Individual and contextual factors affect the implementation fidelity of youth-friendly services, northwest Ethiopia: A multilevel analysis.

BACKGROUND: The evaluation of all potential determinants of implementation fidelity of Youth-Friendly Services (YFS) is crucial for Ethiopia. Previous studies overlooked investigating the determinants at different levels. Therefore, this study aimed to assess the determinants of implementation fidelity of YFS considering individual and contextual levels.
METHODS: This study was conducted among 1,029 youths, from 11 health centers that are implementing the YFS in Central Gondar Zone. Data were collected by face to face interview and facility observation using a semi-structured questionnaire. A Bivariable multi-level mixed effect modelling was employed to assess the main determinants. Four separate models were fitted to reach the full model. The fitness of the model was assessed using Akaike Information Criterion (AIC) and level of significance was declared at p-values < 0.05. The results of fixed effects were presented as adjusted odds ratio (AOR) at their 95% CI.
RESULTS: Four hundred one (39.0%) of the respondents got the YFS with high level of fidelity. Had high level of involvement in the YFS provision (AOR = 1.35, 95% CI: 1.15, 1.57), knew any peer educator trained in YFS (AOR = 1.60, 95% CI: 1.36, 1.86), and involved as a peer educator (AOR = 1.46, 95% CI: 1.24, 1.71), were the individual level determinants. Whereas, got capacity building training; (AOR = 1.93, 95% CI (1.12, 3.48), got supportive supervision, (AOR 2.85, 95% CI (1.99, 6.37), had a separate waiting room (AOR = 9.84, 95%CI: 2.14, 17.79), and system in place to provide continuous support to staff (AOR = 2.81, 95%CI: 1.25, 6.34) were the contextual level determinants.
CONCLUSIONS: The level of implementation fidelity remains low. Both individual and contextual level determinants affect the implementation fidelity of YFS. Therefore, policy makers, planners, managers and YFS providers could consider both individual and contextual factors to improve the implementation fidelity.

Background

Youth-Friendly Services (YFS) are Evidence Based Practices (EBPs) that are available, accessible, acceptable, appropriate, and equitable for youth [1, 2]. The YFS intervention was developed by World Health Organization (WHO) with the intent to avert the Sexual and Reproductive Health (SRH) problems among youth [1-3]. The intervention has previously been highlighted as a successful model for providing SRH services within a public health system [1, 4]. In Ethiopia, by 2012, YFS was implemented and provided with integration to the public health system [5].

The YFS is a complex intervention having many components integrated and provided in a room [4]. A range of services like, counseling and provision of information on SRH, Human Immunodeficiency Virus (HIV) testing, gynecological examinations, pregnancy testing, contraceptive provision, management for Sexually Transmitted Infections(STIs), abortion care, and more are integrated in YFS [1, 4]. Implementation of complex programs like YFS in real-world setting involves multifaceted processes, which are often influenced by several levels of determinants [6], hence implementation rarely succeeded as intended [6-8].

Even if YFS is widely implemented, youth in developing countries(including Ethiopia), suffer from many SRH diseases like STIs including HIV/AIDS, unsafe abortion, unintended pregnancy and child birth and more [3, 9]. One of the possible reasons for the high prevalence of SRH problems among youth could be the YFS intervention may not be implemented as designed by the original program developers. Little evidences showed as the YFS are not implemented as intended [10, 11].

Program implementation is influenced by contextual factors, which impact on an organization’s capacity to implement with high fidelity [12-16]. Hasson, operationalized context as factors related to levels of policies, finances, organizations, and groups of participants [17]. Contextual factors like providers training and competency [18-20], supportive context and skilled providers, and receptive participants [21] are some of the determinants of program implementation with fidelity. Other studies verified pre-implementation training, presence of detailed delivery manuals or guidelines, ongoing support or supervision as main determinants of program implementation [12–14, 19, 22, 23].

Literature on similar interventions showed contextual factors like, lack of technical support and monitoring, limited resources, providers commitment [24-26], poorly designed facilities [27], inconvenient opening hours [28], long waiting times and distances to the health centers [29] as the main determinants of fidelity of implementation (FoI) of interventions. In addition, operating hours, travel time, costs [4], program specific training [27], poor providers counseling skills [30], year of experience [6, 12], provider competency, as the main determinants of FoI of interventions [7, 12–14, 17, 22].

Evidence from other interventions showed, provider characteristics like provider’s perception of the program [12, 14], provider’s attitude towards an intervention and their motivation to fully implement the program [14, 15], provider’s judgments about, and confidence in, having the skills required for implementing the program [12, 14, 15], are some of the determinants of implementation fidelity of interventions. Moreover, participant responsiveness is one of the factors affecting FoI of interventions at an individual level [7, 13, 18, 31, 32]. Investigating the determinants of FoI of YFS using the multilevel perspective is very important, in that, it will uncover evidences related to the determinants of implementation fidelity of YFS. In addition, the finding from this research could help health care providers, planners, programmers and decision makers working on YFS to have a good insight on determinants of FoI of YFS at each level, to take appropriate measures and this in turn may strengthen the provision of YFS with fidelity, and to reach the desired intervention outcomes. Therefore, the aim of this study was to determine the determinants of FoI of YFS using the multilevel modeling approach.

Materials and methods

Design and context

A cross-sectional study with a linked YFS program and individual youth survey was conducted, from September to December of 2019 in Central Gondar Zone. These surveys were conducted concurrently to analyze all potential determinants of implementation fidelity of YFS at two levels YFS program (level-two) and youth level determinants (level-one). The use of linked survey is usually considered as stronger approach to analyze causality in non-experimental studies like this [33].

Participants and setting

The source populations of the study were youth of age 15–24 who were using YFS in the study area and the study population were youth of age 15–24 who were using YFS in that specific area and available at the data collection period. Youth, who provided informed written consent, parental consent or assents during the data collection period, were included in the study. In addition, health centers providing YFS, the YFS program, and health care professionals working on YFS were also another study population. Health centers and the YFS program were assessed for their level of readiness to provide the YFS using a standard checklist. In addition, the YFS providers were assessed to show the providers competency in the YFS provision.

Central Gondar Zone has a total of 14 districts with 430 kebeles (the smallest administrative units locally), 76 public health centers (from which 35 health centers were implementing YFS). The total population resided in the aforementioned zone was, 2,265,200. Of these, 1, 1411,325 were males according to the 2018 Zonal report [34]. There were 807,606 youth aged 10–24 years in the zone accounting for 36% of the total population. Besides, Gondar city administration (the capital city of Central Gondar Zone) is located at the center of this zone and had 25 urban and 11 rural kebeles [34]. According to the city 2018 plan, Gondar City Administration had a total of 390,644 populations, and youth population accounted 111,325. In addition, the city had also a total of 8 health centers and all the health centers were implementing the YFS since [34].

Description of the intervention (YFS)

The YFS intervention was developed by WHO by the year 2000 [1, 2]. It was designed to address youth SRH service demands and hence to avert the impact of SRH problems among youth. The YFS intervention implementation strategy was designed to be delivered as an integrated service with in the public health system in a one-stop-shop approach. A range of SRH and other health care services (around 11 services) are integrated and provided for youth in a room designed for this intervention. In addition, in a single visit youth can get a range of services starting from counseling on SRH issues to other SRH and/ medical conditions. Moreover, health care providers first get pre-service training on the provision of the YFS intervention.

Sample size determination

To determine the sample size for this study, a pilot study was conducted among 60 youth residing in similar setting but was not included in the final study. One health center from Central Gondar Zone (Enfranz health center), and two health centers in Bahir Dar City (Han and Bahir Dar health center) were included in the pilot study. These health centers had already implementing YFS. Then the single population proportion formula [35] was used considering the assumptions of the proportion of high level of fidelity, 26.7%, from the pilot study, and considering 95% CI, margin of error of 4%, design effect of 2, and 10% non-response rate. The final calculated sample size was 1,034. In addition, 11 health centers providing YFS and 27 YFS providers working in those 11 health centers were included in the study.

Sampling procedure

In Central Gondar Zone, there are 14 rural districts and one city administration. Out of the 14 rural districts, 5 districts were selected by simple random sampling technique. Then, if there are two or more health centers implementing YFS in each district, 1 health center, was chosen by random sampling. Hence, 5 health centers from the Central Gondar Zone (Amba Giorgis, Maksegnit, Kolladiba, Chuahit and Delgie) were selected and included. On the other hand, from the 8 health centers that were implementing the YFS in Gondar city administration, 6 health centers (Gondar, Azezo, Tseda, Gebriel, Woleka and Maraki) were selected randomly and included in the study. Finally, when we sum up those selected health centers (from the Central Gondar Zone (5 HCs) and Gondar City Administration (6 HCS)), a total of 11 health centers were included and considered as clusters. Within each cluster the YFS program strength, the health facility readiness and the YFS providers’ competency was assessed.

Then the sample size was proportionally allocated according to the size of the population in each health center to get representative participants in each selected health center. Finally, youths were selected by systematic random sampling technique, in all working hours of the week during the data collection period in each health center.

Data collection instrument and procedures

Data collection instrument

The instrument which has 17 general items; which measured the socio-demographic and other individual characteristics was used. In addition, a validated tool, comprised of 65 items with 5category Likert scaled items was designed to measure the fidelity of implementation of YFS. Moreover, an instrument having 73 items was used to observe and evaluate the YFS program competency. Furthermore, another instrument having 38 items was used to assess the YFS providers’ competency and lastly an instrument having 90 items was used to assess the health facility readiness. All the tools used to assess the YFS program strength, the YFS providers’ competency and the health facility readiness were adopted from the WHO standard [36].

Facility level factors are those characteristics like if the health facility has signal listing for all the YFS available or not, if the health facility had a separate discreet entrance for youth to ensure youth privacy or not, if the health facility offered YFS for free or at rates affordable to youth, if the health facility have adequate fund allocated for YFS, if the health facility had clear, written guidelines or standard operating procedures exist for YFS and the like.

To Measure the implementation fidelity of services like YFS are conceptually developed from three major constructs called adherence, quality of service delivery and participant responsiveness [37, 38]. Hence, it is vital to quantify the three main constructs that are intended to measure fidelity of YFS [37, 38]. To measure the overall fidelity of YFS, the three constructs used to measure the fidelity of YFS (adherence, quality of YFS delivery and participant responsiveness) were quantified separately. Then the overall fidelity score was computed. The 65 items scales were mainly from the WHO-Plus standard tool (quality assessment tool) [36]. The scale was developed to measure the three dimensions of fidelity i.e. adherence, quality of service delivery, and participant responsiveness. Then a fidelity score was developed for each fidelity domain, based on 5 Likert scale level. The scale passed the standard tool validation process, starting from face validity, content validity, construct validity, pilot tested and finally internal consistency was checked using the information from the pilot study. Finally, 9 items were developed to measure the participant responsiveness dimension, with high internal consistency (Cronbach’s alpha value of 0.85), 15 items were developed to measure the adherence dimension with Cronbach’s alpha value of 0.91 and 41 items were developed to measure the quality of delivery dimension, with high internal consistency having Cronbach’s alpha value of 0.93. The quality of delivery dimension was further constructed based on the Donavidian model quality of care framework, that aimed to assess the structural quality (11 items), process quality (23 items) and outcome quality dimensions (7 items).

Some of the questions used in the fidelity measure based on the three domains (adherence, quality of delivery and participant responsiveness) are described below. Questions used in the adherence domain were: Confidentiality of the service was assured for you, provider was respectful to you and the provider explained to you on all the range of available YFS there. Questions used in the quality of delivery domain were: The hours and day that you came to the facility were convenient for you, you were very clear of the information given by the provider, you are welcomed and get the YFS without appointment, and the provider encouraged you to ask any questions. Questions used in the participant responsiveness domain were: You were involved as a peer educator in YFS, you were involved in contributing to decisions about how health services should be delivered to youth clients, and you were involved in YFS service design and delivery.

In this study level of youth engagement or participant responsiveness is defined as the participation of youth in the YFS intervention in aspects like participation in the YFS design, planning and delivery, participation in the YFS as a peer educator (counselor), involvement in the YFS on decisions about how health services should be delivered to youth clients and the like.

Data were collected by an interviewer administered, predetermined and structured questionnaire. Eleven BSc holders (5 Health Officers and 6 Midwives), who had special training on YFS and working out of the data collection area, collected the data. The data collectors were not involved in the implementation of YFS in the study area. One supervisor having a master of public health and with work experience on supervision in research data collection was involved. In addition, structured interview and direct observation of the health centers were used to collect data regarding the YFS provider competency, health facility readiness and YFS program competency.

Variables of the study

In this study, the outcome variable was the fidelity of implementation of YFS, which was dichotomized in to high fidelity groups and low fidelity groups. The authors’ of this study were interested to investigate the effects of variables at two levels on the fidelity of implementation of YFS.

Level 1 variables: factors related to individual youth who utilized the YFS like; had high level of involvement in the YFS provision, knew peer educator trained on YFS, involved as a peer educator, involved in YFS service design and delivery, and level of involvement in making decision regarding your treatment was very high.

Level 2 variables: YFS program level variables were considered as level 2/context level factors which are described below. Variables like presence or absence of health facility on; signal listing YFS available, counseling area that ensured visual privacy, examination room that ensured auditory privacy, separate discreet entrance for youth to ensure their privacy, separate waiting room for youth clients, peer education program, educational posters displayed, and services provision was attractive and friendly to youth. In addition, variables like YFS provider’s age, sex, educational level, got pre-service training or not, means of capacity building training were provided, assessed using quality standard checklists, all staff were oriented to provide confidential YFS, youth clients’ privacy and confidentiality were ensured, used visual materials to help you in your daily work, and used computers to help you in your daily work were considered. Furthermore, variables like presence or absence of support and commitments that the RHBs have made towards YFS, human resource allocation adequate in terms of the volume of work, youth involved in monitoring the quality YFS, written guidelines for staff, system in place to provide continuous support to staff, policies and strategies that help youth to be involved in decision-making, written guidelines or standard operating procedures exist, the program publicize the services available to youth by stressing confidentiality, staff or volunteers who do outreach activities, and more.

Operational definitions

Fidelity of implementation: is defined as the extent to which youth get the YFS intervention as compared to the original YFS program protocol based on the three domains called adherence, quality of service delivery and participant responsiveness.

High fidelity of implementation groups: In this study, those youth who receive the YFS with total fidelity score of greater than or equal to 60%(> = 195/325) [7].

Low fidelity of implementation groups: Those youth who receive the YFS with total fidelity score below 60% (<195/325).

Data quality control

To control the data quality, three days training was provided to 11 data collectors and a supervisor before the actual data collection period. In addition, the instrument was validated (face validity, content validity, construct validity, internal consistency was high). Moreover, appropriate modifications were made on the instrument, after conducting the pilot study. The questionnaire was first translated in to the local (Amharic language) by a language and a professional experts. Furthermore, it was back translated to English language by another one language expert and one professional expert. Then, to ensure consistency, the Amharic version of the instrument was back translated in to English language by another English language expert and by another professional expert.

Statistical analysis

The collected data were manually cheeked for completeness, entered in to EpiData software version 3 and exported to STATA version 14 for further analysis. First, descriptive analyses summaries, frequency, and percentages were done on the characteristics of the study population the explanatory variables, each fidelity construct and overall fidelity score of implementations of YFS presented in terms of frequency, percentages and tables.

The unit of analysis was at an individual level and then aggregated in to the health center level in order to compare the level of fidelity of implementation in all health centers. Then individuals and facilities with total implementation fidelity scores were graded separately in to two levels. In this study, those youth whose total fidelity score of greater than or equal to 60%(> = 195/325) [7], were declared as had received the YFS intervention with high FoI, and those youth whose total fidelity score below 60%(<195/325) were declared as had received the YFS intervention with low FoI. In this study, the WHO cutoff value (> = 75%, ≥243.75/325) was not used in the data analysis and interpretation sections to declare good fidelity. The reason why we did not used the WHO cutoff value was, while we were using the WHO cutoff value, the proportion of youth who get the YFS with higher fidelity became very small, 48 (4.7%). Which made the data analysis very difficult and therefore running/fitting/ the multilevel modeling using such small proportions was impossible. Hence, we reviewed the available evidence and used 60% as a cut off value. Finally, the individual level and health facility level data sets were merged and linked for analysis using the STATA merge command.

A two-level multivariable multilevel logistic regression analysis was applied with fitting four different models. The rationales for using a multilevel modeling were the following. Firstly, the FoI patterns YFS are influenced by the characteristics of different levels (individuals and contextual factors like YFS program, YFS providers and health facilities). Analyzing variables from different levels at one single common level using the standard binary logistic regression model leads to bias (loss of power or Type I error) [39, 40]. This approach also suffers from a problem of analysis at the inappropriate level (atomistic or ecological fallacy). Multilevel models allow us to consider the individual level and the group level in the same analysis, rather than having to choose one or the other. Secondly, due to the multistage cluster sampling procedure, individual youth were nested within health centers; hence, the likelihood of youth seeking YFS is likely to be correlated to the health care providers, facilities, accessibility and availability. The assumption of independence among individuals within the same cluster and the assumption of equal variance across clusters are violated in the case of nested data. Hence, the multilevel analysis is the appropriate method for such cases [39, 40].

In this study, the following equation elaborates the multilevel analysis for FoI of YFS, the link function is logit, and we get the logistic regression model as:

Where, πij is probability of the presence of High FoI of YFS, (1- πij) is probability low FoI of YFS, β is log odds of the intercept, β … β are effect sizes of individual and health center level factors, X… X are independent variables of individuals and HCs, u are random errors at cluster level, and e show random errors at individual level. The distribution of u is normal with mean 0 and variance σ2u0, the random effect was explained using ICC, which was calculated using between-cluster variance and within-cluster variance [ICC = δ2u0/δ2u0+π2/3], in log distribution, the residual variance of FoI of YFS within a cluster is zero but variance is considered constant at π2/3(where, π2/3 denotes the variation within a cluster and δ2u0 is the variation between clusters. The ICC was used to show the level of between-cluster variation and finally we used the Variance Inflator Factor (VIF) to examine instability of effect size of predictors as the result of high collinearity among the factors.

Steps in multi-level modelling

Screening for determinants at level one and level two for FoI of YFS was done by conducting bivariable logistic regression analysis separately. Then factors having p-value of <0.2 in the Bivariable model were selected and fitted in to the Multi-level modeling [41]. Then four separate models were fitted to reach the full model. First the null model (model I), contained no exposure variables was run which was used to test the random effect of between and within-cluster variability by determining the Intra-Cluster Correlation (ICC). Then model II that was adjusted for individual-level variables, with the fixed level one determinant with randomly varying intercepts. The effects of individual level characteristics on FoI of YFS were determined. Next, Model III was adjusted for level two determinants with randomly varying intercepts. Finally, model IV (full model), adjusted for both individual and contextual level variables, and with fixed level 1 and level 2 predictors with randomly varying intercepts and slope were fitted. The important characteristics of individual youth and clusters were concurrently fitted to one model to reveal their net fixed and random effects.

Statistically significance association was declared using two-tailed test and at p-values less than 0.05. The results of fixed effects were presented as adjusted odds ratio (AOR) at their 95% confidence interval (95% CI) after considering potential confounders. Random effects were expressed in terms of Intra Class Correlation Coefficient (ICC) that explains the amount of health center variation. The clustered nature of the data, and the within and between health center variations were taken in to account by assuming each health canter has different intercept (β0) and fixed coefficient (β). Proportional Change in Variance (PCV), expresses the change in the community level variance between Model-I (empty model) and the consecutive models (Model-II, III and IV) [42].

Model fitness and precision

The fitness of the model was assessed using Akaike Information Criterion (AIC), AIC was used to choose a model that best explains the data and the model with low AIC value was taken [43]. A test of how well the model explains the data (goodness of fit test) was checked by using Hosmer-Lemshow statistics and it was non-significant (prob> chi2 = 0.1270), indicating the model fits the data reasonably well. The multicollinearity (correlation of predictors with each other) was checked by using variance inflation factors (VIF) and no variable had VIF greater than 10 as a cut off value, indicated the absence of significant collinearity among explanatory variables [44]. Two-tailed Wald test at significance level of alpha equal to 5% was used to determine the statistical significance of the determinants and all the analyses were performed with Stata SE 14 software package.

Five variables from the individual level variables, and 19 variables from the higher level variables that fulfilled the screening criteria were selected and fitted in to the multi-level modeling. In summary, a total of 24 variables from individual and contextual level factors were fitted in to the multi-level model.

Ethical considerations

Ethical clearance was obtained from the University of Gondar, Institutional Review Board (IRB) with reference number, R. no.-O/V/P/RCS/05/1047/2019. Official permission was obtained from respective Zonal and local authorities to cascade data collection. Informed and written consent was sought from each study participant. In addition, for those respondents of age below 18 years individual assent and parental consent was obtained. Moreover, confidentiality was maintained through anonymity and privacy measures to protect respondent’s right through the research process. Moreover, respondents were informed about their right to withdraw from the study at any time and they could not be harmed by doing so.

Results

Socio-demographic and other characteristics of the youth

Of the total 1034 youths, 1,029 (99.5%) responded to the survey. The majority of the respondents 717(69.7%) were aged between 20–24 years, while 752(73.1%) were females. Regarding their religion, 874(84.9%), were Orthodox Christians, while 781(75.9%) were urban residents. Concerning their educational status, 453(44.0%) of them were attending secondary education (grade 9–12), and 601(58.4%) were not married ().

Characteristics of the YFS providers

A total of 27 health care providers working on YFS in the 11 health centers were included in the study. Males accounted 15(55.6%), while 22(81.5%) had pre-service training on YFS. Regarding their profession, 12(44.4%) were clinical nurses at diploma level, 13(48.2%) were BSc nurses and 2(7.4%) were BSc health officers. Twenty (74.1%) of the services providers used the National Adolescents and Youth Reproductive Health Services Strategy as a reference, while 8(29.6%) were supervised by higher officials, who were using the national YFS quality standard checklist (

The level of implementation fidelity and respondents’ level of engagement on Youth-Friendly Services intervention

The results of the fidelity of implementation of YFS showed that 401(39.0%) of youths got the YFS with high level of FoI. Four hundred fifty five (44.2%) of the respondents were involved in decision-making regarding the YFS, while 341(33.3%) had high overall level of engagement in the provision of YFS. Two hundred eighty six (27.8%) of them were involved as a peer educator in the YFS, and 212(20.6%) were involved in YFS service design and delivery (

Health facility and Youth-Friendly Services program level characteristics

Five out of the eleven health centers had signal listing YFS available, while 6/11 had a separate discreet entrance for youth to ensure their privacy. Six out of the health centers had counseling area that provided for visual privacy, while 7/11 offered YFS for free or at affordable rates to youth. Three out of the eleven health centers had peer education program available, while 8/11 had educational posters displayed in the health center (

Regarding the YFS program level characteristics, 4/11 health centers got support from the regional health bureau, while 5/11 had adequate fund allocated for the YFS. Eight out of eleven health centers had written guidelines for the staff (who were providing the YFS in the HC), while 7/11 of the HCs had system in place to provide continuous support to staff who work on the YFS. Eight out of the eleven HCs had clearly written guidelines or standard operating procedures (SOPs) in the YFS room, while 5/11 HCs had private registration process (

Determinants of implementation fidelity of Youth-Friendly Services

The multilevel analysis was started by the intercept only model, to test the null hypothesis, that stated there is no variation in FoI of YFS between clusters (HCs) and to decide in evaluation of the random effects at the health facility level. The results presented in Table 4 indicated that considerable heterogeneity between health facilities was observed for each indicator of FoI of YFS. In all the three indicators, FoI of YFS was clustered significantly by HC. The intra-class correlation in the empty model for FoI of YFS indicated that 16.4% of the total variance in FoI of YFS was attributable to the differences across HCs (.

Table 4

The health facility and YFS program level characteristics on YFS, Northwest Ethiopia, 2019.

Characteristics	Responses
	Frequency
The counseling area kept visual privacy
Yes	6/11
No	5/11
The examination room kept auditory privacy
Yes	6/11
No	5/11
There was a separate entrance to ensure youth privacy
Yes	6/11
There was a transparent and confidential system to submit youths’ comments
Yes	4/11
No	7/11
There was a separate waiting room for youth
Yes	4/11
No	7/11
There was adequate waiting room for youth
Yes	5/11
No	6/11
There were educational posters displayed
Yes	8/11
No	3/11
There were posters that describe clients’ rights
Yes	8/11
No	3/11
There were materials for youth clients to take home
Yes	8/11
No	3/11
Service provision was attractive and friendly to youth
Yes	7/11
No	4/11
System in place to provide continuous support to YFS staff
Yes	7/11
No	4/11
Clear, written guidelines or SOPs exist in the YFS
Yes	8/11
No	3/11

Individual level effects

The final Multi level modeling analysis result showed that from the individual level factors, factors like youth who had high overall level of involvement in the provision of YFS (AOR = 1.35, 95%CI: 1.15, 1.57), youth who knew any peer educator there trained in YFS (AOR = 1.60, 95%CI: 1.36, 1.86), and youth who were involved as a peer educator in YFS (AOR = 1.46, 95% CI:1.24, 1.71), were statistically significant determinants of the FoI of YFS. The odds of getting the YFS with fidelity was nearly 1.4 times higher among youth who had high overall level of involvement in the provision of YFS as compared to those who had not with (AOR = 1.35, 95%CI:1.15, 1.57). The odds of getting the YFS with fidelity was 1.6 times higher among those youth who knew any peer educator there trained in YFS as compared to those who did not know with AOR 1.60, 95%CI(1.36, 1.86). The odds of getting the YFS with fidelity was nearly 1.5 times higher among youth who have been involved as a peer educator in YFS as compared to those youth who were not involved as peer educator with AOR 1.46, 95% CI(1.24, 1.71) ().

Contextual-level effects

Factors like health care providers who got capacity building training AOR 1.93, 95% CI(1.12, 3.48), health care providers who got supportive supervision, AOR 2.85, 95% CI (1.99, 6.37), health facilities that had separate waiting room for youth AOR 9.84, 95%CI (2.14,17.79), and health facilities that established system in place to provide continuous support to staff AOR 2.81, 95%CI(1.25, 6.34) were statistically significant determinants of FoI of the YFS ().

The odds of getting the YFS with fidelity was nearly two times higher among those youth who were served by health care providers who got capacity building training as compared to their counter parts with AOR 1.93, 95% CI(1.12, 3.48). The odds of getting the YFS with fidelity was almost three times higher among those youth who were served by health care providers who got supportive supervision as compared to those youth who had not got supportive supervision with AOR 2.85, 95% CI (1.99, 6.37). The odds of getting the YFS with fidelity was nearly ten times more among those youth who were served from health facilities that had separate waiting room for youth AOR 9.84, 95%CI (2.14,17.79), as compared to those youth who were served from health facilities that had no separate waiting room. The odds of getting the YFS with fidelity was nearly three times higher among those youth who were served from health facilities that already established system in place to provide continuous support to the YFS staff as compared to those who were not with AOR 2.81, 95%CI(1.25, 6.34) ().

Discussion

The findings of the study showed that level of implementation fidelity remains low; both individual level and contextual level determinants affect the implementation fidelity of YFS. The analysis indicated that FoI of YFS among individual youth depends on the joint effect of individual, health care provider and facility characteristics.

At the individual level variables like youth who had high overall involvement in the provision of YFS, youth who know the presence of trained peer educator in the area and youth who have been involved as a peer educator in YFS were found to be with the main determinants of FoI of YFS. At the contextual level, variables related to YFS providers and YFS program related characteristics were found to be much more relevant for FoI of YFS. A strong facility level determinant for FoI of YFS was related to the provision of capacity building/training to the YFS health care providers.

According to the intra-class correlation results, the contribution of unobserved health facility level characteristics was 16.4%. In all the three intercept-only models, the contributions were significant and indicated that determining association without the control of variables at different levels would give a misleading result. This was also observed during analysis where many of the significant associations disappeared when the effect of clustering by health center was controlled. Previous studies based on a similar analysis showed consistent findings [45].

The first individual level variable which is a strong determinant factor for FoI of YFS was related to youth over all involvement in the YFS provision. The odd of getting the YFS with fidelity is 1.4 times higher among those youth who had high overall involvement in the provision of YFS as compared to those who had not. This finding is supported by a theory developed by Christopher Carroll et al., they verified that as participants involved more in the provision of an intervention the possibility of getting the intervention with fidelity will increase [13]. In addition, the National Adolescent and Youth health strategy also documented as establishing supporting and facilitating youth engagement and ownership of health programs like YFS is an enabling condition to deliver the YFS with high fidelity [3]. Involvement of the youth in the day-to-day planning and running of activities, including monitoring of services ensures the services are of good quality and acceptable to the youth. When the youth perceive the services to be acceptable, they are most likely to refer the said services to their colleagues and peers [4]. The possible explanation could be as youth are involved more in the provision of interventions like YFS, they have already belonged to the YFS providers and they may ask any services they demand, they may have a better communication, better knowledge on the available services and hence better chance of getting the intervention with fidelity [13]. This implied that involving youth in the YFS intervention is crucial in order to increase the fidelity of implementation of the intervention.

The second individual level factor that affects the implementation fidelity of YFS was related to youth knowledge on the presence of trained peer educator in the area. The odds of getting the YFS with fidelity is 1.6 times higher among those youth who know any peer educator there trained in YFS as compared to those who did not know. This finding is in agreement with a study conducted in Kenya [46], where the study showed that over all youth knowledge on SRH as the main enabler to YFS uptake by youth. In addition, the finding is supported by another study conducted in Myanmar [47], where youth who had better knowledge on SRH including the presence of trained youth in YFS has increased the uptake of YFS. The possible justification could be those youth who already know trained peer educators in the area can have a better chance to discuss with the trained peer on how to communicate with the YFS provider and hence get the intervention with fidelity. Besides, those youth who know peer educators may have a possibility to go to the health facility accompanied with those peer educators so that the peer educator can facilitate the provision of the YFS intervention so that they can get the YFS with high fidelity. Furthermore, as adolescents preferred peer educators as a source of sexual and reproductive information since they considered them knowledgeable and trustworthy [46, 47].

The third individual level variable that was found to be a strong determinant factor for FoI of YFS was related to presence of youth involvement as a peer educator in YFS. The odd of getting the YFS with fidelity is one and half times higher among youth who have been involved as a peer educator in YFS as compared to those youth who were not involved. This finding is supported by the general theoretical frame work developed by Christopher Carroll et al. [13] where participants involvement including youth is mentioned as the main individual level variable that affects the implementation fidelity of interventions. Similarly, this finding is supported by a study conducted in Awabel district, where in the study youth who were participated a peer educators had a higher chance of SRH service utilization [48]. The possible justification could be the more enthusiastic participants are about an intervention, the most likely they get the intervention with a better fidelity [13]. In addition, as young people engaged in SRH peer education; they would have a better understanding and their need for the service and getting the service with high fidelity might increase too [13].

The odds of getting the YFS with fidelity is nearly two times higher among those youth who were served by health care providers who had got capacity building training as compared to their counter parts. This result is supported by the finding of a review article, where capacity building trainings are critical for ensuring retention of the YFS providers’ knowledge and skills up to date and hence help them provide the YFS with higher fidelity [49]. Besides this finding is in line with a study conducted in New Mexico and Bahaman where provision of capacity building training to intervention providers was identified as a factor that increased the implementation fidelity of evidence-based practices for integrated treatment in behavioral health agencies [50, 51]. The possible explanation could be providing capacity building training to the intervention providers is one of the possible motivation factor that could help intervention providers develop more confidence and hence provide the intervention with a higher fidelity [22]. In addition, those providers who get training can have a better knowledge and technical skills on the provision of a specific intervention with a higher fidelity, since they can easily adhere to the intervention protocol [22].

Another strong facility level determinant for FoI of YFS was related to presence of supportive supervision to YFS providers’. The odds of getting the YFS with high implementation fidelity is almost three times higher among those youth who were served by health care providers who have got supportive supervision as compared to those youth who had not. This finding is in agreement with a review research and a study conducted in Addis Ababa that showed program implementation fidelity is clearly predicted by the level of supportive supervision provided to the organizational staff [12, 52]. The possible justification could be as program implementers get technical assistance including the training of program facilitators and program administrators, program evaluation and feedback, program monitoring, and coaching the providers will get more skills; hence the possibility of providing the intervention with fidelity increases [53].

The odds of getting the YFS with fidelity is nearly ten times more among those youth served from health facilities that had a separate waiting room for youth as compared to those youth served from health facilities that had no separate waiting room. This finding is supported by a study conducted in USA where those youth who were served by health facilities that had a separate waiting room showed a better care on retention among HIV-infected youth [54]. Besides, this finding is in line with the WHO quality assessment standard [36] that stated as the presence of separate waiting room for the YFS will enhance the intervention delivery with a better fidelity. The possible explanation could be, usually waiting rooms for youth are equipped with many educational materials like visual and audio, leaf lets, TV, posters and even peer educators there. Hence, youth in the waiting area have a better information on the YFS services available, how to approach the YFS provider and the like [36]. In addition, separate waiting rooms allow youth to be kept from visual and auditory privacy from adult clients and that may increase youth confidence on seeking the YFS and hence all the above may contribute to get the YFS with fidelity [36, 54].

The last strong facility level determinant for FoI of YFS was related to the presence of already established system to provide continuous support to staff who works on YFS. The odds of getting the YFS with fidelity was nearly three times higher among those youth who were served from health facilities that already had established system in place to provide continuous support to staff who work with young clients as compared to those who were not. This finding is similar with a study conducted in New Mexico, where the presence of continuous organizational support to the staff has an influence to the intervention to be implemented with a higher fidelity [50]. Besides, this finding is in line with a study conducted in USA that was intended to evaluate the efforts to increase implementation of evidence-based clinical practices to improve adolescent-friendly reproductive health services [55], where by support from health center leadership, communication between leadership and staff, were reported as factors that facilitated the implementation of new practices [55]. The possible reason could be establishing a system to provide continuous support to staff may motivate and increase commitment of the staff to implement the intervention with a higher fidelity [3, 56].

The results of the study implied that efforts to build systems that apply the policy and principles of implementation fidelity of YFS in the health facilities are crucial. These initiatives will not only benefit youth but the health system overall, as the principles for implementation fidelity of the National Adolescent and Youth Health Strategy are in step with those of YFS to be delivered with a high level of adherence, quality of delivery and youth engagement [3]. Another implication of the study finding is considering high levels of implementation fidelity of YFS is essential to avert the SRH problems among youth, in addition to the YFS scale up. Furthermore, investing in effective interventions (like YFS), is important to improve its implementation fidelity. There is a need to strengthen the YFS to be delivered with a high level of fidelity to achieve the desired intervention outcomes.

The findings of the study have some policy implications in that, while designing the YFS by considering on both individual and contextual level factors if important to strengthen and provide the YFS with high fidelity if implementation. In addition, the findings also has some practical implications, in that while providing the YFS intervention for youth it is vital to consider the youth involvement in the planning and provision of YFS. Another practical implication is considering contextual level factors like the YFS program level characteristics, the YFS provider and the health facility environment had paramount important.

Limitations

The study was not triangulated with a qualitative design, which could probably explore in-depth reasons for the low level of fidelity of implementation of YFS. Besides, the measure of Fidelity of implementation of YFS was from youth perspectives, which means, the study did not consider the providers’ perspective and direct observation. Hence, some fidelity items that should be filled by the providers were not considered.

Conclusions

In this study, the level of implementation fidelity remains low. Both individual and contextual level factors are found independent determinants on the FoI of YFS. High overall involvement in the provision of YFS, youths knowledge on the presence of trained peer educator in the area, have been involved as a peer educator in YFS, health care providers who had got capacity building training, health care providers who have got supportive supervision, health facilities that have a separate waiting area for youth clients and health facilities that already established system in place to provide continuous support to staff who work on YFS were predictors of FoI of YFS. Therefore, policy makers, partners, planners, managers and YFS providers could consider both individual and contextual level factors to improve the implementation fidelity of YFS.

12 Aug 2021

PONE-D-21-19080

Individual and Contextual Factors affect the Implementation Fidelity of Youth-Friendly Services, northwest Ethiopia: a Multilevel Analysis

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Additional Editor Comments:

Thank you for submitting this interesting assessment of fidelity on the implementation of youth services. The major comments on this manuscript are on the method section as indicated by the two reviewers. It is great that you utilised a tool that has been recommended by WHO to assessment tool. However, in the analysis and interoperation of the results you did not follow those guidelines (according to ref 36) - WHO: Quality Assessment Guidebook. A guide to assessing health services for adolescent clients. 2009.

Please explain in the methods section why you did not follow these guidelines on data analysis and interpretation. For example you utilised 60% as a good level of fidelity based on a different article instead of the quality assessment guidebook recommendations.

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Reviewer #2: Yes

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Reviewer #2: Yes

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Reviewer #1: This is a very interesting and important piece of work so well done for putting in the effort. There is however room for improvement and clarification needed particularly in the methodology section. My concerns are as follows;

Line 87-89: Under your rationale you mention that the undertaking of the study would uncover evidences related to IFidelity of the program. In what way would that happen? what evidences are you talking about?

Line 100-101; Reword the section, make it clear that you were assessing determinants on two levels; individual & program level and be consistent throughout the paper. My understanding is that characteristic of program and provider information fall under "Program level" please be clear.

You mention the assessment of readiness and competencies as well in your methodology, how do these tie in with your objectives. It seems to me you are dealing with too many constructs.

Line 118-120: Please clarify how you got from the 8 Health centres to 11 health centres. This comment is tied in with your sampling procedure. My suggestion is you reword it in a logical sequence so one is clear how you got to the 11 centers.

Calrify also what is "lottery method?" is this the same as random sampling?

You have too many variables, i suggest you categories into the two levels you are assessing and be consistent.

Line 393, this section on determinants of IF sounds like it should go into the analysis section.

Check your tenses and grammar under your results.

The discussion is clear and well written. All the best with your revisions.

Reviewer #2: Review (Manuscript: PONE-D-21-19080)

August 05, 2021

This is a good paper for the field of implementation science. Youth-friendly service programs (YFS) are a fantastic way to link and retain youth in care services. Given the broad implementation of the YFS program in parts of Ethiopia (as noted by the authors), this research is necessary to the field. Overall, the approach to assessing fidelity I also think is valuable. However, there were some points in the manuscript that confused me as a reader. To use the Carroll et al. (2007) study you cited, implementation fidelity is focused on the degree to which an intervention is delivered as intended. In my view, an evaluation of implementation will be focused on the health facility and the providers. This is not to say that clients (i.e., youth, adolescents, etc.) cannot evaluate fidelity, but that their role in measuring the success of the intervention is different.

And this is where I came off confused. You, the authors, are looking at the fidelity of implementation, and your focus appears to be clients, those youth who seek care services from the facilities in Gondar, Ethiopia. And you don’t do a good job explaining why this became your target population. Typically, the clients (i.e., youth) will be used to assess adherence to the intervention. Then, for example, a high adherence becomes an indicator of the success of implementation.

See below for more specific comments about different sections of the manuscript.

Introduction

Line 78, I think you meant to write fidelity of implementation and not “fidelity f implementation”

I may be misunderstanding the manuscript, but why is the question of fidelity being posed to youth? Who is the target population? Fidelity would seem to be an issue for the program implementers and providers. The providers and program implementation team would be the ones to assess whether providers delivered YFS as it was designed.

The question for the youth would be one of adherence. The success of YFS for youth would be whether they came for services and continued to come for services for the length of the program can be given a better assessment of w

Methods

The section on instrument development is a bit long, with considerable repetition. For example, you mention that aspects of the final instrument were adapted from the WHO standard on Line 163 and 216. Consider shortening this section, given that you are interested in one component of the instrument, which is fidelity. It would help if you also considered writing a manuscript on the instrument development or the study protocol. The development of the instrument is itself an interesting process with worthwhile contributions to the literature.

What are some examples of questions used in the fidelity component of the instrument?

It is not clear why the study (or the part of the study reported in this manuscript) has both youth and providers as the study population. Specifically, was the instrument given to providers the same as the instrument given to the youth participants? Why is that? Providers would have a different perspective on issues around fidelity; I would expect you to look to capture those differences.

And again, if it is the fidelity of implementation, why do you need the perspective of the youth. I don’t imagine that the youth, who are clients of these health care facilities, would have a significant say in how a program is implemented. Or at least they would have a lesser say compared to providers.

How was fidelity understood and defined by the authors? Reading the manuscript, I feel you assume your readers have the same understanding of fidelity as you do. For example, in the methods the items used to capture fidelity, what domains do they cover. You mention that it is based on an existing instrument used by the WHO. But what aspects/constructs of fidelity does it cover?

Results

You report youth and health care providers together in Table 01; should that not be separated? The factors that impact providers when it comes to the question of fidelity I imagine, are distinct.

Table 02 and Table 03 cover issues that are not discussed in the methods section. That is level of youth engagement and facility-level factors are not evident in the methods. For table 02, in particular, what is meant by the level of engagement?

Table 02 could be made more clear if you categorized the engagement levels. When I reference Table 05, it is clear that the levels of engagement form part of the independent variables in your multi-level model. So, for example, if model II was adjusted for individual-level variables, then have Table 02 show this so that your readers can better connect Table 02 and Table 05.

Consider shortening the Items/ variable names in Tables 02, 03, and 05; it makes the tables clunky and challenging to read.

Discussion

Is there a reason you reference implementation in education and not the implementation in health care to support your point here? It is not wrong, but I think your argument would be stronger if you found implementation studies in the health sector and the sexual health field specifically to support notions of fidelity of implementation (Lines 512 - 514).

So, what are the practice implications of your study findings? YFS programs are demonstrated in the literature to be effective and successful ( I think several clinical studies bear this out). The question then is the state of fidelity of implementation in Gandor, Ethiopia, and more importantly, what would the iteration and scale-up of YFS programs in Ethiopia look like, given your analysis data? I think this should be a significant focus of your discussion. Ethiopia has already begun implementing YFS programs, so what will need to change to enhance fidelity in light of the results?

Limitation

You may wish to say a bit more regarding the limitations of the study. What do the survey items on fidelity leave out when it comes to understanding implementation?

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Reviewer #1: No

Reviewer #2: No

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Submitted filename: Review - PONE-D-21-19080.docx

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22 Sep 2021

Point by point response to Editor’s comments

Thanks a lot dear Editor, for the efforts and support you made to improve our manuscript. In the table below, we write the Editor comment in column 1, the Author responses in column 2 and page/line numbers in column 3 to show the changes we made in the revised clean manuscript.

Editor’s Comments Authors’ responses Page and line #, R(Implies Authors' responses), C (Implied Editor's or reviewers' Comment )

C: Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

R: We thank the Editor for providing the chance to review and submit the revised manuscript. We have tried to address almost all of the points raised by you and the two reviewers. -

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

R: Thanks again. We have cheeked the manuscript to meet the PLOS ONE’s style requirements including the file naming. -

2. We note that the grant information you provided in the ‘Funding Information’ and ‘Financial Disclosure’ sections do not match.

When you resubmit, please ensure that you provide the correct grant numbers for the awards you received for your study in the ‘Funding Information’ section.

R: Dear editor, we ask an excuse for the information mismatch provided in the ‘Funding Information’ and ‘Financial Disclosure’ sections on the grant information.

Now we have included the correct grant numbers for the awards we received from the University of Gondar in the Funding Information Section.

“The University of Gondar provided the grant with the grant number:

No: Res/Com/Serv/Vice/Pres/05/1203/2011 -

3. Thank you for stating the following financial disclosure:

R: This research was conducted as an academic research contribution. The University of Gondar covered the costs for the data collection procedures. Otherwise, the authors received no specific funding for this work.

Please state what role the funders took in the study. If the funders had no role, please state: "The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript."

If this statement is not correct you must amend it as needed.

Please include this amended Role of Funder statement in your cover letter; we will change the online submission form on your behalf.

R: Thanks again dear editor for asking further clarity.

The funder/The University of Gondar/ has no role in the study design, data collection and analysis, decision to publish or preparation of the manuscript.

We have incorporated this statement as “The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript”, in the cover letter. -

Additional Editor Comments:

C: Thank you for submitting this interesting assessment of fidelity on the implementation of youth services. The major comments on this manuscript are on the method section as indicated by the two reviewers. It is great that you utilised a tool that has been recommended by WHO to assessment tool. However, in the analysis and interoperation of the results you did not follow those guidelines (according to ref 36) - WHO: Quality Assessment Guidebook. A guide to assessing health services for adolescent clients. 2009.

Please explain in the methods section why you did not follow these guidelines on data analysis and interpretation. For example you utilised 60% as a good level of fidelity based on a different article instead of the quality assessment guidebook recommendations.

R: Thanks again for your appreciation of the manuscript.

The major comments provided by the two reviewers on the methods section of the manuscript are addressed in the revised version.

Dear editor, you are right. We utilized the WHO quality assessment tool to generate most of the questions used to measure fidelity. However, we did not use the WHO cutoff value (>=75%) in the data analysis and interpretation sections. The reason why we did not use the WHO cutoff value was, while we were using the WHO cutoff value the proportion of youth who get the YFS with higher fidelity became very small(4.7%), and it was very difficult to run/fit/ the multilevel modeling due to small proportion of youth get the YFS with good fidelity. Hence, we have to review the available evidence and use 60% as a cut off value.

We have included the reasons why we used 60% cutoff value instead of using the WHO cutoff value in the methods section of the revised manuscript as:

“In this study, the WHO cutoff value (>=75%, ≥243.75/325) was not used in the data analysis and interpretation sections to declare good fidelity. The reason why we did not used the WHO cutoff value was, while we were using the WHO cutoff value, the proportion of youth who get the YFS with higher fidelity became very small, 48 (4.7%). Which made the data analysis very difficult and therefore running/fitting/ the multilevel modeling using such small proportions was impossible. Hence, we reviewed the available evidence and used 60% as a cut off value.” Page 13 Line 264-270

Point by point response to Reviewer one

R: First of all, we want to appreciate reviewer #1 for evaluating our manuscript and providing these constructive comments that potentially improve the revised manuscript to be accepted for publication. We have tried to incorporate almost all the comments and suggestions made by the reviewer. The reviewer comments (column 1), the author responses (column 2) and the place where the changes we made in the revised manuscript are described in column 3 of the table below.

Reviewer # 1 Comments Author responses Page/Line #

C: This is a very interesting and important piece of work so well done for putting in the effort. There is however room for improvement and clarification needed particularly in the methodology section. My concerns are as follows;

R: Thanks a lot, dear reviewer for providing your immense appreciation for our work and the efforts we made.

Again we recognized your requests for some clarifications and concerns, which will help for the improvement of the manuscript. We have tried to address all of your concerns and comments you raised especially in the methodology section. -

C: Line 87-89: Under your rationale you mention that the undertaking of the study would uncover evidences related to IFidelity of the program. In what way would that happen? what evidences are you talking about?

R: Thanks for requesting further clarification for the evidences that this study tried to uncover.

The determinants of Fidelity of Implementation (FoI) of interventions (like YFS) are usually not clear unless otherwise investigations are made. There is no previous study conducted to uncover or show the determinants of FoI of YFS. Other evidences from similar interventions showed the determinants of FoI are related to the program or to the clients’ side. In this case, we used the term ‘the evidences’ to mean ‘the determinants’. Hence, this study was conducted to verify the determinants of FoI of YFS that could arise from (related to) the program side or from the user side. To verify those determinants we employed an advanced statistical modeling named as the multi-level modeling approach that helped us to clearly verify the determinants by considering program and individual levels.

To make it clear for the reader we amended the statement as: “Investigating the determinants of FoI of YFS using the multilevel perspective is very important, in that, it will uncover evidences related to the determinants of implementation fidelity of YFS.”; and included in the revised manuscript. Page 5 Line 88-90

C: Line 100-101; Reword the section, make it clear that you were assessing determinants on two levels; individual & program level and be consistent throughout the paper. My understanding is that characteristic of program and provider information fall under "Program level" please be clear.

R: We appreciated the reviewer for providing such constructive suggestions.

You are right dear reviewer! Program and provider-level characteristics fall under the program-level characteristics. Based on your suggestions we made changes in the whole manuscript. We put program and provider information into program level determinants. Page 5 Line 100-101

C: You mention the assessment of readiness and competencies as well in your methodology, how do these tie in with your objectives. It seems to me you are dealing with too many constructs.

R: Yes, you are correct dear reviewer. We have assessed the health centers level of readiness to provide the YFS by using the WHO standard checklist. Unfortunately, we did not get any determinant factor that affected the FoI of YFS from the health center level of readiness side. Besides, we also employed a separate checklist (that was also adopted from the WHO standard checklist) which was intended to assess the level of YFS providers’ competency in the provision of YFS. Similarly, we did not get any determinant in this construct.

The study objective was to assess the determinants of FoI of YFS using the Multilevel perspective by considering many constructs that are described in the paper.

Really we employed many constructs to deal with the potential determinants of FoI of YFS in this study. -

C: Line 118-120: Please clarify how you got from the 8 Health centres to 11 health centres. This comment is tied in with your sampling procedure. My suggestion is you reword it in a logical sequence so one is clear how you got to the 11 centers.

Calrify also what is "lottery method?" is this the same as random sampling?

R: We ask an apology for the confusion we imposed on the procedure we wrote for the selection of the health centers. The 11 Health centers, which were included in the study, were selected from two areas. The two areas are the Central Gondar Zone administration and the Gondar City administration. Gondar city administration (located at the center of Central Gondar Zone administration) is the capital city of the Central Gondar Zone administration.

The five health centers were selected randomly from the health centers that were found under the Central Gondar Zonal administration and that were implementing the YFS. On the other hand, the 6 health centers were selected from the available health centers that were implementing the YFS in Gondar city administration.

The sampling procedure is rephrased logically and included in the revised manuscript as:

“In Central Gondar Zone, there are 14 rural districts and one city administration. Out of the 14 rural districts, 5 districts were selected by simple random sampling technique. Then, if there are two or more health centers implementing YFS in each district, 1 health center, was chosen by random sampling. Hence, 5 health centers from the Central Gondar Zone (Amba Giorgis, Maksegnit, Kolladiba, Chuahit and Delgie) were selected and included. On the other hand, from the 8 health centers that were implementing the YFS in Gondar city administration, 6 health centers (Gondar, Azezo, Tseda, Gebriel, Woleka and Maraki) were selected randomly and included in the study. Finally, when we sum up those selected health centers (from the Central Gondar Zone (5 HCs) and Gondar City Administration (6 HCS)), a total of 11 health centers were included and considered as clusters. Within each cluster, the YFS program strength, the health facility readiness and the YFS providers’ competency was assessed.”

R: In this study “lottery method” is the same as “random sampling”. To make it clear for the reader we replaced the phrase “lottery method” with “random sampling” in the revised manuscript. Page 7 Line 140-151, Page 7 Line 143-144

C: You have too many variables, i suggest you categories into the two levels you are assessing and be consistent.

R: We accepted the reviewer suggestions.

Now we have categorized the variables into two levels and revised the manuscript based on the reviewer suggestions. Page 10 Line 215-218, Page 11 Line 219-234

C: Line 393, this section on determinants of IF sounds like it should go into the analysis section.

R: Dear reviewer, the section you stated on the determinants of IF seam sounds like it should go into the analysis section. However, the issue you raised here is a bit different. The analysis section of the manuscript (in the methods part) described the overall data analysis plan, where the authors of the manuscript plan ahead of the actual data collection period. On the other hand, what we wrote in Line 393 supported by Table 5 (in the results section of the manuscript), included the actual multilevel analysis results, which were described by showing each step with its subsequent findings while we run the Multilevel modeling. We believe that this is the appropriate place to show (describe) the steps and the results of the multilevel analysis in the results section.

Most papers published (that employed the multilevel model) also put or described this findings (in the results section) (e.g., Ayal Debie et al., 2020, Negero et al., 2018, Worku et al., 2021., etc… ). -

C: Check your tenses and grammar under your results.

R: Comment accepted. We have cheeked and revised the tenses and grammar under the results section. Page 17 Line 349-357, Page 18 Line 358-367, Page 19 Line 370-378,

Page 20 Line 382-393, Page 22 Line 405-422, Page 23 Line 423-444, Page 24 Line 445-449

C: The discussion is clear and well written. All the best with your revisions.

R: Thanks for the interest and commitment you made to review the whole paper, provide constructive comments and evaluate the whole manuscript.

Again thanks a lot dear reviewer, for the best wishes you forwarded to us! -

Point by point response to Reviewer Two

R: First of all, we want to appreciate reviewer #2 for evaluating our manuscript and providing these constructive comments that potentially improve the revised manuscript and make it to be accepted for publication. We have tried to address most of the comments and suggestions made by the reviewer. The reviewer comments (column 1), the author responses (column 2) and the place where the changes we made in the revised manuscript are described in column 3 of the table below.

Reviewer #2 Comments Author responses Page/Line #

C: This is a good paper for the field of implementation science. Youth-friendly service programs (YFS) are a fantastic way to link and retain youth in care services. Given the broad implementation of the YFS program in parts of Ethiopia (as noted by the authors), this research is necessary to the field. Overall, the approach to assessing fidelity I also think is valuable. However, there were some points in the manuscript that confused me as a reader. To use the Carroll et al. (2007) study you cited, implementation fidelity is focused on the degree to which an intervention is delivered as intended. In my view, an evaluation of implementation will be focused on the health facility and the providers. This is not to say that clients (i.e., youth, adolescents, etc.) cannot evaluate fidelity, but that their role in measuring the success of the intervention is different.

R: Thanks a lot, dear reviewer for your appreciation of the manuscript.

Dear reviewer, as you have mentioned implementation fidelity is measured by using different perspectives (study population) ((Fixsen, D. L., Van Dyke, M. K., & Blase, K. A. (2019). Implementation methods and measures. Chapel Hill, NC: Active Implementation Research Network)).

Some authors use the health facility and providers’ responses to evaluate the implementation fidelity of interventions. Others use direct observation to evaluate the implementation fidelity. Still, some researchers use a camera or audio recording to measure implementation fidelity (Elaine Toomey et al., 2017). Furthermore, many scholars use service users’/clients’ responses to evaluate the implementation fidelity of interventions (Silvia Escribano et al., Spain, 2016, Lisha et al., 2012).

During the design stage of the current study, we (the authors of this manuscript) made arguments to select the best method (study population) to evaluate the implementation fidelity of the YFS. Pieces of evidence showed using the service providers as a source for measuring implementation fidelity showed inflated results (eg., Sarah K. et. al., Wang et al. 2015). As the service providers are part of the intervention/as a provider/, usually they give a high score for each fidelity measure(dimension) and finally, the overall fidelity of implementation score will be inflated and which will not give space for improving the program implementation. Direct observation and camera recordings have many ethical issues and are resource-intensive; hence those methods are very difficult to apply in an Ethiopian (our) setup. After taking so many methodological reviews, we reached at a consensus to use the responses’ of the clients/youths/ to measure the fidelity of implementation fidelity of YFS in the current study. -

C: And this is where I came off confused. You, the authors, are looking at the fidelity of implementation, and your focus appears to be clients, those youth who seek care services from the facilities in Gondar, Ethiopia. And you don’t do a good job explaining why this became your target population. Typically, the clients (i.e., youth) will be used to assess adherence to the intervention. Then, for example, a high adherence becomes an indicator of the success of implementation.

R: We thank the reviewer for asking further clarification. The YFS intervention was designed (by WHO, 2001) to be delivered to youth (15 -24 years old). Ethiopia adopted the YFS intervention from the WHO, and also delivers the YFS for youth aged 15 – 24 years. That is the reason why youth are our target population.

The YFS is designed to be delivered by health care providers who took pre-service training on the YFS. The checklists designed to evaluate the implementation fidelity of YFS from the youth perspectives are almost equivalent as compared to the checklist designed for the providers. The reason why we collected data from the YFS providers and the health facilities as study participants was to assess the determinants of the fidelity of implementation of YFS at the program level (in addition to the individual level determinants).

In this study, the fidelity of implementation was developed from three main constructs. These constructs were adherence, quality of YFS delivery, and the youth engagement in the YFS intervention. -

Introduction

C: Line 78, I think you meant to write fidelity of implementation and not “fidelity f implementation”

R: Thanks to the reviewer for the spelling corrections you suggested. We have corrected the spelling mistake and write it as “fidelity of implementation”, in the revised manuscript. Page 4 Line 79

C: I may be misunderstanding the manuscript, but why is the question of fidelity being posed to youth? Who is the target population? Fidelity would seem to be an issue for the program implementers and providers. The providers and program implementation team would be the ones to assess whether providers delivered YFS as it was designed.

R: Dear reviewer, the measure of fidelity of implementation of an intervention like the YFS can be assessed by using different perspectives (respondents).

The program implementers, the providers and/or the users/clients’ (youth) can be the source of information to evaluate (measure) the implementation fidelity of an interventions (like the YFS). Using either of the study population as a source of information to measure implementation fidelity has its own limitations and strengths. After having a deep discussion with the research team (during the design phase of this study) we have agreed to use youth as a study population (source of information) to evaluate (measure) the fidelity of implementation of the YFS. We provided the interviewer-administered questionnaire for each youth just after they exit the YFS room immediately (after) youth got the YFS.

As stated above, youth are the target population for this study for the measure of the fidelity of implementation of YFS. Moreover, we used the YFS providers and the YFS program (health center) as another study population to assess the determinants of the implementation fidelity of the YFS at a program level. Since the determinants may came (arise) from the YFS program side or from the YFS users’ side (youth).

Finally, the providers and program implementation team should not be the ones to assess whether providers delivered the YFS as it was designed. Because, the providers and the program implementation team are part of the implementation and the results will probably be inflated /maybe near to 100 %/ due to bias (Hawthorne effect). The Hawthorne effect is a type of bias that referring to the tendency of some people (here the YFS providers) to work harder and perform better when they are participants in an experiment (Adeoti et al., The fidelity of implementation of recommended care for children with malaria by community health workers in Nigeria, 2020(94% adherence level was found in this study)) & ((Asgary-Eden, V., & Lee, C. M. (2011). So now we've picked an evidence-based program, what's next? Perspectives of service providers and administrators. Professional Psychology: Research and Practice, 42(2), 169–175. (In this study the average adherence rate reported by the service providers who used the program was 85.9%)).). Therefore, to minimize or avoid the effect of Hawthorne effect, the evaluators should be independent researchers like us. We the current research team are scholars/academicians and researchers/ working at the University of Gondar and have a deep understanding of the YFS intervention. We are not participating as a provider or as a program implementer in the YFS intervention currently. -

C: The question for the youth would be one of adherence. The success of YFS for youth would be whether they came for services and continued to come for services for the length of the program can be given a better assessment of w

R: Regarding the items we included, questions that were designed to assess adherence were incorporated. In addition, questions designed to assess the quality of delivery and the participant engagements were also included. Page 8 Line 166-173, Page 9 Line 174-176

Methods

C: The section on instrument development is a bit long, with considerable repetition. For example, you mention that aspects of the final instrument were adapted from the WHO standard on Line 163 and 216. Consider shortening this section, given that you are interested in one component of the instrument, which is fidelity. It would help if you also considered writing a manuscript on the instrument development or the study protocol. The development of the instrument is itself an interesting process with worthwhile contributions to the literature.

R: Thanks a lot, dear reviewer for providing this constructive comment.

We also believe that the instrument development part was long. Now we made a revision on it and tried to make it short and precise. Based on your recommendations, we have planned to write another manuscript regarding the instrument development or the study protocol. Page 8 Line 156-165, Page 8 Line 171-173, Page 9 Line 174-188

C: What are some examples of questions used in the fidelity component of the instrument?

R: Thanks again dear reviewer for requesting some examples of questions used for the fidelity component of the instrument. Based on your request below are some of the questions used to assess the fidelity component in the three domains are described and included in the revised manuscript as:

“Some of the questions used in the fidelity measure based on the three domains (adherence, quality of delivery and participant responsiveness) are described below. Questions used in the adherence domain were: Confidentiality of the service was assured for you, the provider was respectful to you and the provider explained to you all the range of available YFS there. Questions used in the quality of delivery domain were: The hours and day that you came to the facility were convenient for you, You were very clear of the information given by the provider, You are welcomed and get the YFS without an appointment, and the provider encouraged you to ask any questions. Questions used in the participant responsiveness domain were: You were involved as a peer educator in YFS, you were involved in contributing to decisions about how health services should be delivered to youth clients, and you were involved in YFS service design and delivery.” Page 9 Line 189-196, Page 10 Line 197-198

C: It is not clear why the study (or the part of the study reported in this manuscript) has both youth and providers as the study population. Specifically, was the instrument given to providers the same as the instrument given to the youth participants? Why is that? Providers would have a different perspective on issues around fidelity; I would expect you to look to capture those differences.

R: Dear reviewer, we are sorry for the confusion we made on this issue. Let us explain it more. Both youth and health care providers are the study population for this specific research. The information from the youth was used to assess the fidelity of implementation of YFS, while the information from the health care providers (YFS providers) was used to assess the providers’ level of competency in the provision of the YFS. Besides, information from the health care providers was used to assess the level of health facility readiness in the provision of the YFS. The fidelity instrument that was filled by youth is different from the instrument prepared for the health care providers. -

C: And again, if it is the fidelity of implementation, why do you need the perspective of the youth. I don’t imagine that the youth, who are clients of these health care facilities, would have a significant say in how a program is implemented. Or at least they would have a lesser say compared to providers.

R:Thanks again dear reviewer. Scholars used different approaches to measure the fidelity of implementation of interventions like the YFS. Some use providers as a study population. Others use clients/here youth/ as a study population. Still, others use the combination from providers and clients by preparing to provide similar questionnaires for the provider and the clients. Using this combined method is resource-intensive and findings showed the fidelity measure that was from the providers was inflated or higher compared to the fidelity measure from the clients’ side (Asgary-Eden, V., & Lee, C. M. (2011). So now we've picked an evidence-based program, what's next? Perspectives of service providers and administrators. Professional Psychology: Research and Practice, 42(2), 169–175. (In this study the average adherence rate reported by the service providers who used the program was 85.9%)). Still, some other scholars use audio and video recording as well as direct observation as a source to measure the fidelity of the implementation of interventions. The final method has a lot of ethical issues to employ in our setup.

We the authors of this manuscript had a lot of arguments during the design stage of this research and agreed and conducted to use the youth as a source of information to the fidelity measure. -

C: How was fidelity understood and defined by the authors? Reading the manuscript, I feel you assume your readers have the same understanding of fidelity as you do. For example, in the methods the items used to capture fidelity, what domains do they cover. You mention that it is based on an existing instrument used by the WHO. But what aspects/constructs of fidelity does it cover?

R: Thanks, dear reviewer for providing these constructive comments. We accepted the comments and included the definition of fidelity in this specific research as:

“Fidelity of implementation is defined as the extent to which youth get the YFS intervention as compared to the original YFS program protocol based on the three domains called adherence, quality of service delivery and participant responsiveness). ”

In addition, we have incorporated the different domains/aspects/constructs of fidelity covered in this study by citing additional references that we have based on. The included concepts are written as:

“To Measure, the implementation fidelity of services like YFS is conceptually developed from three major constructs called adherence, quality of service delivery and participant responsiveness [37, 38]. Hence, it is vital to quantify the three main constructs that are intended to measure the fidelity of YFS [37, 38]. To measure the overall fidelity of YFS, the three constructs used to measure the fidelity of YFS (adherence, quality of YFS delivery and participant responsiveness) were quantified separately”. Page 11 Line 236-238, Page 9

Line 189-196

Results

C: You report youth and health care providers together in Table 01; should that not be separated? The factors that impact providers when it comes to the question of fidelity I imagine, are distinct.

R: You are right dear reviewer and your comments are accepted. We reported the youth and health care provider’s data together in table one.

Now based on your comments we separately reported the youth (Table 1) and health care providers (Table 2) responses separately (in separate tables).

In the revised manuscript the number of tables became 6. Re-arrangements and renaming of all the tables were made. Page 17 Line 350-357, Page 18 Line 358-367

C: Table 02 and Table 03 cover issues that are not discussed in the methods section. That is level of youth engagement and facility-level factors are not evident in the methods. For table 02, in particular, what is meant by the level of engagement?

R: Comment appreciated.

Now we have included brief descriptions of the level of youth engagement or participant responsiveness (reported in Table 2) and facility-level factors (reported in table 3) in the methods section.

“In this study level of youth engagement is defined as the participation of youth in the YFS intervention in aspects like participation in the YFS design, planning and delivery, participation in the YFS as a peer educator/counselor, Involvement in the YFS on decisions about how health services should be delivered to youth clients and the like. ”

“Facility level factors are those characteristics like if the health facility has signal listing for all the YFS available or not, if the health facility had a separate discreet entrance for youth to ensure youth privacy or not, if the health facility offered YFS for free or at rates affordable to youth if the health facility has adequate fund allocated for YFS, if the health facility had clear, written guidelines or standard operating procedures exist for YFS and the like.”

Page 10 Line 199-202, Page 8 Line 166-170

C: Table 02 could be made more clear if you categorized the engagement levels. When I reference Table 05, it is clear that the levels of engagement form part of the independent variables in your multi-level model. So, for example, if model II was adjusted for individual-level variables, then have Table 02 show this so that your readers can better connect Table 02 and Table 05.

R: We accept the comment and revised accordingly.

In table 02(Now Table 3 in the revised manuscript), those respondents who said ‘yes’ represent those youth who had the level of engagement in the YFS provision. In the original instrument, they responded to the scale as either Agree or Strongly Agree are categorized as having engaged in the YFS provision.

Those respondents who said ‘no’ represent those respondents who had no level of engagement in the YFS provision. In the original instrument, they responded to the scale as either Neutral or Disagree or Strongly disagree are categorized as having no level of engagement.

To make clear for the reader we have added sub-headings in Table 5(Now Table 6 in the revised manuscript), that clearly demarcated those individual and program-level determinants separately. Page 19 Line 377-378, Page 24 Line 447-449

C: Consider shortening the Items/ variable names in Tables 02, 03, and 05; it makes the tables clunky and challenging to read.

R: Comment accepted.

We have shortened the variable names that were described in Tables 02(Now Table 3), 03(Now Table 4) and 05 (Now Table 6). Page 19 Line 377-378, Page 21 Line 402-403,

Page 24 Line 447-449

Discussion

C: Is there a reason you reference implementation in education and not the implementation in health care to support your point here? It is not wrong, but I think your argument would be stronger if you found implementation studies in the health sector and the sexual health field specifically to support notions of fidelity of implementation (Lines 512 - 514).

R: We accept the comment. Dear reviewer the reason why we compared the current finding with the cited implementation research conducted in education was due to the gaps in existing evidence conducted in the health care set-up, specifically in sexual and reproductive health.

Now after making an extensive literature review we have got one related review article and made the revisions accordingly.

The revisions are included in the revised manuscript as:

“This result is supported by the finding of a review article, where capacity building training is critical for ensuring retention of the YFS providers’ knowledge and skills up to date and hence help them provide the YFS with higher fidelity [49].” Page 27 Line 514-516

C: So, what are the practice implications of your study findings? YFS programs are demonstrated in the literature to be effective and successful ( I think several clinical studies bear this out). The question then is the state of fidelity of implementation in Gandor, Ethiopia, and more importantly, what would the iteration and scale-up of YFS programs in Ethiopia look like, given your analysis data? I think this should be a significant focus of your discussion. Ethiopia has already begun implementing YFS programs, so what will need to change to enhance fidelity in light of the results?

R: Thanks for the comment. Now we have added some practice implications of the YFS based on our findings and included in the revised manuscript as:

“The results of the study implied that efforts to build systems that apply the policy and principles of implementation fidelity of YFS in the health facilities are crucial. These initiatives will not only benefit youth but the health system overall, as the principles for implementation fidelity of the National Adolescent and Youth Health Strategy are in step with those of YFS to be delivered with a high level of adherence, quality of delivery and youth engagement [3]. Another implication of the study finding is considering high levels of implementation fidelity of YFS is essential to avert the SRH problems among youth, in addition to the YFS scale up. Furthermore, investing in effective interventions (like YFS), is important to improve its implementation fidelity. There is a need to strengthen the YFS to be delivered with a high level of fidelity to achieve the desired intervention outcomes”

Page 29 Line 562-564, Page 30 Line 565-571

Limitation

C: You may wish to say a bit more regarding the limitations of the study. What do the survey items on fidelity leave out when it comes to understanding implementation?

R: We accepted the comment. Now we added some limitations of the study.

“The measure of Fidelity of implementation of YFS was from youth perspectives, which means, the study did not consider the providers’ perspective and direct observation. Hence, some fidelity items that should be filled by the providers were not considered ” Page 30

Line 581-584

Submitted filename: Response to Reviwers.docx

Click here for additional data file.

26 Jan 2022

Individual and Contextual Factors affect the Implementation Fidelity of Youth-Friendly Services, northwest Ethiopia: a Multilevel Analysis

PONE-D-21-19080R1

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31 Jan 2022

PONE-D-21-19080R1

Individual and Contextual Factors affect the Implementation Fidelity of Youth-Friendly Services, northwest Ethiopia: a Multilevel Analysis

Dear Dr. Habitu:

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Table 1

Socio-demographic and other characteristics of youth Northwest Ethiopia in 2019.

Variables	Frequency	(Percent)
Age (in years)
15–16	58	5.6
17–19	254	24.7
20–24	717	69.7
Religion
Muslim	147	14.3
Orthodox	874	84.9
Others*	8	0.8
Educational status
Unable to read and write	58	5.6
Able to read and write	5	0.5
Primary education (1–8)	210	20.5
Secondary education (9–12)	453	44.0
Vocational/Diploma	211	20.5
Degree and above	92	8.9
Work for money
No	593	57.6
Yes	436	42.4
Mother alive at the time of the survey
No	126	12.2
Yes	903	87.8
Father alive at the time of the survey
No	312	30.3
Yes	717	69.9
Do you have peer friend/s at the time of the survey
No	201	19.5
Yes	828	80.5

Others implied

*protestant and Catholic

Table 2

Characteristics of the YFS providers, Northwest Ethiopia, 2019.

Variables	Frequency	(Percent)
YFS providers educational level
Degree	18	66.7
Diploma	9	33.3
Trained on YFS
Yes	22	81.5
No	5	18.5
There were means of capacity building training provided to you
Yes	7	25.93
No	20	74.07
You have got supportive supervision
Yes	8	29.63
No	19	70.37

Table 3

Youths level of engagement in the YFS intervention, Northwest Ethiopia, 2019.

Items	Responses
	Yes	No
	Frequency (%)	Frequency (%)
You were involved in decision-making regarding the YFS	455(44.2)	574(55.8)
Your overall level of involvement in the provision of YFS was high	341(33.3)	688(66.7)
You have been involved as a peer educator in YFS	286(27.8)	743(72.2)
You know any peer educator trained in YFS	337(32.7)	692(67.3)
You are involved in decisions about how YFS should be delivered to youth	283(27.5)	746(72.5)
You are aware of youth who are involved in decisions about how YFS should be delivered to youth	283(27.5)	746(72.5)
level of involvement in making decision regarding your treatment was very high	407(39.5)	662(60.5)
Community involvement in YFS program design, monitoring and evaluation was high	229(22.2)	800(77.8)
Involvements in YFS service design and delivery were high	212(20.6)	817(79.4)

Table 5

Parameter coefficients and model comparisons of each successive model in FoI of YFS, Central Gondar Zone, 2019.

Random effect	Model-I	Model-II	Model-III	Model-IV
Community variance (SE)	0.63655	0.3396243	5.11e-32	1.22e-33
ICC (%)	16.4%	23.5%	2.1%	2.4%
PCV (%)	Ref	99.9%	1%	1%
Model comparison statistics
Log likelihood	-630.22393	-478.29331	-476.153	-431.60187
AIC	1264.448	1084.603	877.1524	817.8602

Table 6

Bivariable and multivariable multi level logistic regression analysis of individual and contextual determinants of implementation fidelity of YFS, Northwest Ethiopia, 2019.

Fixed effects of individual and contextual level variables		Model-I	Model-II	Model-III	Model-IV
			AOR [95%CI]	AOR [95%CI]	AOR [95%CI]
Individual level determinants
Your overall level of involvement in the YFS provision was high	Yes	-	1.41(1.21, 1.63)	-	1.35(1.15, 1.57) *
	No	-	1	-	1
You know any peer educator trained in YFS	Yes	-	1.83(1.58, 2.11)	-	1.60(1.36, 1.86) *
	No	-	1	-	1
You have been involved as a peer educator	Yes	-	1.47(1.26, 1.72)	-	1.46(1.24, 1.71) *
	No	-	1	-	1
Program level determinants
There is a separate waiting room for youth	Yes	-	-	7.85(5.28, 9.06)	9.84(2.14,17.79) *
	No	-	-	1	1
There are means of capacity building training provided to you	Yes	-	-	3.40(2.51, 5.72)	1.93(1.12, 3.48) *
	No	-	-	1	1
You have got supportive supervision	Yes	-	-	1.71(1.28, 4.02)	2.85 (1.99, 6.37) *
	No	-	-	1	1
System in place to provide continuous support to YFS staff	Yes	-	-	4.92(2.63, 7.04)	2.81(1.25, 6.34) *
	No	-	-	1	1

*P-value <0.05