Table 2.
Summary of AGYW and KI workshop findings on implementation barriers and implementation strategies
| Implementation barrier domain a | Theme | ERIC implementation strategy category | Description of specified implementation strategy b |
|---|---|---|---|
| AGYW Workshop Findings | |||
| Judgement taking PrEP or seeking mental healthcare | There is judgement and stigma around PrEP and mental health service seeking | Develop educational materials; distribute educational materials; use mass media | Community education via social media and television advertisements to share with the community the benefits of taking PrEP and participating in a mental health intervention |
| Poor service | AGYW feel they are mistreated, ignored or disrespected and are concerned about confidentiality | Audit and provide feedback; provide clinical supervision | Counsellor monitoring and management to help hold staff accountable, improve their skills and make management more visible to AGYW |
| Time spent at clinic | AGYW do not want to spend a lot of time at the clinic or travel a large distance to get there | Create new clinical teams; revise professional roles | Increase staffing capacity |
| Trust issues | Parents and partners will be concerned about PrEP use and mental health issues | Inform local opinion leaders; involve patients and family members | Hold community meetings at schools to talk about PrEP and mental health issues; allow partners to accompany one another at the clinic |
| Consistency of participation | AGYW may start sessions but will not continue with sessions regularly | Intervene with patients to enhance uptake and adherence | Empowering SMS reminder messages to encourage AGYW to keep coming to the clinic and engaging with PrEP and mental healthcare |
| KI Workshop Findings | |||
| Accessibility | It is important to ensure appropriate location for the bench itself and to help make the clinic more accessible for AGYW; will need to ensure confidentiality and safety on the bench | Change service sites | Create an option for a virtual Friendship Bench to make the service tailored to AGYW needs, if they would prefer a physical bench or a phone call |
| Staff knowledge and ability | Counsellors may not know where to refer patients and will not know about mental health counselling or the Friendship Bench | Provide clinical supervision; centralize technical assistance; create a learning collaborative | Set up WhatsApp groups for supervision and debriefing |
| Stigma | There is a large amount of community, family and facility‐level stigma related to PrEP, HIV and mental health issues | Identify and prepare champions; inform local opinion leaders | Engage community stakeholders (e.g. key celebrities, gatekeepers, school administrators) in creating a dialogue around mental health awareness |
| Resources | Clinics are lacking staff (including counsellors, social workers), referral points outside the clinic and screening tools | Change physical structure and equipment | Use a mobile, digitized self‐screening tool (with a WiFi screening point) so that AGYW can screen themselves, which would reduce stigma and also help streamline clinic flow |
| AGYW needs | AGYW may not want to talk about mental health issues, they likely have other more pressing concerns (e.g. food insecurity), and do not want to spend a lot of time at the facility | Increase demand | Reframe mental health needs from a positive lens (e.g. use words like “well‐being” instead of “problems”) |
Abbreviations: AGYW, adolescent girl and young women; ERIC, Expert Recommendations for Implementing Change; PrEP, pre‐exposure prophylaxis; SMS, short message service.
Barriers were ranked by perceived strength of the barrier to negatively impact integrated mental health and PrEP service delivery. Participants were asked to rank each barrier on a scale from 1 to 5, with 1 being the barrier they perceived to have the strongest influence on intervention delivery and 5 being the barrier they perceived to have the weakest influence on intervention delivery. AGYW workshop rankings were as follows: poor service = 1.7; judgement taking PrEP = 2.8; time spent at the clinic = 2.8; trust issues = 3.0; consistency of participation = 3.5. KI workshop rankings were as follows: accessibility = 2.3; staff knowledge and ability = 2.7; stigma = 3.0; resources = 3.0; AGYW needs = 4.0.
The implementation strategies shown are those that participants selected to specify during subsequent workshops. This was determined based on how likely the strategy would be to succeed and how feasible the strategy would be to implement. Participants were asked to provide Likert‐style responses on how likely a strategy would be to succeed (from 1: Strongly Agree to 4: Strongly Disagree) and how feasible a strategy would be to implement (from 1: Strongly Agree to 4: Strongly Disagree). From AGYW workshops, all selected strategies had high likelihood of success (range: 1.1–1.6) and feasibility (range: 1.6–1.9). From KI workshops, all selected strategies had high likelihood of success (range: 1.0–1.7) and feasibility (range: 1.3–2.3).