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New Conceptual Framwork4
New Conceptual Framwork4
Implementation defined
Implementation has been defined in several ways (Carroll et al., 2007; Dane & Schneider,
1998; J. Durlak, 1998) and described with inconsistent terms (Berkel, Mauricio, Schoenfelder,
& Sandler, 2011; Dane & Schneider, 1998; J. Durlak, 1998), making ‘what’ and ‘how’ to
measure sometimes difficult. Domitrovich et al. (2010, p. 2) citing Yeaton and Sechrest (1981)
defined implementation as ‘the degree to which an intervention is followed as prescribed by
the developer…’. Durlak and DuPre (2008) on the other hand referred to implementation as
what a programme (e.g. opt-out HIV testing and counselling) consist of when it is delivered in
a particular setting. In this thesis, implementation will be referred to as how the opt-out HIV
testing policy was delivered at selected antenatal care clinics in Ghana, compared with how the
testing programme was intended to be delivered (policy intended vs policy implemented).
The dimension of quality in this study will refer to how well the HIV testing and
counselling is performed, rather than just delivering the core elements (5Cs). To be
of quality, the testing and counselling service must be accessible, meets the needs
of clients and providers, conforms with recognised HTC standards (the 5Cs), has
measures in place to monitor quality of services, including external quality
assurance of the testing, and is in line with national guidelines (WHO, 2010, 2012).
Participant responsiveness
This dimension has been conceptualise as behaviour of participants in response to
intervention (Dillman et al., 2007). This proposal conceptualises four subjective
components of responsiveness: (1) participants evaluation of the intervention’s
content and how well it meets their needs, particularly their psychosocial needs (2)
pregnant women’s perception of the environment within which they received the
counselling and testing, including sense of confidentiality, trust and woman
centeredness; and (3) overall satisfaction with the programme, which may not be
specific to any single component of the content or context of the programme.
Adaptations
Using this framework, the researcher plans to describe the key components of the opt-out HIV
testing program as adopted in Ghana, and give insight into the degree to which Midwives and
other professionals working in the antenatal clinics adhered to the delivery of these components
(5Cs). In order to provide context and explanation to my findings, moderating factors and other
factors that may influence implementation of the intervention is described. I hope to contribute
to the existing knowledge about implementation of the opt-out HIV testing in antenatal clinic
setting, and to the assessment of fidelity of complex interventions within the field of HIV care.
Potential moderators
1. Quality of delivery1
2. Participant responsiveness2
3. Facilitating strategies
4. Adaptations4
Adherence5
Intervention Key components of 5Cs Outcomes
delivered Number of women accepting testing and
Opt-out HIV testing at ANC HIV positive pregnant women linked to
Exposure or dose care
Duration
Evaluation
Evaluation of
implementation
fidelity
Programme differentiation;
To identify ‘essential’ components
Definition of terms
1. Quality of delivery: the manner in which midwives delivered the core components of the opt-out HIV testing program
2. Participant responsiveness: how pregnant women and health care providers responded to, or were engaged in the intervention
3. Exposure or dose: the amount of an intervention received by the participants (both health care providers and pregnant women)
a. Frequency and duration of intervention: whether all elements of the intervention were delivered as often as specified
b. Coverage: whether all the people who should be participating in or receiving the benefits of the intervention did so
4. Adherence: Whether the 5Cs in the opt-out HIV testing is being implemented as it was intended by WHO/UNAID
5. Programme differentiation: identifying which elements of the opt-out testing intervention are important without which the program will not have its intended effect
1. To document how the opt-out HIV testing policy has been implemented in Ghana,
including facilitating strategies put in place to ensure smooth delivery of the program
2. To explore nurses’ and midwives’ adherence to the opt-out HIV testing program
guidelines.
3. To explore the quality of programme delivery, including adaptations made to the
core components of the program during implementation.
4. To explore the participant responsiveness in terms of pregnant women’s satisfaction
with the content of pre-test information and counselling and intervention delivery.
5. To explore health care provider’s engagement with the program, including perceived
implementation facilitators and barriers when implementing the program.
Research questions
1. What measures have been put in place at the national, regional and local level to
facilitate smooth implementation of the opt-out testing programme? (facilitating
strategies)
2. To what extent are midwives in each clinic performing HIV testing and counselling
according to written opt-out HIV testing guidelines? (adherence to core content of
5Cs)
3. What adaptations are made to the core components of testing protocol during
implementation? (adaptations)
4. What is the quality of testing and counselling services provided in the selected
facilities?(quality of delivery)
5. How did nurses and midwives experience the intervention, in terms of perceived
barriers and facilitators? (participant response)
6. How did pregnant women experience the intervention, in terms of quality of delivery,
being respected and confidentiality maintained? (participant response)
Key indicators are the active ingredients or program component that must be implemented
with fidelity in order for the intervention to be successful. Identification of these indicators
and related research questions was done using the DoView program. Identitified indicators
What adaptations (negative, positive and Modifications made to (1) Offer of pre-test information (2) HIV testing Observation Semi-structured T & C sessions
Adaptations neutral) were made to the core components (3) Post-test counselling and (4) Linkages to care checklist Interview observation Health care providers
at the point of delivery? guide Focus group discussion
To what extent were the essential elements Evidence that testing was carried in a way that (1) respected the dignity of Interview guide FGDs
Quality of delivery (5Cs) implemented with quality? pregnant women (2) woman centred (4) empowering questionnaire
Communication skills, rapport building
Nurse-patient interactions
Enthusiasm of nurse
Participant How did health care providers respond to Pregnant women Survey questionnaire Semi-structured Pregnant women
responsiveness testing intervention in terms of barriers, Experience with the entire testing experience interviews ( pregnant
facilitators, workload and training needs? Interview guide women and health care Health care providers
Field notes providers
What were the level of participation and
satisfaction in the testing and counselling Health care providers Exit interviews (pregnant
programme among pregnant women? Perceived barriers and enablers of the intervention women)
Baggaley, R., Hensen, B., Ajose, O., Grabbe, K., Wong, V., & Schilsky, A. (2012). From caution to
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