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Background Although many behavioral interventions are adapted, little is known about the reasons for adaptations and the process and outcomes influencing adaptations. To address this gap, we explored the adaptations made to promote HIV prevention services, including HIV self-testing (HIVST), among Nigerian youth. Methods The main objective of this qualitative case study design was to document the adaptations made over time using the Framework for Reporting Adaptations and Modifications – Expanded (FRAME). Between 2018 and 2020, we organized four participatory activities as part of the 4 Youth by Youth project to increase the uptake of HIVST services in Nigeria—an open call, a designathon, a capacity-building bootcamp and a pilot feasibility trial. We also began the process of implementing a final intervention using a pragmatic randomized control trial (RCT). The open call solicited creative strategies to promote HIVST among Nigerian youth and then had experts evaluate them. The designathon brought together youth teams to further develop their HIVST service strategies into implementation protocols. Teams determined to be exceptional were invited to a four-week capacity-building bootcamp. The five teams that emerged from the bootcamp were supported to pilot their HIVST service strategies over a 6-month period. The adapted intervention is currently being evaluated in a pragmatic RCT. We transcribed meeting reports and conducted document reviews of study protocols and training manuals. Results Sixteen adaptations were identified and categorized into three domains: (1) modifications to the content of the intervention (i.e. photo verification system and/or Unstructured Supplementary Service Data (USSD) system to verify HIVST); (2) modifications to the delivery the intervention (i.e. implement participatory learning community sessions to provide supportive supervision and technical support); (3) modifications to the evaluation processes (i.e. economic evaluation to estimate the cost of implementing intervention on a larger scale). Frequent reasons for adaptation included increasing intervention reach, modifying interventions to enhance their appropriateness and fit with the recipient, and increasing the intervention’s feasibility and acceptability. Most adaptations were planned and reactive, and the need for modifications was determined by the youths, 4YBY program staff, and advisory group. Conclusions Findings suggest that the nature of adaptations made throughout the implementation process reflects the necessity of evaluating services in context while adjusting to specific challenges as they are identified. Further research is needed to understand the effect of these adaptations on the overall intervention effect as well as the quality of youth engagement.

Background Advances and proliferation of technologies such as mobile phones may provide opportunities to improve access to HIV/STI services and reach young people with high risk for HIV and STI. However, the reach, uptake, and sustainability of mobile health (mHealth) HIV/STI interventions targeting young people aged 10–24 years in low- and middle-income countries (LMICs) are largely unknown. To address this gap and to inform implementation science research, a review was conducted to summarize what is known, and what we need to know about implementing mhealth interventions for HIV/STI prevention targeting young people in LMICs. Methods We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for this review. Drawing upon Proctor’s eight implementation outcome measures, we evaluated the acceptability, adoption, appropriateness, cost, feasibility, fidelity, penetration, and sustainability of m-health HIV/STI interventions targeting young people in LMICs. The search was performed from September 2020–January 2021 and updated on March 1, 2021, in Cumulative Index to Nursing and Allied Health Literature (CINAHL), PubMed, SCOPUS, Global Health, and Web of Science. Eligible studies were required to include an HIV/STI prevention outcome, target young people aged 10–24 years, include a comparison/control group, and reporting of atleast one implementation outcome as outlined by Proctor. Results A total of 1386 articles were located, and their titles and abstracts were screened. Of these, 57 full-text articles were reviewed and subsequently, and 11 articles representing 6 unique interventions were included in the systematic review. Acceptability 6 (100%), appropriateness 6 (100%), and feasibility 5(83%) were the most frequently evaluated implementation outcomes. Adoption 2 (33%), fidelity 1 (17%), and cost 1 (17%) were rarely reported; penetration and sustainability were not reported. Conclusions This review contributes to implementation science literature by synthesizing key implementation outcomes of mHealth HIV/STI interventions targeting young people in LMICs. Future research is needed on m-health HIV/STI implementation outcomes, particularly the penetration, cost, and long-term sustainability of these interventions. Doing so will enhance the field’s understanding of the mechanisms by which these interventions lead or do not lead to changes in high HIV/STI risk and vulnerability among young people in LMICs.

Despite the high prevalence of HIV among adolescent girls and young women (AGYW) aged 15–24 years in Ghana, HIV testing remains low among this population. The objective of this study was to examine the relationship between ethnicity and HIV testing among AGYW in Ghana. The 2014 Ghana Demographic and Health Survey data were used and analyses were restricted to 3325 female participants aged 15–24 years. Chi-squared tests and a logistic regression model were used to assess the association between ethnicity and HIV testing. Furthermore, the PEN-3 cultural model informed the conceptual framework that explained the relationship between ethnicity and HIV testing behaviour. Results from the bivariate analysis showed an association between ethnicity and HIV testing among AGYW (p

Child mortality is the lowest it has ever been, but the burden of death in low- and middle-income countries (LMICs) is still prevalent, and the numbers average above the global mean. Breastfeeding contributes to the reduction of child mortality by improving chance of survival beyond childhood. Therefore, it is essential to examine how evidence-based breastfeeding interventions are being maintained in resource-constrained settings. Guided by Scheirer and Dearing's sustainability framework, the aim of this systematic review was to explore how evidence-based breastfeeding interventions implemented to address child mortality in LMICs are sustained. The literature search included randomized controlled trials (RCTs) of breastfeeding interventions from the following electronic databases: Cochrane Library, Global Health, PubMed, Scopus, and Web of Science. Literature selection and data extraction were completed according to the PRISMA guidelines. A narrative synthesis was used to investigate factors that contributed to sustainability failure or success. A total of 497 articles were identified through the database search. Only three papers were included in the review after the removal of duplicates and assessment for eligibility. The three RCTs included breastfeeding interventions predominately focusing on breastfeeding initiation and exclusivity in rural, semi-rural, and peri-urban areas in South Africa, Kenya, and India. The number of women included in the studies ranged from 901 to 3,890, and the duration of studies stretched from 6 weeks to 2.5 years. In two studies, sustainability was reported as the continuation of the intervention, and the other study outlined program dissemination and scale-up. Facilitators and barriers that influenced the sustainability of breastfeeding interventions were largely related to specific characteristics of the interventions (i.e., strong intervention implementers—facilitator; small number of CHWs involved—barrier). Optimizing the sustainability of breastfeeding interventions in LMICs is imperative to reduce child mortality. The focal point of implementation must be planning for sustainability to lead to continued benefits and changes in population outcomes. A defined action plan for sustainability needs to be included in both funding and research.

Although HIV self-testing (HIVST) has expanded in many regions, a few HIVST services have been tailored for and organized by youth. Innovative HIVST models are needed to differentiate testing services and generate local demand for HIVST among youth. The current pilot study aimed at examining the feasibility and efficacy of crowdsourced youth-led strategies to enhance HIVST as well as sexually transmitted infection (STI) testing. Teams of youth iteratively developed HIVST interventions using crowdsourcing approaches and apprenticeship training. Five interventions were selected and then evaluated among youth (ages 14-24) from September 2019 to March 2020. Given the similar outcomes and approaches, we present cumulative data from the completed interventions. We assessed HIVST uptake (self-report), STI uptake (facility reports for gonorrhea, syphilis, hepatitis B, and chlamydia testing), and quality of youth participation. Mixed-effect logistic regression models estimated intervention effects at baseline and 6 months. Of the 388 youths enrolled, 25.3% were aged 14-19, 58.0% were male, and 54.1% had completed secondary education. We observed a significant increase in HIVST from 3 months compared with 6 months (20% vs. 90%; p

It is important to understand how to frame the formats for promoting HIV self-testing to increase uptake among young people. In this study, we used a culture-centered model to understand the narratives of HIV self-testing preferences among young people in Nigeria. We conducted a crowdsourcing contest to solicit ideas surrounding HIV self-testing promotion among young people (10–24 years) in Nigeria from October to November 2018 as part of the 2018 World AIDS Day event. We received 903 submissions and employed thematic content analysis to evaluate 769 eligible youth narratives. Thematic content analysis of the statements from the youth narratives was guided by the PEN-3 cultural model to examine the positive, existential, and negative perceptions (beliefs and values), enablers (resources), and nurturers (roles of friends and family) of HIV self-testing promotion among young people in Nigeria. Several themes emerged as factors that influence the uptake of HIV self-testing among young people in Nigeria. Specifically, seven themes emerged as perceptions: HIV testing accessibility, stigma reduction, and autonomy (positive); HIV self-testing kit packaging and advertisements (existential); lack of knowledge and increased stigma (negative). Seven themes emerged as enablers: social media, school, and government promotion (positive); gamification and animation (existential); high cost and access to linkage to care services (negative); And seven themes emerged as nurturers: peer, families, and faith-based communities (positive); parents and family-centered approach (existential); and partners and family (negative). Our data suggests that increased awareness around HIV self-testing on current youth-friendly platforms, de-stigmatization of HIV and HIV self-testing, decreased prices for HIV self-testing kits, reliability of testing kits, increased linkage to care services, and promotion of self-testing among family members and the community will be beneficial for HIV self-testing scale-up measures among young people in Nigeria.

Introduction: Youth-friendly health service (YFHS) interventions are a promising, cost-effective approaches to delivering sexual and reproductive services that cater to the developmental needs of young people. Despite a growing evidence-base, implementation of such interventions into practice have proven to be challenging in sub-Saharan Africa (SSA). Thus, the purpose of this review is to synthesize existing evidence on YFHS implementation in SSA and understand which implementation strategies were used, in what context, how they were used, and leading to which implementation outcomes.Methods: A comprehensive literature search in PubMed, Embase, Scopus, and CINAHL, was conducted to identify peer-reviewed research articles published from database inception up until August 2020. Eligible studies were required to include young people (ages 10–24 years) in sub-Saharan Africa. Studies that described implementation strategies, as conceptualized by the Expert Recommendations for Implementing Change (ERIC) project, used to enhance the implementation of YFHS were included. Implementation outcomes were extracted using Proctor and colleagues' 8 taxonomy of implementation outcomes.Results: We identified 18 unique interventions (reported in 23 articles) from an initial search of 630 articles, including seven from East Africa, seven from South Africa, and four from West Africa. In most studies (n = 15), youth-friendly health services were delivered within the context of a health facility or clinic setting. The most frequently reported categories of implementation strategies were to train and educate stakeholders (n = 16) followed by infrastructure change (n = 10), to engage consumers (n = 9), the use of evaluative and iterative strategies (n = 8), support clinicians (n = 8), and providing interactive assistance (n = 6). The effectiveness of the strategies to enhance YFHS implementation was commonly measured using adoption (n = 15), fidelity (n = 7), acceptability (n = 5), and penetration (n = 5). Few studies reported on sustainability (n = 2), appropriateness (n = 1), implementation cost (n = 1) and feasibility (n = 0).Conclusion: Results of the review emphasize the need for further research to evaluate and optimize implementation strategies for promoting the scale-up and sustainability of evidence-based, YFHS interventions in resource-constrained settings. This review also highlights the need to design robust studies to better understand which, in what combination, and in what context, can implementation strategies be used to effectively enhance the implementation of YFHS interventions.

Background Community-based interventions (CBIs) are interventions aimed at improving the well-being of people in a community. CBIs for HIV testing seek to increase the availability of testing services to populations that have been identified as at high risk by reaching them in homes, schools, or community centers. However, evidence for a detailed cost analysis of these community-based interventions in sub-Saharan Africa (SSA) is limited. We conducted a systematic review of the cost analysis of HIV testing interventions in SSA. Methods Keyword search was conducted on SCOPUS, CINAHL, MEDLINE, PsycINFO, Web of Science, and Global Health databases. Three categories of key terms used were cost (implementation cost OR cost-effectiveness OR cost analysis OR cost-benefit OR marginal cost), intervention (HIV testing), and region (sub-Saharan Africa OR sub-Saharan Africa OR SSA). CBI studies were included if they primarily focused on HIV testing, was implemented in SSA, and used micro-costing or ingredients approach. Results We identified 1533 citations. After screening, ten studies were included in the review: five from East Africa and five from Southern Africa. Two studies conducted cost-effectiveness analysis, and one study was a cost-utility analysis. The remainder seven studies were cost analyses. Four intervention types were identified: HIV self-testing (HIVST), home-based, mobile, and Provider Initiated Testing and Counseling. Commonly costed resources included personnel (n = 9), materials and equipment (n = 6), and training (n = 5). Cost outcomes reported included total intervention cost (n = 9), cost per HIV test (n = 9), cost per diagnosis (n = 5), and cost per linkage to care (n = 3). Overall, interventions were implemented at a higher cost than controls, with the largest cost difference with HIVST compared to facility-based testing. Conclusion To better inform policy, there is an urgent need to evaluate the costs associated with implementing CBIs in SSA. It is important for cost reports to be detailed, uniform, and informed by economic evaluation guidelines. This approach minimizes biases that may lead decision-makers to underestimate the resources required to scale up, sustain, or reproduce successful interventions in other settings. In an evolving field of implementation research, this review contributes to current resources on implementation cost studies.

BACKGROUND: The World Health Organization recommends HIV self-testing (HIVST) as an additional approach to HIV testing and the Nigerian government is supportive of this policy recommendation. However, effectively increasing uptake and sustainability among Nigerian youth is unknown. The goal of this study is to conduct a full-powered type I hybrid effectiveness-implementation trial to test the effectiveness of youth-friendly implementation science strategies in increasing uptake and sustainability of HIVST led by and for Nigerian youth. METHODS: Our 4 Youth by Youth (4YBY) strategy combines four core elements: 1) HIVST bundle consisting of HIVST kits and photo verification system; 2) a participatory learning community; 3) peer to peer support and technical assistance; and 4) on-site supervision and performance feedback to improve uptake and sustainability of HIVST and enhance linkage to youth-friendly health clinics for confirmatory HIV testing where needed, sexually transmitted infection (STI) testing (i.e. syphilis, gonorrhea, chlamydia, and hepatitis, STI treatment, and PrEP referral. Utilizing a stepped-wedge, cluster-randomized controlled trial, a national cohort of youth aged 14–24 recruited from 32 local government areas across 14 states and four geo-political zones in Nigeria will receive the 4YBY implementation strategy. In addition, an economic evaluation will explore the incremental cost per quality adjusted life year gained. DISCUSSION: This study will add to the limited “how-to-do it literature” on implementation science strategies in a resource-limited setting targeting youth population traditionally underrepresented in implementation science literature. Study findings will also optimize uptake and sustainability of HIVST led by and for young people themselves. TRIAL REGISTRATION: This study is registered in ClinicalTrials.gov NCT04710784 (on January 15, 2021).

Background There is a critical gap in the uptake of HIV testing among young people in sub-Saharan Africa. In Nigeria, only a quarter of young people aged 14–24 years have ever tested for HIV. Recent evidence suggests that HIV self-testing (HIVST) may play a role in addressing gaps in HIV testing coverage and serve as an entry point for HIV prevention services. However, there is limited information on strategies that may increase the uptake of HIV testing among young people. Current strategies rarely include young people in the design stages, which often results to poor adoption of HIV interventions. We aimed to address this gap with the development of an innovation bootcamp for participants aged 14–24 years to generate interventions to promote HIVST among young people in Nigeria. Methods The innovation bootcamp was a 4-week accelerated training programme to build entrepreneurial and research capacities among young people to develop HIV self-testing social enterprise. The training programme consisted of social enterprise and research development modules. At the completion of the bootcamp, we also examined participants' perspectives of the programme using surveys. Findings Between May 6 and May 30, 2019, 20 people participated in the innovation bootcamp in Lagos State, Nigeria; 13 (65%) were male and age range was 22–24 years. The innovation bootcamp generated five youth-participatory HIVST social enterprises. Two of the social enterprise focused on repacking HIVST kits to increase their appeal among young people, one idea focused on leveraging community engagement platforms (vocational skills training and youth community events) to promote HIVST, and another social enterprise seeks to use a reward-referral system to promote HIVST in young people. Participants' survey responses suggest that the innovation bootcamp fostered an environment for young people to connect with their peers to generate ideas and solutions. The bootcamp also provided opportunities for skills development such as logistics management and research (protocol writing, data collection, and needs assessment) skills. Interpretation The innovation bootcamp model can leverage the resourcefulness, capabilities, and resilience of youth to generate youth-centred and youth-sensitive interventions to promote HIV testing. The innovation bootcamp led to the development of five youth-centred and participatory interventions to promote uptake of HIV self-testing among young people in Nigeria. Funding Eunice Kennedy Shriver National Institute of Child Health and Human Development Grant number: 1UG3HD096929 and NIAID K24AI143471

BackgroundAdolescent girls in Nigeria are at heightened risk for HIV and other sexually transmitted infections. However, there are limited studies on psychosocial factors that are associated with safe sex intentions among this population. Self-efficacy has been established as an important correlate of behavioral intentions and the actual behavior. The objective of this research was to examine how key psychosocial factors such as social support, parental monitoring, and future orientation influence perceived safe sex self-efficacy among in-school adolescent girls in Nigeria. Furthermore, we assessed the associations between these psychosocial factors and HIV-related knowledge and safe sex self-efficacy.MethodsA self-administered questionnaire was distributed to 426 adolescent girls attending public and private school systems in Lagos, Nigeria. Multiple linear regression was used to evaluate the influence of psychosocial and demographic factors on safe sex self-efficacy. Further, stratified analysis was conducted to compare the estimates between participants attending public schools (n = 272) and those attending private schools (n = 154).FindingsResults from the study show that future orientation (β = 0.17; p < 0.05), participants age (β = 0.14; p < 0.05), and HIV knowledge accuracy (β = 0.17; p < 0.05) were associated with safe sex self-efficacy. Future orientation remained statistically significant in the sub-group analysis among participants attending public (β = 0.13; p < 0.05) and private schools (β = 0.24; p < 0.05). Among participants attending public schools, HIV accuracy (β = 0.2; p < 0.05) remained a significant correlate of safe sex self-efficacy while this association dissipated among private school attendees.ConclusionsThese findings point to the importance of including future orientation strategies in interventions developed for in-school adolescent girls in Nigeria. School-based interventions that increase positive future orientation outcomes may be beneficial to improve safe sex intentions among adolescent girls in Nigeria.

Links are the most important new punctuation mark since the invention of the comma, but it has been years since the last in-depth discussions of link poetics. Taking inspiration Raymond Queneau'sExercices De Style, we explore the poetics of contemporary link usage by offering exercises in which the same piece of text is divided and linked in different ways. We present three different exercises---varying the division of a text into lexia, varying links among lexia, and varying links within lexia---while pointing toward potential aesthetic considerations of each variation. Our exercises are intended descriptively, not prescriptively, as a conversational starting point for analysis and as a compendium of useful techniques upon which artists might build.

Procedural storytelling offers immense promise for games to offer more reactive narrative experiences that feel more deeply tailored to players' decisions. To date, interactive narrative systems have tended toward either a large emergent possibility space with less focus on narrative structure, or toward greater structure with smaller possibility spaces. In this paper, we introduce Lume, a system for procedural narrative generation that combines the best of these two approaches through a novel combinatorial scene architecture in which storylet scenes are comprised of parameterized node-trees. We detail how the system works and discuss how it moves toward creating reactive interactive narratives that are both dynamic and coherent.

This paper presents a case study in the experience-first prototyping of a generative game. Our goal in this process was to create a PCG-based mystery story construction game ncentered on a social simulation of characters and their motivations, and driven by a set of core themes and experiences we wanted players to encounter. In pursuit of this goal, we created a series of prototypes to test how a variety of generative and AI-based techniques---including character generation, character action suggestion based on game state, story sifting, and social simulation---may be used in support of collaborative storytelling. In this paper we catalogue these prototypes and what we have learned by creating them, detailing design elements we found to be successful in supporting player creativity and that may be useful to the developers of similar games and experiences going forward.

Background Providing a platform to engage young people as active participants and decision-makers in the design and delivery process of HIV testing efforts is critical to optimise uptake of HIV testing and other preventive services among this population. Designathon, an intensive team-based contest to crowdsource solutions, is a form of participatory approach that may increase the effectiveness of implementation strategies by fully engaging the end users in the design process. In this study, we explore strategies for HIV self-testing (HIVST) delivery developed at a designathon contest in Nigeria. Methods The 48-h HIVST designathon held from March 29 to March 31, 2019, in Lagos state, Nigeria, occurred in three phases. First, we solicited solutions from Nigerian youth on how to encourage self-testing for HIV and other sexually transmitted infections in a way that is low-cost, accessible, youth-friendly and confidential. Second, submissions were shortlisted by an advisory committee and the top teams were invited to compete at the designathon contest. Third, the top teams presented their strategies using the business model canvas (BMC) to an expert panel. The BMC included: (1) description of the value of the HIVST service; (2) how and where to deliver HIVST; and (3) youth-friendly HIVST service strategies. Thematic analysis was used to explore key elements of the business model canvas. Findings Of the 127 submissions received, 13 teams (with a total of 42 participants) were selected to participate at the designathon. Participants' median age was 22·5 years (IQR 21–24 years) and 28 (67%) were male. Teams developed segment-specific approaches such as online (ie, unstructured supplementary service data (USSD) services, gamification) and offline (ie, vending machines, community youth mobilisers) options for distributing and promoting the HIVST kit to reach a wider range of young people in both urban and rural settings. Multi-stakeholder partnerships at the local, state, and federal level were identified as key implementation mechanisms to drive scale-up and sustainability efforts. Interpretation Designathons are a feasible method of facilitating meaningful youth engagement to develop deployable strategies to increase the uptake of HIV testing in young people in Nigeria. Additional refinement and rigorous evaluations of the proposed strategies in practice is an important next step to assess the effectiveness and impact of the models. Funding Eunice Kennedy Shriver National Institute of Child Health and Human Development Grant number: 1UG3HD096929 and NIAID K24AI143471

Older adults account for 17% of new HIV diagnoses in the US and are more likely to be diagnosed with HIV later in the course of the disease compared to younger people. We calculated the prevalence and associated factors of having ever been tested for HIV among sexually active older adults. We analyzed data from the 2008-2016 General Social Survey Limited to respondents ≥65 years of age who reported more than one sex partner(s) in past 12 months (n = 757). HIV testing prevalence, prevalence ratios, and 95% confidence intervals were calculated by demographic variables and HIV-related risk behaviors. An estimated 16.3% of sexually active older adults have tested for HIV, and 15.9% were at increased risk for HIV infection (reported injection drug and/or crack-cocaine use, exchanging money for sex, more than three sex partners in the past year, or men who reported having sex with another man). In the adjusted model, adults aged 65-70, not married, self-identified as gay/bisexual, and at increased risk for HIV infection were more likely to have tested for HIV. An estimated 83.7% of sexually active older adults never tested for HIV. Strategies are needed to increase HIV awareness and testing among potentially high-risk older adults.

As multitouch phones and tablets become more popular, multitouch technologies receive increasing attention. The underlying interaction paradigm of such devices is the space on which objects are manipulated by the user's fingertips. It is natural that hypertext narratives find their way from primarily mouse-driven interaction to spatial structures and visually rich presentations. In this article we propose three features for multitouch hypertext narrative applications: (i) Native multitouch support and direct manipulations of fictive objects; (ii) using the space as a structuring mechanism rather than a means for presentation; and (iii) supporting presentation of visually rich objects. Our prototype, TouchStory, is a novel tool specialized for authoring and reading hypertext narratives that integrates these features.

The opposition between narrative agency–the ability for readers and players to make meaningful choices–and narrative immersion has been an ongoing conflict in the world of interactive storytelling. Some forms, such as games, have been argued to be more successful at balancing the tension between interactivity and immersion than forms like hypertext fiction [16]. Using these two forms as illustration, this paper will argue for the need for more nuanced understandings of "agency" and "immersion" by introducing definitions of diegetic and extra-diegetic agency alongside definitions of narrative and mechanical immersion. Extending the vocabulary of agency and immersion highlights some key differences in how games and hypertexts have been understood.

As our attitude toward technology has fluctuated between viewing it as either a benevolent aid or a dangerous threat, the arts have responded with various ways of expressing this anxiety. Glitch art confronts this technological anxiety, and continues the modernist and postmodernist fascination with representation and medium. An extension of remix culture, intentional glitching---or databending---presents an interesting new form for combining narrative and visual art.