Keeping the Essentials in Place: Lessons Learned from a Qualitative Study of DREAMS in Northern Uganda

Reviewer 1 Comments

Response

This is a very timely, relevant, carefully composed, and very well-written and referenced paper. It's a real contribution to the field. My main comment/suggestion centers on the challenge of having a paper that would like to offer observations about scale-up based on a study that wasn't really about the process of scale-up; as I read it, it was a study mainly about the impact of a large-scale approach on individual lives.  I see these as two different albeit interlinked questions and there's an inherent challenge in tying the two from the "strength of argument" perspective.

Thank you for your comments.

The authors agree that it was a challenge to center the paper on the issue of implementation successes and challenges when adapting and scaling evidence-based approaches, rather than what the study was focused on – how and whether the initiative affected individual lives.

We made substantive edits to strengthen the connection between these, primarily in the discussion section.

The reader comes away understanding that a project like this, based on a model delivered at scale, had a certain impact in the lives of 56 young women from District 1 and District 2 (if possible, would be helpful to identify the districts, or to indicate why the districts aren't being named).  The paper is formed around this and all fits together very well. 

We added our rationale to a paragraph under Ethics. This is to further protect the anonymity of study participants in communities that are relatively small.

When it then comes to the Discussion section, I think many of the observations could also apply to interventions that are not delivered at scale and the line of argument gets a little lost. In the intro section, there is quite a lot of focus on scale, scale comes up in the discussion section, and the conclusions section also speaks to scale.  I think the points put forth about the scale up process or challenges of delivery at scale in the Discussion section would have to be drawn mainly from the results sections "peer facilitator perspectives on DREAMS implementation" and "implementor perspectives on challenges", and indeed those findings are referenced but the bulk of the findings aren't necessarily about scale up.  It makes the line of argument a little confusing to follow.  Some refinements in flow and connection across these points could benefit the overall impact of this very strong paper. 

The authors appreciate this comment. The discussion section has been revised to more clearly connect points made to relevant results.

Reviewer 2 Comments

Response

The authors attempt to present in an academic format the findings of a developmental project implemented in Uganda. While this effort is welcomed, the paper, as it is, more effort is needed to transfer, and to enhance, the information available in the project report, so they properly fit the requirement for an academic article.

Thank you for letting us know this is your impression from reading the article. The authors want to clarify that this article reports on a qualitative study conducted to learn about participants’ perspectives about how an intervention had affected their lives and an important finding from that study about the need for careful attention to program implementation guidelines to achieve desired results relating to GBV.

We hope the shift in the article title will support an understanding of this.

Title: The title “Implementation Successes and Challenges: Lessons Learned from a Qualitative Study” is both elusive, (to which implementation, successes, and challenges are the author referring? What qualitative study are they referring?) and obscure, it does not indicate what is the focus of the paper

The title has been changed to “Keeping the Essentials in Place: Lessons Learned from a Qualitative Study of DREAMS in Northern Uganda”

”

Introduction: In the introduction, the authors refer to the relevance that HIV and AIDS have on adolescent girls and young women (AGYM) and to some of the causes of spreading HIV and AIDS among the AGYM group. It is not, however clearly explained neither the link between the problem described and the role that developmental capacity building and awareness projects, in general, can have nor the specific case of DREAMS is presented.

We are not clear about this comment. Given space constraints we provided a succinct explanation of the DREAMS initiative (paragraph 6 of the Introduction) and its objectives with references that can provide more in-depth information.

Concurrently GBV is also introduced as one of the side aspects of the analysis although the correlation between HIV/AIDS and GBV is not properly explicated nor is it significant for the DREAMS project, considering that as one can gather from what is said by the authors addressing GBV is not one of the aims of DREAMS. The introduction should be extensively elaborated to provide the readers with a general overview of the relevance of the problem to be investigated. It would help if the DREAMS project is described more extensively in particular the concepts of scale-up interventions and the stepping stones.

Thank you for this comment. The link between HIV/AIDS and GBV has been more clearly articulated with citations added.

We tried to provide a solid explanation of the problem and of DREAMS (see paragraph 6) without going beyond the recommended length for an article in this journal.

Material and Methods (could be named methodology): This section is unsystematic, it would help if the type of methodology (qualitative methods) used is presented, then the sample followed by the instruments used to gather the information and ultimately the ethical concerns, indicating, as well, how respondents’ anonymity has been ensured.  

We named this section “Material and Methods” to conform to the journal’s conventions.

We have revised the order in this section and added numbers to sub-headings.

We added a sentence to explain how respondent confidentiality and anonymity was ensured.

Data Analysis: In this section, the authors refer to code and themes that have emerged from the analysis of the respondents’ narrative, probably this part could be specified in the methodological section, explaining how they were extracted, while in the data analysis section, the code and themes identified could be described, this will link the data analysis section to the result section.

Data analysis is a sub-heading under Material and Methods, consistent with the journal’s conventions. We describe our approach to data analysis here. We feel it will add to the length of the article to describe the codes and themes in detail here.

Results: This part would benefit from subsections referring to the themes that emerged from the analysis of the interviews. A synoptic table with the participants’ demographic would make this section more reader-friendly  

Very little use is made of extracts from the respondents’ narratives, which, in a qualitative study are an important component to describe the finding and to understand how they are correlated with the discussion section.

The sub-headings that are used in the article represent overarching categories under which participant responses are grouped. For example – under 3.2.1 Addressing Health-related Drivers of HIV we discuss the main themes that emerged from interviews related to this heading.

We acknowledge the challenges of reporting on qualitative studies where brevity is needed. Much of the rich data we have had to be summarized with brief excerpts of longer narratives.

We added a few additional quotes that we had deleted in a final edit to make the article briefer.

Discussion: This section does not seem to emerge straight from the findings, on the other hand, while is correctly noted that facilitators’ behavior has an impact on changes in norms which indirectly affect GBV in the case of adolescent girls and young women, this aspect it is not critically analysed with reference to the main problem investigated. If the facilitators encourage AGYW to be subservient to the men/partners, the project DREAMS investigated in Uganda (and hence generally if the same facilitators’ attitude is found elsewhere) has de facto failed to address the causes of HIV/AIDS since, for example, an AGYW will hardly object her partner not to use a condom or leave him if he is going to cheat.

The authors revised the discussion section to more clearly articulate the idea that not adhering to the program’s original standards of implementation, including facilitator training, affected facilitators embracing ideas the program sought to convey to participants.

On a more technical note, in the participants' demographic section, it is not clear why if the peer groups are made of 15- to 24- years old AGWY then the sample age then varies between 15 and 25. If the 25 years old is a special case, then this should be explained

We added a footnote to explain this.

For sake of clarity maybe it will also help if Uganda’s school system is briefly described to help the readers to understand the grade indicated when dealing with school performances.

Some clarification is made in the text and a footnote was added to describe the Uganda school system.

Not all participants’ narratives refer to the respondent which could either be given an imaginary name or numbered 1 to 56

We added in the participant code where these were missing. Codes were created by peer group (each had a pseudonym): PF = peer facilitator, and participants were numbered P1-P7.

Reviewer 3 Comments

Response

The research is interesting and very important. Unfortunately, the article is still very immature because it requires a major revision.

Thank you for this comment. Revisions have been made.

The title does not recall the object of the research. It is better to clarify the subject of Aids

The title has been changed.

The abstract is confusing. It should be rewritten by reducing it and structuring it with: background; research question and objective; participants; method and means of detection; results; conclusions.

We appreciate your comment. However, although some abstracts do use the approach you present, others are consistent with the approach we have taken.

The research question is not clearly formulated and neither are the objectives

We hope the research question is more clear in the revised version of the article.

The interview questions should be placed in the methodology section. 

Thank you – we added the interview guide as Appendix A.

The description of the limitations should be placed after the conclusions.

We moved the limitations to after the conclusions.

The approach adopted for the qualitative analysis is not clear. In fact, the results seem to present only the selection of a few answers considered representative. It is suggested that the analysis be re-done using thematic analysis, which makes it possible to recognise dominant themes over and above the questions. The study of the following texts is recommended: 

Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative research in psychology, 3(2), 77-101.

Guest, G., MacQueen, K. M., & Namey, E. E. (2011). Applied thematic analysis. sage publications.

Thank you for these suggestions. The analysis used thematic analysis with a combination of inductive and deductive coding supported by use of software.

We added a reference that we consult as anthropologists related to qualitative analysis.

Reviewer 4 Comments

Response

This research, a qualitative analysis of response of some 55 young women enrolled in HIV education and prevention programs, is an excellent example of successful qualitative research. The research methods and analysis are of an excellent standard for qualitative research, and the results, which are very clearly presented, are interesting and potentially important got program designers in public health and gender equality in other countries.

Thank you so much for this comment.

My only reservation is that this research was undertaken in 2017, and being five years old, its relevance should be discussed with an update of Uganda's current status in terms of health education programming. A final paragraph updating the paper, perhaps referring to new programs in other African countries (and elsewhere) might be valuable.

We provided a slight revision to highlight the recent information about HIV and GBV interventions in the introduction and added some information about new programming in the discussion.