Barriers
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CFIR Domain (Construct)
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Facilitators
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CFIR Domain (Construct)
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High cost of data
“So one of the problems we have in South Africa is the cost of our data is so high, we have some of the highest cost data in the world…” (Int.11)
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Intervention Characteristics (Cost)
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Easy and accessible technology
“…it is a technology that is accessible to all and that makes a huge difference.” (Int.11)
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Intervention Characteristics (Design Quality & Packaging)
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Uncontrollable market fluctuations
“… I think you can do so much for the technology, but the barriers to the use of technology are often about the market and that’s something that the department of health always will struggle to affect.” (Int.11)
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Intervention Characteristics (Cost)
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Positive user feedback
“There was very good response from users, moms love it. Testing with mothers provided very positive feedback, being human centered in design here was a good response. Which helps for scale because mothers encourage other mothers and urge them to ask for this.” ( Int.2)
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Intervention Characteristics (Adaptability)
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Inadequate internet connectivity
“We actually had quite a few of those barriers, just to highlight some – one was the issue of internet connectivity, SA is having an issue of connectivity. There needed to be internet connection to register pregnant women, this contributed to low registration.” (Int.1)
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Intervention Characteristics (Design Quality & Packaging)
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Effective two-way communication
“Two-way messaging is much more powerful than one way; required establishment of help-desk and staffing and FAQ’s and process of logging in those complaints and escalating complaints appropriately in department of health.” (Int. 2)
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Intervention Characteristics (Design Quality & Packaging)
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Unreliability of USSD
“…there’s quite a number of registration fields that need to be completed, and to do all of that over USSD is quite tricky…I’m not sure if you’re familiar with USSD, you have a session and in the session if it times out or if the connection is broken or minimal you have to dial it up again and get that connection…” (Int. 13)
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Intervention Characteristics (Design Quality & Packaging)
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Effective content adaptation
“And obviously these are all the adaptations they made along the way and also in terms of you know your age groups. So somebody who’s a teen mom is not very excited about SMS whereas somebody who is much older maybe easier to work with in SMS as opposed to working in an app. So the content started evolving overtime so that there were different things to bring people again and gain interest.” (Int.10)
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Intervention Characteristics (Design Quality & Packaging)
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Inadequate training
“The training from what I could tell was not done. I think there was a standard way to that was intended for the training, but it didn’t turn out that way. Everybody got a little bit different level of training, little bit different kind of training.” (Int.6)
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Inner Setting (Available Resources)
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Effective guidelines from MAMA
“I think that it took a lot of the model from MAMA and the content and then it completely reworked it to the South-African context. I think that, that it made it easier.” (Int. 6)
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Intervention Characteristics (Design Quality & Packaging)
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Gaps in funding
“I do know that there was not any government or very limited if there is any government funding going to the Mom Connect project and it was mostly donor funded.” (Int.12)
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Inner Setting (Available Resources)
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Strong political will
“There was very strong and very senior level government buy in for the Mom Connect project, as it was being implemented in a way that I've never seen. I have never seen with any health project before that such a senior level individual in the Department of Health would be so interested in getting mHealth project implemented at as large of a scale as possible, as quickly as possible, so that was a significant benefit that I haven't seen before.” (Int. 12)
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Process (Champions)
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Insufficient publicity
“I don’t know if there is enough signage in these facilities around this. I haven’t seen any radio adverts or TV adverts about it.” (Int. 10)
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Inner Setting (Available Resources)
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Strong stakeholder champions
“…what made the project so successful was also the collaboration – and was the partners that really did come together, and each had a really unique perspective, and a really focused area of work within the project.” (Int. 4)
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Process (Champions)
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Inadequate language translation
“…some instances, there were a few issues with the translation of the Xhosa the dialect which was because of the difference between the dialects spoken in Eastern Cape and the used in the translation of any of the guides…” (Int. 7)
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Intervention Characteristics (Adaptability)
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Cost-efficient technology
“A combination of SMS, WhatsApp and USSD, or relatively inexpensive technologies… ” (Int.13)
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Intervention Characteristics (Cost)
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Unequal mobile access
“…the moment you move to an application it becomes slightly harder because then you need compatibility with the phone.” (Int. 10)
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Intervention Characteristics (Adaptability)
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Cost-effective messaging system
“So Vodacom was the service provider that we worked with. And when we worked with them, they subsidized the costs of the SMS’s… we found it easier for us to reach more people because the costs were subsidized.” (Int. 10)
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Intervention Characteristics (Cost)
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Insufficient baseline
“Because we just did it so fast, we didn’t really do a proper baseline and very quickly there was nothing we could really compare it to. And I’d say that was the single biggest problem. Because that meant we couldn’t actually come up with anything that was convincing to show the impact of it…”(Int.5)
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Intervention Characteristics (Complexity)
Process (Planning)
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Smooth integration process
“We can go back and look at actual facts, it was working in over 90% of health facilities in South Africa. That is amazing. You don’t get aspirin in 90% of the health facilities in South Africa”(Int. 5)
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Inner Setting (Compatibility)
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Inability to test intervention
“…we went national almost immediately and we didn’t have a clear RCT that we ran or even a staple model to build up the evidence in a very robust way that this was worthwhile from an impact perspective, which really has delayed our ability to be able to put a clear return on investment case for it.” (Int. 3)
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Intervention Characteristics (Trialability)
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Effective project promotion
“…things like marketing materials, having ministers talk about these things in public forums and newspapers and things like that has kind of shown it to be a flagship program of the NDoH.” (Int.4)
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Process (Engaging)
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Timeline pressure from stakeholders
“The department, they wanted to implement and scale very fast, and so it was a massive, radical experience and we didn’t have the time to set up a really nice study ahead of time…” (Int 13)
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Process (External Change Agents)
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Appropriate content translations
“There are nine official languages in South Africa and the minister said yes it had to be in every one. We did proper translations. If you know the term back translation, so there were some verification of it.” (Int.5)
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Intervention Characteristics (Adaptability)
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Incompatibility with health system
“…there was a number of facilities throughout South Africa that just refused to do this work that felt was imposed on them when they were already stretched for resources, for time, for staff they felt they just did not have that—the ability to add one more thing to their list of things to do…” (Int.12)
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Inner Setting (Compatibility)
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Sufficient donor funding
“And of course, having funders who could commit, say to 3 years of funding. Initially there was a lot of funding which was made available for the initial pull, a lot.” (Int.13)
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Inner Setting (Available Resources)
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Insufficient government buy-in
“Another barrier was lack of support from premier principals. People who were involved in launching MomConnect – we needed operational managers and we find that the CEOs and the others were not involved… There was disconnection between what they were doing and probably the vision of the principals.” (Int.1)
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Process (Champions)
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Comprehension of user needs
“…the content that was created was really great and it’s obviously a time of the person’s life – the woman’s life where they’re extremely engaged and really, really hungry for knowledge. So I think the content was extremely important and also making a mom feel like she’s not alone and there’s someone providing her with just some messages to reassure her and support her and understand where she is.” (Int.13)
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Inner Setting (Compatibility)
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Gap in technical leadership
“…an NDoH technical lead who understood the technology stacks. You know that kind of person is hard to find and generally is quite an expensive resource which the national department of health didn’t have.” (Int.14)
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Process (Formally Appointed Internal Implementation Leaders)
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Effective immediate scaling design
“…the system architecture that was developed from the start was built to scale… It wasn’t built to be a pilot I think is one of the things that’s enabled it to be successful there was this vision of scale from the start and it was built accordingly.” (Int. 4)
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Intervention Characteristics (Trialability)
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Stakeholder mismanagement
“The hardest part of all was trying to get everybody linked up and to get adequate political pressure in enough places.” (Int.9)
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Outer Setting (Cosmopoli-tanism)
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Strong partner relations
“MomConnect had a strong relationship with HIPPA and the NDoH, etc. so the combo of strong top-down directive created a strong relationship between the health system. Also a very strong leadership particularly in the minister; strong top-down director coupled with simple tech, and relationship amongst the funders, and with HIPPA and NDoH made the project scale quickly.” (Int. 2)
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Process (External Change Agents)
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Insufficient evidence to scale
“They didn’t pilot the MomConnect platform so there was no proof that it could work.” (Int.1)
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Intervention Characteristics
(Evidence Strength & Quality)
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High literacy rates
“Additionally and this relates back to the lessons learned in the MAMA project not every medium resource country, and especially not every low-resource country has high literacy but South Africa does have very high literacy.” (Int. 12)
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Inner Setting
(Implementation Climate)
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Pushback from focal people
“Some workers felt like it was an added burden and felt like it was an additional task in need of fulfilling…” (Int. 2)
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Inner Setting (Implementation Climate)
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Cleaner registration system
“…they insisted women should only be registered if there was confirmed pregnancies and it had to be at a healthcare facility by a healthcare worker, there was much cleaner database because of this...” (Int.2)
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Intervention Characteristics (Design Quality & Packaging)
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Unequal access to information
“the nurses were saying these women are getting information we don't know what it is, sometime this information we don’t know ourselves, we want to know what we are giving them” (Int. 11)
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Inner Setting (Access to Knowledge & Information)
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Addition of Whatsapp
“Because when most people receive an SMS, that’s it, they read it and that’s it. But if you receive a text on WhatsApp, the mental association is you are more likely to respond to it. Because WhatsApp is more conversational communication, while SMS is one push boom, it’s not a conversation it’s just one bit of information spat out at you.” (Int.5)
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Intervention Characteristics (Design Quality & Packaging)
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Inadequate privacy features
“…you have to be very careful about was the fact that it’s a SMS there is no form of privacy around it. So anybody could pick it up and read it...” (Int. 10)
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Intervention Characteristics (Design Quality & Packaging)
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Efficient coding system
“Each facility then was assigned a 6 digit code which through a kind of standardized approach that we recommended and that was then implemented into the whole structure. Without that coding system we wouldn’t have been able to realistically get the flows into making it simple to identify where the data was coming from… helped design up the reports which would give the maximum information back to the government to then help put on the further implementation.” (Int.9)
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Intervention Characteristics (Design Quality & Packaging)
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Insufficient support for individuals with HIV
“We had—one of the things that MAMA had that MomConnect did not have was a large focus in a separate stream of messages for HIV positive women and because the population we were working with in the inner-city Johannesburg the HIV positivity rate was around 30%.” (Int. 12)
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Intervention Characteristics (Adaptability)
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Effective automation system
“So with an automated system it decreases the human error but it also increases the feasibility of reaching more people” (Int. 10)
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Intervention Characteristics (Design Quality & Packaging)
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Inability to register privately or postnatally
“Some women receive ANC in the private sectors because they prefer evading wait times, but will transfer to public sector for delivery because they can’t afford the delivery part of care. So they may not be registered to MomConnect because you can’t register privately or postnatally either. So she’ll miss out on the information provided by MomConnect.” (Int. 2)
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Inner Setting (Compatibility)
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Effective group registration system
“We introduced group registration; take details of clients…they would register them before they go home or early in the morning before they start, this decongests the system and can reduce the load of registration.” (Int.1)
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Intervention Characteristics (Design Quality & Packaging)
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Adaptation of legislation
“MomConnect set out to put into practice, the South African Normative Standards Framework…having those principles and standards and legislations in pace already, it made it easier to get passed some of the technical hurdles that might be hurdles in other places where there isn’t that standard framework to start with.” (Int.4)
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Outer Setting (External Policy & Incentives)
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