Interventions connecting young people living in Africa to healthcare; a systematic review using the RE-AIM framework.

Introduction: Africa's young people are among the least focused groups in healthcare linkage. The disproportionally high burden of youth-related health problems is a burden, especially in developing regions like Africa, which have a high population of young people. More information is needed about factors that impact linkages in healthcare and the sustainability of health interventions among young people in Africa. Methods: A systematic literature search was performed from October 2020 to May 2022 in PubMed, CINAHL, Scopus, Global Health, and the Web of Science. Studies included in the review were conducted among young people aged 10-24 living in Africa, written in English, and published between 2011 and 2021. Results were reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Data was analyzed using narrative synthesis, synthesizing the details of the RE-AIM reporting component. Interventions were systematically compared using the Cochrane Collaboration risk-of-bias tool to evaluate the rigor of each intervention. Results: A total of 2,383 potentially relevant citations were obtained after an initial database search. Retained in the final group were seventeen articles from electronic data searches; among these articles, 16 interventions were identified. Out of the seventeen studies, nine (53%) were randomized controlled trials, three (18%) were quasi-experimental designs, and five (29%) were observational studies. At the same time, the included interventions were reported on 20 (76.92%) of the 26 components of the RE-AIM dimensions. In eastern Africa, twelve (80%) interventions were conducted, and all the interventions addressed linkage to care for young people in preventing and treating HIV. The least reported RE-AIM dimensions were implementing and maintaining interventions connecting young people to care. Discussion: Timely care remains critical to treating and preventing ailments. This review indicates that interventions created to link young people to care, especially HIV care, can help link them to health care and strengthen the programs. It is also clear that further research with more extended follow-up periods is needed to examine connections to care in all other aspects of health and to bridge the gap between research and practice in the care of young people in Africa. Systematic Review Registration: PROSPERO [CRD42022288227].

Expanding Youth-Friendly HIV Self-Testing Services During the COVID-19 Pandemic: Qualitative Analysis of a Crowdsourcing Open Call in Nigeria.

BACKGROUND: HIV self-testing (HIVST) among young people is an effective approach to enhance the uptake of HIV testing recommended by the World Health Organization. However, the COVID-19 pandemic disrupted conventional facility-based HIV testing services, necessitating the exploration of innovative strategies for the effective delivery of HIVST. OBJECTIVE: This study analyzed the outcomes of a digital World AIDS Day crowdsourcing open call, designed to elicit youth responses on innovative approaches to promote HIVST among young people (14-24 years) in Nigeria during COVID-19 restrictions. METHODS: From November 2 to 22, 2020, a World AIDS Day 2020 crowdsourcing open call was held digitally due to COVID-19 restrictions. The crowdsourcing open call followed World Health Organization standardized steps, providing a structured framework for participant engagement. Young people in Nigeria, aged 10-24 years, participated by submitting ideas digitally through Google Forms or email in response to this crowdsourcing open call prompt: "How will you promote HIV self-testing among young people during COVID-19 pandemic?" Data and responses from each submission were analyzed, and proposed ideas were closely examined to identify common themes. Four independent reviewers (AE, SM, AZM, and TG) judged each submission based on the desirability, feasibility, and impact on a 9-point scale (3-9, with 3 being the lowest and 9 being the highest). RESULTS: The crowdsourcing open call received 125 eligible entries, 44 from women and 65 from men. The median age of participants was 20 (IQR 24-20) years, with the majority having completed their highest level of education at the senior secondary school level. The majority of participants lived in the South-West region (n=61) and Lagos state (n=36). Of the 125 eligible entries, the top 20 submissions received an average total score of 7.5 (SD 2.73) or above. The panel of judges ultimately selected 3 finalists to receive a monetary award. Three prominent themes were identified from the 125 crowdsourcing open call submissions as specific ways that HIVST can adapt during the COVID-19 pandemic: (1) digital approaches (such as gamification, photoverification system, and digital media) to generate demand for HIVST and avoid risks associated with attending clinics, (2) awareness and sensitization through existing infrastructures (such as churches, schools, and health facilities), and (3) partnerships with influencers, role models, and leaders (such as religious and youth leaders and social influencers in businesses, churches, organizations, and schools) to build trust in HIVST services. CONCLUSIONS: The crowdsourcing open call effectively engaged a diverse number of young people who proposed a variety of ways to improve the uptake of HIVST during the COVID-19 pandemic. Findings contribute to the need for innovative HIVST strategies that close critical knowledge and practice gaps on ways to reach young people with HIVST during and beyond the pandemic. TRIAL REGISTRATION: ClinicalTrials.gov NCT04710784; https://clinicaltrials.gov/study/NCT04710784.

Tracking adaptation strategies of an HIV prevention intervention among youth in Nigeria: a theoretically informed case study analysis of the 4 Youth by Youth Project.

BACKGROUND: Although many behavioral interventions are adapted, little is known about the reasons for adaptations and the process and outcomes influencing adaptations. To address this gap, we explored the adaptations made to promote HIV prevention services, including HIV self-testing (HIVST), among Nigerian youth. METHODS: The main objective of this qualitative case study design was to document the adaptations made over time using the Framework for Reporting Adaptations and Modifications - Expanded (FRAME). Between 2018 and 2020, we organized four participatory activities as part of the 4 Youth by Youth project to increase the uptake of HIVST services in Nigeria-an open call, a designathon, a capacity-building bootcamp and a pilot feasibility trial. We also began the process of implementing a final intervention using a pragmatic randomized control trial (RCT). The open call solicited creative strategies to promote HIVST among Nigerian youth and then had experts evaluate them. The designathon brought together youth teams to further develop their HIVST service strategies into implementation protocols. Teams determined to be exceptional were invited to a four-week capacity-building bootcamp. The five teams that emerged from the bootcamp were supported to pilot their HIVST service strategies over a 6-month period. The adapted intervention is currently being evaluated in a pragmatic RCT. We transcribed meeting reports and conducted document reviews of study protocols and training manuals. RESULTS: Sixteen adaptations were identified and categorized into three domains: (1) modifications to the content of the intervention (i.e. photo verification system and/or Unstructured Supplementary Service Data (USSD) system to verify HIVST); (2) modifications to the delivery the intervention (i.e. implement participatory learning community sessions to provide supportive supervision and technical support); (3) modifications to the evaluation processes (i.e. economic evaluation to estimate the cost of implementing intervention on a larger scale). Frequent reasons for adaptation included increasing intervention reach, modifying interventions to enhance their appropriateness and fit with the recipient, and increasing the intervention's feasibility and acceptability. Most adaptations were planned and reactive, and the need for modifications was determined by the youths, 4YBY program staff, and advisory group. CONCLUSIONS: Findings suggest that the nature of adaptations made throughout the implementation process reflects the necessity of evaluating services in context while adjusting to specific challenges as they are identified. Further research is needed to understand the effect of these adaptations on the overall intervention effect as well as the quality of youth engagement.

Sustainability of breastfeeding interventions to reduce child mortality rates in low, middle-income countries: A systematic review of randomized controlled trials.

Child mortality is the lowest it has ever been, but the burden of death in low- and middle-income countries (LMICs) is still prevalent, and the numbers average above the global mean. Breastfeeding contributes to the reduction of child mortality by improving chance of survival beyond childhood. Therefore, it is essential to examine how evidence-based breastfeeding interventions are being maintained in resource-constrained settings. Guided by Scheirer and Dearing's sustainability framework, the aim of this systematic review was to explore how evidence-based breastfeeding interventions implemented to address child mortality in LMICs are sustained. The literature search included randomized controlled trials (RCTs) of breastfeeding interventions from the following electronic databases: Cochrane Library, Global Health, PubMed, Scopus, and Web of Science. Literature selection and data extraction were completed according to the PRISMA guidelines. A narrative synthesis was used to investigate factors that contributed to sustainability failure or success. A total of 497 articles were identified through the database search. Only three papers were included in the review after the removal of duplicates and assessment for eligibility. The three RCTs included breastfeeding interventions predominately focusing on breastfeeding initiation and exclusivity in rural, semi-rural, and peri-urban areas in South Africa, Kenya, and India. The number of women included in the studies ranged from 901 to 3,890, and the duration of studies stretched from 6 weeks to 2.5 years. In two studies, sustainability was reported as the continuation of the intervention, and the other study outlined program dissemination and scale-up. Facilitators and barriers that influenced the sustainability of breastfeeding interventions were largely related to specific characteristics of the interventions (i.e., strong intervention implementers-facilitator; small number of CHWs involved-barrier). Optimizing the sustainability of breastfeeding interventions in LMICs is imperative to reduce child mortality. The focal point of implementation must be planning for sustainability to lead to continued benefits and changes in population outcomes. A defined action plan for sustainability needs to be included in both funding and research.

Understanding factors that promote uptake of HIV self-testing among young people in Nigeria: Framing youth narratives using the PEN-3 cultural model.

It is important to understand how to frame the formats for promoting HIV self-testing to increase uptake among young people. In this study, we used a culture-centered model to understand the narratives of HIV self-testing preferences among young people in Nigeria. We conducted a crowdsourcing contest to solicit ideas surrounding HIV self-testing promotion among young people (10-24 years) in Nigeria from October to November 2018 as part of the 2018 World AIDS Day event. We received 903 submissions and employed thematic content analysis to evaluate 769 eligible youth narratives. Thematic content analysis of the statements from the youth narratives was guided by the PEN-3 cultural model to examine the positive, existential, and negative perceptions (beliefs and values), enablers (resources), and nurturers (roles of friends and family) of HIV self-testing promotion among young people in Nigeria. Several themes emerged as factors that influence the uptake of HIV self-testing among young people in Nigeria. Specifically, seven themes emerged as perceptions: HIV testing accessibility, stigma reduction, and autonomy (positive); HIV self-testing kit packaging and advertisements (existential); lack of knowledge and increased stigma (negative). Seven themes emerged as enablers: social media, school, and government promotion (positive); gamification and animation (existential); high cost and access to linkage to care services (negative); And seven themes emerged as nurturers: peer, families, and faith-based communities (positive); parents and family-centered approach (existential); and partners and family (negative). Our data suggests that increased awareness around HIV self-testing on current youth-friendly platforms, de-stigmatization of HIV and HIV self-testing, decreased prices for HIV self-testing kits, reliability of testing kits, increased linkage to care services, and promotion of self-testing among family members and the community will be beneficial for HIV self-testing scale-up measures among young people in Nigeria.

Factors influencing the integration of evidence-based task-strengthening strategies for hypertension control within HIV clinics in Nigeria.

BACKGROUND: Evidence-based task-strengthening strategies for hypertension (HTN) control (TASSH) are not readily available for patients living with HIV in sub-Saharan Africa where the dual burden of HTN and HIV remains high. We are conducting a cluster randomized controlled trial comparing the effectiveness of practice facilitation versus a self-directed control (i.e., receipt of TASSH with no practice facilitation) in reducing blood pressure and increasing the adoption of task-strengthening strategies for HTN control within HIV clinics in Nigeria. Prior to implementing the trial, we conducted formative research to identify factors that may influence the integration of TASSH within HIV clinics in Nigeria. METHODS: This mixed-methods study was conducted with purposively selected healthcare providers at 29 HIV clinics, followed by a 1-day stakeholder meeting with 19 representatives of HIV clinics. We collected quantitative practice assessment data using two instruments: (a) an adapted Service Availability and Readiness Assessment (SARA) tool to assess the capacity of the clinic to manage NCDs and (b) Implementation Climate Scale to assess the degree to which there is a strategic organizational climate supportive of the evidence-based practice implementation. The quantitative data were analyzed using descriptive statistics and measures of scale reliability. We also used the Consolidated Framework for Implementation Research (CFIR), to thematically analyze qualitative data generated and relevant to the aims of this study. RESULTS: Across the 29 clinics surveyed, the focus on TASSH (mean=1.77 (SD=0.59)) and educational support (mean=1.32 (SD=0.68)) subscales demonstrated the highest mean score, with good-excellent internal consistency reliability (Cronbach's alphas ranging from 0.84 to 0.96). Within the five CFIR domains explored, the major facilitators of the intervention included relative advantage of TASSH compared to current practice, compatibility with clinic organizational structures, support of patients' needs, and intervention alignment with national guidelines. Barriers included the perceived complexity of TASSH, weak referral network and patient tracking mechanism within the clinics, and limited resources and diagnostic equipment for HTN. CONCLUSION: Optimizing healthcare workers' implementation of evidence-based TASSH within HIV clinics requires attention to both the implementation climate and contextual factors likely to influence adoption and long-term sustainability. These findings have implications for the development of effective practice facilitation strategies to further improve the delivery and integration of TASSH within HIV clinics in Nigeria. TRIAL REGISTRATION: ClinicalTrials.gov , NCT04704336.