Understanding barriers and facilitators to voluntary medical male circumcision and Spear and Shield uptake in Zambian community health centers

Abstract

Voluntary medical male circumcision (VMMC) has been an effective method for reducing the risk of HIV transmission by 50%–70% in Eastern and Southern Africa. The Spear and Shield (S&S) program is a community health center (CHC)-based biobehavioral VMMC HIV prevention intervention that increased VMMC uptake in male CHC attendees in Lusaka, Zambia. Qualitative data organized using the Consolidated Framework for Implementation Research (CFIR) has been used to characterize factors that may impact S&S/VMMC implementation. This manuscript uses the CFIR to examine S&S implementation across 96 CHCs in four Zambian provinces using a mixed-methods approach to (a) quantify successful S&S implementation; (b) understand how CFIR domains might provide insight into the degree of implemental success; (c) identify major themes among least and most successful CHCs; and (d) help guide future prevention efforts and policy related to VMMC promotion in the Zambian CHC context. In contrast with CFIR quantitative analyses, 12 major qualitative themes associated with the least and most successful CHCs provided unique insight into S&S and VMMC implementation and guidance for future implementation studies. Themes included lack of resources (staff, space, transportation) for the former and strong staff relationships and active community engagement for the latter. The CFIR framework appears extremely useful for the identification of qualitative themes related to intervention implementation, and reduction of qualitative data for quantitative analyses may sacrifice more nuanced information. Consideration of CFIR themes may be useful to inform HIV prevention strategies in Zambia and similar contexts.

Healthcare workers in Zambian community health centers provide information on factors impacting implementation and sustainment of the Spear and Shield intervention to promote Voluntary Medical Male Circumcision.

Implications.

Practice: This study used a mixed-methods approach to examine factors associated with implementation and dissemination success across 96 community health centers in Zambia implementing Spear and Shield, an evidence-based biobehavioral intervention associated with increased rates of voluntary medical male circumcision.

Policy: Mixed methods, as opposed to single method approaches, may be beneficial in identifying factors that promote increased implementation and dissemination success, thus helping maximize resources.

Research: Reduction of qualitative data for quantitative analyses may be at the sacrifice of more nuanced information. Consideration of Consolidated Framework for Implementation Research themes may be useful in informing HIV prevention strategies in Zambia and similar contexts.

INTRODUCTION

Combating HIV on a global scale—especially in low- and middle-income countries with high incidence and prevalence of HIV—is of significant public health importance. Globally, 38 million people are living with HIV (PLWH) [1]. Responding to the need to avert new infections the Joint United Nations Programme on HIV/AIDS (UNAIDS) developed the Fast-Track initiative to end the AIDS epidemic by 2030 [2, 3]. The ambitious 95-95-95 objectives for 2030 utilize the proven strategies of testing, tracing, treatment, and de-stigmatization of HIV. Yet clearly, as the 90-90-90 goals of 2020 were not met, novel approaches to reduce HIV transmission are essential to end the epidemic. To promote widespread, impactful change, public health policy emphasizes the need for guidance from research with key populations, such as PLWH and those at greatest risk of HIV infection.

There are roughly 1.2 million PLWH in Zambia, with a combined prevalence of 11.3% among individuals aged 15 to 49 (14.3% of women; 8.8% of men) [4]. Voluntary medical male circumcision (VMMC) is a surgical procedure to remove the foreskin of the penis—an area highly susceptible to infection from HIV [5]. Consequently, VMMC is a viable option to reduce the risk of HIV transmission. Seminal studies have illustrated that VMMC reduces the chance of HIV acquisition by 50%–70% [6–12]. Over the past decade, the World Health Organization, in partnership with UNAIDS, has recommended VMMC as a method of HIV prevention, especially in countries with high HIV transmission and low circumcision rates [5].

Described previously [6, 13–16], the Spear and Shield (S&S) program is a biobehavioral demand creation intervention centered around educating and empowering program attendees with knowledge of VMMC and safer-sex practices while also training CHC staff to provide VMMC services. S&S was shown to significantly influence the uptake of VMMC in Lusaka, Zambia, among men not previously interested in undergoing VMMC; men participating in S&S were more than twice as likely to undergo VMMC (adjusted odds ratio 2.45, 95% CI: 1.24 to 4.90; p = .016) compared to those in the control condition (VMMC only) [6]. To promote the continued uptake of VMMC, S&S was disseminated and implemented as the S&S2 program, providing S&S and VMMC services to nearly 100 community health centers (CHCs) in four Zambian provinces with high incidence and prevalence of HIV: Lusaka, Central, Southern, and Copperbelt.

The Consolidated Framework for Implementation Research (CFIR) has been used in implementation sciences studies as a tool for sorting and quantifying intervention data in diverse contexts. The CFIR is composed of five overarching domains and a total of 41 constructs that are designed to characterize program components that impact intervention implementation, with concepts spanning multiple implementation science theories [17]. Jones et al. [15] found that Lusaka CHCs most successful in providing S&S2 had significantly higher domain scores related to the Process of the intervention (e.g., planning, engaging, executing). Another interim examination of CHCs in Lusaka and Central provinces yielded significant differences in scores for three of the five CFIR domains—Outer Setting, Inner Setting, and Characteristics of Individuals—between CHCs deemed more successful in providing S&S2 in comparison with those less successful [16].

Following initial implementation of S&S2 in Lusaka, S&S2 was introduced into CHCs in Central, Southern, and Copperbelt. It was hypothesized that the domains previously identified would be significantly associated with more successful implementation of the S&S2 program [15, 16]. This manuscript aimed to assess whether the same CFIR trends would be observed in the latter three Provinces, which could suggest a valuable characterization of factors impacting HIV risk reduction interventions in similar contexts.

METHODS

S&S intervention

S&S has been previously described [6, 13–16]. S&S2 is a demand creation program consisting of S&S, a manualized group intervention comprised of four 90-minute sessions with up to 10 participants per group, aimed at increasing participants’ knowledge of HIV/AIDS, prevention and treatment options, and the advantages of undergoing VMMC [6, 15, 16]. S&S2 also trains CHC staff to conduct VMMC to ensure supply is available to respond to an increased demand for VMMC services. CHC clients were invited by CHC staff to attend S&S2 as part of their post-test Voluntary Counseling and Testing (VCT) activities and received a Certificate of Attendance upon completion of the S&S sessions. CHC staff were compensated for their work in the program, but CHC clients were not financially compensated for involvement in the program.

CHC selection and inclusion (S&S2)

A total of N = 96 CHCs from Lusaka, Central, Southern, and Copperbelt provinces participated in the study. CHC inclusion criteria included [16]: (a) conducting more than 50 VCT services per month; (b) located in a catchment area with greater than 10,000 residents; (c) sufficient space to conduct VMMC and S&S programs; and (d) available staff to conduct VMMC and S&S services and availability for training. CHCs were provided with supplies to conduct VMMC procedures and S&S sessions. CHCs unable to recruit clients or carry out group sessions were deactivated N = 13 following efforts to stimulate recruitment and sessions.

Staff interviews

Participants in this implementation and dissemination study were clinic staff; all participants interviewed (N = 358) were over the age of 18 and provided written consent to be interviewed and audio recorded by trained S&S personnel. These participants included sisters in charge (trained nurses in charge of a ward in the infirmary/hospital), VCT counselors, physicians, nurses, and clinic officers. Qualitative interviews with staff were then conducted one-year post-introduction of the intervention, to asses CHC staff’s experiences with implementation and provision of the intervention. All interviews were in-person and conducted in English.

Qualitative data

Qualitative data was collected via semi-structured interviews designed to assess staff perceptions of S&S and VMMC services at their CHC. Interview guides and questions have been described previously and were kept constant for these interviews [6, 15]. These interviews were recorded and sent to the University of Miami, where a team of trained research assistants and associates transcribed and coded them in accordance with an established CFIR protocol. As described by Rodriguez et al. [16], trained research assistants completed practice coding sheets and reached 87% agreement in CFIR coding and valence scoring of qualitative statements.

CFIR for qualitative data collection

CFIR domains were examined to identify factors that related to the degree of success in S&S and VMMC implementation [15, 16]. CFIR has numerous applications for assessing intervention success and has been used across diverse subsets of clinical medicine and public health [18–21]. In accordance with Rodriguez et al. [16], all transcribed statements from each participant’s interviews were assigned into one of the 41 CFIR constructs [17]. Once assigned to one of the 41 constructs, each statement was given a valence score, ranging from −2 to +2, based on its content. Negative scores denoted barriers to implementation, zero denoted neither positive nor negative comments in the statement, and positive scores indicating implementation success. Valence scores have been used in prior evaluations of S&S and other mixed-method assessments [15, 16, 21], helping to contextualize important staff feedback with respect to intervention implementation. They aid in bridging the gap between qualitative feedback and quantitative analyses of mixed-methods works. Data included 358 interviews that were transcribed and coded from August 2018 to February 2021. In accordance with previous methodologies [15, 16, 21], major themes across the domains were identified for the most and least successful CHC S&S2 implementation.

Quantitative data collection

Quantitative data was collected from study participants and client attendance records and included: (a) male group retention rates; (b) staff retention percentages; (c) total number of men attending S&S sessions at each CHC; (d) CHC performance ratings; (e) CFIR valence scores assigned to qualitative statements. Quantitative data was obtained from bi-weekly reports from the University of Miami.

“Success” in the context of S&S in Zambian CHCs

In this manuscript, success was defined as: (a) Male group retention—the sustainment of male S&S groups at each CHC, that is, the number of group sessions still being conducted over the course of the study; (b) Staff rating of CHC performance—performance rated on a five-point scale of 1 = “extremely poor”, 2 = “poor”, 3 = “average”, 4 = “good”, and 5 = “extremely good”; (c) Staff dropout measured by staff retention—higher percentages of staff retention indicated greater implementation success; (d) Male group attendance—how many men were in each S&S session at all CHCs. Table 1 describes measures of central tendency for each definition of success and the total clinic score.

Table 1.

Breakdown of CHC scores by measure of success and total scores (N = 96)

	Male group retention (%)	Clinic performance (%)	Staff retention (%)	Male group attendance (%)	Total clinic score
Minimum	77.02	20.00	25.00	7.50	184.84
Maximum	100.00	100.00	100.00	100.00	381.02
Mean	94.47	81.68	77.82	39.70	293.40
Range	22.98	80.00	75.00	92.50	196.18
Standard Deviation	4.58	19.50	22.38	21.79	38.02

CHC community health center.

Total clinic score

To evaluate clinic success, each of the four measures of success was converted into percentage scores out of 100. A total score for each CHC was then computed out of 400 points to better evaluate success. For the male group attendance variable, no correlation was found between attendance and the catchment area for the CHC, which demonstrated that CHC size was not a confounding factor for this variable.

CHC ranking

CHCs were ranked in three categories (Bottom, Middle, Top) by evaluating the percentiles (33.33% = ≤ 277.8745, 66.66% = ≤ 309.2033, and 100.00% = <381.0244, respectively) of the total clinic score variable. Tertiles were used to include a reasonable number of CHCs per group. The “bottom” denoted the least successful CHCs while the “top” denoted the most successful in this context of success.

CFIR score calculations

All interviewees received a score for each of the 41 constructs in the CFIR matrix consisting of the sum of statement valence scores (positive and negative separately) within a construct. Domain scores (both total positives and total negatives) per participant were summed for each of the five domains using associated construct scores. The domain scores were then averaged amongst the subjects from each CHC, giving positive and negative average scores per CHC. These positive and negative scores were summed to give one total score per CHC for each domain. Z-scores were calculated to standardize the CFIR domain scores. Each CFIR domain was assessed for normality, and it was determined that only the Inner Setting domain was normally distributed. Parametric analyses were used to analyze the relationship between Inner Setting domain scores and CHC success. Non-parametric analyses were used to assess relationships between the other four domains and total clinic success scores.

Individual correlation analyses

Bivariate correlation analyses were run to assess any correlation between the CFIR domains, between each CFIR domain and each measure of success.

Assessment of CFIR scores and overall CHC success relationship

To better understand the potential relationship between specific CFIR domain scores and CHC success, One-way ANOVA and Kruskal-Wallis tests were conducted. These tests allow for insight into any variation in CFIR domain scores across different degrees of CHC success. Data collection and preparation were completed using Microsoft Excel for Mac version 16.46. Variable computation, data cleaning, and quantitative analyses were conducted using SPSS v26 on macOS 11.2.3 operating system.

Compliance with ethical and institutional standards

Before the commencement of the study, both institutional and ethical approval were obtained in Zambia (University of Zambia School of Medicine) and in the United States (University of Miami Miller School of Medicine).

RESULTS

Quantitative

Correlation analyses

A correlation matrix was generated to examine overall associations between each CFIR domain and the four measures of success (Table 2). There was a significant positive association between Characteristics of the Individual Domain scores and male attendance scores for the CHCs where r = .286, p (two-tailed) = .005. A significant positive association was found between Process Domain scores and male attendance scores for the CHCs where r = .219, p (two-tailed) = .043.

Table 2.

Correlations between standardized CFIR domain scores and measures of success (N = 96 CHCs)

	Intervention characteristics	Outer setting	Inner setting	Characteristics of the individual	Process
Male group retention	−0.138	0.023	0.038	−0.038	−0.076
Staff retention	0.058	−0.080	0.100	−0.059	−0.013
Clinic performance	−0.002	0.066	0.072	−0.065	−0.022
Male attendance	−0.050	−0.008	0.024	.286 a	.219 b

CHC community health center; CFIR Consolidated Framework for Implementation Research.

^aCorrelation is significant at the .01 level (two-tailed).

^bCorrelation is significant at the .05 level (two-tailed).

Comparative analyses

For atypically distributed CFIR domains, Kruskal-Wallis Evaluations of Mean Ranks were used to assess any relationships with success of the CHCs (Table 3). There were no statistically significant differences between most and least successful CHCs with respect to their average domain scores. No significant differences in domain scores between least and most successful CHCs emerged in Inner Setting domain (Table 4).

Table 3.

Kruskal-Wallis evaluation of mean ranks comparison of CFIR constructs by clinic performance^a

CFIR domainsb	All M (SD)	Bottom N = 30	Middle N = 32	Top N = 31	H, p
Intervention characteristics	0.168 (0.252)	44.83	49.72	46.29	1.007, .604
Outer setting	−0.042 (0.628)	45.22	46.58	49.16	0.362, .835
Characteristics of the individual	2.41 (1.79)	44.05	47.23	49.61	0.665, .717
Process	2.42 (1.53)	42.90	49.98	47.89	1.123, .570

CHC community health center; CFIR Consolidated Framework for Implementation Research.

^aClinic performance score is based on male group retention, CHC performance, staff retention, and male group attendance.

^bCFIR domains are based on standardized average valence scores.

Table 4.

One-way analysis of variance (ANOVA) comparison of inner setting domain across top, middle, and bottom CHCs^a

Inner settingb	Sum of squares	df	Mean square	F	p
Between groups	1.774	2	0.887	0.876	.420
Within groups	91.088	90	1.012
Total	92.862	92

CHC community health center.

^aRankings are determined from clinic performance score. Scoring is based on male group retention, CHC Performance, staff retention, and male group attendance.

^bCFIR domains are based on standardized average valence scores.

Qualitative

Least successful CHCs and major themes identified

Review of CFIR matrices for participants interviewed at follow-up (N = 358) identified major themes for the least successful CHCs (N = 30): (a) Staff shortages; (b) Lack of space; (c) Lack of transportation; (d) Myths, misconceptions, and traditional beliefs; (e) Formation and maintenance of S&S groups; (f) Community engagement and sensitization. Supplemental Table 6 provides additional examples of qualitative feedback for both least and most successful CHCs.

Staff shortages hindered delivery of the S&S and VMMC services according to interviewees from the least successful CHCs.

The challenge is lack of manpower. The staff who are trained as providers of VMMC are very few (Domain: Inner Setting, Construct: Available Resources, Lusaka, Professional Nurse, Female, 55).

Space was also identified as a crucial component to carrying out the programs. CHC staff often conveyed that the lack of dedicated space or infrastructure to S&S services proved challenging when the CHC needed to also implement other services. The lack of a dedicated space created challenges with execution of S&S group sessions.

Maybe infrastructure, it is limited, sometimes we fail to keep up with demand… the number is sometimes more than we can cope (Domain: Inner Setting, Construct: Available Resources, Copperbelt, Sister in Charge, Female, 48).

Transport

Transportation was needed to venture out in the surrounding communities and was identified as inadequate. Participants conveyed that transport is a critical resource for outreach and engagement of CHCs’ catchment areas with VMMC and S&S services.

There are other areas that are difficult to reach out because of lack of available transportation… because we are surrounded by farmers, so certain places need to be reached and transport is usually a problem… (Domain: Inner Setting, Construct: Available Resources, Central, Counsellor, Male, 33).

Myths, misconceptions, and traditional beliefs

Uptake of VMMC and S&S services requires trust and support from the community. Many CHC staff members believed that certain myths, misunderstandings, and out-of-date views regarding VMMC and S&S negatively influenced their ability to carry out such services. Some of these myths or misconceptions about the services were directly related to the VMMC procedure itself, while others were about S&S.

[People] they say “I heard that some[one] who did circumcision died in ten years because of the instruments which you are using, the medications you are using” those are some of the barriers that need to be cleared…There are certain myths are misconceptions in the community … as a result, and they are shying away. (Domain: Inner Setting, Construct: Culture, Central, Professional Nurse, Male, 40).

Formation and maintenance of S&S groups

The assembly and utilization of effective groups are vital for S&S success. These group sessions are the backbone of the program and many participants noted difficulties in creating these groups and maintaining them for the required four sessions per group. Some barriers associated with maintaining S&S groups were related to scheduling issues, availability of adequate space or conflicts, and lack of incentives.

Most men are busy so, you find that for you to form a group, some will come, some won’t show up, some will just come on days they are free and other days they are not free so that’s the challenges where we have (Domain: Process, Construct: Innovation Participants, Lusaka, Counsellor, Female, 36).

Community engagement and sensitization

The community surrounding the CHC must be engaged and aware of current programs. While some of the least successful CHCs noted challenges related to transportation as a means of outreach, CHCs also noted broader issues related to engagement.

The most challenging aspect is the community sensitization, for now, since we started running out the VMMC, yes numbers have come aboard but we are not yet efficient, we have not reached a number which is satisfactory… (Domain: Process, Construct: External Change Agents, Southern, Physician/Clinic Officer, Male, 29).

Most successful CHCs and major themes identified

Subsequent review of the CFIR matrices containing staff feedback from most successful CHCs (N = 31) revealed prominent themes: (a) Strong Staff Relationships; (b) Support from clinic leadership; (c) Staff commitment and self-efficacy; (d) Active community engagement; (e) Inclusion of influential leaders; (f) Integration of S&S and VMMC with other services.

Staff relationships/cooperation

One theme that remained constant for the most successful CHCs was strong inter-staff relationships and a high degree of cooperativity. Staff members demonstrated that in times of need, other staff who might not have responsibilities related to VMMC or S&S would still do their best to support the services and help whenever possible. If staff members were unsure of how to address a situation, colleagues were utilized as a resource for support and guidance. The importance of working with other CHC staff (e.g., doctors, nurses, lay health workers, counselors) was commonly cited. In many instances, staff members viewed their work colleagues as family who all shared a common goal: to implement and support VMMC and S&S services at their facilities.

From almost all angles, we work together. When you are not sure, you ask your colleague. And for example, like myself I am not trained in that, but when I see my fellow staff doing it, I would rather be there to learn, so we share knowledge. (Domain: Inner Setting, Construct: Networks & Communication, Southern, Professional Nurse, Female, 29).

Support from clinic leadership

The involvement of clinic leadership (e.g., supervisors and sisters in charge) in the services was instrumental as they oversee CHC operations and work directly with all staff members. In the most successful CHCs, staff noted that guidance and support from these individuals was often associated with greater ability to implement the services.

The supervisors work hand-in-hand with the staff. If there are new guidelines, we have meetings and we can give our opinions… (Domain: Inner Setting, Construct: Leadership Engagement, Southern, Counsellor, Male, 29).

Staff attitudes/commitment/self-efficacy

To adequately disseminate proper information about a health intervention, the staff must be equipped with the knowledge, be committed to the project, and feel ready to actively sensitize the target population. Staff members at the most successful CHCs noted there is always a willingness to help, even from staff members who have not yet been trained in providing VMMC or S&S services.

I think they are committed because I have seen that even those who are not trained, they have that desire to come and learn, and be trained so they can come and help us as well (Domain: Inner Setting, Construct: Learning Climate, Lusaka, Counsellor, Male, 22).

Generally, interviewees from most successful CHCs held extremely positive outlooks on the services, demonstrating their understanding of VMMC and S&S’s importance for clients. Often, comprehension of the potential impact of these services on the community is a self-motivator.

Influential leader engagement

In conjunction with support from clinic leadership, engaging influential leaders (e.g., community leaders, headmen, chairmen, political leaders) was often noted as key to carrying out the programs because they can help to facilitate community engagement and support.

Headmen normally have village meetings… we [are] there, we ask for a short time to teach, when we teach, some know the goodness, they come privately, and we recruit them, so we give them more ideas… The headmen normally emphasize that [VMMC] is… supposed to be done (Domain: Process, Construct: External Change Agents, Central, Counsellor, Male, 38).

Active community engagement/community response

Unlike the least successful CHCs, staff from most successful CHCs noted positive community engagement and responses throughout their interviews. These CHCs made active efforts to advertise the services in the communities through multiple modalities such as campaigning with local organizations, giving health talks, or utilizing drama groups for education. In many cases, community members who attended became advocates for S&S and VMMC, taking on the role of disseminators of information to those who have not been exposed to these services.

We talk to them about S&S, henceforth those we have trained already, … [they are] out there in the community spreading the information about S&S (Domain: Process, Construct: Engaging, Southern, Counsellor, Male, 34).

Integration of S&S/VMMC with other services

The CHCs offer a diverse set of services. Many interviewees from the most successful CHCs noted the importance of bridging the gap between different services and integrating them into one cohesive network to better disseminate information and reach a wider range of individuals. Some staff demonstrated the importance of using the Out-Patient Department as a means of recruiting participants for S&S and VMMC. Some used their roles in Maternal and Child Health (MCH) to educate new parents on these services.

There is a room there which is MCH, when there are sessions post-natal, there is also family-planning. So, if they come to access family planning, they do talk to them so that they can talk to their partners about the importance of VMMC (Domain: Process, Construct: Engaging, Copperbelt, Counsellor, Male, 25).

DISCUSSION

The goal of this study was to better understand characteristics associated with S&S and VMMC service implementation in Zambian CHCs using qualitative data and the CFIR domains. The added value of S&S in improving VMMC uptake has been established [6, 13–16], however, characteristics associated with implementation of S&S can provide guidance to successfully widen its reach in the future. It was hypothesized that CFIR domain scores would be significantly associated with success of S&S implementation. Though limited significance emerged from correlational analyses (Table 3), this hypothesis was partially supported, demonstrating modest association between individual characteristics and the process of implementation with the numbers of men attending sessions.

“Characteristics of the Individual” refers to the relationship that individuals have with the intervention as defined by their understanding, actions, and behaviors [17]. “Process” encompasses the main pieces of carrying out the intervention [17]. Results suggest that greater men’s attendance in S&S groups was achieved when CHC attendees formed stronger relationships with S&S, and CHCs were better able to effectively complete the activities associated with implementing the intervention. Zambian CHCs are generally linked with local communities and include networks of neighborhood leaders who maintain connections between clinic activities and community members; as such, stronger relationships are an achievable goal. In contrast, CHCs may experience challenges in completing activities due to competing demands within the clinic; practices such as task shifting may reduce the CHCs capacity to achieve this goal. Considerations of financial resources and adequate staffing remain key to this aim. Targeting these two issues to improve men’s attendance could improve service uptake. For example, stimulating staff interest in S&S may foster an environment in which staff sustain referrals to attend S&S sessions and continue to engage the community.

In this investigation, quantitative analyses did not provide a guidepost to CHC success. The total CHC success score, however, was useful in ranking CHCs into tertiles to determine the least and most successful program implementation as related to qualitative data. The goal of this analysis was to create a distinction between poor and high performing. It should be noted that all active clinics, regardless of tertile ranking, met the minimum amount of space and staffing to carry out the intervention. However, despite adequate resources, as the program increased demand, in some cases the increased demand outweighed supply. This scenario may have placed additional pressure on CHCs, increasing the divide between “most and least” successful. Further understanding the impact of a disparity between supply and demand the qualitative data may prove useful in modifying this program in future rollouts and maximizing returns from implementation.

Qualitatively, themes from the least and most successful CHCs emerged from four of the five CFIR domains (Table 5). “Outer Setting” refers to external factors impacting S&S implementation including interactions with other networks, external policies, and pressure to implement the intervention [17]. “Inner Setting” refers to any internal component impacting S&S/VMMC delivery from within the CHC [17]. Three of six themes identified in the least successful CHCs addressed the availability of resources and the ability to carry out services. While the most successful CHCs may have noted issues related to resources and materials, these issues did not dominate the interview, as found in previous qualitative studies [16]. Existing studies have stressed the need for enhanced infrastructure to improve implementation of HIV-related services in the Zambian context [22]. A cost-benefit analysis of the program is warranted to determine, and champion, an adequate level of funding or resources needed to enhance less successful CHCs’ delivery of services.

Table 5.

Summarizing qualitative themes using CFIR

Themes	Description	Domain(s)	Construct(s)
Least successful CHCs
1) Staff shortages	Not having enough staff to carry out services.	Inner setting	Structural characteristics, Available resources
2) Lack of space	Not having enough space for S&S sessions or VMMC procedures.	Inner Setting	Structural characteristics, Available resources
3) Lack of transport	Outreach and engagement efforts are hindered by a lack in available transportation.	Outer setting Inner setting	Needs and resources of those served by the organization Available resources
4) Myths and misconceptions	Misunderstandings, out-of-date views/beliefs, or myths circulating the community pertaining to VMMC and S&S.	Inner setting Characteristics of the individual	Culture Knowledge and beliefs about the organization
5) S&S group formation and maintenance	Scheduling issues/conflicts and lack of incentives contributed to difficulty in running S&S sessions.	Outer setting Inner setting Process	Needs and resources of those served by the organization Structural characteristics Innovation participants, reflecting and evaluating
6) Community engagement/sensitization	Broad issues identified related to involving the community in VMMC and S&S programs.	Process	Engagement, external change agents, reflecting and evaluating
Most successful CHCs
1) Staff relationships	Good relationships between staff members; strong sense of cooperativity.	Inner setting	Networks and communication
2) Clinic leadership support	Active involvement of leadership at the CHC, good working relationship with leaders.	Inner setting	Leadership engagement
3) Staff attitudes/commitment	Staff were willing and able to assist in program implementation, demonstrating positive perceptions of the programs.	Inner setting Characteristics of the individual	Implementation climate, learning climate Knowledge and beliefs, self-efficacy
4) Influential leadership engagement	The involvement of influential leaders in the community to promote VMMC and S&S services.	Process	External change agents
5) Active community engagement	CHCs made valiant efforts to promote the services and used community members who underwent the programs as ambassadors.	Process	Engaging, reflecting, and evaluating
6) Service integration	Other CHC services such as OPD and MCH incorporated conversations about S&S and VMMC with patients to increase uptake in services.	Outer setting Process	Cosmopolitanism Engaging, reflecting, and evaluating

CHC community health center; CFIR Consolidated Framework for Implementation Research; MCH Maternal and Child Health; S&S Spear and Shield program; VMMC Voluntary medical male circumcision.

The most successful CHCs noted internal and external support as facilitators to the program. The staff interviewed from the most successful CHCs maintained an interest in the program and voiced a passion for implementing these services at their facilities, often feeling empowered and capable of engaging more community members in S&S and VMMC, consistent with previous findings [16]. Increasing the support of HIV-prevention services at the CHC could increase effective delivery of care. In less successful CHCs, implementing new measures to revitalize interest in S&S (e.g., incentives, praise from superiors, promotion in job titles) may help re-ignite a passion for S&S and VMMC services in these lower-resource settings. Findings related to myths and misconceptions regarding S&S, and more broadly, VMMC, suggest that CHC staff may also benefit from increased education to understand the value and goals of S&S, which are ultimate to decrease HIV transmission. Refresher trainings may help address these concerns as they emerge during implementation.

Community engagement remains essential. A preliminary study of S&S in Lusaka noted that the Process domain was a key element in the highest achieving CHCs, a finding consistent with the current investigation, in which the importance of community sensitization of VMMC and S&S services was emphasized [15]. Similarly, a study of religious leaders’ contribution to HIV prevention in Lusaka and Copperbelt provinces stressed the scientific education of faith-based leaders as community members who had the power to stimulate long-term community involvement [23]. While engaging community with religious leadership, they can work to rebut myths and misconceptions that hindered S&S/VMMC at poorer-performing CHCs.

Proper engagement of staff, clinic leadership, and influential leaders were all important components at the most successful CHCs. Less successful CHCs struggled to form and maintain groups to carry out sessions; future interventions could consider programs using novel modalities to engage and sustain participants in intervention sessions, while also considering the importance of all kinds of available resources to sustain the intervention.

Limitations

Several limitations should be considered in interpreting the results of this study. Perceptions of CHC performance were rated on a scale of one to five, however, only two individuals assigned the ratings that were an important element of overall success. In addition, three or four different staff members were interviewed in most of the CHCs across Lusaka, Central, and Southern provinces, while some Copperbelt CHCs only interviewed two staff members, limiting the scope of implementation perspective from Copperbelt staff in comparison with the other three provinces. Finally, study inclusion criteria are also a potential limitation to the generalizability of results. However, the obtained qualitative data presents a highly informative picture of the process of implementation and sustainment of a national program in the Zambian context.

CONCLUSION

This investigation into the process of implementation and sustainment of the S&S2 program at CHCs in four provinces utilizes the CFIR framework to characterize themes associated with the most and least successful facilities. The themes identified represent novel qualitative information drawn from health professionals implementing the services. These qualitative interviews provided insight into the climate surrounding the delivery and sustainment of the intervention. However, despite differing levels of performance, all clinics were ultimately successful in achieving the implementation and dissemination of S&S2.

Next steps

This study illustrated that the identification of noteworthy CFIR themes in a diverse collection of CHCs can be used to guide the provision of VMMC services in the Zambian context. Qualitative data provided an in-depth picture that can contribute to future implementation studies and could guide public health VMMC efforts in similar contexts burdened by HIV. However, the development, dissemination, and implementation of programs in similar environments must be informed by resources, community engagement, staff involvement, leadership by-in, integration with other services, and logistics.

Compliance With Ethical Standards

Conflicts of Interest: The authors declare no conflicts of interest.

Ethical approval: Before the commencement of the study, both institutional and ethical approval were obtained in Zambia (University of Zambia School of Medicine) and in the United States (University of Miami Miller School of Medicine).

Informed Consent: “Informed consent was obtained from all individual participants included in the study.”

Welfare of Animals: “This article does not contain any studies with animals performed by any of the authors.”

Transparency Statement

This study is not a clinical trial or registered with clinicaltrials.gov; data, analytic code, and study materials are available by request.