Implementing a provider-initiated testing and counselling (PITC) intervention in Cape town, South Africa: a process evaluation using the normalisation process model

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dc.contributor.authorLeon, Natalieen_ZA
dc.contributor.authorLewin, Simonen_ZA
dc.contributor.authorMathews, Catherineen_ZA
dc.date.accessioned2015-10-30T09:36:22Z
dc.date.available2015-10-30T09:36:22Z
dc.date.issued2013en_ZA
dc.description.abstractBACKGROUND:Provider-initiated HIV testing and counselling (PITC) increases HIV testing rates in most settings, but its effect on testing rates varies considerably. This paper reports the findings of a process evaluation of a controlled trial of PITC for people with sexually transmitted infections (STI) attending publicly funded clinics in a low-resource setting in South Africa, where the trial results were lower than anticipated compared to the standard Voluntary Counselling and Testing (VCT) approach.METHOD:This longitudinal study used a variety of qualitative methods, including participant observation of project implementation processes, staff focus groups, patient interviews, and observation of clinical practice. Data were content analysed by identifying the main influences shaping the implementation process. The Normalisation Process Model (NPM) was used as a theoretical framework to analyse implementation processes and explain the trial outcomes. RESULTS: The new PITC intervention became embedded in practice (normalised) during a two-year period (2006 to 2007). Factors that promoted the normalising include strong senior leadership, implementation support, appropriate accountability mechanisms, an intervention design that was responsive to service needs and congruent with professional practice, positive staff and patient perceptions, and a responsive organisational context. Nevertheless, nurses struggled to deploy the intervention efficiently, mainly because of poor sequencing and integration of HIV and STI tasks, a focus on HIV education, tension with a patient-centred communication style, and inadequate training on dealing with the operational challenges. This resulted in longer consultation times, which may account for the low test coverage outcome. CONCLUSION: Leadership and implementation support, congruent intervention design, and a responsive organisational context strengthened implementation. Poor compatibility with nurse skills on the level of the clinical consultation may have contributed to limiting the size of the trial outcomes. A close fit between the PITC intervention design and clinical practices, as well as appropriate training, are needed to ensure sustainability of the programme. The use of a theory-driven analysis promotes transferability of the results, and the findings are therefore relevant to the implementation of HIV testing and to the design and evaluation of complex interventions in other settings.TRIAL REGISTRATION:Current controlled trials ISRCTN93692532en_ZA
dc.identifier.apacitationLeon, N., Lewin, S., & Mathews, C. (2013). Implementing a provider-initiated testing and counselling (PITC) intervention in Cape town, South Africa: a process evaluation using the normalisation process model. <i>Implementation Science</i>, http://hdl.handle.net/11427/14542en_ZA
dc.identifier.chicagocitationLeon, Natalie, Simon Lewin, and Catherine Mathews "Implementing a provider-initiated testing and counselling (PITC) intervention in Cape town, South Africa: a process evaluation using the normalisation process model." <i>Implementation Science</i> (2013) http://hdl.handle.net/11427/14542en_ZA
dc.identifier.citationLeon, N., Lewin, S., & Mathews, C. (2013). Implementing a provider-initiated testing and counselling (PITC) intervention in Cape town, South Africa: a process evaluation using the normalisation process model. Implement Sci, 8(1), 97.en_ZA
dc.identifier.ris TY - Journal Article AU - Leon, Natalie AU - Lewin, Simon AU - Mathews, Catherine AB - BACKGROUND:Provider-initiated HIV testing and counselling (PITC) increases HIV testing rates in most settings, but its effect on testing rates varies considerably. This paper reports the findings of a process evaluation of a controlled trial of PITC for people with sexually transmitted infections (STI) attending publicly funded clinics in a low-resource setting in South Africa, where the trial results were lower than anticipated compared to the standard Voluntary Counselling and Testing (VCT) approach.METHOD:This longitudinal study used a variety of qualitative methods, including participant observation of project implementation processes, staff focus groups, patient interviews, and observation of clinical practice. Data were content analysed by identifying the main influences shaping the implementation process. The Normalisation Process Model (NPM) was used as a theoretical framework to analyse implementation processes and explain the trial outcomes. RESULTS: The new PITC intervention became embedded in practice (normalised) during a two-year period (2006 to 2007). Factors that promoted the normalising include strong senior leadership, implementation support, appropriate accountability mechanisms, an intervention design that was responsive to service needs and congruent with professional practice, positive staff and patient perceptions, and a responsive organisational context. Nevertheless, nurses struggled to deploy the intervention efficiently, mainly because of poor sequencing and integration of HIV and STI tasks, a focus on HIV education, tension with a patient-centred communication style, and inadequate training on dealing with the operational challenges. This resulted in longer consultation times, which may account for the low test coverage outcome. CONCLUSION: Leadership and implementation support, congruent intervention design, and a responsive organisational context strengthened implementation. Poor compatibility with nurse skills on the level of the clinical consultation may have contributed to limiting the size of the trial outcomes. A close fit between the PITC intervention design and clinical practices, as well as appropriate training, are needed to ensure sustainability of the programme. The use of a theory-driven analysis promotes transferability of the results, and the findings are therefore relevant to the implementation of HIV testing and to the design and evaluation of complex interventions in other settings.TRIAL REGISTRATION:Current controlled trials ISRCTN93692532 DA - 2013 DB - OpenUCT DO - 10.1186/1748-5908-8-97 DP - University of Cape Town J1 - Implementation Science LK - https://open.uct.ac.za PB - University of Cape Town PY - 2013 T1 - Implementing a provider-initiated testing and counselling (PITC) intervention in Cape town, South Africa: a process evaluation using the normalisation process model TI - Implementing a provider-initiated testing and counselling (PITC) intervention in Cape town, South Africa: a process evaluation using the normalisation process model UR - http://hdl.handle.net/11427/14542 ER - en_ZA
dc.identifier.urihttp://hdl.handle.net/11427/14542
dc.identifier.urihttp://dx.doi.org/10.1186/1748-5908-8-97
dc.identifier.vancouvercitationLeon N, Lewin S, Mathews C. Implementing a provider-initiated testing and counselling (PITC) intervention in Cape town, South Africa: a process evaluation using the normalisation process model. Implementation Science. 2013; http://hdl.handle.net/11427/14542.en_ZA
dc.language.isoengen_ZA
dc.publisherBioMed Central Ltden_ZA
dc.publisher.departmentDepartment of Public Health and Family Medicineen_ZA
dc.publisher.facultyFaculty of Health Sciencesen_ZA
dc.publisher.institutionUniversity of Cape Town
dc.rightsThis is an open access article distributed under the terms of the Creative Commons Attribution Licenseen_ZA
dc.rights.holder2013 Leon et al.; licensee BioMed Central Ltd.en_ZA
dc.rights.urihttp://creativecommons.org/licenses/by/2.0en_ZA
dc.sourceImplementation Scienceen_ZA
dc.source.urihttp://www.implementationscience.com/en_ZA
dc.subject.otherRoutine opt-out HIV testingen_ZA
dc.subject.otherProcess evaluationen_ZA
dc.subject.otherNormalisation process modelen_ZA
dc.subject.otherSexually transmitted infectionen_ZA
dc.subject.otherQualitative methoden_ZA
dc.titleImplementing a provider-initiated testing and counselling (PITC) intervention in Cape town, South Africa: a process evaluation using the normalisation process modelen_ZA
dc.typeJournal Articleen_ZA
uct.type.filetypeText
uct.type.filetypeImage
uct.type.publicationResearchen_ZA
uct.type.resourceArticleen_ZA
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