Positive attitudes toward adoption of a multi-component intervention strategy aimed at improving HIV outcomes among adolescents and young people in Nampula, Mozambique: perspectives of HIV care providers

In recent years, public health researchers across different domains have recognized the importance of planning and developing health interventions responsive to the healthcare needs of priority populations to ensure their impact where they are delivered [1‐4]. However, the success of needs-based interventions is not solely determined by how they are developed; it also depends on how well they are implemented. Successful implementation of novel evidence-based interventions (EBIs) is vital for ensuring that such interventions can reproduce lasting, effective health outcomes in the intended settings [5]. With the evolution of implementation science, researchers can now develop strategies that support the effective and timely translation of EBIs into practice [6, 7]. The advances are crucial, particularly in sub-Saharan Africa (SSA), where many efforts are being made to develop effective and contextually appropriate interventions to improve HIV-associated health outcomes [8‐15]. Moreover, policymakers find evidence from such work relevant in determining which interventions to scale up, especially in resource-constrained situations.

According to implementation literature, implementing new interventions into practice is complicated since it involves a series of interlinked phases, such as pre-implementation (adoption), implementation, and post-implementation (sustainability) [16]. As part of the implementation process continuum, interventions introduced into a new setting must be adopted effectively by individual providers and organizations that will deliver them. Proctor and colleagues define adoption as the “intention, initial decision, or action to try or employ an innovation or evidence-based practice” [17]. Based on this definition, any challenges with provider or organization decisions to adopt an intervention in the early stages of implementation may negatively affect the later stages of the implementation process and, consequently, the overall success of an intervention [18]. Given this viewpoint, researchers should identify early in the implementation process the factors that may affect the adoption of new interventions in order to develop effective context-specific strategies to increase their adoption. Although, in recent years, there has been an increase in empirical studies that have focused on intervention adoption across different research disciplines, data within the HIV context remains limited [19‐30]. Moreover, since most of these studies were conducted in high-income countries, owing to differences in contexts, their findings do not apply to SSA, where evidence from such studies may be particularly beneficial.

A review on adoption by Wisdom et al. has highlighted the importance of attitudes of individual providers toward an intervention in influencing intervention adoption [18]. Positive provider attitudes appear to be associated with an increased likelihood of adoption and subsequent use of new interventions [18, 31, 32]. The premise is that even if an organization adopts a novel EBI in practice, if there is a lack of acceptance among service providers, EBI may either not be used or may not be used as intended [19]. Furthermore, studies indicate that providers' attitudes toward implementing interventions are influenced by several complex factors related to the intervention (e.g., content and structure), the context in which the intervention is delivered (i.e., setting, organization, political climate, etc.), and provider characteristics [19, 33‐35]. Therefore, understanding the role of these factors may be crucial for any new intervention implementation effort.

The CombinADO study (ClinicalTrials.gov NCT04930367) is a cluster-randomized trial (cRCT) of a novel multi-component HIV care package that aims to improve HIV outcomes such as viral suppression, retention, and adherence to ART among adolescents and young adults living with HIV (AYAHIV), ages 10–24 years, in routine HIV care in Nampula, northern Mozambique. Following the successful participatory development of the study interventions based on the identified needs surrounding the treatment of AYAHIV within this setting, we sought to understand the attitudes of stakeholders providing HIV care among AYAHIV in adopting interventions within health facilities [36‐38]. In addition, we aimed to identify factors that would need attention to support effective implementation. In this paper, we present findings on attitudes of key stakeholders towards adopting CombinADO intervention packages in HIV care facilities for AYAHIVs. In addition, we report on the impact of stakeholder and facility-level characteristics on stakeholders' attitudes.

This study aimed to examine the attitudes of HIV service providers towards adopting CombinADO interventions for improving HIV outcomes in AYAHIV receiving ART care in Mozambique. To our knowledge, this is the first study that considered the impact of service providers' attitudes toward adopting novel HIV interventions planned for services offered to AYAHIV in the SSA setting. Overall, service-providing stakeholders dedicated to HIV care of AYAHIV within this setting reported positive attitudes regarding adopting either the intervention or control CombinADO study intervention packages within health services. We found that the study package assessed (i.e., control or intervention condition) and the number of HCWs delivering ART care in participating clinics were the only significant explanatory variables to explain variations in stakeholder attitudes. Other individual and context-level factors most noted in the existing literature to influence providers' attitudes towards adoption in various interventions in different fields were not significant predictors in this setting.

Our study showed an overall positive attitudinal endorsement of adopting interventions tested for effectiveness in the CombinADO study. Since the stakeholders will ultimately be responsible for delivering them in actual practice, this is especially important. Previous studies have suggested that implementers tend to value needs-driven interventions since they incorporate feedback from priority populations and end-users on what would be most appropriate to address the identified contextual needs. Given that in developing the CombinADO intervention packages we aimed to address needs of AYAHIV, our results suggest that these stakeholders were already supportive of implementing these interventions within HIV services offered to AYAHIV in this setting, likely contributing to their positive attitudes [36, 38]. We recommend that as more researchers consider developing appropriate HIV interventions targeted at AYAHIV, they also consider incorporating the perspectives of service providers throughout the process. This may ensure that interventions are deemed by service providers, as ultimate implementers, to have value in intervening to meet the needs of AYAHIV in improving their HIV outcomes.

The results of the ARTAS questionnaire items showed that respondents broadly endorsed positive attitudes, as observed in the high mean values shared for each item used to measure attitudes. However, we noted that stakeholders in the CombinADO intervention package group were more likely than control package stakeholders to report that the intervention package would be easy to implement after training, which may explain the observed differences in total scores between intervention groups. Notably, in the CombinADO study, the intervention group package was developed to include six additional components to those in the ESOC package. Thus, it would be very reasonable for the stakeholders expected to implement this package to report higher needs for training to acquire the necessary skills and confidence to engage the different intervention components during implementation. Even with the high levels of attitudes reported in this study, it was essential to identify these differences in perspectives on the importance of training among stakeholders within different package groups prior to active implementation of the intervention in clinics because it assisted in scaling training based on the needs highlighted by stakeholders, thus supporting provider self-efficacy [19, 26]. Our study provides evidence of the usefulness of the ARTAS attitude subscale in understanding stakeholders' attitudes towards intervention adoption. In addition, we recognize its benefit in identifying factors relating to intervention content and structure that may hinder the successes of implementation efforts beyond adoption that may require attention before the active implementation of interventions in health services.

Our results also showed an association between the number of HCWs delivering ART care in clinics and stakeholder attitude scores. It was less surprising to observe that having one HCW at the clinic offering services to AYAHIV would predict lower attitudinal scores towards adopting new interventions in practice, especially given the multi-component nature of packages tested in the CombinADO study. It has previously been suggested that service providers may be reluctant to implement new interventions if they add to their workload, especially when inadequate personnel are available. Existing implementation literature has highlighted that adequate resources, such as training and staffing, are necessary to successfully adopt new EBI in healthcare settings [46, 47]. The mechanisms by which they influence providers' attitudes toward adopting EBI may be complex and beyond the scope of this article; however, studies have noted that these factors can impact readiness to implement new EBIs [32, 46, 47]. As a result, adequacy of resources may partly explain the significant variation in stakeholder attitudes in this study due to the number of health care workers in practice and training requirements related to the type of package proposed. We recommend that before implementing new interventions in healthcare, especially in resource-limited settings, researchers should consider the role of resources such as training and staffing when addressing barriers.

In contrast to other studies on the subject, we found no additional significant relationship between reported provider attitudes and the remaining individual and facility-level characteristics considered in the study [26, 27, 31, 48]. First, there may be more complex factors influencing providers' attitudes in this setting that were not investigated in this study, and second, this could be explained in part by a lack of adequate power to show any associations that may have existed between different stakeholder groups due to the small sample size of our study. One interesting pattern that emerged was a change in the direction of the relationship between stakeholder attitudes and the age variable. Though not statistically significant in our study, we found that older stakeholders had less favourable attitudes toward intervention adoption. Previous research has revealed a similar relationship pattern and provided several explanations [31, 48, 49]. According to studies, younger stakeholders are generally in the early stages of their careers and may be more open to learning new skills and acquiring new knowledge than their older counterparts who may value their "traditional" practices [26, 49]. Because our study sample was generally younger, it is possible that our study was underpowered to demonstrate the significance of these age differences. A similar pattern was observed for the clinic location variable. Stakeholders in peri-urban clinics reported less favourable attitudes toward intervention adoption when compared to stakeholders representing clinics in other geographic locations. Although this is beyond the scope of this study, we recognize that this relationship may merit further investigation in future studies. Nonetheless, we believe these findings highlight the importance of understanding how various individual and facility-level characteristics may influence intervention adoption in each setting.

The major strength of this study lies in the purposive sampling and the use of a validated measure to understand better key stakeholders' attitudes who may influence whether these interventions reach AYAHIV in the future if interventions are found effective in improving their HIV outcomes. Given our study results, we could streamline training needs and consider additional human resource support needed to promote adoption in clinics before moving forward with active implementation. However, we acknowledge several limitations of our study. First, the self-report nature of our study is prone to social desirability bias, a problem commonly found in self-report studies, which may have led to higher attitudes towards adopting interventions reported by providers than they felt. Second, given our study was cross-sectional, we could not ascertain the temporality of provider attitude in the long term; however, we plan to re-examine these in the later stages of the study. Third, we acknowledge that using quantitative methods and including a priori explanatory variables may not have allowed us to capture additional perspectives on factors that may have been critical in this setting to shape individual providers' attitudes toward adopting these interventions. We recommend that future studies consider using various research methods, such as mixed methods, to better understand the complexities of individual attitudes. Finally, given the sample size, our data may not be generalizable to other settings; thus, future studies should consider assessing provider attitudes based on their unique interventions and contextual factors. However, we believe that the data shared in this study are the beginning of understanding approaches that can be used and considered in future implementation studies within similar settings to assess the role of key stakeholders' attitudes in the success of intervention implementation efforts. We also believe this study helped with the future direction of our research. We think it would be beneficial to understand how providers' attitudes would have changed in the active implementation of the intervention packages in clinics. In addition, we will consider using various research methods, such as mixed methods, to better understand the complexities related to the attitudes of individual providers in this setting. Such efforts may help identify barriers that in the future may hinder moving towards successful sustainability and scale-up of these interventions within this setting.

This study found positive attitudes toward adopting CombinADO study interventions among HIV care providers for AYAHIV in Nampula, Mozambique. According to this study, developing needs-based interventions and understanding the contextual factors before active implementation is key to promoting HIV interventions in healthcare settings. Including service providers in developing interventions addressing their clients' needs and considering factors specific to their work context is likely to improve attitudes towards interventions and, accordingly, the adoption of interventions. Furthermore, our study shows that perceived adequacy of resources―in this study, training and human resources―may be necessary for shaping attitudes towards adopting new interventions in this and similar healthcare settings. Achieving success in the implementation process of novel interventions, especially those with complex components, requires understanding implementers' perspectives, as well as their characteristics and their work contexts.