Study Participants’ Enrollment Outcome
Figure 3 is a summary of how data records for the retrospective cohort analyses were extracted. As shown in figure 3, there were 2,379 ALHIV registered with Teen Clubs in the period of interest for the study in the 14 health facilities, of whom 146 were potential eligible for the study. However, we could only verify records for 131 participants across the key source documents (registers and master cards). This is because of poor record keeping characterised by use of multiple registers which had dissimilar information with incomplete records. Thus we could not achieve our desired sample size of 145.
Characteristics of Study Participants
Cohort Study
Table 2 shows the characteristics of ALHIV enrolled in the study. The mean age of all the study participants was 19.3 (SD = 1.5). Two -thirds (61.8%) of the total participants were female. Nearly two-thirds (60.3%) of the participants were students and almost three quarters (73.3%) of them were attending health facilities owned by government. The mean time spent in an HIV Teen Club for participants was 2.4 years (SD = 0.6). More than one third (36.4%) of the participants were living with their parents.
Table 2: Participants characteristics
Variable
|
Total Enrolled (N=131)
|
Age in years, mean (SD)
|
19.3 (1.5)
|
Length of Membership in years, Mean (SD)
|
2.4 (0.6)
|
Gender, n (%)
Female
Male
|
81 (61.8)
50 (38.2)
|
Facility Location, n (%)
Urban
Rural
|
64 (48.9)
67 (51.1)
|
Facility Ownership, n (%)
Government
Non-Government
|
96 (73.3)
35 (26.7)
|
Occupation of adolescent n (%)
Student
Other [1]
Unknown[2]
|
79 (60.3)
7 (5.3)
45 (34.4)
|
Adolescent Guardian n (%)
Biological Parents
Other [3]
Unknown[4]
|
48 (36.4)
33 (25.2)
50 (38.2)
|
[1] These constitute those that are farmers, doing business and housewife
[2] This indicate missing data
[3] This include guardians that are unties, uncles, grandparents and other relatives
Teens transitioning to adult care – “Effectiveness” dimension of the RE-AIM Framework
Of the 131 participants who were eligible for transition between July 2017 and December 2017, only 9 (6.9%, 95% CI: 2.2, 10.7) were registered to have transitioned into adult care at the same clinic, of whom seven were female. The remaining 93.6% of the participants (n= 122) were still in the same facilities at the Teen Club. Only 2 the 14 health facilities (DREAM Sant'Egidio and Chikowa Health center) managed to successfully transition eligible ALHIV to adult care. The majority (8) of the transitioned ALHIV were from DREAM Sant'Egidio.
Factors associated with successful transition– “Maintenance” dimension of the RE-AIM Framework
Table 3, below, shows the results of the bivariate and multivariate logistic regression models assessing the predictors of successful transitions. In bivariate analyses, the following variables were not significantly associated with successful transition: age of the adolescent, sex of the adolescent and type of adolescent guardian. However, the following variables were significantly associated with successful transition: facility location and facility ownership. In multivariate analyses only facility location and facility ownership were significantly associated with successful transitioning. There was high collinearity between adolescent occupation and adolescent length of membership with successful transition. Therefore, these variables were omitted for further consideration in the regression modelling.
Table 3: Socio-demographic factors associated with successful transition from HIV Teen Club to adult care
Variable
|
% who transitioned
|
Crude OR (95%CI)
|
P-value
|
Adjusted OR (95%CI)
|
p-value
|
Gender
Male
Female
|
4.0%
8.6%
|
1 (Reference)
2.3 (0.5, 11.4)
|
0.319
|
_______
|
_______
|
Age[1]
≥20
<20
|
5.3%
7.5%
|
1 (Reference)
1.5(0.3,7.4)
|
0.460
|
________
|
_______
|
Facility Location
Urban
Rural
|
12.5%
1.5%
|
1 (Reference)
0.1(0.01, 0.9)
|
0.037
|
1 (Reference)
0.1(0.01,0.9)
|
0.041
|
Facility Ownership
Government
Private
|
1.0%
22.9%
|
1 (Reference)
28.1(3.4, 235.0)
|
0.002
|
1 (Reference)
22.8(2.4, 219.7
|
0.007
|
Adolescent Guardian
Parents
Other
|
12.3%
6.3%
|
1 (Reference)
0.5(0.1,2.4)
|
0.374
|
_______
|
_______
|
[1] This is age at transition
Implementation fidelity – “Implementation” dimension of the RE-AIM Framework
The overall implementation fidelity of the HIV Teen Club protocols was medium (61.7%). As shown in Figure 4 below, the clinical care domain was implemented with high fidelity (97.6%) while the teen club operation and capacity building domains were implemented with medium fidelity (68.3% and 57.1%, respectively). Teen Club Health Education domain registered the lowest implementation fidelity (23.8%).
As shown in Figure 5, implementation fidelity varied widely across the 14 health facilities. Only 3 (21.4%) facilities implemented Teen Club protocols with high fidelity. Nearly three-quarters (71.4%) of the health facilities implemented with medium fidelity and 1 implemented with low fidelity. Interestingly, 2 of the 3 health facilities with high implementation fidelity successfully transition a few ALHIV to adult care, suggesting a potential association between implementation fidelity and transition outcome.
Health system factors associated with successful transition – “Maintenance” dimension of the RE-AIM Framework
Qualitative study
To further explore the challenges with operating Teen Clubs, we conducted in-depth interviews with a total of 28 SPs. These included 9 providers with nursing experience, 11 providers with a clinical experience, and 8 providers with HTS counselling background. Most participants had more than 2 years of experience working with HIV Teen Clubs. Half of the providers were trained in HIV Teen Club curriculum while only 11 (39.3%) were trained in transitioning of adolescents from HIV Teen Club to adult care.
Transitioning challenges
The majority of providers acknowledged that they have not managed to transition adolescents to adult care as expected. The challenges were at provider, patient and health facility levels. Most providers reported that lack of provider training was main contributing factor to failure to properly transition the adolescents. Several acknowledged lack of knowledge on the guidelines for transitioning, as noted below by one provider,
“I am not sure that we have successfully transitioned these teens according to the guidelines since we have not been trained in the guidelines for transitioning the ALHIV.” (Respondent # 11).
At the patient level, the providers observed that most adolescents prefer to remain in Teen Club despite being eligible for transition according to transition guidelines, due to their perceived higher quality of care provided in Teen Clubs than in the adult ART clinics. They also reported that school-going adolescents find teen clubs to be convenient and not to interfere with schooling, as quoted below:
“A lot of kids are unwilling to be transitioned to adult care despite being eligible because of the care they receive at teen club and also they say they don’t want to miss school as some are still in school and adult care appointments are always during weekdays”. (Respondent #28)
The SPs also reported human resource challenge of as a key contributing factor to successful transitioning. They reported shortage of human resource to provide specialized care which is exacerbated by the high numbers of adolescents attending Teen clubs and limited time allocated to Teen Club sessions. As lamented by one of the providers,
“The challenge we have is the inadequacy of the human resource who are trained in the teen club specifically. We have a lot of adolescents but we are just 4 nurses”. (Respondent # 9)
This challenge limits the level of interaction and communication between the provider and the teen thereby adversely affecting the adolescents’ readiness to transition.