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

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.