Table 2 Summary of themes and sub themes highlighting barriers and facilitators of CHW CVD prevention intervention implementation
CFIR domain and constructs | Theme | Sub-theme (barriers) | Sub-theme (facilitators) |
|---|---|---|---|
Intervention characteristics ▪ Design quality and packaging ▪ Complexity ▪ Adaptability ▪ Cost | Design, complexity and adaptability of intervention | • Intervention is extensive • Difficulties with filling forms and doing calculations • Intervention activities time consuming • Behaviour change is not easy • Not finding men at home during their visits and fishing communities being mobile | • Incorporated the intervention within other routine activities • Focussed education majorly on risks identified during the interheart screening • Educated family members together on general risks before individual counselling • Utilised public gatherings to supplement house visits which were also done on evenings and weekends |
Quality and supply of inputs | • Waist and hip ratio tape measure breaking down. • Calculators not provided for calculation of waist and hip measures and adding interheart scores. | • Waist and hip ratio tape measures replaced with those of better quality. • CHWs used phones were available. | |
Gradual change process | • Community behaviour change is slow. | • Encouraged incorporation of lifestyle practices into daily routines. • Elaborated cost of unhealthy behaviours. • Utilised motivational interviewing techniques. • CHWs shared experiences among themselves. | |
Costs of fieldwork | • Large distances due to big sparsely populated villages • Unfavourable weather • Doing fieldwork while sometimes hungry • Less time for other responsibilities | • Some CHWs had smaller villages easing field work • CHWs provided with gumboots and umbrellas to help during harsh weather • Planning time and going to the field in the afternoon after lunch. | |
Outer settings ▪ External Policy and Incentives ▪ Patient needs and resources | Resources availability, | • Community demands: a playing field and balls to increase their physical activity levels, blood pressure machines to measure blood pressure at home and drugs for treatment, fruits and vegetables and their seedlings to increase supply. | • Encouraged community members to start vegetable gardens • Provided community members with their own seedlings where possible • Encouraged community members to seek care from health facilities which had been strengthened • Liaised with health workers to conduct outreaches |
Health services accessibility and quality, | • Unavailability of required services or their being of poor quality. • Health worker negative about CHW referral | • Availability of quality health services. • Health worker positive about CHW referral • Health workers involvement in CHW training • Transfer of health workers | |
Media reinforcement |  | • Media raised awareness on CVDs and reinforced messages passed by CHWs • Media message consistency with that passed by CHWs. | |
Policies and procedures. | • Non remuneration of CHWs • Prioritising existing CHWs for community engagements | • Replacement of some CHWs engaged with many activities to devote time to the intervention. | |
Inner settings ▪ Available resources ▪ Access to knowledge and information ▪ Learning climate ▪ Tension for change ▪ Relative priority ▪ Implementation climate ▪ Compatibility ▪ Organizational incentives and rewards ▪ Culture ▪ Networks and communications | Training and learning environment |  | • CHW training on intervention and its implementation including piloting field work. • Presence of training manuals in local language for consultation. • Positive learning environment. |
Community awareness and interest | • Low awareness and perceived risk of CVDs. • Uncooperative members and access barriers. | • High awareness and perceived risk of CVDs. • CVD screening programmes. • Use of community strictures such as leaders and groups. • Encouraging group activities such as for physical exercise. | |
Trust | • Mistrust of CHW motives attributed to politics or western interests | • Trust of CHWs. • CHW popularity and close relationship with community. • Local leaders support • Project branded t-shorts eased identification with community members. | |
Culture and beliefs | • Unease in taking waist and hip measurements of opposite genders. • Wrong perception of the need for waist and hip measurements. • Physical activity related activities such as running or riding a bicycle was not culturally acceptable. • Tendency to cook only one kind of food without balancing diet. • Belief that fruits and vegetables are meant for young children and sometimes sold for income. | • Carried out the measurements in public places while adopting a sideways posture. • Requested a family member to support taking measurements • CHWs providing thorough explanations to community members regarding need for measurements | |
Demographic composition | • Resistance, several questions and less cooperation among youths and males. | • Elderly and female community members more cooperative. | |
Support supervision and feedback |  | • Frequent support supervision and feedback • Setting and reviewing goals and targets • Continuous refresher training for CHWs • Addressing CHW feedback and providing response • Friendly and approachable supervisors who communicated well. | |
Characteristics of individuals involved ▪ Individual stage of change ▪ Other personal attributes ▪ Individual identification with organization ▪ Self-efficacy | Stage of change | • Lower spectrum to stage of change | • Higher motivation to change such as those already hypertensive or diabetic. • Community members’ testimonies. • CHW experiences and exemplariness. |
Competing demands | • High workload due to several CHW work tasks and other personal responsibilities | • Set aside time for intervention implementation. • Incorporate intervention duties within similar usual works. • Utilise community engagements for example at public events to share intervention message. • Setting targets and goals bi-weekly. • Flexibility in scheduling the meetings. | |
Motivation and commitment | • Lack of financial incentives | • Motivation from non-financial sources including the recognition and respect and project incentives such as t-shirts and training certificate. • Observed changes in community behaviours and reported improved health outcomes. • Transport refunds for the bi-weekly meetings. | |
CHW attributes | • Being village leaders ensured that CHWs were busy to devote sufficient time to intervention implementation. • Low experience in dealing with community. • CHW sickness | • Some CHWs were village leaders having influence and authority. • CHWs supporting referral at health facility. • High CHW self-efficacy and experience | |
Socio-demographic characteristics | • Older and female CHWs found it harder to influence the youth and male community members | • higher educated CHWs grasped concepts much faster, explained them better and produced data of good quality • Personal experiences of CHWs who had CVD risk factors. |