Out of 12 participants targeted for IDIs, our target saturation threshold (5 %) was reached with 10 IDIs beyond which it was unlikely for additional themes to emerge (Table 1). Most of the participants in IDIs were males (n=8, 80%). Participants’ age range was 30 to 57 years with equal median (42.5) and mean (43.3) values and years of service between 10 to 25 years (median = 15.5, Mean = 15.9, ±5.0). On the second phase of identifying strategies, a total of 25 key healthcare workers (HCWs) participated in series of stakeholders meetings with 60% (n=15) of the participants being males. All key departments including laboratory, ART Clinic and hospital wards were equally represented (Table 2)
Table 1 demographic characteristics of participants in IDI
Table 2 Demographic characteristic of participants in stakeholders meetings
CFIR ERIC- tailored strategies, practices and actors
Using CFIR frame work, we identified several barriers, matched to CFIR constructs: the seven most prominent barriers were related to availability of resources, intervention complexity, and work infrastructure, access to knowledge and information, belief about intervention, networks and communication, as well as implementation leads. Two CFIR facilitators were also identified: partnership and connections as well as policies and laws. A list of CFIR constructs, specific barriers and their quotations from the IDIs are provided in Table 3 while definitions of the ERIC strategies, practices and proposed actors are outlined in Table 4. Overall, there were 6 Level 1 strategies and 11 Level 2 strategies produced through the CFIR-ERIC Matching tool targeting contextual barriers. The matrix of level 1 and level 2 strategies generated by the CFIR-ERIC Matching Tool version 1.0 with detailed information about ERIC strategies corresponding CFIR barriers are provided in Table 5.
Below is an overview of CFIR categorized barriers and the CFIR-ERIC recommended strategies with expert endorsement percentage (%) scores in two categories: level 1 strategies (≥ 50% expert endorsement score) highlighted in green; level 2 strategies (≥ 20%, ≤ 49% expert endorsement score) highlighted in yellow (Table 5). Most of the strategies identified aimed at enhancing clinician and member knowledge as well as revising the clinic work flow to improve implementation process.
Intervention complexity
Intervention complexity is reflected by its scope and/or the nature as well as the number of connections and steps involved in the implementation process. Respondents in IDIs reported implementation challenges attributed to multi-phases of AHD screening which led to under screening as well as long clients waiting times.
Recommended ERIC strategies: To address the barriers associated with complexity of the intervention, CFIR-ERIC guiding tool recommended four level 2 strategies that include development of a blue print (43%), promoting adaptability (40%,) conduct on-going training for AHD providers in key departments (37%), and identify& prepare champions (30%) to build capacity and motivate staff members to adopt strategies for optimizing AHD screening. Other strategy put forward by Powell and colleague which experts recommended was the redesigning of the facility work flow, involving shifting AHD rapid diagnostic test package from the laboratory to ART clinic.
Communication & networks
Communication in this context refers to the quality of both formal and informal information sharing practices within and across departments. Our investigation revealed communication challenges among different teams involved in AHD screening. Absence of communication platforms such as ground telephones, WhatsApp groups, and inter-departmental meetings contributed to poor work coordination.
“Currently we have started fixing the ground phone lines connecting different departments. Already other departments are currently connected and we hope by the end of this year all departments will be covered” [HM1]
Recommended CFIR-ERIC strategies aimed at establishing stakeholder’s interrelationship and they included one level 1 strategy: network weaving which got the highest endorsement score of 70% and two level 2 strategies: build coalition (39%); as well as creation of a learning collaborative environment (35%) to promote information sharing among implementing teams.
Access to knowledge and information
The accessibility of guidance, training, and education related to the intervention and its implementation process are critical to successful implementation and delivery of the intervention. In this study, respondents in IDIs reported that healthcare providers lacked familiarity of the intervention and this was evidenced by decreased in self-efficacy and poor AHD screening. Most respondents argued that training was not adequate. Besides, infographics such as posters for AHD screening eligibility criteria were not readily available.
Recommended CFIR-ERIC strategies selected were those centered on enhancing providers and practice member knowledge about the intervention and they included two level 1 strategies (conduct education meetings 79%; develop education materials 59% and distributing education materials 56%) and two level 2 strategies (create a learning collaborative 45%; conduct on-going trainings 38%). Similarly, education meetings (56%) from level 1 strategy: as well as identifying champions (40%) plus developing education materials (38% level 2 strategies) were endorsed as strategies for addressing barriers relating to Knowledge and belief about the intervention.
Availability of resources
Availability of resources such as funding, space, materials and equipment are key for a successful implementation and delivery of the intervention [34]. However, respondents in our study cited barriers relating to lack of funds to support healthcare trainings and provision of incentives to implementers. Others respondents cited lack of equipment to operationalize a min-lab for AHD screening tests at ART clinic.
Recommended CFIR-ERIC matched strategies for addressing gaps relating to unavailable resources include access to new funding (78%, level 1 strategy) and development of resource sharing agreements (26%) through strong partnerships with MoH implementing organizations.
Structural characteristics
Dimensions of structural characteristics directly connected with implementation, though many of these characteristics have had mixed effects, most likely because they interact with other features of the Inner setting such as availability of resources. We evaluated the structural characteristics in terms of physical, work and technological infrastructure of the facility. Our findings revealed low staffing at ART Clinic, and that key departments (ART clinic and Laboratory) are far apart.
Recommended ERIC strategies for addressing barriers of structural characteristics are the same as those for availability of resources: lobbying for new funding, resource sharing agreements and strategies focused on modifying physical structure and equipment (48%, level 1 strategy) to improve clinical work flow.
Work infrastructure
CFIR defines work infrastructure as organization of tasks and responsibilities within and between individuals and teams, and general staffing levels, and support functional performance of the Inner setting. Increased TAT and client waiting time reported by respondents provided strong evidence of poor work flow and high workload. To address the challenge, stakeholders agreed to the proposal of having clients’ samples for CD4, CrAg and LAM collected from ART clinic or alternatively escort the client to the laboratory to ensure that testing is done with urgency.
“If I am free, I do escort patients to lab. But when I have a line of clients waiting here that becomes a problem. Currently we just send them to lab and we do not know whether the patient will reach the lab or not. Thus why I was saying we are losing clients because if we could have someone to escort the patient to the lab who could talk to the technicians to do the test quickly, we wouldn’t have those challenges”. [Rep2, ART]
CFIR-ERIC recommended strategies for barriers related to work infrastructure included only level 2 strategies which cross-cutting across multiple CFIR barriers. Such ERIC strategies include building coalition (27%), identifying site champions (27%) and promoting adaptability and network weaving (23%).
Implementation facilitators
Regardless the existing barriers, the facility was able to implement the AHD screening taking advantage of the availability of updated guidelines and the integrated MoH-ART supported supervision and mentorships programmes which include some components of AHD management package. It is also important to note that the facility had two implementation leads coordinating HIV testing services (HTS) and ART, even though the absence of an officially appointed coordinator for AHD services was a barrier to effective coordination of AHD screening. On the choice of motivations, most stakeholders opted for incentives inform of continuous trainings for technical staff, daily allowances for lay cadres escorting clients to the laboratory as well as having periodical site visits to centers of excellences as part of developing stakeholders interrelationships which promote collaborative learning and information sharing.
“Our friends in central hospitals are doing fine in ART and AHD management because they are well supported. We can be organizing trips to such sites to learn a few best practices”, [RTC2]
Table 3 Summary of CFIR barriers, descriptions and the exemplar quotations
Table 4 Summary of Expert Recommendation for Implementing Change (ERIC) strategies and proposed actors
Table 5 CFIR- ERIC matched strategies