Discussion
This study aimed to examine the attitudes of HIV service providers towards adopting CombinADO interventions for improving HIV outcomes in AYAHIV receiving ART care in Mozambique. To our knowledge, this is the first study that considered the impact of service providers' attitudes toward adopting novel HIV interventions planned for services offered to AYAHIV in the SSA setting. Overall, service-providing stakeholders dedicated to HIV care of AYAHIV within this setting reported positive attitudes regarding adopting either the intervention or control CombinADO study intervention packages within health services. We found that the study package assessed (i.e., control or intervention condition) and the number of HCWs delivering ART care in participating clinics were the only significant explanatory variables to explain variations in stakeholder attitudes. Other individual and context-level factors most noted in the existing literature to influence providers' attitudes towards adoption in various interventions in different fields were not significant predictors in this setting.Our study showed an overall positive attitudinal endorsement of adopting interventions tested for effectiveness in the CombinADO study. Since the stakeholders will ultimately be responsible for delivering them in actual practice, this is especially important. Previous studies have suggested that implementers tend to value needs-driven interventions since they incorporate feedback from priority populations and end-users on what would be most appropriate to address the identified contextual needs. Given that in developing the CombinADO intervention packages we aimed to address needs of AYAHIV, our results suggest that these stakeholders were already supportive of implementing these interventions within HIV services offered to AYAHIV in this setting, likely contributing to their positive attitudes [The results of the ARTAS questionnaire items showed that respondents broadly endorsed positive attitudes, as observed in the high mean values shared for each item used to measure attitudes. However, we noted that stakeholders in the CombinADO intervention package group were more likely than control package stakeholders to report that the intervention package would be easy to implement after training, which may explain the observed differences in total scores between intervention groups. Notably, in the CombinADO study, the intervention group package was developed to include six additional components to those in the ESOC package. Thus, it would be very reasonable for the stakeholders expected to implement this package to report higher needs for training to acquire the necessary skills and confidence to engage the different intervention components during implementation. Even with the high levels of attitudes reported in this study, it was essential to identify these differences in perspectives on the importance of training among stakeholders within different package groups prior to active implementation of the intervention in clinics because it assisted in scaling training based on the needs highlighted by stakeholders, thus supporting provider self-efficacy [Our results also showed an association between the number of HCWs delivering ART care in clinics and stakeholder attitude scores. It was less surprising to observe that having one HCW at the clinic offering services to AYAHIV would predict lower attitudinal scores towards adopting new interventions in practice, especially given the multi-component nature of packages tested in the CombinADO study. It has previously been suggested that service providers may be reluctant to implement new interventions if they add to their workload, especially when inadequate personnel are available. Existing implementation literature has highlighted that adequate resources, such as training and staffing, are necessary to successfully adopt new EBI in healthcare settings [In contrast to other studies on the subject, we found no additional significant relationship between reported provider attitudes and the remaining individual and facility-level characteristics considered in the study [The major strength of this study lies in the purposive sampling and the use of a validated measure to understand better key stakeholders' attitudes who may influence whether these interventions reach AYAHIV in the future if interventions are found effective in improving their HIV outcomes. Given our study results, we could streamline training needs and consider additional human resource support needed to promote adoption in clinics before moving forward with active implementation. However, we acknowledge several limitations of our study. First, the self-report nature of our study is prone to social desirability bias, a problem commonly found in self-report studies, which may have led to higher attitudes towards adopting interventions reported by providers than they felt. Second, given our study was cross-sectional, we could not ascertain the temporality of provider attitude in the long term; however, we plan to re-examine these in the later stages of the study. Third, we acknowledge that using quantitative methods and including a priori explanatory variables may not have allowed us to capture additional perspectives on factors that may have been critical in this setting to shape individual providers' attitudes toward adopting these interventions. We recommend that future studies consider using various research methods, such as mixed methods, to better understand the complexities of individual attitudes. Finally, given the sample size, our data may not be generalizable to other settings; thus, future studies should consider assessing provider attitudes based on their unique interventions and contextual factors. However, we believe that the data shared in this study are the beginning of understanding approaches that can be used and considered in future implementation studies within similar settings to assess the role of key stakeholders' attitudes in the success of intervention implementation efforts. We also believe this study helped with the future direction of our research. We think it would be beneficial to understand how providers' attitudes would have changed in the active implementation of the intervention packages in clinics. In addition, we will consider using various research methods, such as mixed methods, to better understand the complexities related to the attitudes of individual providers in this setting. Such efforts may help identify barriers that in the future may hinder moving towards successful sustainability and scale-up of these interventions within this setting.