The application of two communication approaches in the implementation of a stepped-wedge stigma reduction and mitigation intervention in rural China: A qualitative study

The application of two communication approaches in the implementation of a stepped-wedge stigma reduction and mitigation intervention in rural China: A qualitative study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The application of two communication approaches in the implementation of a stepped-wedge stigma reduction and mitigation intervention in rural China: A qualitative study Menglin Shang, Abdul-Hanan Saani Inusah, Xiaoming Li, Shan Qiao This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7659482/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 4 You are reading this latest preprint version Abstract Background: Communication is a central but often overlooked determinant of intervention implementation, and little empirical work has examined how different communication approaches operate in real-world delivery settings. This study explores how communication dynamics shaped the implementation of a resilience-based HIV-related stigma reduction and mitigation intervention (RISE-Up project) in rural China. Method: A qualitative study was conducted within the RISE-UP project, a stepped-wedge cluster trial implemented across 40 HIV clinics in Guangxi Province. Data were collected through in-depth interviews of 14 project team members in the field, including site project facilitators (local implementers) and central coordinators. Interview recordings were transcribed verbatim. Data were managed and analyzed using NVivo. Thematic analysis was conducted with typical quotes of the participants presented. Result: Two complementary communication approaches, Top-Down and Bottom-Up, emerged as central to the implementation process. The Top-Down approach provided structured oversight through strategic planning, real-time feedback, supervision, cross-site capacity-building, and informing the implementation of the following sites. The Bottom-Up approach enabled local implementers to identify local challenges, generate solutions, and foster feedback and peer learning. The stepped-wedge design further supported iterative learning, allowing earlier sites to inform later ones and strengthening collective adaptation. Conclusions: Communication was an active, dynamic shaping of decision-making, adaptation, and sustainability. Balancing Top-Down oversight with local responsiveness can strengthen fidelity and adaptation. Timely documentation, peer-to-peer mentoring, and enhanced feedback loops may further institutionalize these communication practices and improve sustainability in future public health interventions. Communication approach Implementation science Stigma reduction Stepped-wedge trial People with HIV Contributions to the literature • • Highlights communication as a critical factor shaping implementation in intervention implementation in real-world health systems. • Shows how top-down and bottom-up communication approaches jointly supported fidelity and local adaptation in a large-scale stigma-reduction intervention. • This study offers practical strategies, such as feedback loops, peer mentoring, and timely documentation, that could strengthen sustainability in future public health interventions. Background Communication is a critical driver of successful intervention implementation. It serves not only as a conduit for delivering information but also as a mechanism for shaping stakeholder engagement, fostering collective understanding, and building support for change ( 1 ). Most implementation strategies, whether in the form of training, supervision, service provision, or education, rely on deliberate communication processes to introduce new practices and align actors around shared goals ( 2 , 3 ). Beyond information delivery, communication processes actively influence how interventions are perceived in terms of feasibility, acceptability, and appropriateness ( 2 ). Recent studies have emphasized that inadequate or poorly structured communication is a common contributor to implementation failure ( 2 , 4 ). A growing body of implementation science literature highlights communication as a foundational mechanism shaping intervention delivery ( 1 , 5 ). While often not the central focus, communication is embedded, either explicitly or implicitly, within many theoretical frameworks. A systematic review of 27 implementation theories and frameworks found that nearly 60% referenced communication as a critical factor shaping implementation outcomes, emphasizing its structural role in guiding intervention processes ( 2 , 5 ). Some models conceptualize communication narrowly, as the transfer of information across hierarchical levels. Others, however, frame it as a dynamic and interactive process that enables coordination, collective understanding, and trust-building across implementation teams ( 5 , 6 ). Despite its embeddedness, communication remains an underexplored determinant of implementation success. Its role is often backgrounded or taken for granted, limiting insight into how communication approaches influence real-time decision-making and cross-level learning ( 1 , 7 ). Scholars have criticized this oversight, arguing that the treatment of communication as a neutral conduit fails to capture its relational and interpretive dimensions, factors that are especially critical in complex, community-based interventions ( 1 , 5 ). Within this discourse, two predominant communication approaches have been identified: Top-Down and Bottom-Up approaches. Top-down strategies emphasize centralized oversight, structured messaging, and fidelity to intervention protocols, while Bottom-Up strategies prioritize the agency of frontline implementers in shaping how interventions unfold on the ground. The former enables consistency and alignment with core program objectives, whereas the latter enhances contextual fit and ownership through localized problem-solving ( 8 , 9 ). Rather than treating these approaches as oppositional, recent scholarship advocates for integrative models that balance centralized guidance with frontline flexibility ( 10 , 11 ). However, studies examining how these approaches interact during real-world implementation remain limited. Many of the existing implementation science studies lacked details on the operational dynamics of communication in real-world delivery settings. To address this gap, the current study examines how Top-Down and Bottom-Up communication approaches were employed during the implementation of a multicomponent, community-based HIV stigma reduction intervention in rural China ( 12 ), and how these approaches shaped implementation processes and supported sustainable delivery. Methods Study setting This qualitative study was conducted in the Guangxi Zhuang Autonomous Region, one of the regions in China with the fastest-growing HIV epidemic. The research was embedded within the RISE-Up project ( 12 ). The RISE-UP project was a multimodal resilience-based stigma reduction and mitigation intervention designed to support PWH, their family members, and healthcare providers in terms of clinical outcomes, psychosocial well-being, and quality of life through promoting social support for PWH and fostering resilience among this population. The project was conducted in 40 community-based HIV clinics or treatment centers (“HIV clinics”) from 11 sites (2 urban cities and 9 rural counties) in Guangxi, China. Based on a stepped wedge cluster randomized clinical trial, the 11 sites were grouped into 5 clusters to implement the intervention in a random order (i.e., at different waves 6 months apart). Since most participating HIV clinics were affiliated with local Centers for Disease Control and Prevention (CDC) at each site, the provincial CDC played an important role in project coordination and implementation. At each participating clinic, CDC staff and local implementers, including doctors, nurses, and HIV case managers, received training to deliver the intervention based on standardized curricula and protocols. Participants A total of 14 participants were recruited, including 2 provincial CDC project coordinators and 12 local project facilitators (local implementers) from 7 clinics in 2 project sites that had completed the intervention delivery at the time of the interview in April 2024. Inclusion criteria include ( 1 ) 18 years or older; and ( 2 ) currently working for the RISE-Up project, planning, implementing, administering, or managing any aspect of the intervention study. Recruitment was conducted by the University of South Carolina (USC) research team, in collaboration with the Guangxi Provincial CDC. Procedures In-depth individual interviews were conducted by a team of four trained qualitative researchers (two females and two males), all holding doctoral degrees in public health or psychology. Each interview lasted approximately 45–60 minutes and was conducted in a private setting at the participants’ workplace to ensure confidentiality and comfort. Interviews followed a semi-structured guide that explored participants’ roles and experiences in implementation, perceptions of the intervention, encountered challenges, adaptation strategies, and suggestions for improvement. To reduce social desirability bias, interviewers were not in any supervisory role relative to the participants. Prior to each interview, researchers explained the purpose and procedures of the study and obtained written informed consent, including permission to audio-record the interviews. Participants were assured that their responses would be kept confidential and used only for research purposes. This study protocol was approved by the Institutional Review Boards at the University of South Carolina (Protocol# Pro00099388) and the Guangxi Center for Disease Control and Prevention (Protocol# GXIRB2020-39-1). Data collection All interviews were audio-recorded and transcribed verbatim using Feishu, a digital tool capable of transcribing audio files into written text in simplified Mandarin. Transcriptions were reviewed and verified by the original interviewers and cross-checked by additional team members to ensure accuracy. Observation notes were also collected during fieldwork to supplement interview data. Data analysis Thematic analysis was conducted using NVivo V14.23.0. The initial coding framework was based on the interview guide and was developed through a combination of deductive and inductive approaches. Deductive codes were informed by predefined domains of interest (e.g., communication approaches, implementation processes, and associated strengths and challenges, while inductive codes captured emerging concepts and contextual nuances. Coding was conducted iteratively by a team of two analysts, with regular meetings held to resolve discrepancies and refine code definitions. Final themes were synthesized to provide a nuanced understanding of communication practices and their influence on intervention implementation. Credibility was ensured through triangulation of interview data and field notes, and consensus-based coding practices among analysts. Results Sample characteristics Among the 14 participants, 11 (78.6%) were female. The participants were primarily site-level healthcare providers (8, 57.1%), followed by 4 (28.6%) site-level clinical administrators and 2 (14.3%) central-level (Provincial CDC) coordinators. Participants had an average of 13.36 years ( SD = 9.34) of experience in HIV-related services. These participants had collectively provided critical insights on how the intervention implementation of a resilience-based stigma reduction intervention was shaped by the following two communication approaches, i.e., Top-Down approach and Bottom-Up approach Top-Down approach: structured oversight and directed support Strategic decision-making and timely feedback A key function of the Top-Down approach was the central team’s role in high-level planning and decision-making, which formed the operational backbone of the intervention across heterogeneous sites. Rather than issuing abstract or generic guidance, the central team engaged in strategic communication to coordinate concrete deployment plans. This included group structuring, timeline coordination, and resource allocation, all tailored based on each site’s logistical constraints, implementation capacity, and past performance. These efforts aimed to maximize both efficiency and equity across sites. As one of the central level project coordinators shared, “ As a manager, when forming groups of intervention, I will consider the capabilities and characteristics of each location to ensure the balance across all teams.” In addition to upfront planning, the central team maintained the ability to identify/correct site-level deviations and respond quickly to emerging issues, made possible through ongoing communication channels. Real-time data on progress, such as recruitment figures or timeline delays, were monitored and acted upon. For example, in response to some unanticipated recruitment challenges in one site, the central team swiftly adjusted the sampling scheme and redistributed part of the recruitment task to another site, where it was completed within a week. As noted by the central level project coordinator, “ One unexpected challenge was that the sample size in [one site] was lower than expected… Consequently, we decided to adjust the sample target and add some in [another site], which completed the [additional] recruitment in one week. ” This case illustrates how timely responsiveness was not only possible but built into the system. Such adjustments were supported by a multi-level feedback mechanism designed to ensure continuous information flow between the central and site levels. This included formal channels such as progress reports, performance tracking, and site visits, as well as informal means such as phone calls and messaging on WeChat (a popular Chinese communication app with functions of instant messaging and social networking). These feedback loops allowed the central team to stay attuned to both quantitative indicators and qualitative nuances. Importantly, the effectiveness of these feedback channels relied on the early-stage communication efforts to establish interpersonal relationships. Central level project coordinators emphasized the value of investing time in establishing rapport with local implementers in project sites. As another central level project coordinator explained, “ During the project handover process, for example, between me and the central director, I had to understand a lot of things in the early stage, including the contact information of each project site. I had to get this information. Then, I must follow her to each site to get to know the clinical section chief and staff, so that communication will be more convenient later. I think this link is very important and critical. ” Such deliberate relationship-building in the pre-implementation stage laid the groundwork for more efficient and trusted communication later in the implementation. Through a combination of formal planning, real-time communication, and trust-based feedback, the Top-Down approach functioned not merely as a control structure but as a coordinated communication system that maintained momentum while responding adaptively to local needs. On-site supervision and tailored guidance Another key function of the Top-Down pathway was on-site supervision by central level project coordinators. These on-site supervisions served as a direct, embodied form of communication, extending far beyond basic monitoring. Supervisors engaged face-to-face with local implementers, observed operations in real time, and provided context-specific, bidirectional communication that addressed both technical and adaptive challenges. For instance, a central team member would conduct quality checks, including reviewing whether data forms were complete, verifying adherence to protocols, and troubleshooting barriers to delivery. As one central level project coordinators noted, “ I may be able to provide some standardized operating procedures or check the data on site, such as whether the data is complete and whether the data quality meets the standards. ” These issues also functioned as a form of real-time communicative accountability. In cases where local activities stalled or deviated from the protocol, central level project coordinators could proactively intervene and redirect focus. One central level project coordinator highlighted the importance of active engagement, stating, “ And we need to go to the site frequently and point out problems in a timely manner, so that they can know their own shortcomings. ” Physical presence allowed supervisors to observe early signs of implementation lag, such as limited mobilization or delays in training, and initiate corrective actions. “ If certain sites say they’re planning to implement [the project] but there is no progress, then you have to proactively follow up with them. Some teams might reach out to you on their own, but others won’t. In those cases, it’s up to you to take the initiative and check in. ” Beyond technical oversight, these site visits were often interpreted by local implementers as a form of symbolic and emotional communication, a gesture of recognition and encouragement in resource-constrained settings where implementers felt stretched or isolated. One participant reflected, “ By the third session, Director XX had personally attended. This was in-person training for medical doctors and improving intervention work in the towns… Her guidance helped us better align the content with PWH’s actual lived experiences. ” The presence of leadership helped validate local efforts and inspired stronger alignment with the project goals. However, practical constraints such as limited staffing and broad geographic coverage meant that consistent supervision across all sites at the same time was not feasible, particularly during the early stages. The stepped-wedge study design of the intervention project rolled out the intervention in staggered phases. This allowed senior supervisors to attend each site sequentially, dedicating more time and attention to each implementation wave. As one central level project coordinator described, “ In the projects that are being carried out [in multiple sites] at the same time, I can only go to one or two sites in person and cannot cover all places. The echelon intervention method allows me to go to the counties one by one to participate in the guidance. ” This supervision structure, which combined interpersonal communication, timely feedback, and iterative learning, ensured that even within resource limits, sites could benefit from quality guidance and adaptive leadership. Capacity building and knowledge exchange In addition to direct oversight, the central team played a critical role in cultivating cross-site communication and learning through structured workshops and training sessions. These sessions served not only as technical training but also as intentional platforms for communication and knowledge exchange, where teams from different localities could share challenges, lessons, and adaptation strategies. The workshops brought together diverse actors like clinicians, outreach workers, and site coordinators, who otherwise operated in silos, and created space for collaborative problem-solving. Crucially, the workshops emphasized peer-to-peer communication. Early implementing teams were encouraged to reflect on their experiences and communicate practical insights to later cohorts. “ We can continuously summarize experience during the implementation process and provide useful suggestions to subsequent teams, thereby improving the quality of intervention. ” In this way, field-based wisdom was leveraged to guide others, reducing duplication of mistakes and accelerating learning curves. Communication extended beyond verbal sharing. Teams reviewed actual intervention materials, including recorded sessions and training outlines, from other sites. This multimodal communication enabled local teams to visualize concrete practices and evaluate their relevance. As a central level project coordinator described, “ I listened to [site]’s intervention group recordings... I will consider having them and share their approach with other sites for reference. ” The stepped-wedge rollout model further facilitated this staggered communication infrastructure. While the early clusters benefited from the intensive and comprehensive intervention delivery training that took place immediately before the implementation, later cohorts benefited directly from the accumulated knowledge of earlier groups. As noted by one local implementer, “ Later cohorts will surely perform better than the first because they can learn from previous successes and challenges. ” Another echoed, “ We can also learn from the experience and lessons of the previous echelon to guide the next echelon to better carry out interventions. ” By embedding structured and participatory communication approaches into the implementation system, the Top-Down strategy supported not only technical competency but also a sense of collective growth, shared learning, and evolving dialogue across the implementation network. Informing the implementation of the following sites As the intervention trial progressed, the central team shifted focus from timely delivery to experience sharing across clusters. Communication became a central tool in this transition for both sharing technical knowledge and translating localized insights into standardized practices that could be adopted elsewhere. Effective communication across sites and implementation waves was essential for identifying which practices, particularly those developed through frontline innovation, had proven effective across settings and could be standardized for broader dissemination. Successful local adaptations, such as outreach techniques or peer-led facilitation strategies, were documented and gradually transformed into implementation templates. These practices were then embedded into official communication materials, including training manuals and standard operating procedures, ensuring their relevance extended beyond the originating sites. At the same time, the team conducted capacity assessments to evaluate each site’s readiness for expansion and determine the level of support required to maintain fidelity. The capacity building workshops, which included progress evaluation and booster training, also played an expanded role at this stage. In addition to facilitating experience sharing, they became a vehicle for codifying best practices and transferring them to future implementers. As one local implementer noted, “ Tomorrow is a training day, so we will definitely ask [site] people to share their experience. The team after [site] will definitely do better...because they will learn more methods and techniques, as well as communication and exchange skills. ” This shift illustrates how peer experience was formalized into a structured process for guiding subsequent clusters. Nonetheless, participants emphasized that the effectiveness of implementation in later clusters would be affected by the quality of experience sharing from the early cluster. As one local implementer cautioned, “ It can serve as a good demonstration. In this way, the second and third clusters can learn from their experience and do better. But if the first wave's sites do not report the implementation in detail, the second and third wave's sites will not get enough help. ” This underscores the importance of communicative fidelity, which is the ability to clearly articulate and document lessons, rather than simply perform well. Thus, the Top-Down strategy was not just about coordination, but a process of communicative translation and selective replication, grounded in early implementation experience. Yet, the success of implementation did not rely on central leadership alone. Frontline teams also played a crucial role through the Bottom-Up approach. Bottom-Up approach: local engagement and adaptive practices Identifying and framing local challenges Loca implementers, including outreach workers, nurses, and site coordinators, were often the first to observe mismatches between intervention activities and community realities. Through their daily interactions with participants, they engaged in situated and relational communication that identified subtle but consequential implementation challenges that would not have been immediately visible through formal reporting. These included linguistic barriers due to local dialects, disengagement stemming from conflicting work schedules, and participant resistance rooted in persistent stigma and distrust. Unlike structured data, these insights typically emerged from informal communication, including casual conversations, participant behavior, or patterns such as repeated dropouts from intervention sessions. Implementers’ deep familiarity with local norms enabled them to recognize when intervention content failed to resonate with their audience. For example, the original intervention curriculum used gardening as an example of stress reduction strategies. One local implementer recalled the issue that was corrected during the implementation, “ For urban retirees, gardening might relieve stress, but for rural participants already engaged in farming, it is not an everyday appropriate example. ” Such reflections highlight how communicative relevance, how well content “speaks” to participants’ realities, was critical to program engagement. Despite their observational acuity, many local implementers lacked structured tools to analyze and communicate the challenges upward. Most relied on personal intuition or informal peer discussion through channels like WeChat groups rather than structured methods such as root cause analysis or needs assessment. As a result, they could flag that something wasn’t working, but struggled to explain why, or to distinguish isolated incidents from broader trends. This made it difficult for implementation issues to be communicated upward in a form that could inform program-wide decision-making. Moreover, the absence of shared frameworks across sites led to inconsistencies in problem interpretation. What one team described as a content mismatch, another might attribute to facilitation style or group composition. These divergent diagnoses limited opportunities for cross-site coordination and collective learning. This suggests that while front-line insight was essential, it required stronger communication systems for interpretation, prioritization, and upward communication to be fully leveraged. In short, the front line served as the intervention’s sensory system, highly perceptive but in need of better analytical tools and communication pathways to convert observations into systemic improvements. To keep interventions moving forward, local teams often devised their own solutions in real time. Generating local solutions Faced with immediate challenges, many site teams responded with context-specific, self-directed solutions. These strategies were typically not instructed from above but emerged organically from implementers’ understanding of their communities. They often arose from direct communication with participants and informal exchanges among team members. Teams modified group schedules to accommodate agricultural work schedules, adjusted facilitation styles to engage older participants, and substituted abstract content with relatable examples drawn from local life. Local implementers also mobilized informal community-based communication resources to enhance intervention credibility and participation. For instance, respected figures such as retired cadres, teachers, or local elders were enlisted to bridge the gap between implementers and skeptical participants. This was especially helpful in locations where HIV stigma remained pronounced. Low-cost, culturally appropriate incentives (such as small prizes for participation) played an important role in fostering trust and encouraging engagement, particularly during the early stages. As one director described, “ The idea of those small prizes was also their own... The patients seemed to be quite active and actively answered those questions. The participation rate was quite high. I think it was mainly due to the small prizes they gave away ”. Teams also adapted specific intervention activities to better fit the physical and emotional profiles of participants. For example, one site modified warm-up exercises originally designed for younger groups to better suit older adults. These changes helped participants feel more included and maintained group energy. However, because most of these adaptations were undocumented and remained confined to local practice, the strategies might not be shared with other teams or codified for future use if they were not mentioned in workshops or cross-site communications. While these strategies demonstrated remarkable creativity and responsiveness, their implementation often depended on the initiative of individual team members rather than institutionalized support. Without structured mechanisms to capture and disseminate successful innovations, many effective solutions remained invisible to the broader program network. This highlights both the strength and fragility of the Bottom-Up approach: its adaptability and creativity are invaluable, but without integration into the broader communication infrastructure, their impact can remain limited and uneven. While many of these solutions stayed localized, some were communicated upward through reporting mechanisms, linking site-level improvisation with centralized oversight. Reporting and feedback The reporting mechanism served as an important channel for conveying site-level insights to the central implementation team. Across sites, a combination of formal and informal methods, including monthly reports, WeChat updates, phone calls, and in-person meetings, was used to document progress and challenges. These mechanisms were intended not only to track intervention activities but also to support timely communication, allow for troubleshooting, and inform strategy refinement at higher levels. In practice, reporting implementation varied across sites. Some teams took initiatives to document local adaptations and reflect on their experiences in detail, while others focused more on fulfilling routine reporting requirements. A commonly noted challenge was the lack of clarity around communication expectations; some implementers were unsure whether to prioritize logistical updates, participant feedback, or reflections on local adjustments. This variation led to differences in how comprehensive and useful the submitted reports were for decision-making. The degree of responsiveness from the central team also shaped how implementers perceived the reporting process. In some cases, field teams were uncertain whether their updates had been reviewed or whether their input had informed any follow-up decisions. While the system enabled information flow, feedback loops were sometimes perceived as incomplete. That said, there were also instances where field-level reporting contributed directly to adjustment and support. As one local implementer recalled, “ While seeking leadership support... I carefully explained the situation and why this change was needed. In the end, Director XX acknowledged its value for our team and offered his support. ” These moments illustrate how upward communication, when clearly articulated and grounded in local context, could be recognized and acted upon. As one central level project coordinator reflected, “ I believe it is important to give the team more flexibility... For instance, when [site] informed us they couldn’t complete the March training as planned, we accommodated their needs and adjusted the schedule to maintain work quality.. ” This perspective highlights the value of maintaining a balance between responsiveness and oversight within the reporting structure and the importance of open, two-way communication. Overall, while the reporting and feedback system played a valuable role in linking field insights to centralized coordination, its impact depended on how clearly expectations were communicated, how consistent responses were provided, and how much space was created for mutual understanding and dialogue. Beyond formal reporting, local teams also built flexible and informal systems of collaboration and learning, further shaping how challenges were addressed on the ground. Dynamic team formation and informal learning In addition to formal roles and responsibilities, local implementation often relied on spontaneously formed, cross-functional teams. These temporary configurations, composed of outreach workers, clinicians, peer counselors, and data staff, emerged in response to immediate operational challenges. Whether to boost follow-up rates or troubleshoot dropouts, these flexible teams allowed for rapid communication, collaboration, and problem-solving. As one central level project coordinator explained, “ In the process of recruitment, it was necessary to adapt the strategies in response to the challenges that arose. ” These dynamic collaborations were accompanied by informal learning processes such as peer observation, peer coaching, mock delivery sessions, and improvised role-play. These practices allowed team members to test facilitation strategies, refine content delivery, and troubleshoot anticipated participant reactions before conducting actual sessions. One local implementer recalled, “ It wasn’t until the first mock lecture that we realized some parts were quite difficult to articulate. ” These exercises functioned as low-stakes communication rehearsals, enabling problem detection and team-based revision. Mock delivery session along with peer coaching emerged as a particularly valuable tool for improving confidence and consistency among implementers, especially those new to the intervention or less experienced with public speaking. Though not formally required, it became a practical way for almost all teams to prepare, revise, and adapt content to suit their audience through internal team communication. However, these practices were rarely institutionalized. Their success often depended on the initiative of particular central level project coordinators and local implementers. Without documentation or integration into the official workflow, these innovations remained temporary, localized, and difficult to scale. The new team member had limited access to these learning spaces unless explicitly included, and valuable team knowledge risked being lost in transitions. These informal communication and learning systems were a powerful asset within the Bottom-Up structure, but to be sustained and leveraged program-wide, they require mechanisms for capture, recognition, and integration. Taken together, these Bottom-Up practices completed the Top-Down strategies by ensuring that the intervention remained responsive and contextually grounded. The dynamic interplay between these two communication pathways was central to sustaining implementation in resource-limited settings. Discussion This study highlights communication as a central approach that shaped the implementation process of a resilience-based stigma reduction intervention in resource-limited settings. Rather than serving as a background function, communication actively structured the way that project implementers identified challenges, generated solutions, and developed and strengthened coordination across time and sites. Two interrelated communication pathways, Top-Down and Bottom-Up, were embedded in daily implementation practices and interacted dynamically. Communication occurred across multiple levels: within teams, across sites, and between local and central actors. It took diverse forms, including WeChat messaging, field visits, formal reports, mock delivery sessions, and capacity-building workshops. These exchanges fulfilled multiple functions, ranging from technical coordination and strategic guidance to emotional support and team morale boosting. The Top-Down approach provided the structure, oversight, and technical reinforcement needed to guide implementation. Meanwhile, the Bottom-Up approach offered local responsiveness and adaptive creativity that grounded the intervention in real-world conditions. Communication thus played critical roles in all phases of implementation: identifying barriers, co-developing solutions, refining team processes, and facilitating sustained engagement across the system. Top-Down communication facilitated centralized planning, technical guidance, and strategic oversight. It encompassed formal channels such as written reports, structured check-ins, WeChat updates, and supervisory site visits. Regional workshops also served as spaces for coordinated training, dissemination of guidelines, and experience-sharing across sites. The strengths of this approach included timely troubleshooting, technical standardization, and efficient dissemination of programmatic changes. Particularly when trust had been built between central and local actors, feedback and support were perceived as collaborative rather than Top-Down enforcement ( 13 ). However, limitations also emerged. Supervisors often faced constraints in bandwidth and travel capacity, resulting in infrequent site visits. In some cases, implementers perceived feedback as one-directional or overly formal, reducing its perceived utility. To address these issues, this study recommends building phased and flexible supervision structures that align with intervention rollout. Documentation processes can be improved by creating semi-structured forms that allow both quantitative tracking and qualitative feedback. Institutionalizing opportunities for peer-to-peer mentoring, for example, implementers in early sites visiting later sites, can enhance the value of Top-Down learning while reducing the burden on central teams. Bottom-Up communication enabled implementers to adapt intervention content in response to contextual realities and participant needs ( 14 ). These innovations and adaptations were often sparked by daily interactions, informal reflections, or team discussions. Much of the local knowledge circulated via WeChat groups, ad-hoc meetings, or site-level chats. These channels supported rapid problem-solving and fostered a sense of team autonomy ( 15 ). However, without structured mechanisms for documenting and reporting these insights, many of these innovations remained isolated to individual sites. The reliance on individual initiative also meant that not all implementers engaged in reflective practice or felt confident to share adaptations. Future practice should build mechanisms to formalize and elevate local insights. This could include simplified adaptation templates, team debrief protocols, and periodic horizontal dialogues across sites. Training implementers in how to reflect on and articulate adaptation rationales would further enhance the visibility and transferability of these grassroots solutions ( 16 ). During the practical implementation process, the stepped-wedge design of the broader trial provided structural support for both Top-Down and Bottom-Up communication ( 17 ). By rolling out the intervention sequentially across sites, the design created natural pauses for learning, refinement, and support. Earlier sites served as pilot hubs whose experiences were shared with subsequent sites through slide decks, workshop discussions, and annotated WeChat messages. This sequencing enabled central directors to allocate resources more effectively, such as scheduling supervisory visits and tailored coaching. It also opened up space for horizontal learning, with earlier implementers often stepping into mentorship roles for new teams. The stepped-wedge structure allowed time for iterative adjustments, increased the visibility of challenges, and reinforced a culture of collective learning. Building upon these advantageous features of this design, the implementation became a living process shaped by ongoing feedback and shared adaptation across time. This study underscores the importance of conceptualizing communication not merely as a facilitative tool but as a core operational system in implementation science. In complex, real-world interventions, especially in resource-constrained settings, the success of implementation depends on how communication systems are designed, maintained, and adapted across contexts and levels. Researchers and practitioners should pay close attention to the infrastructure and quality of communication across levels. This includes examining how formal and informal communication channels operate, how relational trust is built, and how the emotional needs of implementers are addressed through various channels and types of communication, particularly in the digital age when social media products and platforms are shaping the approach of communications and information exchange. In this study, WeChat served as a crucial bridge not only for coordination but also for reassurance, feedback, and informal peer support. Future research should explore how to transform successful informal practices such as digital messaging groups, peer rehearsals, and reflective conversations into scalable communication strategies. Doing so will strengthen implementation fidelity, promote equity in adaptation, and support more resilient delivery systems in public health interventions. This study has several limitations. First, interviews were conducted post-implementation, raising the possibility of recall bias, particularly regarding early-stage challenges. Second, the study did not systematically collect participant-level perspectives from people with HIV or family members, which may have provided additional insight into how communication shaped their engagement with the intervention. Finally, the study was conducted within a single geographic region (Guangxi, China), which may limit the generalization of findings to other cultural or organizational contexts. Conclusions This study demonstrates that communication is a core operational system in dynamic intervention implementation, shaping how challenges are identified, solutions are developed, and practices are sustained over time. Top-Down communication facilitated strategic alignment, oversight, and capacity-building, while Bottom-Up communication fostered local adaptation, responsiveness, and creativity. Their interaction was critical for balancing fidelity with adaptation, particularly within a stepped-wedge design that encouraged iterative learning across sites. Future interventions should move beyond treating communication as a background process and instead design explicit systems to strengthen documentation, feedback loops, and peer learning. By embedding robust communication systems, public health interventions can achieve more equitable, adaptable, and sustainable implementation in resource-limited settings. Declarations Ethics approval and consent to participate This study protocol was reviewed and approved by the Institutional Review Board of the University of South Carolina (Protocol #Pro00099388) and the Guangxi Center for Disease Control and Prevention (Protocol #GXIRB2020-39-1). All participants provided informed consent prior to participation, and they were assured that their responses would remain confidential and be used solely for research purposes. Consent for publication Not applicable. Availability of data and materials The data that support the findings of this study are available on request from the corresponding author. Competing interests The authors declare that they have no competing interests. Funding Research reported in this publication was supported by the National Institute of Mental Health of the National Institutes of Health under Award Number R01MH127961. Authors' contributions M.S. conducted the data analysis, drafted the original manuscript, and contributed to review and editing. A.I. assisted with drafting the manuscript and participated in the review process. X.L. contributed to the conceptualization and methodology development and was involved in reviewing and editing. S.Q. provided overall conceptualization, supervision, and critical review of the manuscript. All authors read and approved the final version. Acknowledgements Research reported in this publication was supported by the National Institute of Mental Health of the National Institutes of Health under Award Number R01MH127961. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The authors would like to thank other team members and collaborators, including Drs. Cheuk Chi Tam, Sayward Harrison, Xueying Yang, and Fanghui Shi from the University of South Carolina for their contribution to the study design, interview guideline development. We would especially thank Cuihong Huang for her contribution to transcribing and data cleaning for this study. References Johnson NL, Van Tiem J, Balkenende E, Jones D, Friberg JE, Chasco EE, et al. Gaps in communication theory paradigms when conducting implementation science research: qualitative observations from interviews with administrators, implementors, and evaluators of rural health programs. Implementation Science. 2024;19(1):66. Zhao X, Toronjo H, Shaw CC, Murphy A, Taxman FS. Perceived communication effectiveness in implementation strategies: a measurement scale. Implementation Science Communications. 2022;3(1):38. Keane L, Kite J, Grunseit A, Vineburg J, Tawil V, Thomas M. “Perceived fit,”“understanding,” and “communication”: Key factors underpinning stakeholder and partnership engagement with the Make Healthy Normal campaign. Health Promotion Journal of Australia. 2021;32(1):117-25. Juskevicius LF, Luz RA, da Silva Felix AM, Timmons S, Padoveze MC. Lessons learned from a failed implementation: Effective communication with patients in transmission-based precautions. American Journal of Infection Control. 2023;51(6):687-93. Manojlovich M, Squires JE, Davies B, Graham ID. Hiding in plain sight: communication theory in implementation science. Implementation Science. 2015;10(1):58. Luig T, Asselin J, Sharma AM, Campbell-Scherer DL. Understanding implementation of complex interventions in primary care teams. The Journal of the American Board of Family Medicine. 2018;31(3):431-44. Jordan ME, Lanham HJ, Crabtree BF, Nutting PA, Miller WL, Stange KC, McDaniel Jr RR. The role of conversation in health care interventions: enabling sensemaking and learning. Implementation Science. 2009;4(1):15. Walton H, Crellin N, Litchfield I, Sherlaw-Johnson C, Georghiou T, Massou E, et al. Applying the major system change framework to evaluate implementation of rapid healthcare system change: a case study of COVID-19 remote home monitoring services. Implementation science communications. 2025;6(1):24. Walton OE, Davies T, Thrandardottir E, Keating VC. Understanding Contemporary Challenges to INGO Legitimacy: Integrating Top-Down and Bottom-Up Perspectives. VOLUNTAS: International Journal of Voluntary and Nonprofit Organizations. 2016;27(6):2764-86. Pérez D, Van der Stuyft P, Zabala MdC, Castro M, Lefèvre P. A modified theoretical framework to assess implementation fidelity of adaptive public health interventions. Implementation Science. 2015;11:1-11. Movsisyan A, Arnold L, Evans R, Hallingberg B, Moore G, O’Cathain A, et al. Adapting evidence-informed complex population health interventions for new contexts: a systematic review of guidance. Implementation Science. 2019;14:1-20. Li X, Qiao S, Yang X, Harrison SE, Tam CC, Shen Z, Zhou Y. A resilience-based intervention to mitigate the Effect of HIV-Related Stigma: protocol for a stepped Wedge Cluster Randomized Trial. Frontiers in Public Health. 2022;10:857635. Mosier S. Does the gown help the town? Examining town–gown relationship influence on local environmental sustainability in the United States. International Journal of Public Administration. 2015;38(11):769-81. Urbancová H, Vrabcová P, Pacáková Z. Communication from below: Feedback from employees as a tool for their stabilisation. Heliyon. 2024;10(7):e28287. Tang Y, Hew KF. Does mobile instant messaging facilitate social presence in online communication? A two-stage study of higher education students. International Journal of Educational Technology in Higher Education. 2020;17(1):15. Carr ER, Nalau J. Adaptation rationales and benefits: A foundation for understanding adaptation impact. Climate risk management. 2023;39:100479. Hemming K, Haines TP, Chilton PJ, Girling AJ, Lilford RJ. The stepped wedge cluster randomised trial: rationale, design, analysis, and reporting. Bmj. 2015;350:h391. Supplementary Files SRQRChecklist.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 12 Jan, 2026 Reviewers invited by journal 08 Oct, 2025 Editor assigned by journal 25 Sep, 2025 First submitted to journal 23 Sep, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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strategies, such as feedback loops, peer mentoring, and timely documentation, that could strengthen sustainability in future public health interventions.\u003c/p\u003e"},{"header":"Background","content":"\u003cp\u003eCommunication is a critical driver of successful intervention implementation. It serves not only as a conduit for delivering information but also as a mechanism for shaping stakeholder engagement, fostering collective understanding, and building support for change (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Most implementation strategies, whether in the form of training, supervision, service provision, or education, rely on deliberate communication processes to introduce new practices and align actors around shared goals (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Beyond information delivery, communication processes actively influence how interventions are perceived in terms of feasibility, acceptability, and appropriateness (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Recent studies have emphasized that inadequate or poorly structured communication is a common contributor to implementation failure (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eA growing body of implementation science literature highlights communication as a foundational mechanism shaping intervention delivery (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). While often not the central focus, communication is embedded, either explicitly or implicitly, within many theoretical frameworks. A systematic review of 27 implementation theories and frameworks found that nearly 60% referenced communication as a critical factor shaping implementation outcomes, emphasizing its structural role in guiding intervention processes (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Some models conceptualize communication narrowly, as the transfer of information across hierarchical levels. Others, however, frame it as a dynamic and interactive process that enables coordination, collective understanding, and trust-building across implementation teams (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eDespite its embeddedness, communication remains an underexplored determinant of implementation success. Its role is often backgrounded or taken for granted, limiting insight into how communication approaches influence real-time decision-making and cross-level learning (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Scholars have criticized this oversight, arguing that the treatment of communication as a neutral conduit fails to capture its relational and interpretive dimensions, factors that are especially critical in complex, community-based interventions (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eWithin this discourse, two predominant communication approaches have been identified: Top-Down and Bottom-Up approaches. Top-down strategies emphasize centralized oversight, structured messaging, and fidelity to intervention protocols, while Bottom-Up strategies prioritize the agency of frontline implementers in shaping how interventions unfold on the ground. The former enables consistency and alignment with core program objectives, whereas the latter enhances contextual fit and ownership through localized problem-solving (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Rather than treating these approaches as oppositional, recent scholarship advocates for integrative models that balance centralized guidance with frontline flexibility (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eHowever, studies examining how these approaches interact during real-world implementation remain limited. Many of the existing implementation science studies lacked details on the operational dynamics of communication in real-world delivery settings. To address this gap, the current study examines how Top-Down and Bottom-Up communication approaches were employed during the implementation of a multicomponent, community-based HIV stigma reduction intervention in rural China (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e), and how these approaches shaped implementation processes and supported sustainable delivery.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eStudy setting\u003c/p\u003e\u003cp\u003eThis qualitative study was conducted in the Guangxi Zhuang Autonomous Region, one of the regions in China with the fastest-growing HIV epidemic. The research was embedded within the RISE-Up project (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). The RISE-UP project was a multimodal resilience-based stigma reduction and mitigation intervention designed to support PWH, their family members, and healthcare providers in terms of clinical outcomes, psychosocial well-being, and quality of life through promoting social support for PWH and fostering resilience among this population. The project was conducted in 40 community-based HIV clinics or treatment centers (\u0026ldquo;HIV clinics\u0026rdquo;) from 11 sites (2 urban cities and 9 rural counties) in Guangxi, China. Based on a stepped wedge cluster randomized clinical trial, the 11 sites were grouped into 5 clusters to implement the intervention in a random order (i.e., at different waves 6 months apart). Since most participating HIV clinics were affiliated with local Centers for Disease Control and Prevention (CDC) at each site, the provincial CDC played an important role in project coordination and implementation. At each participating clinic, CDC staff and local implementers, including doctors, nurses, and HIV case managers, received training to deliver the intervention based on standardized curricula and protocols.\u003c/p\u003e\u003cp\u003eParticipants\u003c/p\u003e\u003cp\u003eA total of 14 participants were recruited, including 2 provincial CDC project coordinators and 12 local project facilitators (local implementers) from 7 clinics in 2 project sites that had completed the intervention delivery at the time of the interview in April 2024. Inclusion criteria include (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) 18 years or older; and (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) currently working for the RISE-Up project, planning, implementing, administering, or managing any aspect of the intervention study. Recruitment was conducted by the University of South Carolina (USC) research team, in collaboration with the Guangxi Provincial CDC.\u003c/p\u003e\u003cp\u003eProcedures\u003c/p\u003e\u003cp\u003eIn-depth individual interviews were conducted by a team of four trained qualitative researchers (two females and two males), all holding doctoral degrees in public health or psychology. Each interview lasted approximately 45\u0026ndash;60 minutes and was conducted in a private setting at the participants\u0026rsquo; workplace to ensure confidentiality and comfort. Interviews followed a semi-structured guide that explored participants\u0026rsquo; roles and experiences in implementation, perceptions of the intervention, encountered challenges, adaptation strategies, and suggestions for improvement. To reduce social desirability bias, interviewers were not in any supervisory role relative to the participants. Prior to each interview, researchers explained the purpose and procedures of the study and obtained written informed consent, including permission to audio-record the interviews. Participants were assured that their responses would be kept confidential and used only for research purposes. This study protocol was approved by the Institutional Review Boards at the University of South Carolina (Protocol# Pro00099388) and the Guangxi Center for Disease Control and Prevention (Protocol# GXIRB2020-39-1).\u003c/p\u003e\u003cp\u003eData collection\u003c/p\u003e\u003cp\u003e All interviews were audio-recorded and transcribed verbatim using Feishu, a digital tool capable of transcribing audio files into written text in simplified Mandarin. Transcriptions were reviewed and verified by the original interviewers and cross-checked by additional team members to ensure accuracy. Observation notes were also collected during fieldwork to supplement interview data.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eData analysis\u003c/h2\u003e\u003cp\u003eThematic analysis was conducted using NVivo V14.23.0. The initial coding framework was based on the interview guide and was developed through a combination of deductive and inductive approaches. Deductive codes were informed by predefined domains of interest (e.g., communication approaches, implementation processes, and associated strengths and challenges, while inductive codes captured emerging concepts and contextual nuances. Coding was conducted iteratively by a team of two analysts, with regular meetings held to resolve discrepancies and refine code definitions. Final themes were synthesized to provide a nuanced understanding of communication practices and their influence on intervention implementation. Credibility was ensured through triangulation of interview data and field notes, and consensus-based coding practices among analysts.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eSample characteristics\u003c/p\u003e\u003cp\u003eAmong the 14 participants, 11 (78.6%) were female. The participants were primarily site-level healthcare providers (8, 57.1%), followed by 4 (28.6%) site-level clinical administrators and 2 (14.3%) central-level (Provincial CDC) coordinators. Participants had an average of 13.36 years (\u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;9.34) of experience in HIV-related services. These participants had collectively provided critical insights on how the intervention implementation of a resilience-based stigma reduction intervention was shaped by the following two communication approaches, i.e., Top-Down approach and Bottom-Up approach\u003c/p\u003e\u003cp\u003eTop-Down approach: structured oversight and directed support\u003c/p\u003e\n\u003ch3\u003eStrategic decision-making and timely feedback\u003c/h3\u003e\n\u003cp\u003eA key function of the Top-Down approach was the central team\u0026rsquo;s role in high-level planning and decision-making, which formed the operational backbone of the intervention across heterogeneous sites. Rather than issuing abstract or generic guidance, the central team engaged in strategic communication to coordinate concrete deployment plans. This included group structuring, timeline coordination, and resource allocation, all tailored based on each site\u0026rsquo;s logistical constraints, implementation capacity, and past performance. These efforts aimed to maximize both efficiency and equity across sites. As one of the central level project coordinators shared, \u0026ldquo;\u003cem\u003eAs a manager, when forming groups of intervention, I will consider the capabilities and characteristics of each location to ensure the balance across all teams.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003cp\u003eIn addition to upfront planning, the central team maintained the ability to identify/correct site-level deviations and respond quickly to emerging issues, made possible through ongoing communication channels. Real-time data on progress, such as recruitment figures or timeline delays, were monitored and acted upon. For example, in response to some unanticipated recruitment challenges in one site, the central team swiftly adjusted the sampling scheme and redistributed part of the recruitment task to another site, where it was completed within a week. As noted by the central level project coordinator, \u0026ldquo;\u003cem\u003eOne unexpected challenge was that the sample size in [one site] was lower than expected\u0026hellip; Consequently, we decided to adjust the sample target and add some in [another site], which completed the [additional] recruitment in one week.\u003c/em\u003e\u0026rdquo; This case illustrates how timely responsiveness was not only possible but built into the system.\u003c/p\u003e\u003cp\u003eSuch adjustments were supported by a multi-level feedback mechanism designed to ensure continuous information flow between the central and site levels. This included formal channels such as progress reports, performance tracking, and site visits, as well as informal means such as phone calls and messaging on WeChat (a popular Chinese communication app with functions of instant messaging and social networking). These feedback loops allowed the central team to stay attuned to both quantitative indicators and qualitative nuances.\u003c/p\u003e\u003cp\u003eImportantly, the effectiveness of these feedback channels relied on the early-stage communication efforts to establish interpersonal relationships. Central level project coordinators emphasized the value of investing time in establishing rapport with local implementers in project sites. As another central level project coordinator explained, \u0026ldquo;\u003cem\u003eDuring the project handover process, for example, between me and the central director, I had to understand a lot of things in the early stage, including the contact information of each project site. I had to get this information. Then, I must follow her to each site to get to know the clinical section chief and staff, so that communication will be more convenient later. I think this link is very important and critical.\u003c/em\u003e\u0026rdquo; Such deliberate relationship-building in the pre-implementation stage laid the groundwork for more efficient and trusted communication later in the implementation.\u003c/p\u003e\u003cp\u003e Through a combination of formal planning, real-time communication, and trust-based feedback, the Top-Down approach functioned not merely as a control structure but as a coordinated communication system that maintained momentum while responding adaptively to local needs.\u003c/p\u003e\n\u003ch3\u003eOn-site supervision and tailored guidance\u003c/h3\u003e\n\u003cp\u003eAnother key function of the Top-Down pathway was on-site supervision by central level project coordinators. These on-site supervisions served as a direct, embodied form of communication, extending far beyond basic monitoring. Supervisors engaged face-to-face with local implementers, observed operations in real time, and provided context-specific, bidirectional communication that addressed both technical and adaptive challenges. For instance, a central team member would conduct quality checks, including reviewing whether data forms were complete, verifying adherence to protocols, and troubleshooting barriers to delivery. As one central level project coordinators noted, \u0026ldquo;\u003cem\u003eI may be able to provide some standardized operating procedures or check the data on site, such as whether the data is complete and whether the data quality meets the standards.\u003c/em\u003e\u0026rdquo;\u003c/p\u003e\u003cp\u003eThese issues also functioned as a form of real-time communicative accountability. In cases where local activities stalled or deviated from the protocol, central level project coordinators could proactively intervene and redirect focus. One central level project coordinator highlighted the importance of active engagement, stating, \u0026ldquo;\u003cem\u003eAnd we need to go to the site frequently and point out problems in a timely manner, so that they can know their own shortcomings.\u003c/em\u003e\u0026rdquo; Physical presence allowed supervisors to observe early signs of implementation lag, such as limited mobilization or delays in training, and initiate corrective actions. \u0026ldquo;\u003cem\u003eIf certain sites say they\u0026rsquo;re planning to implement [the project] but there is no progress, then you have to proactively follow up with them. Some teams might reach out to you on their own, but others won\u0026rsquo;t. In those cases, it\u0026rsquo;s up to you to take the initiative and check in.\u003c/em\u003e \u0026rdquo;\u003c/p\u003e\u003cp\u003eBeyond technical oversight, these site visits were often interpreted by local implementers as a form of symbolic and emotional communication, a gesture of recognition and encouragement in resource-constrained settings where implementers felt stretched or isolated. One participant reflected, \u0026ldquo;\u003cem\u003eBy the third session, Director XX had personally attended. This was in-person training for medical doctors and improving intervention work in the towns\u0026hellip; Her guidance helped us better align the content with PWH\u0026rsquo;s actual lived experiences.\u003c/em\u003e\u0026rdquo; The presence of leadership helped validate local efforts and inspired stronger alignment with the project goals.\u003c/p\u003e\u003cp\u003eHowever, practical constraints such as limited staffing and broad geographic coverage meant that consistent supervision across all sites at the same time was not feasible, particularly during the early stages. The stepped-wedge study design of the intervention project rolled out the intervention in staggered phases. This allowed senior supervisors to attend each site sequentially, dedicating more time and attention to each implementation wave. As one central level project coordinator described, \u0026ldquo;\u003cem\u003eIn the projects that are being carried out [in multiple sites] at the same time, I can only go to one or two sites in person and cannot cover all places. The echelon intervention method allows me to go to the counties one by one to participate in the guidance.\u003c/em\u003e\u0026rdquo;\u003c/p\u003e\u003cp\u003eThis supervision structure, which combined interpersonal communication, timely feedback, and iterative learning, ensured that even within resource limits, sites could benefit from quality guidance and adaptive leadership.\u003c/p\u003e\n\u003ch3\u003eCapacity building and knowledge exchange\u003c/h3\u003e\n\u003cp\u003eIn addition to direct oversight, the central team played a critical role in cultivating cross-site communication and learning through structured workshops and training sessions. These sessions served not only as technical training but also as intentional platforms for communication and knowledge exchange, where teams from different localities could share challenges, lessons, and adaptation strategies. The workshops brought together diverse actors like clinicians, outreach workers, and site coordinators, who otherwise operated in silos, and created space for collaborative problem-solving.\u003c/p\u003e\u003cp\u003eCrucially, the workshops emphasized peer-to-peer communication. Early implementing teams were encouraged to reflect on their experiences and communicate practical insights to later cohorts. \u0026ldquo;\u003cem\u003eWe can continuously summarize experience during the implementation process and provide useful suggestions to subsequent teams, thereby improving the quality of intervention.\u003c/em\u003e\u0026rdquo; In this way, field-based wisdom was leveraged to guide others, reducing duplication of mistakes and accelerating learning curves.\u003c/p\u003e\u003cp\u003e Communication extended beyond verbal sharing. Teams reviewed actual intervention materials, including recorded sessions and training outlines, from other sites. This multimodal communication enabled local teams to visualize concrete practices and evaluate their relevance. As a central level project coordinator described, \u0026ldquo;\u003cem\u003eI listened to [site]\u0026rsquo;s intervention group recordings... I will consider having them and share their approach with other sites for reference.\u003c/em\u003e\u0026rdquo;\u003c/p\u003e\u003cp\u003eThe stepped-wedge rollout model further facilitated this staggered communication infrastructure. While the early clusters benefited from the intensive and comprehensive intervention delivery training that took place immediately before the implementation, later cohorts benefited directly from the accumulated knowledge of earlier groups. As noted by one local implementer, \u0026ldquo;\u003cem\u003eLater cohorts will surely perform better than the first because they can learn from previous successes and challenges.\u003c/em\u003e\u0026rdquo; Another echoed, \u0026ldquo;\u003cem\u003eWe can also learn from the experience and lessons of the previous echelon to guide the next echelon to better carry out interventions.\u003c/em\u003e\u0026rdquo;\u003c/p\u003e\u003cp\u003e By embedding structured and participatory communication approaches into the implementation system, the Top-Down strategy supported not only technical competency but also a sense of collective growth, shared learning, and evolving dialogue across the implementation network.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eInforming the implementation of the following sites\u003c/h2\u003e\u003cp\u003eAs the intervention trial progressed, the central team shifted focus from timely delivery to experience sharing across clusters. Communication became a central tool in this transition for both sharing technical knowledge and translating localized insights into standardized practices that could be adopted elsewhere. Effective communication across sites and implementation waves was essential for identifying which practices, particularly those developed through frontline innovation, had proven effective across settings and could be standardized for broader dissemination.\u003c/p\u003e\u003cp\u003eSuccessful local adaptations, such as outreach techniques or peer-led facilitation strategies, were documented and gradually transformed into implementation templates. These practices were then embedded into official communication materials, including training manuals and standard operating procedures, ensuring their relevance extended beyond the originating sites. At the same time, the team conducted capacity assessments to evaluate each site\u0026rsquo;s readiness for expansion and determine the level of support required to maintain fidelity.\u003c/p\u003e\u003cp\u003eThe capacity building workshops, which included progress evaluation and booster training, also played an expanded role at this stage. In addition to facilitating experience sharing, they became a vehicle for codifying best practices and transferring them to future implementers. As one local implementer noted, \u0026ldquo;\u003cem\u003eTomorrow is a training day, so we will definitely ask [site] people to share their experience. The team after [site] will definitely do better...because they will learn more methods and techniques, as well as communication and exchange skills.\u003c/em\u003e\u0026rdquo; This shift illustrates how peer experience was formalized into a structured process for guiding subsequent clusters.\u003c/p\u003e\u003cp\u003eNonetheless, participants emphasized that the effectiveness of implementation in later clusters would be affected by the quality of experience sharing from the early cluster. As one local implementer cautioned, \u0026ldquo;\u003cem\u003eIt can serve as a good demonstration. In this way, the second and third clusters can learn from their experience and do better. But if the first wave's sites do not report the implementation in detail, the second and third wave's sites will not get enough help.\u003c/em\u003e\u0026rdquo; This underscores the importance of communicative fidelity, which is the ability to clearly articulate and document lessons, rather than simply perform well.\u003c/p\u003e\u003cp\u003eThus, the Top-Down strategy was not just about coordination, but a process of communicative translation and selective replication, grounded in early implementation experience. Yet, the success of implementation did not rely on central leadership alone. Frontline teams also played a crucial role through the Bottom-Up approach.\u003c/p\u003e\u003cp\u003eBottom-Up approach: local engagement and adaptive practices\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eIdentifying and framing local challenges\u003c/h3\u003e\n\u003cp\u003eLoca implementers, including outreach workers, nurses, and site coordinators, were often the first to observe mismatches between intervention activities and community realities. Through their daily interactions with participants, they engaged in situated and relational communication that identified subtle but consequential implementation challenges that would not have been immediately visible through formal reporting. These included linguistic barriers due to local dialects, disengagement stemming from conflicting work schedules, and participant resistance rooted in persistent stigma and distrust. Unlike structured data, these insights typically emerged from informal communication, including casual conversations, participant behavior, or patterns such as repeated dropouts from intervention sessions.\u003c/p\u003e\u003cp\u003eImplementers\u0026rsquo; deep familiarity with local norms enabled them to recognize when intervention content failed to resonate with their audience. For example, the original intervention curriculum used gardening as an example of stress reduction strategies. One local implementer recalled the issue that was corrected during the implementation, \u0026ldquo;\u003cem\u003eFor urban retirees, gardening might relieve stress, but for rural participants already engaged in farming, it is not an everyday appropriate example.\u003c/em\u003e\u0026rdquo; Such reflections highlight how communicative relevance, how well content \u0026ldquo;speaks\u0026rdquo; to participants\u0026rsquo; realities, was critical to program engagement.\u003c/p\u003e\u003cp\u003eDespite their observational acuity, many local implementers lacked structured tools to analyze and communicate the challenges upward. Most relied on personal intuition or informal peer discussion through channels like WeChat groups rather than structured methods such as root cause analysis or needs assessment. As a result, they could flag that something wasn\u0026rsquo;t working, but struggled to explain why, or to distinguish isolated incidents from broader trends. This made it difficult for implementation issues to be communicated upward in a form that could inform program-wide decision-making.\u003c/p\u003e\u003cp\u003eMoreover, the absence of shared frameworks across sites led to inconsistencies in problem interpretation. What one team described as a content mismatch, another might attribute to facilitation style or group composition. These divergent diagnoses limited opportunities for cross-site coordination and collective learning. This suggests that while front-line insight was essential, it required stronger communication systems for interpretation, prioritization, and upward communication to be fully leveraged.\u003c/p\u003e\u003cp\u003eIn short, the front line served as the intervention\u0026rsquo;s sensory system, highly perceptive but in need of better analytical tools and communication pathways to convert observations into systemic improvements. To keep interventions moving forward, local teams often devised their own solutions in real time.\u003c/p\u003e\n\u003ch3\u003eGenerating local solutions\u003c/h3\u003e\n\u003cp\u003eFaced with immediate challenges, many site teams responded with context-specific, self-directed solutions. These strategies were typically not instructed from above but emerged organically from implementers\u0026rsquo; understanding of their communities. They often arose from direct communication with participants and informal exchanges among team members. Teams modified group schedules to accommodate agricultural work schedules, adjusted facilitation styles to engage older participants, and substituted abstract content with relatable examples drawn from local life.\u003c/p\u003e\u003cp\u003e Local implementers also mobilized informal community-based communication resources to enhance intervention credibility and participation. For instance, respected figures such as retired cadres, teachers, or local elders were enlisted to bridge the gap between implementers and skeptical participants. This was especially helpful in locations where HIV stigma remained pronounced. Low-cost, culturally appropriate incentives (such as small prizes for participation) played an important role in fostering trust and encouraging engagement, particularly during the early stages. As one director described, \u0026ldquo;\u003cem\u003eThe idea of those small prizes was also their own... The patients seemed to be quite active and actively answered those questions. The participation rate was quite high. I think it was mainly due to the small prizes they gave away\u003c/em\u003e\u0026rdquo;.\u003c/p\u003e\u003cp\u003e Teams also adapted specific intervention activities to better fit the physical and emotional profiles of participants. For example, one site modified warm-up exercises originally designed for younger groups to better suit older adults. These changes helped participants feel more included and maintained group energy. However, because most of these adaptations were undocumented and remained confined to local practice, the strategies might not be shared with other teams or codified for future use if they were not mentioned in workshops or cross-site communications.\u003c/p\u003e\u003cp\u003eWhile these strategies demonstrated remarkable creativity and responsiveness, their implementation often depended on the initiative of individual team members rather than institutionalized support. Without structured mechanisms to capture and disseminate successful innovations, many effective solutions remained invisible to the broader program network.\u003c/p\u003e\u003cp\u003eThis highlights both the strength and fragility of the Bottom-Up approach: its adaptability and creativity are invaluable, but without integration into the broader communication infrastructure, their impact can remain limited and uneven. While many of these solutions stayed localized, some were communicated upward through reporting mechanisms, linking site-level improvisation with centralized oversight.\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eReporting and feedback\u003c/h2\u003e\u003cp\u003eThe reporting mechanism served as an important channel for conveying site-level insights to the central implementation team. Across sites, a combination of formal and informal methods, including monthly reports, WeChat updates, phone calls, and in-person meetings, was used to document progress and challenges. These mechanisms were intended not only to track intervention activities but also to support timely communication, allow for troubleshooting, and inform strategy refinement at higher levels.\u003c/p\u003e\u003cp\u003eIn practice, reporting implementation varied across sites. Some teams took initiatives to document local adaptations and reflect on their experiences in detail, while others focused more on fulfilling routine reporting requirements. A commonly noted challenge was the lack of clarity around communication expectations; some implementers were unsure whether to prioritize logistical updates, participant feedback, or reflections on local adjustments. This variation led to differences in how comprehensive and useful the submitted reports were for decision-making.\u003c/p\u003e\u003cp\u003eThe degree of responsiveness from the central team also shaped how implementers perceived the reporting process. In some cases, field teams were uncertain whether their updates had been reviewed or whether their input had informed any follow-up decisions. While the system enabled information flow, feedback loops were sometimes perceived as incomplete. That said, there were also instances where field-level reporting contributed directly to adjustment and support. As one local implementer recalled, \u0026ldquo;\u003cem\u003eWhile seeking leadership support... I carefully explained the situation and why this change was needed. In the end, Director XX acknowledged its value for our team and offered his support.\u003c/em\u003e\u0026rdquo; These moments illustrate how upward communication, when clearly articulated and grounded in local context, could be recognized and acted upon.\u003c/p\u003e\u003cp\u003eAs one central level project coordinator reflected, \u0026ldquo;\u003cem\u003eI believe it is important to give the team more flexibility... For instance, when [site] informed us they couldn\u0026rsquo;t complete the March training as planned, we accommodated their needs and adjusted the schedule to maintain work quality..\u003c/em\u003e\u0026rdquo; This perspective highlights the value of maintaining a balance between responsiveness and oversight within the reporting structure and the importance of open, two-way communication.\u003c/p\u003e\u003cp\u003e Overall, while the reporting and feedback system played a valuable role in linking field insights to centralized coordination, its impact depended on how clearly expectations were communicated, how consistent responses were provided, and how much space was created for mutual understanding and dialogue. Beyond formal reporting, local teams also built flexible and informal systems of collaboration and learning, further shaping how challenges were addressed on the ground.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eDynamic team formation and informal learning\u003c/h2\u003e\u003cp\u003eIn addition to formal roles and responsibilities, local implementation often relied on spontaneously formed, cross-functional teams. These temporary configurations, composed of outreach workers, clinicians, peer counselors, and data staff, emerged in response to immediate operational challenges. Whether to boost follow-up rates or troubleshoot dropouts, these flexible teams allowed for rapid communication, collaboration, and problem-solving. As one central level project coordinator explained, \u0026ldquo;\u003cem\u003eIn the process of recruitment, it was necessary to adapt the strategies in response to the challenges that arose.\u003c/em\u003e\u0026rdquo;\u003c/p\u003e\u003cp\u003eThese dynamic collaborations were accompanied by informal learning processes such as peer observation, peer coaching, mock delivery sessions, and improvised role-play. These practices allowed team members to test facilitation strategies, refine content delivery, and troubleshoot anticipated participant reactions before conducting actual sessions. One local implementer recalled, \u0026ldquo;\u003cem\u003eIt wasn\u0026rsquo;t until the first mock lecture that we realized some parts were quite difficult to articulate.\u003c/em\u003e\u0026rdquo; These exercises functioned as low-stakes communication rehearsals, enabling problem detection and team-based revision.\u003c/p\u003e\u003cp\u003eMock delivery session along with peer coaching emerged as a particularly valuable tool for improving confidence and consistency among implementers, especially those new to the intervention or less experienced with public speaking. Though not formally required, it became a practical way for almost all teams to prepare, revise, and adapt content to suit their audience through internal team communication.\u003c/p\u003e\u003cp\u003eHowever, these practices were rarely institutionalized. Their success often depended on the initiative of particular central level project coordinators and local implementers. Without documentation or integration into the official workflow, these innovations remained temporary, localized, and difficult to scale. The new team member had limited access to these learning spaces unless explicitly included, and valuable team knowledge risked being lost in transitions.\u003c/p\u003e\u003cp\u003eThese informal communication and learning systems were a powerful asset within the Bottom-Up structure, but to be sustained and leveraged program-wide, they require mechanisms for capture, recognition, and integration.\u003c/p\u003e\u003cp\u003eTaken together, these Bottom-Up practices completed the Top-Down strategies by ensuring that the intervention remained responsive and contextually grounded. The dynamic interplay between these two communication pathways was central to sustaining implementation in resource-limited settings.\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study highlights communication as a central approach that shaped the implementation process of a resilience-based stigma reduction intervention in resource-limited settings. Rather than serving as a background function, communication actively structured the way that project implementers identified challenges, generated solutions, and developed and strengthened coordination across time and sites. Two interrelated communication pathways, Top-Down and Bottom-Up, were embedded in daily implementation practices and interacted dynamically.\u003c/p\u003e\u003cp\u003e Communication occurred across multiple levels: within teams, across sites, and between local and central actors. It took diverse forms, including WeChat messaging, field visits, formal reports, mock delivery sessions, and capacity-building workshops. These exchanges fulfilled multiple functions, ranging from technical coordination and strategic guidance to emotional support and team morale boosting. The Top-Down approach provided the structure, oversight, and technical reinforcement needed to guide implementation. Meanwhile, the Bottom-Up approach offered local responsiveness and adaptive creativity that grounded the intervention in real-world conditions. Communication thus played critical roles in all phases of implementation: identifying barriers, co-developing solutions, refining team processes, and facilitating sustained engagement across the system.\u003c/p\u003e\u003cp\u003eTop-Down communication facilitated centralized planning, technical guidance, and strategic oversight. It encompassed formal channels such as written reports, structured check-ins, WeChat updates, and supervisory site visits. Regional workshops also served as spaces for coordinated training, dissemination of guidelines, and experience-sharing across sites. The strengths of this approach included timely troubleshooting, technical standardization, and efficient dissemination of programmatic changes. Particularly when trust had been built between central and local actors, feedback and support were perceived as collaborative rather than Top-Down enforcement (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). However, limitations also emerged. Supervisors often faced constraints in bandwidth and travel capacity, resulting in infrequent site visits. In some cases, implementers perceived feedback as one-directional or overly formal, reducing its perceived utility. To address these issues, this study recommends building phased and flexible supervision structures that align with intervention rollout. Documentation processes can be improved by creating semi-structured forms that allow both quantitative tracking and qualitative feedback. Institutionalizing opportunities for peer-to-peer mentoring, for example, implementers in early sites visiting later sites, can enhance the value of Top-Down learning while reducing the burden on central teams.\u003c/p\u003e\u003cp\u003eBottom-Up communication enabled implementers to adapt intervention content in response to contextual realities and participant needs (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). These innovations and adaptations were often sparked by daily interactions, informal reflections, or team discussions. Much of the local knowledge circulated via WeChat groups, ad-hoc meetings, or site-level chats. These channels supported rapid problem-solving and fostered a sense of team autonomy (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). However, without structured mechanisms for documenting and reporting these insights, many of these innovations remained isolated to individual sites. The reliance on individual initiative also meant that not all implementers engaged in reflective practice or felt confident to share adaptations. Future practice should build mechanisms to formalize and elevate local insights. This could include simplified adaptation templates, team debrief protocols, and periodic horizontal dialogues across sites. Training implementers in how to reflect on and articulate adaptation rationales would further enhance the visibility and transferability of these grassroots solutions (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eDuring the practical implementation process, the stepped-wedge design of the broader trial provided structural support for both Top-Down and Bottom-Up communication (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). By rolling out the intervention sequentially across sites, the design created natural pauses for learning, refinement, and support. Earlier sites served as pilot hubs whose experiences were shared with subsequent sites through slide decks, workshop discussions, and annotated WeChat messages. This sequencing enabled central directors to allocate resources more effectively, such as scheduling supervisory visits and tailored coaching. It also opened up space for horizontal learning, with earlier implementers often stepping into mentorship roles for new teams. The stepped-wedge structure allowed time for iterative adjustments, increased the visibility of challenges, and reinforced a culture of collective learning. Building upon these advantageous features of this design, the implementation became a living process shaped by ongoing feedback and shared adaptation across time.\u003c/p\u003e\u003cp\u003eThis study underscores the importance of conceptualizing communication not merely as a facilitative tool but as a core operational system in implementation science. In complex, real-world interventions, especially in resource-constrained settings, the success of implementation depends on how communication systems are designed, maintained, and adapted across contexts and levels. Researchers and practitioners should pay close attention to the infrastructure and quality of communication across levels. This includes examining how formal and informal communication channels operate, how relational trust is built, and how the emotional needs of implementers are addressed through various channels and types of communication, particularly in the digital age when social media products and platforms are shaping the approach of communications and information exchange. In this study, WeChat served as a crucial bridge not only for coordination but also for reassurance, feedback, and informal peer support. Future research should explore how to transform successful informal practices such as digital messaging groups, peer rehearsals, and reflective conversations into scalable communication strategies. Doing so will strengthen implementation fidelity, promote equity in adaptation, and support more resilient delivery systems in public health interventions.\u003c/p\u003e\u003cp\u003eThis study has several limitations. First, interviews were conducted post-implementation, raising the possibility of recall bias, particularly regarding early-stage challenges. Second, the study did not systematically collect participant-level perspectives from people with HIV or family members, which may have provided additional insight into how communication shaped their engagement with the intervention. Finally, the study was conducted within a single geographic region (Guangxi, China), which may limit the generalization of findings to other cultural or organizational contexts.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study demonstrates that communication is a core operational system in dynamic intervention implementation, shaping how challenges are identified, solutions are developed, and practices are sustained over time. Top-Down communication facilitated strategic alignment, oversight, and capacity-building, while Bottom-Up communication fostered local adaptation, responsiveness, and creativity. Their interaction was critical for balancing fidelity with adaptation, particularly within a stepped-wedge design that encouraged iterative learning across sites. Future interventions should move beyond treating communication as a background process and instead design explicit systems to strengthen documentation, feedback loops, and peer learning. By embedding robust communication systems, public health interventions can achieve more equitable, adaptable, and sustainable implementation in resource-limited settings.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate\u003c/p\u003e\n\u003cp\u003eThis study protocol was reviewed and approved by the Institutional Review Board of the University of South Carolina (Protocol #Pro00099388) and the Guangxi Center for Disease Control and Prevention (Protocol #GXIRB2020-39-1). All participants provided informed consent prior to participation, and they were assured that their responses would remain confidential and be used solely for research purposes.\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available on request from the corresponding author.\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eResearch reported in this publication was supported by the National Institute of Mental Health of the National Institutes of Health under Award Number R01MH127961.\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; contributions\u003c/p\u003e\n\u003cp\u003eM.S. conducted the data analysis, drafted the original manuscript, and contributed to review and editing. A.I. assisted with drafting the manuscript and participated in the review process. X.L. contributed to the conceptualization and methodology development and was involved in reviewing and editing. S.Q. provided overall conceptualization, supervision, and critical review of the manuscript. All authors read and approved the final version.\u003c/p\u003e\n\u003cp\u003eAcknowledgements\u003c/p\u003e\n\u003cp\u003eResearch reported in this publication was supported by the National Institute of Mental Health of the National Institutes of Health under Award Number R01MH127961. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The authors would like to thank other team members and collaborators, including Drs. Cheuk Chi Tam, Sayward Harrison, Xueying Yang, and Fanghui Shi from the University of South Carolina for their contribution to the study design, interview guideline development. We would especially thank Cuihong Huang for her contribution to transcribing and data cleaning for this study. \u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eJohnson NL, Van Tiem J, Balkenende E, Jones D, Friberg JE, Chasco EE, et al. Gaps in communication theory paradigms when conducting implementation science research: qualitative observations from interviews with administrators, implementors, and evaluators of rural health programs. Implementation Science. 2024;19(1):66.\u003c/li\u003e\n\u003cli\u003eZhao X, Toronjo H, Shaw CC, Murphy A, Taxman FS. Perceived communication effectiveness in implementation strategies: a measurement scale. 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Examining town\u0026ndash;gown relationship influence on local environmental sustainability in the United States. International Journal of Public Administration. 2015;38(11):769-81.\u003c/li\u003e\n\u003cli\u003eUrbancov\u0026aacute; H, Vrabcov\u0026aacute; P, Pac\u0026aacute;kov\u0026aacute; Z. Communication from below: Feedback from employees as a tool for their stabilisation. Heliyon. 2024;10(7):e28287.\u003c/li\u003e\n\u003cli\u003eTang Y, Hew KF. Does mobile instant messaging facilitate social presence in online communication? A two-stage study of higher education students. International Journal of Educational Technology in Higher Education. 2020;17(1):15.\u003c/li\u003e\n\u003cli\u003eCarr ER, Nalau J. Adaptation rationales and benefits: A foundation for understanding adaptation impact. Climate risk management. 2023;39:100479.\u003c/li\u003e\n\u003cli\u003eHemming K, Haines TP, Chilton PJ, Girling AJ, Lilford RJ. The stepped wedge cluster randomised trial: rationale, design, analysis, and reporting. Bmj. 2015;350:h391.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"implementation-science-communications","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"iscm","sideBox":"Learn more about [Implementation Science Communications](https://implementationsciencecomms.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ISCM/default.aspx","title":"Implementation Science Communications","twitterHandle":"@ImplementSci","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Communication approach, Implementation science, Stigma reduction, Stepped-wedge trial, People with HIV","lastPublishedDoi":"10.21203/rs.3.rs-7659482/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7659482/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e\u003cp\u003eCommunication is a central but often overlooked determinant of intervention implementation, and little empirical work has examined how different communication approaches operate in real-world delivery settings. This study explores how communication dynamics shaped the implementation of a resilience-based HIV-related stigma reduction and mitigation intervention (RISE-Up project) in rural China.\u003c/p\u003e\u003ch2\u003eMethod:\u003c/h2\u003e\u003cp\u003eA qualitative study was conducted within the RISE-UP project, a stepped-wedge cluster trial implemented across 40 HIV clinics in Guangxi Province. Data were collected through in-depth interviews of 14 project team members in the field, including site project facilitators (local implementers) and central coordinators. Interview recordings were transcribed verbatim. Data were managed and analyzed using NVivo. Thematic analysis was conducted with typical quotes of the participants presented.\u003c/p\u003e\u003ch2\u003eResult:\u003c/h2\u003e\u003cp\u003eTwo complementary communication approaches, Top-Down and Bottom-Up, emerged as central to the implementation process. The Top-Down approach provided structured oversight through strategic planning, real-time feedback, supervision, cross-site capacity-building, and informing the implementation of the following sites. The Bottom-Up approach enabled local implementers to identify local challenges, generate solutions, and foster feedback and peer learning. The stepped-wedge design further supported iterative learning, allowing earlier sites to inform later ones and strengthening collective adaptation.\u003c/p\u003e\u003ch2\u003eConclusions:\u003c/h2\u003e\u003cp\u003eCommunication was an active, dynamic shaping of decision-making, adaptation, and sustainability. Balancing Top-Down oversight with local responsiveness can strengthen fidelity and adaptation. Timely documentation, peer-to-peer mentoring, and enhanced feedback loops may further institutionalize these communication practices and improve sustainability in future public health interventions.\u003c/p\u003e","manuscriptTitle":"The application of two communication approaches in the implementation of a stepped-wedge stigma reduction and mitigation intervention in rural China: A qualitative study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-21 13:51:10","doi":"10.21203/rs.3.rs-7659482/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"","date":"2026-01-12T15:54:34+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-08T15:05:14+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-25T05:03:36+00:00","index":"","fulltext":""},{"type":"submitted","content":"Implementation Science Communications","date":"2025-09-23T10:58:24+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"implementation-science-communications","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"iscm","sideBox":"Learn more about [Implementation Science Communications](https://implementationsciencecomms.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ISCM/default.aspx","title":"Implementation Science Communications","twitterHandle":"@ImplementSci","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c5b407ce-ed53-4d2c-9442-cdac7a660150","owner":[],"postedDate":"October 21st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-10-21T13:51:10+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-21 13:51:10","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7659482","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7659482","identity":"rs-7659482","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}