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Table 3 CFIR constructs and associated impacts on implementation*

From: Providing reproductive health services for women who inject drugs: a pilot program

CFIR construct [22] Key informant group Findings Findings’ impact on implementation
I. Intervention characteristics (clients, SEP Staff, CBOs)
Relative advantage Clients • SEP is already a convenient location to receive services
• Clients want RH services offered alongside wound-care services
• Clients wish to avoid pregnancy until they are ready to parent
• Reinforced decision to provide services at SEP
• Need for contraception and pregnancy options services for clients and counseling skills for staff
Staff • Unmet need for all health care services in this population, including RH
• SEP is a trusted, safe place where people can enter without judgement
• Desire to test expanding clinical services at SEP
• Motivated expansion of implementation beyond contraception to fuller RH services
CBO • Separate preventive visits are challenging for clients to attend, even with advocates or case managers • Reinforced integration of RH services into primary/wound care services
Design quality & packaging Clients • Services should include contraception and well-woman care
• Services should be offered on a walk-in basis with short wait times to be seen
• Clients prefer a female provider trained in harm reduction/trauma-informed care
• Site should be able to dispense Rx at time of appointment
• Focused training efforts on female provider
• Offered several contraceptive methods on-site
• Maintained walk-in model of care
Staff • Walk-in services
• Focus on novel ways to advertise so clients become aware of services, e.g. use SEP peer-educators to advertise services.
• Collect many forms of contact information for test follow-up, and give clients option to walk in for test results.
• Provide prenatal care, contraception, well woman care.
• Advertised services via flyers, bulletin board in SEP, word of mouth from staff and volunteers
• Utilized walk-in model for follow-up and results as well as care
CBO • Trauma-informed and harm reduction training for all providers involved in delivering care.
• Walk-in services
• Ability to provide same-day contraception, examinations, and testing.
• Avoid stigmatizing women’s desire to be pregnant or parent
• Emphasized trauma-informed approach in clinical training
• Pregnancy options counseling training for staff with emphasis on harm reduction
Cost Staff • Concern over funding to pay for extra providers’ time
• Matching funding source with program mission (i.e. broader healthcare fund rather than STD/HIV prevention)
• Train current providers and provide ongoing mentorship using trainers’ research time
II. Outer setting (clients, SEP Staff, and CBOs)
Patient needs & resources Clients • Desired services: STD testing, contraception, pregnancy care, annual examinations, Pap smears • Expansion from contraception to general RH care
CBO • Challenging to follow up with patients
• Navigating consent with patients in the setting of active substance use and mental health diagnoses can be challenging
• Obtain multiple methods of contact, utilize non-traditional methods if client approves (e.g. leaving message for patient at shelter or day center)
• Abstinence from substances is not a prerequisite for care or procedures; ability to express understanding for and desire for care/procedure is necessary
Staff • Clients need to develop relationships with staff in order to trust them
• Pregnant clients are particularly likely to face judgment and barriers to care
• Clients who do sex work need contraceptive methods other than condoms as condomless sex pays more
• Contraceptive methods requiring daily or weekly user involvement are challenging
• Living homeless and/or with substance use disorder means surviving takes up much of clients’ time, leaving less for preventive care
• Project staff spent weekly time assisting with syringe exchange to become familiar with clients
• Acknowledge and combat the layered stigma of gender, pregnancy, and substance usage
• Offer long-acting reversible contraception on-site
• Make preventive services available where clients are seeking other services related to substance use disorder or living homeless
Peer pressure CBO • Few organizations work in the intersection of RH and substance use disorders
• The nearest clinic has limited walk-in spots that may require an hours-long wait
• Reinforced need for integrating RH into SEP
• Despite proximity of other clinics, lack of walk-in care is a barrier
Staff • Failure to treat patients’ substance use disorder with medication while inpatient frequently leads to adverse experiences and leaving against medical advice • Emphasis on patient-centered care and therapeutic relationships
Staff • SEP cannot advertise any of its services on the sidewalk or outside of its building • Unable to place poster or outward-facing advertisements for services
III. Inner setting (SEP staff)
Structural characteristics Staff • Most staff are comfortable making referrals within and outside the organization • Planned staff education around RH topics and created referral list for RH care
Networks & communications Staff • Management is open to suggestions from staff • Fully involve all types of staff in formative work and evaluation
Culture Staff • Harm reduction and relationship building with clients are highly valued • Create low barrier, friendly services
Implementation climate—tension for change Staff • Client needs and staff’s perceptions of needed improvements drive change • Harness staff’s interest in implementing services given client demand
Readiness for implementation— leadership engagement Staff • SEP manager highly engaged with staff and responsive to feedback • Harness manager’s energy and interest in promoting implementation
Readiness for implementation—available resources Staff • Space is limited
• Examination room has footrests for gynecologic examinations
• Highly functional electronic medical record available
• Limit RH-specific equipment to avoid straining limited space
IV. Characteristics of individuals (SEP staff)
Knowledge & beliefs about the intervention Staff • Aware of increased effectiveness and lower user-related failure associated with IUDs and contraceptive implants
• Desire for improved referral system for pregnancy options
• Designed referral brochure and educated staff on pregnancy options including abortion, adoption, parenting
Self-efficacy Staff • Very comfortable suggesting improvements and advocating for clients • Utilized staff feedback in improving implementation
  1. *Constructs without participant input or not impacting implementation are excluded from this table