Study Design
This was a pilot study which used IS strategies to promote the systematic uptake of the EBP of HIVST into routine practice. Despite the numerous healthcare practices having an empirical-base that guide care delivery, utilizing the evidence is not part of routine practice [39]. Titler (2018) also noted that the disparity between the available evidence-based recommendations and the application of these recommendations to improve population health is associated with poor health outcomes. Figure 1 shows the Evidence Integration Triangle [40] used to understand the uptake of HIVST initiative in this study.
Empirical evidence, end-user perspectives and relevant stakeholders input were utilized in the development of the SAYS (Swipe And know Your Status) initiative at Africa University (AU). Implementation of the initiative adopted Leask et al.’s principle of co-creation in which they hypothesized that the development of a public health intervention is a collaborative effort involving both academics and stakeholders [28]. In co-creating the HIVST intervention at the university, the end-users, service providers, and policy makers at both institutional and national levels were consulted to ensure integration of the HIVST intervention with the pre-existing HTS. Figure 2 shows the systematic flow of the process of intervention mapping implemented in this pilot study.
Baseline enquiry to promote EBP
Step 1. Identifying the need, program planning and stakeholder engagement
To identify gaps related to practice, healthcare facility HTS register reviews were conducted at the two main health facilities serving the University by the research team made up of FMM (Public Health Physician), RAK (Public Health and M & E Specialist) and MT (Social Scientists), EMC (Public Health Nursing Specialist), MM (Psychotherapist and Mental Health Expert), and WM (Social Scientist,Monitoring and Evaluation Officer). The team also did an extensive literature review of how HIVST programs were implemented in different setting by searching for HIVST-related articles on databases such as Google Scholar, MEDLINE in PubMed, EMBASE, EBSCOhost and Scopus with the help of a librarian. After the reviews, the research team and implementing team (health professionals) represented by TM (Nurse) met to map the activity timelines, discuss on the stakeholders to be consulted and material required for the successful implementation of the initiative.
The MOHCC which is the custodian of the national HTS program was consulted through the office of the Manicaland Provincial Medical Director’s Office which offered two HIV/STI/TB focal persons (CU and QM) who also acted as program trainers. The research team, implementers and the MOHCC representatives met twice during the months February to April 2018 to draft proximal program objectives, the HIVST Project Training of Trainers Facilitators Manual Hand Book (Additional File 1) and Training Evaluation Forms for participants (Additional File 2).
Step 2. Community engagement to identify program barriers and enablers
The implementing team led by TM, organized a community dialogue session held on campus where participants were purposively-selected according to their roles on campus and in HTS programming. The session was attended by a total of 83 participants who included student board leaders, Dean of Students, campus club representatives, hostel wardens, Non-governmental organization (NGO) representatives from Students and Youth Working on Reproductive Health Action Team (SAYWHAT) and Fairfield Buddies, and the research team. The session also included representatives from three other institutions of higher education. The aim was to introduce the SAYS initiative and identify potential barriers and enablers of implementing the intervention at an institution of higher learning.
A second community engagement meeting held at Old Mutare Hospital was attended by 17 local adolescents and young adults (16 to 27 years) who were not university students. The group was made up of Community Adolescent Treatment Support (CATS) members some of whom were living with HIV, five hospital nurses working in the Opportunistic Infections Clinic, six members of the AU Peer Network Club and their patron (TM). The aim was to discuss pertinent issues related to HIV/AIDS screening/testing methods and experiences.
Step 3. Capacity building through training of implementers and development of intervention materials.
Thirteen (2 males and 11 females) purposively-selected community health worker group which was made up of university lecturers and scientists with a medical, nursing and laboratory-based background were trained in May 2018. The objective was to provide a background and rationale of the initiative, share key findings and lessons learnt during the MOHCC pilot study. The workshop which was facilitated by CU and QM also equipped participants with knowledge and skills on HIVST counseling.
Another training session was conducted with health workers from the two local health facilities, psychotherapist (MM) and 26 Peer Educators (PEs) (11 female and 15 males) who would be crucial in the implementation of the program. PEs also known as “Champions” from among the students were responsible for providing psychosocial and emotional support to other students within the institutional environment. To cater for the culturally and linguistically diverse pan African environment at the University, the PEs were from different nationalities and a third of them were fluent in either French or Portuguese languages.
CU, QM, MT and FMM facilitated the three day training which equipped participants with background and rationale of the HIVST program, share key findings of the pilot program, discuss self-awareness and its role in counseling. Participants were mentored on counseling principles, techniques and process through presentations, group discussions, and peer counseling role-plays. The workshop was also used as an opportunity to develop program messages that were to be printed on flyers and banners, and these were submitted to the Provincial Office of Health Promotion for review and approval before printing. Survey data collection tools were developed and PEs were trained on research data collection and associated ethical issues. Participants were given program t-shirts and hats to promote visibility.
Step 4. Baseline Survey
A baseline campus-wide cross-sectional survey aiming at identifying the barriers and enablers was conducted, analyzed and reported between June and August 2018. The survey also aimed to understand the student and health worker perspectives and experiences with regards to HTS. Conveniently-selected students were interviewed using semi-structured questionnaires while providers and university management were interviewed as key informants. The interview guides were guided by selected elements from the Consolidated Framework of Implementation Research (CFIR) to explore students’ knowledge of the HTS and HIVST programs, describe the key characteristics of students who were likely to get tested and identify the issues and perceptions around HIVST intervention’s feasibility, acceptability, local relevance demand, practicality and potential sustainability among the key administrative stakeholders. The interview guides enquired about the components of HTS and supporting milestones as recommended by WHO [41] and these are displayed in Table 1.
Table 2 shows the CFIR guide used in survey questionnaire development [42]. The data collection team were ten purposively-selected trained PEs supervised by FNNM, MT and WM. The baseline interview responses elicited data which was classified either as enablers or barriers to HIVST thus, guiding intervention choice components. The observed enablers and barriers to HIVST were compared with the findings in systematic reviews [43-45].
The authors mainly concentrated on the modifiable factors which this study was most likely to address and non-modifiable factors were disseminated to national HTS program stakeholders for action. Findings from the community dialogues, discussions during training and survey interviews were analyzed according to the CFIR guide which is a standard approach that produces actionable findings for improving the effectiveness of implementation of public health interventions [42].
Step 5. Identifying the acceptability, feasibility and local relevance of the SAYS initiative
A multidisciplinary consensus group comprising of FMM, MT, WM, TM, CU, MM and ten PEs met twice to discuss on strategies to be employed in intervening by reviewing the available evidence from community dialogue narratives, training evaluations and survey responses. The team focused on identifying how the evidence fit into the intervention and how non-fitting factors could be adjusted to suit the intervention components. This was done by stratifying the responses into enabling and barrier factors which were operationalized during program implementation. The collaborating consensus group members also contributed their experiences and expertise in the various components of the intervention.
Table 3 displays the scoring grid on practicability and acceptability of the intervention constructs against the HTS components as agreed by the different stakeholders during the consensus meetings. The scoring grid was used to assess the influence of the constructs on the components of the HTS components proposed by WHO. The scores ranging from -2 to 2 were assigned by consensus.
Intervention phase
The intervention was implemented from August 2018 to February 2019. HIVST kits were kept at the university laboratory for quality assurance under the oversight of a Medical Laboratory Scientist and providers collected the kits based on demand. PEs equipped fellow students with information on the SAYS initiative by creating awareness while simultaneously encouraging students to be tested by word of mouth. Emails advertising the initiative were also sent to all student through the University Registrar’s desk.
Print materials (pamphlets) were handed out to potential participants and video materials were distributed via student WhatsApp groups to encourage increased regular repeat testing as well as early access to HIVST [18]. The materials were also adopted for use by translating them to French and Portuguese languages to support the pan-African environment at the university. A one day Health Fare Gala was held in September 2018 to sensitize the students and offer more information on the initiative. This event which was open to all students, was hosted by the implementing team in collaboration with SAYWHAT and PSI.
‘Supervised’ self-testing and counseling meant that the service was offered by a trained healthcare professional or PE. Clients were able to conduct their own HIV test in private, using appropriate supplied test kits, and where necessary support and supervision was rendered by the healthcare workers. Clients needing HTS still had the choice of a regular voluntary counseling and testing conducted by a health worker, or self-testing in private. Students had the option of conducting the self-testing exercise in a room identified for the purpose at the health facility or taking the kit to the hostel/other private space.
Peer Educators assisted in disbursing HIVST kits when the nurses were overwhelmed. At the time of disbursement students provided their demographic information including mobile contact, received orientation and information materials from the provider/PE. The information materials constituted detailed instructions for use, linkage to care, and disposal of used testing swabs. Information on how to use HIVST kits alleviated misinterpretation and misconception of results, thus promoting intervention uptake [10, 47]. Clearly labeled protected bins were placed in the testing room and in strategic points at the hostels for the purposes of disposal. While facilitating infection prevention and control, this effort also provided information on uptake and use of kits through physical counts of the used swabs.
The OraQuick rapid HIV 1/2 antibody test (OraSure Technologies, Bethlehem, PA, USA) which was prequalified by WHO [48] was used for conducting self-testing. A total of 750 kits were availed for use through a donation from OraSure Technologies Inc. Test kit distribution was restricted to the two health facilities serving the University where trained staff could monitor the distribution by PEs during the normal working hours. Kit disbursement registers were used to capture number of kits collected and socio-demographic data of participants without taking down client names. Follow-up messages were sent via phone text by the nurses to participant within 24 to 48 hours of collecting the kit. This was mainly done as a way of checking how the student was coping and if they required any additional services like one-on-one counselling or linkage to care.
End-line evaluation survey
Ten data clerks (PEs) were used to collect data from 349 conveniently sampled participants (who had or had not self-tested) using a semi-structured questionnaire as well as purposively selected key informants and a data sheet guiding collection of statistics from the health facility registers. The evaluation aimed to ascertain the feasibility, acceptability and local relevance of the HIVST intervention (March to April 2019). The survey questionnaire development was guided by the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework of evaluating interventions [49]. The study participants were asked on acceptability, potential concerns, perceived effectiveness of implementation and recommendations for adoption as well as sustainability of the intervention using semi-structured self-administered questionnaires. The findings of the survey were used as reinforcement to enhance self-testing sustainability through rapid evidence review of the HIVST program to inform practice and policy.
Context
The study was carried out at Africa University, a tertiary education institution 18 km north of the Zimbabwean eastern border city of Mutare. Participating health facilities (AU Clinic and Old Mutare Hospital) were purposively-selected and the study population was 1,690 university students from 29 African countries and service providers at the facilities. Enrollment statistics at the time showed that 53% of the students were females, 32% were international students, 65% of the students lived on campus and 25% were housed in University-recommended hostels in Mutare City.
Data Management and Analysis
Data collectors (PEs) were responsible for conducting the informed consent process and issuing questionnaires to students while WM and MT interviewed the health workers and university management. Tools were pre-tested at a tertiary institution and its corresponding health facility in Mutare City for clarification, reliability and validity of the data extraction tools. FMM, PTM (Public Health Officer) and WM were responsible for data entry and analysis. Qualitative data from dialogue sessions and open-ended survey questions were thematically coded before content analysis was done while quantitative data was imported into Epi Info version 7.2.1.0 (CDC, USA) for Chi-squared test of association and multivariate analysis at 95% confidence interval and 5% level of significance.
Ethical clearance and permission
Ethical clearance was issued by the Medical Research Council of Zimbabwe and the Africa University Research Ethics Committee. Permission to carry out the intervention and data collection activities was granted by the Provincial Medical Director of Manicaland and the AU administration.