Endgame grant
Rationale of the study
There continues to be a gap in the adoption of PrEP in Ontario with only 36% of those who met Canadian PrEP guidelines receiving PrEP, and the highest PrEP-to-need ratio being mostly in urban centres such as Ottawa and Toronto (OHTN 2023).
The role of primary care providers (PCPs) in the uptake and adherence of PrEP is well recognized and the determinants of the adoption of PrEP included individual, interpersonal, organizational, and external factors.
Few studies in Canada has been conducted among PCPs and clinical managers in regards to organizational determinants of PrEP adoption, with many limited only to identify individual factors.
Most published research on determinants of PrEP prescription and uptake, and most of the innovative services delivery models in Canada, have been developed for populations living in major metropolitan areas, leaving a gap in our understanding of the unique challenges faced in smaller metropolitan areas or rural areas. Place of residence is an important determinant of PrEP uptake and Prescription.
Objectives
To address the gap in PrEP uptake and prescription in mid-sized and rural areas in Ontario, we designed a mixed-methods study with four objectives. These objectives follow a sequential approach, beginning with a situational analysis that identifies determinants of PrEP adoption at the organizational level and determinants of the PrEP experience at the individual level. The first objective is followed by a second objective that summarizes experiences and recommendations to propose implementation strategies for increasing adoption and enhancing the PrEP experience among primary care providers. The insights from these two objectives then inform the final two objectives, which aim to evaluate the proposed implementation strategies and the educational module.
Aim 1
Conduct formative work with PCPs to identify 1) the PCP’s level of willingness and intention to become consistent PrEP prescribers, 2) PrEP adoption determinants among PCP, managers, and other key stakeholders, and 3) gather recommendations to address adoption barriers.
Aim 2
To use the collective experience in PrEP implementation to formulate 1) a training plan for PCPs, and 2) rapid PrEP implementation strategies/protocols that adjust to different clinic settings.
Aim 3
To roll out and evaluate a PrEP training program for PCPs.
Aim 4
To roll out and evaluate rapid PrEP implementation strategies.
Sample and study population
Primary care practitioners, mostly physicians working in Southeastern Ontario accessible through primary care council.
Primary care practitioners and clinical managers mostly nurses who work in sexual clinics accessible through local and other public health units in the province.
Primary care practitioners, managers, mostly physicians working in educational setting, Street Health, community centres.
Population study was primary care providers working in different settings. We aimed at including family doctors and nurse practitioners working in South Eastern Ontario, providers of sexual health clinics in all Ontario regions, and primary care providers working with special populations. For each objective of the study, this primary populations target changed or were extended.
Sample and study population
Surveys
Online surveys to gather information on PCP experience and knowledge of PrEP.
PrE and Post training surveys to gather information on outcomes of the training PrEP module
Survey to clients of PrEP services to gather information on implementation.
Qualitative interviews
28 interviews with PCPs to identify determinants of adoption and experience with PrEP
Semi-structure interviews with staff and clients of PrEP Clinic to evaluate implementation process.
Stakeholder meetings
Team meetings with PCPs and PrEP Clinic staff to identify recommendations.
Team meetings with PCPs and sexual health Clinic staff to identify a plan for adoption of PrEP.
Literature review
Identify implementation frameworks to delineate our methods, design and analysis.
Identify best practices for educational activities that may increae PrEP prescription in PCPs.
Our work combines different methods, with a predominant a quantitative and qualitative approach as recommended for studies in implementation science. The surveys gather baseline knowledge and attitudes toward PrEP, assess changes following training, and collect feedback from clients about their experiences. Qualitative interviews, including 28 with primary care providers and additional semi-structured discussions with staff and clients, investigate factors that influence adoption and identify both barriers and facilitators. Stakeholder meetings bring together providers and clinic teams to refine recommendations and develop a coordinated plan for PrEP adoption. Finally, the literature review identifies relevant implementation frameworks, best practices for educational interventions to increase PrEP prescription, and lessons from other sexual health initiatives. By combining these methods, the project aimed to assess current practices, uncover improvement opportunities, and guide effective integration of PrEP into clinical and public health settings.