Table 2 Health provider perceptions of determinants influencing adoption, reach, and fidelity of a stepped care tool to support service delivery for adolescents and youth living with HIV
CFIR* domain | CFIR Construct | Description | Illustrative Quotes |
|---|---|---|---|
Facilitators | |||
Adoption | |||
Intervention characteristic | Design quality and packaging | The tool is comprehensive and designed to cover relevant topics | “[T]he tool is short and precise. And it has touched like everything. Because there [are] elements of depression here. There’s [the] element of opportunistic infections, and there are elements of breastfeeding or pregnant mother[s]. And then there’s this step that the client is supposed to be assigned to… So you can’t miss, you can’t miss anything.” – [P3, Facility 12] |
Intervention characteristic | Complexity | The tool is easy to use and provides guidance on what to do during the client visit | “[W]e want to appreciate the tool because the tool is not that complicated. Actually, the experience that we got from the first time is that it even made our work easier. It was more simplified, because without the tool we could just talk and ask anything but at least the tool is guiding us.” – [P2, Facility 11] |
Inner setting | Readiness for implementation: Access to knowledge & information | Training provided information needed to implement the tool | “[T]he training was good generally and it helped us to do the right thing. Yeah, so currently we don’t have any challenge in stepping our clients. Yeah, it was excellent is what I can say.” – [P3, Facility 7] |
Inner setting | Collective efficacy | CQI meetings facilitated collaborative problem solving to address challenges | “[W]hen we started using the tools, that’s why we were evaluating every two weeks to see where we have had the gap or the challenges and at each point we were giving suggestions and then implementing them… we sat, as a team in our discussions…” – [P4, Facility 4] |
Reach | |||
Intervention characteristic | Adaptability | Providers were able to adapt the intervention to meet client needs | “It depends on case-by-case, one-on-one…….Some will come here to date, some might call, depending on the distance. Like the other one I’m managing is in [location], the other one is a form 3 class, so I can’t allow him to be coming here. So sometimes they come over the weekend, sometimes we talk over the phones.” – [P6, Facility 10] |
Outer setting | Patient needs and resources | Providers were able to adjust the clinic appointment schedule to accommodate the school calendar | “[T]he dates we were giving were not matching with their school calendars…So, we realized that and we were able to change. Now we are……giving dates according to school calendars. This helps us because we could now not get missed appointments.” – [P1, Facility 2] |
Fidelity | |||
Intervention characteristic | Perceived intervention effectiveness | Providers observed a positive impact of the intervention on clients | “The adolescents, at first they were not opening up. But through knowledge we got on how to probe the client, you probe, you be friendly with them, then you talk to them well. You are in that age of theirs. And then they just open up and now be your friend [and] tell you everything….Now when they come, they want to see you because the way you are talking to them. I think that it has helped a lot.” – [P1, Facility 2] |
Inner setting | Collective efficacy | Providers problem solved to optimize their ability to provide services | “[A]t some point we had some adolescents which had no valid viral loads. We had to request [them from] the office and they tried their level best and provided us with some viral load tubes, which they brought, and we were able to draw blood for the missing adolescents. And through that….we managed to get some valid results for those adolescents which helped us in managing them.” – [P3, Facility 2] |
Barriers | |||
Adoption | |||
Intervention characteristic | Design quality & packaging | Language in the tool was complicated, which made it challenging for providers to explain to clients | “So, my concern for the tool is about the step three; over the last two weeks, how often have you been bothered by the following problems? So, the question can be posed very well in English to a patient, but now level of understanding is a problem. So, you need to translate this to either Kiswahili or Luo for the patient to understand. So, I find it quite challenging even to translate it for someone to understand….” – [P2, Facility 6] |
Inner setting | Readiness for implementation: Access to knowledge & information | Some providers felt that refresher trainings would have been beneficial | “It is a good thing and even as we proceed even refreshers are needed so that we can really be sure that whatever that we are doing on the ground are the real thing…, yeah so because these are real clients and it needs frequent practice. Yeah, it needs frequent practice for you to master so that you are able to handle. – [P1, Facility 5] |
Reach | |||
Intervention characteristic | Design quality & packaging | Availability of training tools in another language will support providers in assessing mental health | “[I]n the training, it is in English but now it is upon you now to translate to the local language that the client can understand. So now as you are transferring, you may miss and say something totally different than was meant there.… Those clients, maybe they are not up to date. Like if you start talking in English, they may not understand well or maybe they may not respond well, so it is upon you to turn [it] into another language, Kiswahili or any other language that you can fit in.” – [P1, Facility 5] |
Outer setting | Community characteristics | Challenges with assessing mental health for younger AYLHIV | “[T]he younger ones, you have to interrogate probe them. That’s why mostly we want the younger adolescents to come with their guardian or parents. Because for example, if your child has lost some interest or [is] depressed with him or her, she will not know. But the parent or guardian will know. Or the teacher will know, because maybe the patient or the client was doing well in class.” – [P2, Facility 2] |
Fidelity | |||
Intervention characteristic | Design quality & packaging | Availability of training tools in another language will support providers in assessing mental health | “[T]he aspect of mental assessment can only apply on those older adolescents. For those very young adolescents, like let’s say below 15 years….they may not understand so well. So the issue of mental assessment….I don’t know how it can be simplified so that also the very young adolescents can understand….” – [P3, Facility 1] |
Inner setting | Compatibility | Not aligned with ART guidelines | “There is need to [make sure], as we are designing this tool, the designers are up to date with the guideline because you see for us the guidelines reign supreme. Should there be a conflict between any document and the guideline, the guideline carries the day [Laughter]. So that may create a bit of friction because now you don’t know whether to proceed with the tool or revert back to the guideline. So the default setting is the guideline. So the designers should just make it in a way that it does not contradict or be seen to be antagonizing the guideline.” – [P6, Facility 9] |
Inner setting | Readiness for implementation: Available resources | Viral loads needed for step assignment were not readily available | “[T]he tool came about at a season when the facility was also not able to take samples for viral loads. So being able to administer the tool….majority of them could not be assigned properly because of the missing key interventions that would inform the tool.” – [P1, Facility 8] |