Evaluation of a Systems Analysis and Improvement Approach to Optimize Prevention of Mother-To-Child Transmission of HIV Using the Consolidated Framework for Implementation Research

Gimbel, Sarah; Rustagi, Alison S; Robinson, Julia; Kouyate, Seydou; Coutinho, J. O.; Nduati, Ruth; Pfeiffer, James; Gloyd, Stephen; Sherr, Kenneth; Granato, S Adam; Koné, Ahoua; Cruz, Emilia; Manuel, José; Zucule, Justina; Napua, Manuel; Mbatia, Grace; Wariua, Grace; Maina, Martin

doi:10.1097/qai.0000000000001055

Cited by 42 publications

(59 citation statements)

References 26 publications

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“…CFIR constructs can be scored quantitatively and compared across cases according to strength and valence [44]. Quantitative scoring of constructs was employed in three studies [19,24,40]. Another study created a quantitative questionnaire to align with CFIR constructs, in which participants were asked to rate CFIR constructs on a 5-point Likert scale from "very unimportant" to "very important" for implementation success [10].…”

Section: Systematic Reviewmentioning

confidence: 99%

“…Damschroder et al suggest that when the CFIR is applied post-implementation, it should be used to link determinants of implementation to targeted outcomes (e.g., intervention acceptability or effectiveness) [2]. However, only 6 (18%) studies reporting linking outcomes to specific CFIR constructs, all of which took place mid-or post-implementation [10,17,19,21,24,40]. These papers identified relationships between specific CFIR constructs and measures of high and low fidelity to the intervention [19], measures of high and low uptake of the intervention [21,24,40], successful implementation generally [10], as well as variations in implementation success, including successes in intervention management, supervision, and facilitation [17].…”

Section: Systematic Reviewmentioning

confidence: 99%

“…Used to interpret/ contextualize findings utilized constructs added to the CFIR within the process domain: key stakeholders and innovation participants. However, given that these constructs are not widely acknowledged as part of the CFIR, they are not included in the analysis for purposes of consistency [19,40]. Damschroder et al suggest that CFIR constructs be selected for use based on salience, level of application (ex., individual or health facility) and time point of application, and that researchers provide a rationale for why certain constructs were considered pertinent to the research question.…”

Section: Midimplementationmentioning

confidence: 99%

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Evaluating and optimizing the consolidated framework for implementation research (CFIR) for use in low- and middle-income countries: a systematic review

et al. 2020

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Background: The Consolidated Framework for Implementation Research (CFIR) is a determinants framework that may require adaptation or contextualization to fit the needs of implementation scientists in low-and middleincome countries (LMICs). The purpose of this review is to characterize how the CFIR has been applied in LMIC contexts, to evaluate the utility of specific constructs to global implementation science research, and to identify opportunities to refine the CFIR to optimize utility in LMIC settings.Methods: A systematic literature review was performed to evaluate the use of the CFIR in LMICs. Citation searches were conducted in Medline, CINAHL, PsycINFO, CINAHL, SCOPUS, and Web of Science. Data abstraction included study location, study design, phase of implementation, manner of implementation (ex., data analysis), domains and constructs used, and justifications for use, among other variables. A standardized questionnaire was sent to the corresponding authors of included studies to determine which CFIR domains and constructs authors found to be compatible with use in LMICs and to solicit feedback regarding ways in which CFIR performance could be improved for use in LMICs.Results: Our database search yielded 504 articles, of which 34 met final inclusion criteria. The studies took place across 21 countries and focused on 18 different health topics. The studies primarily used qualitative study designs (68%). Over half (59%) of the studies applied the CFIR at study endline, primarily to guide data analysis or to contextualize study findings. Nineteen (59%) of the contacted authors participated in the survey. Authors unanimously identified culture and engaging as compatible with use in global implementation research. Only two constructs, patient needs and resources and individual stages of change were commonly identified as incompatible with use. Author feedback centered on team level influences on implementation, as well as systems characteristics, such as health system architecture. We propose a "Characteristics of Systems" domain and eleven novel constructs be added to the CFIR to increase its compatibility for use in LMICs. Conclusions: These additions provide global implementation science practitioners opportunities to account for systemslevel determinants operating independently of the implementing organization. Newly proposed constructs require further reliability and validity assessments. Trial registration: PROSPERO, CRD42018095762

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Section: Systematic Reviewmentioning

confidence: 99%

Section: Systematic Reviewmentioning

confidence: 99%

Section: Midimplementationmentioning

confidence: 99%

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Evaluating and optimizing the consolidated framework for implementation research (CFIR) for use in low- and middle-income countries: a systematic review

et al. 2020

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“…The systems analysis and improvement approach (SAIA) is designed to optimize cascade performance, is feasible for frontline healthcare workers and managers, and may be applicable to optimize the hypertension testing and treatment cascade for PLHIV across multiple contexts. SAIA, an evidence-based strategy, which is flexible to local context, supports frontline facility staff to gain a comprehensive view of their complex delivery system, identify and prioritize areas to improve, and iteratively test modifications to increase system outputs and patient outcomes [36,37]. Health workers in the original cluster randomized trial that tested the intervention to improve prevention of mother-to-child HIV transmission (PMTCT) services noted that SAIA stimulated communication, consensus decision-making, and accountability across multiple service points in their facility (e.g., patient care, pharmacy, laboratory services); was accessible by relying on routinely collected data to guide decision-making in a real-world service delivery environment; and resulted in significant improvements in service delivery outcomes [37].…”

Section: Contributions To the Literaturementioning

confidence: 99%

“…Case memos will be written and three analysts will assign ratings for each construct. Using a rating process previously applied to the CFIR [36,59], ratings will reflect the positive or negative influence (valence) and the strength of each construct. Constructs will be coded as missing too much data (M), not (0), weakly (+ 1/ − 1), or strongly (+ 2/− 2) distinguishing low/high performance.…”

Section: Consolidated Framework For Implementation Researchmentioning

confidence: 99%

Systems analysis and improvement approach to optimize the hypertension diagnosis and care cascade for PLHIV individuals (SAIA-HTN): a hybrid type III cluster randomized trial

et al. 2020

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Background: Across sub-Saharan Africa, evidence-based clinical guidelines to screen and manage hypertension exist; however, country level application is low due to lack of service readiness, uneven health worker motivation, weak accountability of health worker performance, and poor integration of hypertension screening and management with chronic care services. The systems analysis and improvement approach (SAIA) is an evidence-based implementation strategy that combines systems engineering tools into a five-step, facility-level package to improve understanding of gaps (cascade analysis), guide identification and prioritization of low-cost workflow modifications (process mapping), and iteratively test and redesign these modifications (continuous quality improvement). As hypertension screening and management are integrated into chronic care services in sub-Saharan Africa, an opportunity exists to test whether SAIA interventions shown to be effective in improving efficiency and coverage of HIV services can be effective when applied to the non-communicable disease services that leverage the same platform. We hypothesize that SAIA-hypertension (SAIA-HTN) will be effective as an adaptable, scalable model for broad implementation. Methods: We will deploy a hybrid type III cluster randomized trial to evaluate the impact of SAIA-HTN on hypertension management in eight intervention and eight control facilities in central Mozambique. Effectiveness outcomes include hypertension cascade flow measures (screening, diagnosis, management, control), as well as hypertension and HIV clinical outcomes among people living with HIV. Cost-effectiveness will be estimated as the incremental costs per additional patient passing through the hypertension cascade steps and the cost per additional disability-adjusted life year averted, from the payer perspective (Ministry of Health). SAIA-HTN implementation fidelity will be measured, and the Consolidated Framework for Implementation Research will guide qualitative evaluation of the implementation process in high-and low-performing facilities to identify determinants of intervention success and failure, and define core and adaptable components of the SAIA-HTN intervention. The Organizational Readiness for Implementing Change scale will measure facility-level readiness for adopting SAIA-HTN.

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Contraceptive implant use duration is not associated with breakthrough pregnancy among women living with HIV and using efavirenz: a retrospective, longitudinal analysis

Stalter,

Amorim,

Mocello

et al. 2022

J Int AIDS Soc.

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Introduction Contraceptive implants containing etonogestrel and levonorgestrel have emerged as popular contraceptive options among women in areas of high HIV burden in sub‐Saharan Africa. However, recent pharmacokinetic data have shown drug–drug interactions between implants and efavirenz‐containing antiretroviral therapy (ART), reducing the effectiveness of the implants. Here, we evaluated pregnancy incidence in 6‐month intervals following implant initiation among women using efavirenz and contraceptive implants to assess whether the risk of breakthrough pregnancy is higher after specific periods of implant use. Methods We used data from a retrospective longitudinal analysis of women living with HIV ages 18–45 years in western Kenya who attended HIV‐care facilities between 2011 and 2015. We used Cox proportional hazard models to compute hazard ratios (HRs) for breakthrough pregnancy by implant type and ART regimen. Depending on the model, we adjusted for socio‐demographic and clinical factors, programme, site and interaction between calendar time and ART regimen. We utilized inverse probability weights (IPWs) to account for three sampling phases (electronic medical record [EMR], chart review and phone interview) and calculated overall parameter estimates. Results Women contributed 14,768 woman‐years from the largest sampling phase (EMR). The median age was 31 years. Women used etonogestrel implants for 26–69% of the time and levonorgestrel implants for 7–31% of the time, depending on the sampling phase. Women used efavirenz, nevirapine or no ART for 27–33%, 40–46% and 15–26% of follow‐ups, respectively. When combining sampling phases, there was little evidence to suggest that the relative hazard of pregnancy among efavirenz‐containing ART users relative to nevirapine‐containing ART changed with length of time on implants: IPW‐adjusted HR of 3.1 (CI: [1.5; 6.4]) at 12 months, 3.4 (CI: [1.8; 6.3]) at 24 months, 3.8 (CI: [1.9; 7.7]) at 36 months and 4.2 (CI: [1.6; 11.1]) at 48 months (interaction p ‐value = 0.88). Similarly, no significant change in HRs over time was found when comparing women not using ART to nevirapine‐containing ART users (interaction p ‐value = 0.49). Conclusions We did not find evidence to suggest implants being more fallible from drug–drug interactions with efavirenz at later time intervals of implant use. Thus, we would not recommend shortening the duration of implant use or replacing implants sooner when concomitantly used with efavirenz.

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Evaluation of a Systems Analysis and Improvement Approach to Optimize Prevention of Mother-To-Child Transmission of HIV Using the Consolidated Framework for Implementation Research

Abstract: Supplemental Digital Content is Available in the Text.

Cited by 42 publications

References 26 publications

Evaluating and optimizing the consolidated framework for implementation research (CFIR) for use in low- and middle-income countries: a systematic review

Evaluating and optimizing the consolidated framework for implementation research (CFIR) for use in low- and middle-income countries: a systematic review

Systems analysis and improvement approach to optimize the hypertension diagnosis and care cascade for PLHIV individuals (SAIA-HTN): a hybrid type III cluster randomized trial

Contraceptive implant use duration is not associated with breakthrough pregnancy among women living with HIV and using efavirenz: a retrospective, longitudinal analysis

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