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Implementation

Data collection for the Integra Initiative took place between 2009 and 2012, followed by analysis that concluded in 2015. The evaluation approach was grounded in a kind of implementation science, or ‘programme science’. As far as possible, this approach applied the strengths of a rigorous scientific method to a ‘real world’ setting. To overcome the challenges of the ‘real world’ study setting, details of the implementation process and the context in which it took place have been captured here, as well as details of the specific outcomes achieved,

As an analytical framework, the Integra Initiative employed a Logical Flow Model to help structure and frame different components of the research.

 

Methods

The intervention models and methods of evaluation varied by country. The specific approaches for each country are included in the country pages for Malawi, Swaziland, and Kenya. In each country, one or more of the following methods were used:

  • Client and provider observations and interviews, and facility inventories to inform a series of assessments of health facilities at different points in time to measure changes in the quality of HIV and SRH care, as well as the associated stigma.
  • A study of a group of clients attending health facilities offering integrated and non-integrated services to compare their use of services, SRH- and HIV-related behaviours and health status over a 25-month period.
  • ‘Before and after’ surveys and qualitative research to measure perceptions and use of SRH and HIV services among community members served by health facilities offering integrated and non-integrated services.
  • Economic evaluation to determine the unit costs of service delivery and the economic costs to service users. This enabled a cost-effectiveness comparison between different types of integrated and non-integrated models.

 

Research outcomes

Findings from the project, including peer reviewed articles, presentations, and posters, are available in the open access research library. The research provides insight regarding:

  • The impact of the four integration models on the profile of clients and their frequency of use in settings with different HIV prevalence levels.
  • The impact that different models of integration have on HIV risk behaviour, HIV-related stigma, and the incidence of unintended pregnancies.
  • The process of integration and the incremental costs, potential economic benefits, and value for money associated with the provision of different models of integrated services.
  • Contextual analysis and outcomes from the intervention in Kenya, Malawi, and Swaziland.

 

Validation

The Integra research incorporated a mix of research methods, documenting insights against the main research questions from a variety of sources. This is known as ‘triangulation’ and is imperative for highly complex initiatives as it enables the findings to be cross-checked for consistency. It also overcomes the weaknesses and biases of single-method approaches and increases the credibility and validity of the results.

 

Ethical approval

Ethics approval for the research was obtained from the Kenya Medical Research Institute (approval numbers SCC/113 and SCC/114), the College of Medicine at the University of Malawi, the Swaziland Scientific Review Board (approval number MH/599B), the London School of Hygiene and Tropical Medicine (approval numbers 5426 and 5934), and the Population Council Institutional Review Board (approval numbers 443 and 444).

 

Emerging Themes

The Integra research generated an immense data source and findings are available in the open access resource library. A number of consistent themes have emerged from the research, which found that SRH HIV integration:

  1. Is an important part of the global response to HIV
  2. Is context specific, ie there is no blueprint to integration
  3. Makes good people sense – it can reduce stigma
  4. Can provide an effective way to more efficiently use scarce resources, both human and economic
  5. Can reach out to a ‘broader audience’ and increase the uptake of HIV and SRH services for a diverse clientele
  6. Hinges on a ‘tipping point’ at which more investment may be needed to ensure that efficiency gains are made and services not over strained
  7. May call for creative solutions to enhance planning, budgeting and management; the capacity or skills of health care providers; overcome fear of the unknown or fear of increased workload; and find solutions to commodity stock-outs or supply chain blockages.

 

For more details, see the Integra Analysis Framework.

Integration is not without its challenges!