HLTH 8475 Week 9 Site-Level Outcome Analysis Example

Outcome Analysis at Twelve Months: PrEP Persistence Read Pharmacy by Pharmacy and by How Much Follow-Up Clients Received, With Unintended Effects on Sexually Transmitted Infection Counts, Pharmacist Workload and Where Clients Chose to Go

Student Name

Walden University

HLTH 8475: Advanced Program Implementation and Evaluation

Instructor Name

Month Day, Year

Outcome Analysis at Twelve Months: PrEP Persistence Read Pharmacy by Pharmacy and by How Much Follow-Up Clients Received, With Unintended Effects on Sexually Transmitted Infection Counts, Pharmacist Workload and Where Clients Chose to Go

Why Not One Overall Result

After twelve months, 118 clients had started PrEP across the district's four rural pharmacies. Among the 84 who had been in the program at least six months, 58%, or 49 people, had pills on hand for at least four days in five over their first half year, just under the pre-set level of 60%. No client was diagnosed with HIV while on PrEP. A single overall figure would suggest the program narrowly missed its persistence target. But the process evaluation showed that the program was not delivered the same way everywhere, so this analysis reads the outcome site by site and by the amount of follow-up clients received, following the logic that outcomes can only be interpreted against what was actually delivered (Carroll et al., 2007).

By Pharmacy

The two pharmacies with private rooms and two trained pharmacists met the persistence level. The two that did not had weaker delivery: pharmacy C lost its second trained pharmacist and had no private space, and pharmacy D's phone follow-up depended on a hospital lab that delayed results.

Table 1

Persistence at Six Months by Pharmacy (Clients in Program at Least Six Months)

Percentages are of clients at each site; numbers are small, and differences between sites should be read as patterns, not precise estimates.

By Dose of Follow-Up

Across all sites, clients who completed their first two follow-up visits on time were much more likely to be persistent at six months than those who missed one. That pattern is expected, since staying on PrEP and attending follow-up go together, and it does not prove that visits caused persistence. It does show where clients drop out: most who stopped did so around the first follow-up, three months after starting.

Unintended Effects

Three effects no one planned appeared in the records and interviews.

Sexually transmitted infection diagnoses among clients rose, because every follow-up includes testing. This is a benefit for clients, who were treated, but it showed up in the district's surveillance as an increase that could be misread as a rise in infection.

Pharmacist workload at the smaller sites was heavier than planned, an early warning about sustainability in the sense Proctor et al. (2011) give the term. Pharmacists at C and D reported that PrEP visits took longer than the time budgeted and competed with dispensing during busy hours, and pharmacy C's second pharmacist cited workload when moving to another job.

Some clients chose not to use their nearest pharmacy. Eleven clients living in pharmacy D's town drove to pharmacy A, 40 minutes away. In interviews, several said they did not want to discuss PrEP with a pharmacist who also knew their family. Privacy in a small town worked against the program's idea of care close to home.

What the Analysis Shows

The program appears to work where it was delivered as designed: private space, two trained pharmacists and reliable lab results. Where delivery weakened, persistence fell. The analysis cannot rule out that clients differed between sites, since the larger town may have drawn clients more ready to stay on PrEP. The comparison with published experience, such as the high adherence reported by an urban pharmacist-managed clinic (Tung et al., 2018), suggests that the strongest sites are performing reasonably for a rural setting.

What Follows

The evaluation should treat the persistence shortfall as a delivery problem first: restore a second trained pharmacist at C, build a private space there, address lab delays for D and offer clients from small towns the option of telehealth follow-up with a pharmacist at another site.

References

Carroll, C., Patterson, M., Wood, S., Booth, A., Rick, J., & Balain, S. (2007). A conceptual framework for implementation fidelity. Implementation Science, 2, Article 40. https://doi.org/10.1186/1748-5908-2-40

Proctor, E., Silmere, H., Raghavan, R., Hovmand, P., Aarons, G., Bunger, A., Griffey, R., & Hensley, M. (2011). Outcomes for implementation research: Conceptual distinctions, measurement challenges, and research agenda. Administration and Policy in Mental Health and Mental Health Services Research, 38(2), 65-76. https://doi.org/10.1007/s10488-010-0319-7

Tung, E. L., Thomas, A., Eichner, A., & Shalit, P. (2018). Implementation of a community pharmacy-based pre-exposure prophylaxis service: A novel model for pre-exposure prophylaxis care. Sexual Health, 15(6), 556-561. https://doi.org/10.1071/SH18084