TBM TBM page 87 of 95 ORIGINAL RESEARCH Implications Practice: This study provides practical know- ledge on the adaptation of graphic training methods to youth in impoverished environments. Policy: The results provide new data to aid in the development of policies directed at increasing the reach of current HIV-testing systems. Research: This study expands implementa- tion theory to include self-implemented health practices. 1 Hallie E. Ford Center, College of Public Health and Human Sciences, Oregon State University, Corvallis, OR 97331, USA 2 Oregon Health Sciences University, Portland, OR 97239, USA 3 FASDO, Yatima Group Fund, Tanzania 4 University of South Carolina, Columbia, SC 29208, USA Abstract Tanzanian youth have high levels of HIV risk and poor access to HIV-testing. Oral self-implemented testing (Oral-SIT) provides an alternative that reduces barriers to HIV-testing. We examined adaptations to Oral-SIT training components in a randomized experiment to evaluate a “train-the-trainer” strategy for improving comprehension of graphic training materials. Participants (N = 257, age = 14−19 years) were randomly assigned to one of two self-training conditions: graphic instruction book (GIB) or Video-GIB. Outcomes included behavioral performance fdelity, self-reported comprehension, and intentions to seek treatment. Video-GIB participants, relative to GIB-only participants, had higher performance fdelity scores, made fewer performance errors, had better instruction comprehension, and were more likely to intend to seek treatment. Oral-SIT timing errors were signifcantly more common among GIB-only participants. Graphic training materials in conjunction with a “train-the- trainer” video has signifcant potential for increasing Oral-SIT’s reach by overcoming technological and literacy barriers. Keywords Self-implementation, Fidelity, Oral-HIV self-testing, Tanzania INTRODUCTION Tanzanian youth: HIV risk and testing Tanzanian adolescents are ranked fifth in HIV prevalence among sub-Saharan countries [1], with the highest prevalence observed among youth age 15–24 years [2]. This is a substantial population seg- ment since more than half of Tanzanians, approxi- mately 30.4 million, are under the age of 20 [3] with a median population age of 17.4 years [4]. Low-income Tanzanian youth have poor access to HIV-testing and care [2, 3, 5–9]; with testing estimates ranging widely for 15–24 year olds [1, 10]. Limited access to HIV-testing leads to delays in receiving care and in- creases in HIV mortality among adolescents [11, 12]. Oral HIV-testing HIV-testing is traditionally offered in clinic settings. Barriers to clinic-based testing include social stigma, discrimination, and geographic distance [8, 13–15]. Oral self-implemented testing (Oral-SIT) offers a supplemental strategy for increasing the reach of HIV-testing services for youth. Oral-SIT allows people to self-test under conditions of privacy that avoid stigma and discrimination, increases repeat and partner testing, and, with appropriate dissemin- ation strategies, reduces transportation barriers [16, 17]. The OraQuick test by OraSure is preferred by consumers over other self-implemented tests since the oral swab method is less painful than finger stick methods [17]. Prior studies assess a wide range of Oral-SIT performance outcomes [18, 19]. Findings show that higher levels of education and receiving the training materials in one’s native language are as- sociated with better performance [18, 19]. Research in Kenya and the US illustrate that current “high lit- eracy” variations of Oral-SIT self-training have limi- tations [19, 20]. Self-implementation fdelity Oral-SIT requires the person to self-implement a set of training and testing components, and take appro- priate follow-up actions. In this regard, Oral-SIT can be understood within a broader implementation sci- ence framework (i.e., a special case of program im- plementation involving self-implementation) [18]. Self-implemented programs place a heavier burden on the consumer because consumers must train Overcoming cultural barriers to implementing oral HIV self-testing with high fdelity among Tanzanian youth Joseph A. Catania, 1 Cassidy Huun, 2 M. Margaret Dolcini, 1 Angelmary Joel Urban, 1 Nick Fleury, 1 Clinton Ndyetabula, 3 Ryan Singh, 1 Amy W. Young, 1 Donaldson F. Conserve, 4 James Lace, 3 Joyce Samweli Msigwa 3 Correspondence to: Joseph A Catania, Joseph.Catania@ oregonstate.edu Cite this as: TBM 2021;11:87–95 doi: 10.1093/tbm/ibz157 © Society of Behavioral Medicine 2019. All rights reserved. For permis- sions, please e-mail: journals.permis- sions@oup.com.