Factors associated with program effectiveness in the implementation of a sexual risk reduction intervention for female sex workers across Mexico: Results from a randomized trial

Abstract

ObjectiveThe overall aim of this paper is to examine effectiveness of an evidence-based intervention in community settings, and the factors associated with effectiveness. Limited research in the area of HIV prevention has focused on evaluating intervention program effectiveness in real-world settings.MethodsWe implemented an efficacious theory-based sexual risk reduction intervention for female sex workers (FSW) called Mujer Segura across 13 different clinics in 13 sites across Mexico. The overall design was a cluster randomized Type I design simultaneously testing intervention program effectiveness with an observational study of implementation factors. We aimed to examine the effectiveness of Mujer Segura at reducing HIV/STI incidence among FSW participants at each site, and to examine the client-, provider-, organization-, and structure-related factors associated with program effectiveness.ResultsWe found lower HIV/STI incidence density in the intervention relative to the control group in 5 sites we labeled as “program effective sites,” but not in 8 sites we labeled as “program ineffective sites.” Using generalized estimating equations controlling for site and computed mean difference effect sizes, we examined statistically and practically significant differences, respectively, between the two groups of sites along various client-, provider-, organization-, and structure-related characteristics. Results indicated that client-level HIV/AIDS related knowledge, and proficiency and engagement in the organizational social context were associated with program effectiveness.ConclusionsEnormous resources are required to systematically and adequately test the role of multilevel factors on program effectiveness. We successfully implemented Mujer Segura in 13 sites in Mexico. Results suggest that other measures may need to be included in future implementation studies than the ones included here. We were able to point to a few specific factors that should be targeted to increase effectiveness of similar evidence-based programs in low- and other middle-income countries like Mexico.Trial registrationClinicalTrials.gov NCT01465607.

A mobile caesarean birth center as a solution to improve access to surgical birth in rural Ethiopia: a mixed methods research protocol

“…Specific Objectives: Our multidisciplinary team of cesarean birth and obstetrics, implementation science, and public health experts as well as representative stakeholders from Ethiopia are poised to successfully achieve our objectives, guided by the Exploration-Preparation-Implementation-Sustainment (EPIS) Framework (implementation process framework), as follows: 32,33 Objective 1: EXPLORE (first phase of the EPIS framework) the outer and inner contexts of the communities in rural Ethiopia where we will study pre-implementation of the mobile cesarean birth center 33 Implementation Strategies: Identify barriers and facilitators to the delivery of cesarean and test the appropriateness, acceptability, and feasibility of a mobile cesarean birth center as one potential solution 34 Objective 2: PREPARE (second phase of the EPIS framework) to address the outer and inner contextual components of the communities where we will study pre-implementation of the mobile cesarean birth center 33 Implementation Strategies: Develop a formal implementation blueprint (with implementation strategies) for the center that addresses the barriers and facilitators (including all Three Delays) to the delivery of cesarean birth 34 Research Frameworks: In order to adapt and prepare the mobile cesarean birth center to address the public health problem of low cesarean birth rates in the region, our research is guided by the EPIS implementation research process and determinant framework; the author of the framework is part of our research team and has applied the framework in sub-Saharan Africa, previously. 14,32,33,[35][36][37] EPIS provides guidance on understanding barriers, facilitators, and adapting our intervention (Exploration Phase, AIM 1); taking what is learned in exploration and preparing to implement it (Preparation Phase, AIM 1); putting structures, processes, and action into place (Implementation Phase, AIM 2), and beginning with the end goal in mind (Sustainment Phase) so that implementation gains are realized and have the greatest public health impact. 14 The framework examines both the "Outer Context", which refers to system-level factors in the country and community and "Inner Context", which refers to organizational level factors, and "Bridging Factors" that link outer and inner contexts (e.g., policies, collaborations), interorganizational relationships, and innovation factors (e.g., cesarean procedures in Hospitainers).…”

A mobile cesarean birth center as a solution to improve access to surgical birth in rural Ethiopia: a mixed methods research protocol

“…In order to adapt and prepare the mobile cesarean birth center to address the public health problem of low cesarean birth rates in the region, our research is guided by the EPIS implementation research process and determinant framework; the author of the framework is part of our research team and has applied the framework in sub-Saharan Africa, previously [ 14 , 32 , 33 , 35 – 37 ]. EPIS provides guidance on understanding barriers and facilitators and adapting our intervention (exploration phase, aim 1); taking what is learned in exploration and preparing to implement it (preparation phase, aim 1); putting structures, processes, and action into place (implementation phase, aim 2); and beginning with the end goal in mind (sustainment phase) so that implementation gains are realized and have the greatest public health impact [ 14 ].…”

The impact of multiple-behavior HIV interventions as a function of regional disadvantages: An analysis of syndemics.

“…By doing so, these interventions can take advantage of the ability of change in one behavior to promote changes in another (Albarracín et al, 2017; Albarracín, Sunderrajan, et al, 2018; Albarracín, Wang, et al, 2018). For example, reducing substance use may lead to reductions in alcohol use, sexual violence, having sex under the influence, and increases in condom use (Pitpitan et al, 2018). Addressing multiple behaviors (MBI) that correlate with a target behavior in the syndemics cluster may also increase success in implementing the target behavior.…”