Organizational/Delivery system environment
- My intervention will be implemented at the clinic/community interface. The intervention is designed to improve engagement in clinical care among patients who have missed a clinic appointment, and thus, initial recruitment will take place in collaboration with clinic staff as we seek to identify and locate patients who did not return to clinic for their appointments.
- Ultimately, the intervention itself will be delivered separate from clinical care. Intervention activities will take place at community sites of the participants' choosing, including within participant homes, churches, schools, etc.
- The intervention will be delivered by community health workers and by staff employed by a community-based organization located within the communities where the intervention is being implemented
Organizational barriers
- Environmental forces include transportation challenges between community sites spread out across three islands and other studies/interventions operating within the same catchement area. During the rainy season, transportation is made more challenging due to poor roads and rough water on the lake. With regard to other studies, there is a large trial in Kenya and Uganda that is providing antiretroviral therapy to all HIV-infected patients, regardless of CD4 count. Part of our study area is an intervention site for this study and thus, this other study will be implementing diverse and changing interventions to ensure (perhaps artifically) high levels of retention and engagement in HIV care. This may or may not also exert additional time pressures on clinic staff within the clinics that comprise the intervention site for that study.
- Resource acquisition can be broken down to external and internal resource acquisition. Our intervention depends on resources from external organizations to fund our activities. As it stands, our intervention is funded through 2014 and is dependent on renewal of funds to continue into 2015 and beyond. Regarding internal resource acquisition, we depend on resources from several organizations, namely the Kenya Medical Research Institute for IRB approval and renewal, the Ministry of Health for approval of our ongoing engagement with clinical activities throughout the region, FACES for assistance with electronic data capture and logistical support in local implementation and community organizations for buy-in and participation in the intervention.
- Resource deployment is dependent on our ability to hire, train and retain the appropriate staff to help carry out the intervention and deploy our intervention effectively. Effective resource deployment also depends on our ability to continue to use and improve existing systems for budgeting, accounting, financial management and oversight with our existing staff.
- Quality-centered culture involves our ability to identify, track and report on important implementation outcomes during the course of our project. The study itself is designed to evaluate certain implementation outcomes, as well as clinical outocmes, however the ability for us to ensure effective implementation also depends on staff prioritization of more proximal outcomes.
Methods for addressing barriers
- Environmental challenges - we have met with the study team for the external study that will be operating within the same catchement area. As a result, we have fostered collaboration between the two study teams, but have also recognized the need to expand the scope of our study area to additional locations. This will ensure that we have sufficient sample size to address our question because of the reduced event rate that will likely result from the presence of the other study. Regarding transportation challenges, our team is acquiring two additional motorcycles and a boat to ensure that we have appropriate means of transportation. We have extensive experience conducting fieldwork in adverse weather conditions.
- Resource acquisition - to address this challenge, we are focusing considerable resources to fostering each of the relationships mentioned above. We are inviting investigators (who we know and have collaborated with for the past several years) from KEMRI and FACES to join our study team as co-investigators. We are also sending our local project manager and local co-investigator to a conference hosted by our funder in Tanzania to further foster that relationship.
- Resource deployment - we have been working hard for the past several years to put together a core research department infrastructure to ensure adequate financial management, human resources management and core administrative services. These efforts, combined with a skillful local Research Manager will help ensure effective resource deployment.
- Quality-centered culture - through weekly team meetings, our team will continuously track, report and evaluate implementation progress. We will use this monitoring process to identify quality gaps in our implementation and ensure continual improvement throughout implementation.