Qualitative research and implementation science: Informing the acceptability and implementation of a trial of a conditional cash transfer intervention designed to reduce drug use and HIV risk

Abstract

HIV risk remains high among Cambodian female entertainment and sex workers, driven by amphetamine-type substance use and sexual risk. Conditional cash transfer is an evidence-based approach to reduce stimulant use and optimize HIV/AIDS prevention, but questions remain regarding implementation in resource-limited settings. We conducted formative qualitative research to enhance acceptability of a conditional cash transfer intervention aimed at reducing amphetamine-type substance use and HIV risk among female entertainment/sex workers and inform implementation as part of a large cluster randomized trial. We conducted in-depth interviews with 30 female entertainment/sex workers. Interviews were digitally recorded and conducted and transcribed in Khmer. English transcripts were read for emerging themes and an initial coding scheme was developed. Data were coded using open and axial coding to clarify and consolidate initial themes. While most participants expressed enthusiasm for the intervention, financial and transportation issues emerged as key barriers to participation. The proposed incentive of USD$1 per screen was regarded as unacceptable and participants identified a need for transportation assistance. Participants also expressed concerns about directly observed urine specimen collection. Finally, while most participants found the 4-week aftercare program acceptable, the need for enjoyable as well as educational content was emphasized. Revisions to the protocol taking these data into account were made to optimize the acceptability of the intervention and the implementation of the trial. Findings identified key concerns and preferences that were taken into account in the final trial protocol. In particular, financial and transportation issues were identified as critical barriers to participation, with the potential to impact both intervention uptake and trial feasibility. Results demonstrate the value of formative qualitative research for clinical trial planning and implementation, particularly in settings where little is known about acceptability of interventions or willingness to participate.

Protocol of a cluster randomised stepped-wedge trial of behavioural interventions targeting amphetamine-type stimulant use and sexual risk among female entertainment and sex workers in Cambodia

“…The intervention was extensively planned with involvement from numerous community and governmental groups. The study protocol was informed by qualitative formative research with FESW regarding the acceptability of the proposed CCT+AC intervention and barriers and facilitators to trial participation, including incentive amounts, transportation assistance, directly observed urine specimen collection, and the content of the AC programme described in detail by Dixon et al , 16 in a separate report. Two governmental partners including the Cambodian Ministry of Health Department of Mental Health and the National Authority to Combat Drugs were involved early in protocol planning.…”

“… 14 15 However, relatively little is known about the implementation of behavioural interventions to reduce stimulant use in resource-limited settings like Cambodia where formal substance abuse treatment is often unavailable and structural factors are key determinants of ATS use. 7 16 The primary aim of this article is to describe the study design and outcomes chosen to evaluate the effectiveness of an intervention targeting ATS use and unprotected sex developed as part of a multipart HIV prevention platform named the C ambodia I ntegrated HIV and Drug P revention I mplementation (CIPI) programme. We will also describe the operational challenges encountered in attempting to implement this large cluster randomised stepped-wedge trial in 10 Cambodian provinces.…”

Engaging people who inject drugs in hepatitis C virus testing and prevention through community‐based outreach, in Sydney, Australia

“…While the study highlighted the potential for community-based outreach to engage sub-groups of PWID in the HCV care cascade, it also had limitations. As is the case for research in the field generally, we were not able to assess the potential impact of financial remuneration versus outreach on engagement given the ethical imperative to reimburse vulnerable participants for research participation [39,40]. As an explorative qualitative study, the results may not be generalisable to the broader population of PWID.…”

Behavioral interventions for Cambodian female entertainment and sex workers who use amphetamine-type stimulants

“…Participants were recruited using convenience sampling from five Cambodian provinces (i.e., Phnom Penh, Battambang, Banteay Meanchey, Siem Reap, and Kandal). Participants described possible barriers and facilitators to engagement in CCT as well as perceptions of potential AC components (Dixon et al, in press). A description of the detailed thematic analysis of these qualitative data is in progress, but some findings directly informed efforts to develop CCT and AC.…”