the medical field to assist at times. (Counselor, employed by POWER, IDI 2) |
48a 5 | Organize implementation teams and team meetings Audit and provide feedback | + Reflecting and evaluating + Goals and feedback | POWER staff held weekly meetings to review M & E reports, discuss challenges, and devise improvement plans to reach their goal of enrolling 1000 AGYW. | Through the week, we come with the challenges, the successes. We are getting the information from clients when we are making follow-ups. So in the [weekly] POWER meeting, we come and weigh, “How should we do this to make a change in this?” [If the M & E report shows high lost-to-follow-up rates, we discuss,] “How can we make these clients who are missing to come back for PrEP?” (HTS provider, employed by POWER, IDI 7) |
20 | Create a learning collaborative | + Learning climate +Cosmopolitanism | POWER staff from Kenya and South Africa study sites shared implementation challenges experienced and lessons learned during monthly calls. | [A staff member from the Kenyan sites] reported that, for the past 2 months, they’ve had a lot of follow-up visits. … [A South African colleague] asked how the clients they enrolled during recent outreach activities are different from the ones they had trouble retaining in the past. [The Kenyan colleague] said they are doing more intense [HIV risk] screening and counseling to try to make sure the people [they enroll] are really interested in PrEP. They’ve found that those who come [to the clinic to initiate PrEP] later [i.e., in the days after the outreach event] tend to be more dedicated than the ones who they got on the day of the event. … So now the girls who enroll are doing so because they want to enroll, not because they feel like they need to. (Call notes, December 2018) |
74b 11 | Assess and redesign workflow Change physical structure and equipment | + Patient needs and resources -Perceived sustainabilityc (Site A only) | POWER staff worked with sites to reorganize service delivery to meet AGYW care preferences (e.g., privacy, short service times), though some interviewees expressed concern about sustainability. | When we saw that working within the FP space was not going well, [the head of Site A’s outpatient department] gave us the other room [i.e., a separate room for PrEP delivery] for privacy. … Queuing at the pharmacy was also a challenge to our participants because those who come … for ARVs would take at that [same] pharmacy. So stigma was there. [Clients worried,] “They will see as if I’m also taking ARVs.” So we decided we’d let the nurse or the clinician prescribe and dispense the medication [from the private room]. Clients preferred that. (Other key informant, employed by POWER, IDI 17) Transitioning [i.e., ending POWER’s involvement in PrEP delivery] may be a challenge because the queueing we were trying to avoid [clients from having to do], now it will force them [to queue]. (Counselor, employed by POWER, IDI 7) |
40 | Involve executive boards | + Relative priority | At Site B, leaders had POWER staff report out PrEP implementation progress at weekly all-staff meetings. | [Site B leaders] are like 100% [in favor of PrEP]. They even ask for feedback at the weekly [all-staff] meeting: ‘How is it [PrEP delivery] going?’ And sometimes when we reach our [enrollment] target, they tell us [POWER staff] to stand up and the whole team appreciates [i.e., applauds us]. (Counselor, employed by POWER, IDI 12) |
60 | Shadow other experts | + Knowledge and beliefs about intervention - Relative priority -Perceived sustainabilityc (Site A only) | The study hired nurses and HTS providers to introduce PrEP delivery at study sites so site providers could observe how to deliver PrEP (e.g., how to counsel AGYW about PrEP). This infusion of human resources, however, may have lowered some providers’ sense of responsibility towards PrEP delivery. For some interviewees, it also raised some concerns about sustainability. | [POWER] brought in some other staffs for them [providers at Site B] to shadow … to have a feel of it [PrEP delivery] and understand that there is not much work [involved in delivering PrEP]. … And some [providers] bought [into] the idea. … So bringing in other people to overshadow each one of them, I think those played a role [in facilitating PrEP implementation]. (Counselor, employed by POWER, IDI 12) As much as we had our own responsibilities, I just got to a point and told myself that having knowledge will not hurt you in any way. … The POWER staff were mentors. They guided us [on] how do you enroll? How do you counsel? What do you tell these girls? So that is how I got to learn [about PrEP delivery] and started helping out here. But for the other staff, it was just an added responsibility. Already they had their jobs, the things they had to do. … They really associated PrEP with POWER. (Clinician, not employed by POWER, IDI 1) The POWER study was able to offer timely services because they had more healthcare workers. When that is translated to a normal MOH facility without such support, that may negatively affect it because people [clients] will have long waiting hours and may start to prioritize other things [over PrEP]. (Other key informant, not employed by POWER, IDI 16) |