Feasibility of implementing an integrated hybrid model of service delivery for AGYW sexual and reproductive health in South Africa
Lead Research Organisation:
University of the Witwatersrand
Department Name: Wits Reproductive Health & HIV Inst WRHI
Abstract
Adolescent girls and young women (AGYW) experience significant health challenges including HIV infection, unwanted teenage pregnancies and sexually transmitted diseases in South Africa. Challenges exist with the uptake and utilization of sexual and reproductive health services for AGYW and there are a number of missed opportunities with the health system to provide prevention and care to AGYW. There is a renewed drive for service integration by policy makers to integrate SRH services with newly emerging HIV prevention and treatment services, in addition to scaling up access to prevention, care and treatment of STI's at a primary healthcare level. Current isolated service delivery models adds time and cost to clinic facilities and may be seen as a barrier to accessing care, as young people may have less access to cash, competing demands and less control over their time. There is limited data on effective delivery models for integrated interventions for young populations, therefore this study aims to determine the feasibility of implementing an integrated hybrid model of service delivery for adolescent girls and young women (AGYW) sexual and reproductive health (SRH) at selected facilities in South Africa. The integrated service delivery model will be a hybrid model comprising of both integration of contraceptive, STI/HIV transmission prevention and mental health screening with linkage to care services for HIV treatment, PrEP and psychosocial support. The linkages to appropriate care should be facilitated by health connectors. In order to determine whether such an intervention would be feasible to implement at selected facilities, this study will 4 elements, namely acceptability, demand, practicality and adaptation using the following objectives: (1) determine client, provider and key informant acceptability of the integrated hybrid model for SRH service delivery for AGYW, (2) assess demand and preference for integrated SRH services amongst AGYW, (3) determine the practicality of delivering integrated hybrid model for SRH service delivery for AGYW in a resource constrained setting, and (4) determine current level of integration and the adaptations needed to implement the integrated hybrid model for SRH service delivery for AGYW.
Technical Summary
Adolescent girls and young women face significant health challenges such as HIV infection, unwanted teenage pregnancies and sexually transmitted diseases. However sexual and reproductive health service utilization remains low among this age group. Hence, there is a need to focus on determining optimal service delivery models that are responsive to current barriers faced by AGYW. This study aims to determine the feasibility of implementing an integrated hybrid model of service delivery for adolescent girls and young women (AGYW) sexual and reproductive health (SRH) at selected facilities in South Africa over a 24 month period. The service delivery model proposed will be a hybrid model comprising of both integration of contraceptive, STI/HIV transmission prevention and mental health screening with linkage by health connectors to care services for HIV treatment, PrEP and psychosocial support. Prior to implementing such an intervention, the feasibility of implementation needs to be determined through determining acceptability (client and provider), demand, practicality and adaptations needed. Hence, the principle research questions that the study aims to address include: (1)What level of service integration for SRH already exists at selected health facilities for adolescent girls and young women?, (2) Would an integrated SRH service be acceptable to health care providers and adolescent girls and young women?, (3) Would SRH service integration be practical in terms of time, space, workload, task-shifting, training and resources in a limited resource setting? and (4) What system changes are needed to implement an integrated hybrid model. This study will inform the development of a full trial to implement and evaluate the effectiveness of an integrated hybrid model of service delivery for AGYW SRH at community health care level.
Planned Impact
This study has both short term, mid term and long term impact. With regards to short term impact the study will provide information on feasible service delivery models for providing sexual and reproductive health to AGYW (15-24 years) which will inform implementation and scale up of context appropriate services to improve service uptake for AGYW. Through the activities proposed in this project, we aim to determine what is needed to create an enabling environment for the integration of HIV/STI transmission prevention services anchored on community health care contraceptive services using an integrated hybrid service delivery model in the city of Tshwane in South Africa for an adolescent population (15-24 years) thereby being a precursor for the creation of a platform for sustainable service delivery scale-up based on real-world experience and learning. Wits RHI has strong relationships with both the National Department of Health as well as the provincial and district Department of Health officials and key personnel in the city of Tshwane. Wits RHI serves on the National Technical Working (TWG) group for oral PrEP and HIV prevention, as well as provides technical support for the development and updating of the contraceptive and fertility planning (CFP) guidelines. Hence Wits RHI is a trusted partner in relaying feedback to this group in relation to ongoing implementation, research, programmatic and policy considerations for AGYW health.
With regards to mid term impact, this study will inform the design of a full trial to implement and evaluate an effective service delivery model for delivery of SRH services to AGYW with the aim of improving AGYW health by reducing missed opportunities to provide prevention and care services to AGYW. Through the trial we will determine evidence-based effective and appropriate service delivery models that are both cost-effective and scalable. Once such services are implemented and scaled, the long term benefits can be realized. When AGYW are linked to services, uptake care, are retained in care and adhere to HIV prevention and family planning services it brings about long term benefits for the overall reduction in HIV incidence, decreasing the number of unintended teenage pregnancies each year, managing and preventing STIs more effectively and consistently while screening for other potential needs in this population. When healthcare workers are capacitated through skills building and task shifting to engage more effectively with their client loads and increasing activities, it provides a crucial boost for the health system in terms offering extended services and number patients satisfactorily serviced. Ultimately, this is done in order to implement cost effective interventions to reduce overall HIV incident infections and teen pregnancies to provide AGYW and their male peers the opportunity to live healthy and empowered lives.
With regards to mid term impact, this study will inform the design of a full trial to implement and evaluate an effective service delivery model for delivery of SRH services to AGYW with the aim of improving AGYW health by reducing missed opportunities to provide prevention and care services to AGYW. Through the trial we will determine evidence-based effective and appropriate service delivery models that are both cost-effective and scalable. Once such services are implemented and scaled, the long term benefits can be realized. When AGYW are linked to services, uptake care, are retained in care and adhere to HIV prevention and family planning services it brings about long term benefits for the overall reduction in HIV incidence, decreasing the number of unintended teenage pregnancies each year, managing and preventing STIs more effectively and consistently while screening for other potential needs in this population. When healthcare workers are capacitated through skills building and task shifting to engage more effectively with their client loads and increasing activities, it provides a crucial boost for the health system in terms offering extended services and number patients satisfactorily serviced. Ultimately, this is done in order to implement cost effective interventions to reduce overall HIV incident infections and teen pregnancies to provide AGYW and their male peers the opportunity to live healthy and empowered lives.
| Title | FP- PrEP INFECTION CONTROL AND DATA COLLECTION PROTOCOL |
| Description | Wits RHI data collection methodologies have always ensured the safety of participants and staff and maintained the quality of data. Throughout this period of COVID-19, these measures have been strengthened to avoid any infections. This tool is a guide to infection control and hygiene measures to be implemented during FP-PrEP data collection among all stakeholders (participants, nurses, counsellors, facility managers, community based organisations representatives and policy makers). This infection control and data collection protocol will provide the data collection team with measures on how to deliver safety and prevention services in a timely and responsive manner to ensure the reduction of spread of infectious disease such as COVID-19. This protocol aligns to Wits RHI and other infections control framework of the National Department of Health (NDoH), the World Health organisation (WHO) and the University of the Witwatersrand Health Research Ethics Committee (HREC) procedures in infection control and hygiene (National Department of Health, 2020; WHO, 2020; Wits Health, 2020). The protocol utilises two methodologies for data collection and will be employed based on 2 possible lockdown restriction assumptions: First Assumption (no restrictions); Second Assumption (lock down restrictions 3-5 and 1). These lockdown levels are on a sliding scale where 1 allows for face to face data collection whilst 3-5 will have to employ online methods. |
| Type Of Material | Improvements to research infrastructure |
| Year Produced | 2021 |
| Provided To Others? | No |
| Impact | The tool was only finalised in 2021 in preparation for the submission to the Wits University Human Research Ethics Committee for review and approval. As such the tool has not be used and therefore there are no notable impacts to report at this time. |
| Title | FP- PrEP INFECTION CONTROL AND DATA COLLECTION PROTOCOL |
| Description | Wits RHI data collection methodologies have always ensured the safety of participants and staff and maintained the quality of data. Throughout this period of COVID-19, these measures have been strengthened to avoid any infections. This tool is a guide to infection control and hygiene measures to be implemented during FP-PrEP data collection among all stakeholders (participants, nurses, counsellors, facility managers, community-based organisations representatives and policy makers). This infection control and data collection protocol will provide the data collection team with measures on how to deliver safety and prevention services in a timely and responsive manner to ensure the reduction of spread of infectious disease such as COVID-19. This protocol aligns to Wits RHI and other infections control framework of the National Department of Health (NDoH), the World Health organisation (WHO) and the University of the Witwatersrand Health Research Ethics Committee (HREC) procedures in infection control and hygiene (National Department of Health, 2020; WHO, 2020; Wits Health, 2020). The protocol utilises two methodologies for data collection and will be employed based on 2 possible lockdown restriction assumptions: First Assumption (no restrictions); Second Assumption (lock down restrictions 3-5 and 1). These lockdown levels are on a sliding scale where 1 allows for face-to-face data collection whilst 3-5 will have to employ online methods. |
| Type Of Material | Physiological assessment or outcome measure |
| Year Produced | 2021 |
| Provided To Others? | No |
| Impact | Although the tool has been approved by the IRB, we are currently busy with site approval and study introductions. Therefore, there are no notable impacts regarding use to report at this time. |
| Title | Facility Level Assessment to Determine Adaptations Needed for Implementation of the Model |
| Description | The tool will be utilised in collecting data on degree of systems integration at the facility level, particularly focussing on in-client journey/patient pathway and waiting time analysis; availability of physical and human resources (staff numbers per cadre; supplies, equipment and commodities); data inventory and management systems to ensure timely collection and collation of health indicators; and lastly facility mapping (drawing of the facility layout to indicate opportunities for functional integration) |
| Type Of Material | Physiological assessment or outcome measure |
| Year Produced | 2021 |
| Provided To Others? | No |
| Impact | The tool was only finalised in 2021 in preparation for the submission to the Wits University Human Research Ethics Committee for review and approval. As such the tool has not be used and therefore there are no notable impacts to report at this time. |
| Title | Health Care Provider In-Depth Interview/Focus Group Discussion Guide |
| Description | This is a primary data collection tool to assess provider acceptability, perception of demand and perception of practicality of implementing an integrated hybrid model for SRH and mental health service delivery, as well as current level of service integration. The tool includes questions and probes related to work history and experience in providing SRH services; identification of gaps and opportunities in providing HIV prevention, treatment, care (mental health and psychosocial support) services to AGYW (HIV testing, condoms, risk reduction counselling, post-exposure prophylaxis, PrEP, STI care and treatment); acceptability and practicality of the current and proposed service delivery models (utilising an acceptability assessment framework published by Sekhon et al. BMC Health Services Research (2017) 17:88). the tool will be administered to family planning practitioners located in each of the study sites. |
| Type Of Material | Physiological assessment or outcome measure |
| Year Produced | 2021 |
| Provided To Others? | No |
| Impact | The tool was only finalised in 2021 in preparation for the submission to the Wits University Human Research Ethics Committee for review and approval. As such the tool has not be used and therefore there are no notable impacts to report at this time. |
| Title | Informed Consent - Audio Recording - Client/Provider Interview |
| Description | The tools requests permission from the client and provider to audio record the interview or focus group. the consent form covers topics on voluntary participation, data storage particularly of the audio tapes and confidentiality associated with dissemination of information. |
| Type Of Material | Physiological assessment or outcome measure |
| Year Produced | 2021 |
| Provided To Others? | No |
| Impact | The tool was only finalised in 2021 in preparation for the submission to the Wits University Human Research Ethics Committee for review and approval. As such the tool has not be used and therefore there are no notable impacts to report at this time. |
| Title | Participant Information Sheet and Consent Form - AGYW/Clients |
| Description | The Participant Information Sheet and the consent sheet This tool provides information on the study purpose, what is required as part of study involvement, survey data collection and information storage, affirmation of voluntary participation and withdrawal, benefits and risks, privacy and confidentiality as it pertains to study participation, and investigator contact details. |
| Type Of Material | Physiological assessment or outcome measure |
| Year Produced | 2022 |
| Provided To Others? | No |
| Impact | The tool was revised and finalised in February 2022 after receiving feedback from the University of the Witwatersrand Ethics Committee and University of Liverpool. As such the tool has not been used yet whilst we prepare for study commencement. therefore there are no notable impacts to report at this time. |
| Title | Participant Information Sheet and Consent Form - AGYW/Clients |
| Description | This tool provides information on the study purpose, what is required as part of study involvement, survey data collection and information storage, affirmation of voluntary participation and withdrawal, benefits and risks, privacy and confidentiality as it pertains to study participation, and investigator contact details. |
| Type Of Material | Physiological assessment or outcome measure |
| Year Produced | 2021 |
| Provided To Others? | No |
| Impact | The tool was only finalised in 2021 in preparation for the submission to the Wits University Human Research Ethics Committee for review and approval. As such the tool has not be used and therefore there are no notable impacts to report at this time. |
| Title | Participant Information Sheet and Consent Form - Provider |
| Description | The tool outlines the purpose of the study, what is involved through study participation, affirmation of voluntary participation and withdrawal if required, benefits and risks, confidentiality and privacy and contact details of study investigators if needed. |
| Type Of Material | Physiological assessment or outcome measure |
| Year Produced | 2021 |
| Provided To Others? | No |
| Impact | The tool was only finalised in 2021 in preparation for the submission to the Wits University Human Research Ethics Committee for review and approval. As such the tool has not be used and therefore there are no notable impacts to report at this time. |
| Title | Participant Information Sheet and Consent Sheet for the Provider - |
| Description | The Participant Information Sheet and the consent sheet - This tool provides information on the study purpose, what is required as part of study involvement, survey data collection and information storage, affirmation of voluntary participation and withdrawal, benefits and risks, privacy and confidentiality as it pertains to study participation, and investigator contact details. this is specifically designed for consenting the health care providers. |
| Type Of Material | Physiological assessment or outcome measure |
| Year Produced | 2022 |
| Provided To Others? | No |
| Impact | The tool was revised and finalised in February 2022 after receiving feedback from the University of the Witwatersrand Ethics Committee and University of Liverpool. We are currently obtaining site approval and preparing for study commencement - upon which the tool will be utilized to consent the health providers into the semi-structured interviews and group discussions. |
| Title | Survey Guide - AGYW Client (Family Planning or PrEP) |
| Description | This discussion guide will be used to collect data from adolescent girls and young women on a range of topics which include socio-demographic information, health seeking behaviour and access (acceptability, availability and affordability) to services, knowledge and behavioural practices associated with condom use, HIV counselling and testing, STI, Family Planning, Mental Health, impression of the current service delivery model, and questions assessing acceptability, demand and preference with regards to the proposed integrated hybrid model of FP-SRH service delivery. We have also included questions on client understanding and acceptability for new biomedical prevention products which are imminent i.e. the Dual Prevention (HIV and Contraception) Pill (DPP), Long Acting Cabotegravir (LA-CAB) and the Dapivirine Ring (DVR). It would be important to gather information from AGYW at this early stage to be able to inform the design and delivery of the long acting prevention methods. |
| Type Of Material | Physiological assessment or outcome measure |
| Year Produced | 2021 |
| Provided To Others? | No |
| Impact | The tool has just been finalised and has been submitted to the University of the Witwatersrand Human Research Ethics Committee for review and approval. As such, we have not implemented the tool and therefore there are no notable impacts to report on at this stage. |
| Title | An integrated hybrid Sexual and Reproductive Health and Mental Health Services model to improve adolescent health outcomes |
| Description | The medical intervention referenced here pertains to the proposed model/package of care to which this investment is assessing feasibility. The public health intervention specifically proposes a model which is different from the traditional and current service delivery model in South Africa, in that it embeds new technologies such as HIV self-screening , diagnostic screening for STIs, mental health screening and linkage to/provision of oral PrEP and evaluate the demand and acceptability of long-acting PrEP (Dapivirine ring and LA-CAB). Further to this, it incorporates counselling around expanded choice of family planning methods in line with the newly revised Contraception and Fertility Planning policy in South Africa (2019). The expanded method mix includes access to additional long-acting contraceptives such as the copper IUD; implant, provision of information on oestrogen and progesterone IUDs including increased access to female condoms. In addition, it promotes increased access to emergency contraception pills. Finally, it calls for increased access to contraception including increased expansion of non-clinical settings as outlets for provision of contraception (39). Our model offers HIV screening coupled with risk assessment screening and referrals for PrEP, provision of self-screening kits for partners and mental health screening. |
| Type | Health and Social Care Services |
| Current Stage Of Development | Initial development |
| Year Development Stage Completed | 2021 |
| Development Status | Under active development/distribution |
| Impact | The findings from this feasibility assessment will provide further evidence to strengthen and finalise the model for testing. Therefore, there are no notable impacts to report at this time. |