Barriers and facilitators of implementationof a community cardiovascular diseaseprevention programme in Mukono andBuikwe districts in Uganda using theConsolidated Framework forImplementation ResearchRawlance Ndejjo1,2* , Rhoda K. Wanyenze1, Fred Nuwaha1, Hilde Bastiaens2 and Geofrey Musinguzi1,2
Abstract
Background: In low- and middle-income countries, there is an increasing attention towards communityapproaches to deal with the growing burden of cardiovascular disease (CVD). However, few studies have exploredthe implementation processes of such interventions to inform their scale up and sustainability. Using theconsolidated framework for implementation research (CFIR), we examined the barriers and facilitators influencingthe implementation of a community CVD programme led by community health workers (CHWs) in Mukono andBuikwe districts in Uganda.
Methods: This qualitative study is a process evaluation of an ongoing type II hybrid stepped wedge cluster trialguided by the CFIR. Data for this analysis were collected through regular meetings and focus group discussions(FGDs) conducted during the first cycle (6 months) of intervention implementation. A total of 20 CHWs participatedin the implementation programme in 20 villages during the first cycle. Meeting reports and FGD transcripts wereanalysed following inductive thematic analysis with the aid of Nvivo 12.6 to generate emerging themes and sub-themes and thereafter deductive analysis was used to map themes and sub-themes onto the CFIR domains andconstructs.
Results: The barriers to intervention implementation were the complexity of the intervention (complexity),compatibility with community culture (culture), the lack of an enabling environment for behaviour change (patientneeds and resources) and mistrust of CHWs by community members (relative priority). In addition, the lowcommunity awareness of CVD (tension for change), competing demands (other personal attributes) andunfavourable policies (external policy and incentives) impeded intervention implementation. On the other hand,(Continued on next page)
* Correspondence: [email protected] of Disease Control and Environmental Health, School of PublicHealth, College of Health Sciences, Makerere University, Kampala, Uganda2Department of Primary and Interdisciplinary Care, Faculty of Medicine andHealth Sciences, University of Antwerp, Antwerp, Belgium
Ndejjo et al. Implementation Science (2020) 15:106 https://doi.org/10.1186/s13012-020-01065-0
facilitators of intervention implementation were availability of inputs and protective equipment (design quality andpackaging), training of CHWs (Available resources), working with community structures including leaders andgroups (process—opinion leaders), frequent support supervision and engagements (process—formally appointedinternal implementation leaders) and access to quality health services (process—champions).
Conclusion: Using the CFIR, we identified drivers of implementation success or failure for a community CVDprevention programme in a low-income context. These findings are key to inform the design of impactful, scalableand sustainable CHW programmes for non-communicable diseases prevention and control.
Keywords: Adoption, Cardiovascular disease, Community health workers, Implementation
BackgroundWorldwide, over 40 million deaths, 71% of all globaldeaths, were attributed to non-communicable diseases(NCDs) in 2016 disproportionately affecting low- andmiddle-income countries [1]. Indeed, there is an increas-ing prevalence of NCDs in sub-Saharan Africa (SSA) asdisease burden shifts from mostly communicable condi-tions [2]. The SSA region experiences over a millioncardiovascular disease (CVD) deaths annually with sev-eral risk factors also on the rise [3]. For example, hyper-tension prevalence among persons aged 18 years andabove is estimated between 24% and over 50% [4, 5]. InUganda, over 25% of the adult population are hyperten-sive but awareness remains low [6, 7] and similarly is thepopulation knowledge on CVD and related risk factors[8, 9]. Broader determinants of health such as globalisa-tion and urbanization have had influence on populationlifestyles thus contributing to the increasing prevalenceand incidence of modifiable CVD risk factors [10, 11].Countries in SSA including Uganda have not fully de-
veloped their health system capacity to deal with chronicconditions such as CVD with gaps in human resources
capacity, equipment and drugs [12, 13]. Thus, to addressthe CVD burden, cost-effective and sustainablecommunity-wide interventions premised on health pro-motion and disease prevention are the mainstay in low-income contexts [14]. These interventions should in-volve raising awareness on CVD, encouraging adoptionof healthy lifestyles, and detecting and treating risk fac-tors early. With this, the ability of individuals, familiesand communities to promote and maintain health andprevent disease and disability by their own initiative isenhanced [15]. Moreover, community approaches havebeen successful in supporting infectious disease controlefforts and improvement of health outcomes in SSA [16,17]. However, there is limited evidence of replication ofsimilar efforts for NCDs even with increasing evidenceof the acceptability of such programmes [18].Understanding the barriers and facilitators of imple-
mentation of community programmes for NCD preven-tion and control is critical to inform disease preventionand control efforts especially in SSA to deal with thehigh disease burden in an efficient and sustainable man-ner. However, there is a paucity of studies examining theimplementation processes of community NCD interven-tions as most have focussed on their efficacy and effect-iveness [19, 20]. In China, a systematic review reportedbarriers to CHWs engaging in NCD prevention and con-trol to include the lack of support such as in obtaininginsurance cover or official contracts, lack of economicand healthcare resources, and high technology relianceamidst its unavailability in some areas [21]. On the otherhand, an integrated health system, community trust,high quality training and community health workers’(CHWs) capacity were facilitators [21]. The Scaling-upPackages of Interventions for Cardiovascular diseaseprevention in selected sites in Europe and sub-SaharanAfrica (SPICES) project [22] is implementing a commu-nity CVD prevention programme in Mukono and Buikwedistricts of Uganda. The programme aims to assess theeffectiveness of an enhanced community approach in im-proving population knowledge and screening for CVD riskfactors, referral and enhancing lifestyle change in a real-world setting [22]. The implementation outcomes for the
Contributions to the literature
� This study highlights the implementation of a community-
based cardiovascular disease prevention programme and
how prior processes of assessing the needs of the commu-
nity and implementers influenced implementation.
� The use of the Consolidated Framework for Implementation
Research (CFIR) to understand implementation barriers and
facilitators within a community setting is contextualised.
� We highlight how the CFIR domains and constructs may
positively or negatively influence intervention
implementation and present this diagrammatically to ease
comprehension.
� The comprehensive evaluation of an ongoing
implementation process and addressing challenges while
leveraging on available opportunities is key to achieve
impact.
Ndejjo et al. Implementation Science (2020) 15:106 Page 2 of 17
SPICES programme are reach, acceptability, adoption,appropriateness, feasibility, fidelity, implementation cost,coverage and sustainability [22]. In the programme,CHWs work with existing community networks andstructures to conduct CVD risk assessment and promoteknowledge, improved lifestyles and cardiovascular health[22]. Specifically, the programme involves training andempowerment of CHWs to lead CVD prevention andcontrol activities within their communities. The CHWsconduct house-to-house visits within their communitiesto screen for risk factors using the interheart non labora-tory tool—a CVD risk assessment tool based solely onclinical history and simple physical measurements [23],provide health education and promote lifestyle changethrough motivational interviewing and goal-setting tech-niques [18, 22]. CHWs also refer high risk individuals tohealth facilities and follow them up afterwards in the com-munity [22].Prior to intervention implementation, CHWs antici-
pated barriers in mobilising communities, the lack ofaccompanying treatment services, competing interestsamidst limited time, and their being required to be exem-plary, and they felt that training, support supervision andexperience in similar work would be facilitators [18]. Onthe other hand, community members were concernedabout being unable to access treatment for their condi-tions but looked forward to sufficient information beingprovided to them and health services being extendednearer to them [18]. This study explored the barriers andfacilitators of implementation of the community CVDprevention programme in Mukono and Buikwe districtsof Uganda using the Consolidated Framework for Imple-mentation Research (CFIR).CFIR is a determinant framework, informed by numer-
ous implementation models, theories and frameworks,which presents several domains hypothesized to interactin rich and complex ways to influence implementationoutcomes of an intervention [24, 25]. CFIR has a total of
39 constructs/sub-constructs organised around fivemajor domains: inner setting, outer setting, interventioncharacteristics, characteristics of individuals involvedand process factors [24] as described in Table 1. The CFIRwas applied to fully understand the implementation dy-namics of a community CVD prevention programme inMukono and Buikwe districts of Uganda so as to informprogramme improvements, scale-up and sustainability insimilar contexts.
MethodsStudy areaThe study area consists of 20 parishes in Mukono andBuikwe districts designated to receive the SPICES pro-ject intervention within a type II hybrid stepped wedgecluster randomised trial (trial registration number: ISRCTN15848572) [22, 26]. Mukono and Buikwe districtshave a population of 1,000,000 persons with a male tofemale ratio of approximately 1:1 [27]. In the districts,more than 70% of the population resides in rural areasengaging majorly in subsistence agriculture and fishingwhile others operate small businesses in trading centreswithin the semi-urban areas. The overall study design al-lows for iterative process improvements where interven-tions are refined before implementation is stepped up toother areas. There were four planned cycles of 6 monthsimplementation each targeting a cluster of five parishesin a stepwise manner with activities in each parish lim-ited to four randomly selected villages [22]. For thisstudy, data were collected in five parishes that belongedto the first cluster of the stepped wedge.
Study design and populationThis was a qualitative study that involved process evalu-ation of the implementation of a community CVD pre-vention programme through regular meetings and focusgroup discussions among CHWs who are involved inimplementing the intervention in the study districts. In
Table 1 CFIR domains and their definitions
CFIR domain Definition
Intervention characteristics Features of the intervention that may affect implementation. Has eight constructs: intervention source, evidencestrength and quality, relative advantage, adaptability, trialability, complexity, design quality and packaging, and cost.
Outer setting Characteristics of the external context that might influence implementation. Has four constructs: patient needs andresources, cosmopolitanism, peer pressure, and external policy and incentives.
Inner settings Characteristics of the organization that may influence implementation with 12 constructs. These are structuralcharacteristics, networks and communication, culture, implementation climate (tension for change, compatibility,relative priority, organizational incentives and rewards, goals and feedback and learning climate) and readiness forimplementation (leadership engagement, available resources and access to knowledge and information).
Characteristics of individualsinvolved
Features of implementers that influence intervention implementation with five constructs: knowledge and beliefsabout the intervention, self-efficacy, individual stage of change, individual identification with organization and otherpersonal attributes.
Process factors Strategies and linkages that may influence implementation including planning, engaging (opinion leaders, formallyappointed internal implementation leaders, champions and external change agents), executing, and reflecting andevaluating.
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Uganda, CHWs are referred to as village health teamsand are volunteers with the ability to read and write inthe local language, selected by their communities to linkthem with the health system [28–30]. In each parish,four CHWs each responsible for a village spearheadintervention delivery [22].
Data collectionDuring intervention implementation, CHWs had bi-weekly meetings with their community-based supervi-sor(s) who moderated the session and took notes regard-ing their experiences of implementing the interventionand wrote reports to capture these in addition to theirown reflections and activities. The meetings always in-volved CHWs reporting on their progress of interventionimplementation and elucidating barriers and facilitators.During the meetings, CHWs also asked questionsregarding any aspects that were not clear to them andtheir supervisors provided refresher trainings as neces-sary and followed up on any other issues. Meetingsusually lasted one and a half hours and reports formedpart of the data for this study. At the end of the firstintervention cycle of 6 months in July 2019, five focusgroup discussions, one for each parish, were held withall CHWs to further elaborate on their experiences andtriangulate data from reports. Meetings and discussionswere conducted at the health facility where both CHWsand their supervisors usually met for their feedbackmeetings. An FGD guide developed based on the CFIR(see Additional file 1) and had been pretested in a simi-lar community guided the discussions and probes used.The FGD guide was structured into the introductorysections with greetings and rapport building questionsfollowed by questions that explored the CHW approachin intervention implementation and barriers and facilitatorstherein. The CHWs demographic characteristics includingage, sex, education level, occupation and years working asa CHW were recorded by the note taker at the end of thediscussion. The FGDs were convened for all the fourCHWs in the parish covering all 20 CHWs and saturationwas reached as there was no new information in the finalgroup. The FGDs were moderated by RN (male), a re-search team member who was not field-based and had notany engagements with the participants, supported by acommunity-based supervisor who audio recorded the dis-cussion and took notes and any non-verbal cues. Amongthe five community-based supervisors, all of whom weregraduates with experience conducting qualitative research,three were female. The FGDs were held in Luganda, thelocal language of the area, to which both the CHWs andthe study team were fluent in and lasted about an hour.The discussions provided an opportunity to probe thus en-hancing understanding of forces that influence effectiveintervention implementation [31] while collective
brainstorming of ideas, issues and solutions created a “syn-ergistic group effect” [32].
Data management and analysisAll audio recordings from the FGDs were transcribedverbatim and concurrently translated into English by thenote taker who had expertise in both languages. The mod-erator later read through the transcripts to check the thor-oughness of the transcription process. All study transcripts(5) and process evaluation reports (41) were exported intoNVivo version 12.6 for analysis. RN and GM read the tran-scripts and notes several times and independently devel-oped the initial codebooks which were discussed andunified. Coding was done inductively following the latentapproach [33] identifying and examining words, phrasesand sentences, some with hidden meanings that repre-sented barriers and facilitators and coding them appropri-ately with new codes fitted within the codebook. At theend of the coding process, similar codes were grouped intosub-themes, and these into themes all of which were thenmatched with the CFIR constructs considering the domainand construct of best match. Based on transcripts andreports, the team also determined valence; whether aconstruct or domain majorly exerted a negative (barrier) orpositive (facilitator) influence on intervention implementa-tion or both. To illustrate, sub-themes of intervention beingextensive (barrier), and its implementation being incorpo-rated into routine activities (facilitator) formed the ‘design,complexity and adaptability of intervention’ theme. Thistheme fitted the CFIR domain, intervention characteristicsand its constructs (complexity—for extensive interven-tion—and adaptability—for incorporating implementationin other activities). Selected quotations supporting themesand sub-themes have been presented to supplement thestudy findings. The Consolidated Criteria for ReportingQualitative Research guidelines [34] guided reporting forthis study (see Additional file 2).
ResultsCharacteristics of community health workersA total of 20 CHWs, 13 of whom were female, engagedin intervention implementation in 20 villages across the5 parishes. The average age of the CHWs was 49 years(range 34–65 years) with over a half (13/20) aged be-tween 34 and 50 years and the rest above 50 years.Eleven CHWs had attained secondary education andothers received only primary education. Almost allCHWs (18/20) engaged in farming for subsistence pur-poses and over half (11/20) had served their communi-ties for more than 15 years.
Barriers and facilitatorsDrivers of intervention implementation success or failurewhich spanned 26 of CFIR’s 39 constructs were identified
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as illustrated in Fig. 1. Of these constructs, 4 were majorlybarriers, 16 facilitators and 6 both barriers and facilitators.Emerging themes from analysis of transcripts are pre-sented under the CFIR major domains embedding theframework constructs except for the process domain con-structs that have been integrated within the others (inter-vention characteristics, outer settings, inner settings andcharacteristics of individuals involved). The details ofthemes, sub-themes and supporting participant quotationsare presented in detail below and summarized in Table 2.
Intervention characteristicsUnder this domain, four themes emerged: design, com-plexity and adaptability of intervention; quality and supplyof inputs; gradual change process and costs of fieldwork.These themes embedded four CFIR constructs of designquality and packaging, complexity, adaptability and cost.
Design, complexity and adaptability of interventionThe level of complexity and flexibility of the interventionwas a key factor in its implementation. CHWs sometimesexpressed concern that the intervention was extensivewith elements of risk factor screening using interheart,goal setting and motivational interviewing and referraland follow-up (complexity). CHWs also sometimes re-ported difficulties with filling the interheart form espe-cially explaining questions on stress and depression,calculating the waist and hip ratios and compiling theinterheart scores (complexity). The intervention activities
were also noted to be time-consuming as communitymembers asked many questions especially the youths andelderly members and CHWs would only reach a fewhouseholds while in the field. CHWs also stated thatbehaviour change was not easy adding to thecomplexity.
“I teach individuals the different risk factors forCVDs. I teach about the health risk of excess bodyweight and I measure their waist and hip circumferenceand calculate their score to ascertain if they areoverweight. I thus take a lot of time working onone person and by the time I finish administeringthe interheart form, taking the waist-hip circumferencemeasurements and adding up the scores, I get no timeto work on other things and I don’t get to visit manyhouseholds.” [FGD 4, CHW 4]
To cope, CHWs usually incorporated routine activitieswithin the CVD intervention delivery such as inspectinghousehold sanitation after CVD risk factor screeningand education. Moreover, CHWs focussed their educa-tion majorly on risks identified during the interheartscreening and educated family members together ongeneral risks before providing individual counselling orplanned community-wide events and utilised publicgatherings to supplement house visits (adaptability).These measures led to efficient use of time and easedintervention progress.
Fig. 1 CFIR constructs and their influence on implementation of a community CVD prevention intervention
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Table 2 Summary of themes and sub themes highlighting barriers and facilitators of CHW CVD prevention interventionimplementation
• 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 andfishing communities being mobile
• Incorporated the intervention within other routineactivities
• Focussed education majorly on risks identifiedduring the interheart screening
• Educated family members together on general risksbefore individual counselling
• Utilised public gatherings to supplement housevisits which were also done on evenings andweekends
Quality and supplyof inputs
• Waist and hip ratio tape measure breaking down.• Calculators not provided for calculation of waist andhip measures and adding interheart scores.
• Waist and hip ratio tape measures replaced withthose of better quality.
• CHWs used phones were available.
Gradual changeprocess
• Community behaviour change is slow. • Encouraged incorporation of lifestyle practices intodaily routines.
• Elaborated cost of unhealthy behaviours.• Utilised motivational interviewing techniques.• CHWs shared experiences among themselves.
Costs of fieldwork • Large distances due to big sparsely populatedvillages
• 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 tohelp during harsh weather
• Planning time and going to the field in theafternoon after lunch.
• Community demands: a playing field and balls toincrease their physical activity levels, blood pressuremachines to measure blood pressure at home anddrugs for treatment, fruits and vegetables and theirseedlings to increase supply.
• Encouraged community members to startvegetable gardens
• Provided community members with their ownseedlings where possible
• Encouraged community members to seek carefrom health facilities which had been strengthened
• Liaised with health workers to conduct outreaches
Health servicesaccessibility andquality,
• Unavailability of required services or their being ofpoor 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
Mediareinforcement
• Media raised awareness on CVDs and reinforcedmessages passed by CHWs
• Media message consistency with that passed byCHWs.
Policies andprocedures.
• Non remuneration of CHWs• Prioritising existing CHWs for communityengagements
• Replacement of some CHWs engaged with manyactivities to devote time to the intervention.
Culture and beliefs • Unease in taking waist and hip measurements ofopposite genders.
• Wrong perception of the need for waist and hip
• Carried out the measurements in public placeswhile adopting a sideways posture.
• Requested a family member to support taking
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Quality and supply of inputsThe provision and regular supply of intervention inputsincluding interheart and referral forms, informationsheets for community members and waist and hip tapemeasures was key in intervention implementation.CHWs mentioned that the forms were provided in thelocal language which they preferred, were simple tounderstand and use (design quality and packaging). Thisnotwithstanding, in rare instances, some communitymembers who were not fluent in the local language re-quested for forms in English (complexity) which werelater provided. The CHWs noted that health workerstoo preferred referral forms in English as opposed to the
local language forms that had been provided to theCHWs. However, CHWs countered this demand fromhealth workers who understood that the local languagewas much easier for the CHWs (process—engaging).The CHWs were provided waist and hip ratio tape mea-sures for use during the intervention which sometimesbroke down (design quality and packaging) but wereoften replaced with those of better quality (cost). TheCHWs sometimes required calculators (design qualityand packaging) for their calculations of waist and hip ra-tios and adding up interheart scores but these were notprovided and resorted to using mobile phones whereavailable (adaptability).
Table 2 Summary of themes and sub themes highlighting barriers and facilitators of CHW CVD prevention interventionimplementation (Continued)
measurements.• Physical activity related activities such as running orriding a bicycle was not culturally acceptable.
• Tendency to cook only one kind of food withoutbalancing diet.
• Belief that fruits and vegetables are meant for youngchildren and sometimes sold for income.
measurements• CHWs providing thorough explanations tocommunity members regarding need formeasurements
Demographiccomposition
• Resistance, several questions and less cooperationamong youths and males.
• Elderly and female community members morecooperative.
Supportsupervision andfeedback
• 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 whocommunicated well.
Characteristicsof individualsinvolved▪ Individualstage of change▪ Other personalattributes▪ Individualidentificationwithorganization▪ Self-efficacy
Stage of change • Lower spectrum to stage of change • Higher motivation to change such as those alreadyhypertensive or diabetic.
• Community members’ testimonies.• CHW experiences and exemplariness.
Competingdemands
• High workload due to several CHW work tasks andother personal responsibilities
• Set aside time for intervention implementation.• Incorporate intervention duties within similar usualworks.
• Utilise community engagements for example atpublic events to share intervention message.
• Setting targets and goals bi-weekly.• Flexibility in scheduling the meetings.
Motivation andcommitment
• Lack of financial incentives • Motivation from non-financial sources including therecognition and respect and project incentives suchas t-shirts and training certificate.
• Observed changes in community behaviours andreported improved health outcomes.
• Transport refunds for the bi-weekly meetings.
CHW attributes • Being village leaders ensured that CHWs were busyto devote sufficient time to interventionimplementation.
• Low experience in dealing with community.• CHW sickness
• Some CHWs were village leaders having influenceand authority.
• CHWs supporting referral at health facility.• High CHW self-efficacy and experience
Socio-demographiccharacteristics
• Older and female CHWs found it harder to influencethe youth and male community members
• higher educated CHWs grasped concepts muchfaster, explained them better and produced data ofgood quality
• Personal experiences of CHWs who had CVD riskfactors.
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“I got some challenge, my waist-hip ratio measuringtape was weak and got damaged while in the field,but they brought me another one which is of betterquality that I am currently using.” [FGD 5, CHW 1]
Gradual change processLocal leaders, CHWs and the community believed thatthe intervention created a difference (relative advantage)based on experiences of fellow community members andthe consistency of message they had heard over the yearsthrough health workers and the media (evidencestrength and quality). CHWs though noted that behav-iour change of community members was slow (complex-ity). To elicit change, CHWs therefore encouragedcommunity members to incorporate lifestyle practicesinto their daily routines such as farming to achieve theirphysical activity goals (adaptability), often elaborated thecost of unhealthy behaviours to community memberssuch as funds spent on alcohol which usually provedeye-opening. CHWs also utilised motivational interview-ing techniques encouraging CHWs to undergo a gradualprocess of behaviour change such as setting goals toreduce number of cigarettes smoked in addition tocontinuous health information sharing and follow-up(cost). Additionally, CHWs continually shared experiencesamongst themselves to foster learning and sometimesworked as a team to support one another (process—champions).
“When we computed the amount he was spendingon alcohol in a year, he was alarmed and exclaimed,‘My God! I have never had such money in a wholeyear.’ I advised him to start reducing his consumptionfrom six sachets to four and save money for two sachetsand later reduce further. He left convinced that he waswasting a lot of money.” [FGD 4, CHW 2]
Costs of fieldworkThe implementation strategy involved CHWs traversingtheir whole village to visit all households therein. How-ever, some villages were large and sparsely populatedand thus CHWs had to move large distances to reachhouseholds usually through dusty, rough and uneventerrain, harder to navigate during the rainy season (cost).CHWs were provided with protective wear includinggumboots and umbrellas to support them during therainy season (cost). Relatedly, CHWs incurred opportun-ity costs especially in reduced time to fulfil other socialand gender responsibilities such as parenting, joiningsocial gatherings or attending to their other work (cost).
Outer settingsWithin the outer setting domain, four themes emerged:resources availability, health services accessibility and
quality, media reinforcement and policies and proce-dures. These themes fitted two CFIR constructs: externalpolicy and incentives and patient needs and resources.
Resources availabilityAvailability of resources to accommodate the promotedbehaviour changes in the community was a barrier inintervention implementation. For instance, communitymembers demanded for a playing field and balls toincrease their physical activity levels, blood pressuremachines to measure their blood pressure at home anddrugs for treatment (patient needs and resources). Otherresources of interest to the community were fruits andvegetables and their seedlings as these were limited inmost areas owing to their seasonal nature (patient needsand resources). CHWs in these instances encouragedcommunity members to start vegetable gardens withinsmall spaces that they can irrigate and encouraged com-munity members to seek care from health facilitieswhich had been strengthened by the SPICES project(process—external change agents). Sometimes CHWsliaised with health workers to extend CVD screeningservices to the community which was well received(process—engaging, external change agents).
Health services accessibility and qualityThe availability, accessibility and quality of health serviceswere key determinants of intervention uptake. WhereCVD services were available, accessible and considered ofa high quality, community members expressed willingnessto interact with the community intervention and wherenecessary sought more support from the health facility(patient needs and resources). Community members’ testi-monies encouraged other members to go to the facilitieseasing the CHW work (process—champions).
“As I told you, the people we go to are happy andthey like the [SPICES] programme. When a personyou have worked on goes to the health facility andthey are well attended to and given drugs, they go onsharing this information. Later, you see people fromother households that you have not yet reached askingyou: ‘Doctor, why did you abandon us?’, You tell themthat ‘I have not abandoned you and I will be comingto your place soon’. People are happy and they like theservices.” [FGD 5, CHW 1]
On the other hand, where referred community mem-bers are not attended to or do not receive adequate ser-vices, their testimony became a barrier to CHW work(patient needs and resources). Also, how health workersreceived and interacted with referrals from CHWs mat-tered with those who were positive further motivatingCHWs in referring more individuals unlike those who
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under looked their referrals (process—external changeagents). Health workers at facilities were also involved inthe CHW training and disseminations (external policyand incentives) to bridge the gap between the two andcreate rapport for future interactions and referrals thatCHWs appreciated (process—engaging). It was alsomuch easier for CHWs to sometimes reach out to healthworkers if they had any questions or to plan communityactivities (process—engaging). However, sometimeshealth workers were transferred (external policy and in-centives) and CHWs had to build rapport afresh at thefacility slowing their work (process—engaging).
Media reinforcementThe media (process—external change agents) also playeda role in intervention implementation especially where itraised awareness on CVDs and reinforced messages thathad been passed by CHWs (external policy and incen-tives). In fact, consistency of messages was key in facili-tating the intervention because where communitymembers received a similar message from the CHWs, atthe health facilities and from the media, it increasedtheir trust in CHWs and eagerness to comply with theirmessages (process—external change agents).
Policies and proceduresThe intervention was planned and executed within avail-able policies and procedures including those around re-muneration where CHWs are expected to be voluntaryand are not paid any regular emoluments (external pol-icy and incentives). This sometimes led to dissatisfactionand low motivation of CHWs. The policy that pre-existing CHWs should be given priority in communityprogrammes was challenging especially where someCHWs were engaged in multiple activities with littletime devoted to the intervention and a suboptimal per-formance which warranted replacements (external policyand incentives).
Inner settingsThe emerging themes within the inner settings weretraining and learning environment, community aware-ness and interest, trust, culture and beliefs, demographiccomposition, support supervision and feedback. Thesethemes reflected 10 CFIR constructs: available resources,access to knowledge and information, learning climate,tension for change, relative priority, implementationclimate, compatibility, organizational incentives and re-wards, culture and networks and communications.
Training and learning environmentBefore intervention implementation, CHWs underwent afive half-day face to face training which included theor-etical and practical aspects of the intervention and the
roles and responsibilities they were expected to play, anda two-day field orientation (available resources). Thistraining and dissemination events were a facilitator ofintervention implementation and many CHWs notedthat it empowered them with the knowledge, skills andconfidence (organizational incentive and reward) andprovided them with learning materials such as manualsthat they continuously consulted (access to knowledgeand information). The provided equipment and non-financial incentives such as t-shirts, gumboots and um-brellas (available resources) were also facilitators. Theother aspects of the training they appreciated were thesimplification of materials in the local language for easeof understanding (access to knowledge and information),the piloting field works that reinforced learning and thepositive learning environment where all their questionswere answered freely (learning climate).
Community awareness and interestThe awareness and interest of community members inCVD prevention activities played a role in interventionimplementation. In fact, community members who weremore aware about CVDs or thought of it as a big prob-lem (tension for change) were more cooperative withCHWs and honoured referrals compared to those withlow levels of awareness who usually had a low perceivedCVD risk and were reluctant to seek healthcare (relativepriority). In fact, screening programmes played a big partin increasing awareness of CVD risk factors and stimu-lated community participation in the project (process—engaging). Sometimes community members felt thatother conditions were more urgent than the CVDs andwould divert the CHW to other diseases such as malariaduring house visits or education (relative priority). Insome urban areas, CHWs were sometimes met withwalled fences and uncooperative members who wouldnot let them in their gated houses making access tothese households much harder (implementation climate,culture).Existing community structures were utilised (compati-
bility, process—engaging) in order to increase commu-nity awareness, buy-in and interest. These structuresincluded community leaders such as local and religiousleaders (process—opinion leaders), community groupssuch as savings groups, and community events such asmeetings (process—executing). Where community struc-tures were involved, CHWs felt more support and inter-vention implementation moved more smoothly. Forexample, community leaders supported mobilisation oftheir communities and the church leaders identified withthe intervention usually inviting CHWs to share keymessages during their gatherings (process—champions).For savings groups especially those to which CHWs
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belonged, they were usually allocated time after theirusual meetings to talk about the intervention (process—executing). CHWs also encouraged group activitiesespecially for physical activity mobilising communitymembers to meet and exercise regularly which was moreappealing especially to the youths (process—engaging).
“The CHW mobilised the local council committeemembers of his village to take part in three sessionsof health education on CVD prevention and control.The local council chairperson welcomed the projectand its intentions and pledged to mobilize all hiscommittee members for the education sessions andsupport the project. The first, second and third sessionswere planned and took place in June and Julyattracting several community members.” [CHWsupervisor report]
TrustAlthough most community members trusted the CHWsand this fully facilitated intervention implementation(compatibility), there were instances of mistrust wheremembers attributed CHW activities to politics or west-ern interests which sometimes hindered cooperation(relative priority). CHWs relied on their popularity andclose relationship with their community having workedor lived in the area or their ability to build rapport (net-works and communications) and sometimes sought help(process—engaging) from local leaders (process—opin-ion leaders) to provide re-assurances. Moreover, brandedproject t-shirts (organizational incentives and rewards)also eased their identification to community members(process—formally appointed internal implementationleaders).
“Some don’t want to tell us their age or aboutthemselves. They see us as spies and they say,‘why are you asking me all this, are you a spy?They usually don’t like so many questions. As youreply, you must handle them with politely. Youcan explain to them that I am a fellow communitymember, you cannot suspect that I can have badintentions towards you. Then you go on to explainto them carefully that you are not a spy and thatyou are only interested in health issues. Then yousensitize them. Some of the community membersare witnesses that what we have sensitized themabout are good issues and they have worked forthem.” [FGD 2, CHW 2]
Culture and beliefsOne of the CHW roles was to take waist and hip mea-surements of community members as part of requiredinformation for filling in the interheart forms, and this
aspect was sometimes considered not culturallyappropriate where opposite genders were involvedfor potential of it being misconstrued (culture). Thissometimes led to CHWs preferentially choosingcommunity members of their gender during housevisits (compatibility). Thus, CHWs sometimes carriedout the measurements in public places while adopt-ing a sideways posture and other times requested afamily member to support taking measurements suchas husband taking measurements of their wife (learn-ing climate).
“When I disapproved of her repeatedly working mostlyon women, the CHW said she was uncomfortablefastening a tape measure around men as it wouldlook like they are being touched to evoke sexualfeelings. She also noted that this form of act wasdisapproved of in the Kiganda [local] culture. Iadvised her to explain to them [men] why sheneeds to take their waist and hip measures andwhere necessary solicit the support of anotherfamily member to support taking the measurements.”[CHW Supervisor report]
CHWs said that sometimes community membersinterpreted the purpose of the waist and hip measure-ment to be intended to provide them clothing (relativepriority). CHWs endeavoured to provide thoroughexplanations to community members regarding theintervention to wade off any suspicions and expecta-tions (networks and communications). Some commu-nity members mentioned that running or riding abicycle was not acceptable especially for women andthus they could not engage in such activities (culture).Regarding food choices, the community also had atendency of cooking just one type of food such assweet potatoes served as a big heap on one’s platewithout balancing the diet and others claimed thatfood that is not fried is not delicious (culture). Othercommunity members had the belief that fruits andvegetables were meant for young children or the richwhile others usually looked at them as a source ofincome and sold them to others (culture). The CHWhad to address these issues through thorough sensiti-sations (networks and communications).
“Some [community members] continue asking whydo you measure my buttocks and waist, are yougoing to buy me a trouser? One lady asked mewhy I did not measure her skirt to the bottom.The lady said a skirt starts from the waist to thebottom, take all measurements, and I told her no,am not measuring you for an outfit. There has been alot of questions in that area too.” [FGD 3, CHW 3]
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Demographic compositionFurthermore, owing to the design of the interventionwhich involved house-to-house visits, CHWs sometimesdid not find men at home during their visits since mostworked during daytime and fishing communities wereusually mobile (compatibility). Community groups alsoreacted differently to the intervention with CHWsreporting more resistance, several questions and lesscooperation among youths and males (implementationclimate, compatibility) compared to the elderly andfemales due to less prioritization of the intervention(relative priority, compatibility). The CHW demographiccould have mediated this relationship (networks andcommunications) that whereas youth were more likelyeducated and asked teasing questions, the elderly weremore interested in learning and exploring several dimen-sions of CVDs with CHWs. CHWs continued engagingall community groups (process—executing) and answer-ing any questions and concerns they had (process—en-gaging). The level of cooperation of the community(organizational incentives and rewards) played a role inCHW motivation.
“The CHW noted that capturing men was still achallenge, citing that most men always tell herthat such programmes are for women and in anycase, interviews and other data can equally bebest provided by their wives. She stressed that youcan find both the wife and her husband, and thehusband tells you directly: ‘that is for women, Ieven don’t have time; you ask, screen and discussanything with my wife’. On the other hand, someindividuals claim that they don’t have any signsand symptoms of being unwell especially theyouth.” [CHW Supervisor report]
Support supervision and feedbackFrequent support supervision and feedback (goals andfeedback) provided by community-based supervisors waskey in further supporting CHWs to carry out their roles(process—formally appointed internal implementationleaders). Indeed, CHWs mentioned that working withtheir supervisors at the start built their confidence todeal with community members and learn how toapproach questions (available resources). Supervisorscontinually monitored and supervised CHW activities(goals and feedback), mobilised them for fortnightlyfeedback meetings where any goals and targets were set,and previous ones reviewed (goals and feedback), andprovided any continuous refresher training on conceptsthat were challenging (available resources). The feedbackthat CHWs got from the field work and review of filledforms enabled them to continually improve and performbetter (goals and feedback). The other important component
was the feedback from CHWs regarding the work they weredoing (goals and feedback), and CHWs found it importantwhen the feedback they provided to their supervisors wasacted upon and a response provided to them as they feltmore valued (organizational incentives and rewards). Thesupervisors were also noted to be friendly, approachable,communicated well and established a good relationship withCHWs (networks and communications).
“The bi-weekly feedback meetings give us a platformto ask about things we do not know. Even aftertraining, someone can keep at the same level ofknowledge. However, during the meetings we getenough time to discuss and learn more ratherthan having phone calls when things might not beexplained in detail..” [FGD 1, CHW 2]
Characteristics of individuals involvedThere were five emerging themes under the individualcharacteristic’s domain: stage of change, competing de-mands, motivation and commitment, and CHW attributes.These themes were related to four CFIR constructs: individ-ual stage of change, other personal attributes, individualidentification with organization and self-efficacy.
Stage of changeThe community member’s stage of change was a key im-plementation factor with those on the lower spectrum(e.g. precontemplation) sometimes resistant to receivinginformation and advice regardless of their practices (in-dividual stage of change). On the other hand, individualswho had a higher motivation to change such as thosewho were already hypertensive or diabetic were muchmore open to advise and engagement with CHWs (indi-vidual stage of change) and shared valuable testimoniesthat attracted the attention of other community mem-bers (process—champions). CHWs (process—opinionleaders) also shared experiences among themselves tosupport each other and other personal experiences toencourage change including lifestyle changes made whileothers relied on their being exemplary to motivate com-munity members (individual stage of change, process—engaging).
Competing demandsCHWs had many competing demands and priorities re-lated to other tasks they were supposed to carry out,other personal work such as businesses and engage-ments including those within the community such as at-tending community events and visiting their relativesand friends (other personal attributes). These demandsculminated into a high workload and would sometimestake up CHWs’ time and limit their engagement inintervention delivery (process—executing). CHWs were
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encouraged to set aside a few hours every week to makeprogress (process—planning) with the intervention andsometimes incorporate intervention duties within similarusual works, and this supported intervention implemen-tation (process—executing). CHWs also sometimes cre-atively devised ways to still share about the interventionand pass some messages during their community en-gagements for example at public events (process—cham-pions). The other key facilitator was setting targets andgoals bi-weekly which stimulated CHWs to work hardand meet them for reporting during their feedbackmeetings and this kept them on track (process—reflect-ing and evaluating). There was however need for flexibil-ity in scheduling the meetings to cater for the CHWcompeting demands.
“I had scheduled to meet the CHWs but one of themcalled me early on the meeting day that he had avery urgent matter to attend to and would not makeit for the meeting. We thus re-scheduled the meetingto another day, but this was inconveniencing to allof us. Although the meeting later took place, anotherCHW still left earlier to attend to other priorarranged commitments.” [CHW Supervisor report]
Motivation and commitmentCHW motivation was a key factor that impacted inter-vention implementation. CHWs majorly derived theirmotivation from non-financial sources including the rec-ognition and respect they obtained from the communityand incentives provided by the project (other personalattributes). Moreover, the personal knowledge they ac-quired through trainings, training certificates and invita-tion to attend project events such as disseminationevents motivated them (other personal attributes).
“Attending the project dissemination event upliftedand gave us some bit of change. It helped us analyseour performance because at first, we just worked forthe sake but when we got to meet other CHWs andsaw how they performed, it gave us more passion forwhat we do. I really felt so challenged that immediatelywe got back from that event, I started to work such thatwe can reach the level of the others.” [FGD 2, CHW 1]
The other motivation CHWs had was from observingchanges in behaviour in their villages and obtaining goodfeedback from community members about the interven-tion with some reporting improved health outcomes.Where CHWs were motivated, they showed high com-mitment to their work and their productivity was high(individual identification with organization). This not-withstanding, CHWs continued to demand for financialincentives and the lack of these demotivated some of
them. The only financial incentive the project providedwas in form of transport refunds for the bi-weekly meet-ings and other events which the CHWs appreciated (in-dividual identification with organization).
“On the same note, one CHW stated that she lackedprior motivation of doing the project’s field workbecause she was unsure of her attached benefit.However, she was contented with the transport refundoffered during their work review meetings.” [CHWsupervisor report]
CHW attributesSome CHWs were village leaders and this facilitatedintervention implementation as they were more recog-nised and given much respect and the community weremore likely to listen to them (process—opinion leaders).
“I am the Chairperson of my village so whenever Iget time, I visit a household and I share theknowledge I get from my trainers here and when Icall for meetings I take about 10 minutes andbriefly share with them about the project. I alsoget invited to savings groups cooperatives as aspecial guest and usually pass on messages aboutthe project at such fora.” [FGD 3, CHW 2]
On the other hand, CHWs who were leaders tended tobe busier than their counterparts as they had to balanceleadership responsibilities and CHW roles and in mostcases prioritised the leadership thus dragging interventionimplementation. Similarly, CHWs who also supportedtheir health facilities usually helped the community mem-bers referred from the community to quickly access healthcare when they were present at the facility (process—champions). However, this too came with an increasedworkload and less time for community intervention imple-mentation. The other relevant personal attribute was theCHW self-efficacy and experience doing communityhealth work with more experienced CHWs being famouswith wide networks and skilled in dealing with communitymembers facilitating intervention delivery (self-efficacy).On the other hand, those that had limited experience re-quired empowerment to build their confidence to assertthemselves in carrying out the intervention (self-efficacy).The major personal limitation for CHWs was their healthwhere some would take some time off due to ill healthand other life responsibilities.
“When I inquired from the CHW why she had notperformed well in her village, she explained that shehad episodes of sickness and was too ill to conducthome visits. In addition, she was having stress mobi-lising school fees for four of her children in boarding
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school and all these challenges impeded her work.”[CHW supervisor report]
Socio-demographic characteristicsThe socio-demographic characteristics of the CHW suchas their age, sex and education level influenced interven-tion implementation (other personal attributes). Olderand female CHWs found it harder to influence the youthand male community members respectively and viceversa.
“Sometimes you find when someone is a smoker andyou explain to them about the dangers of the habitand they tell you that: ‘You who was born yesterday,how can you tell me about smoking yet I havesmoked for the last forty or fifty years’. Then youmay just end up referring him/her to the facility forfurther support.” [FGD 5, Participant 1]
On the other hand, higher educated CHWs graspedconcepts much faster, explained them better and pro-duced data of good quality (other personal attributes).CHWs who had CVD risk factors such as hypertension ordiabetes relied on their personal experiences with the dis-ease to elicit change and create interest (knowledge andbeliefs about the intervention, process—opinion leaders).
DiscussionThis study explored the barriers and facilitators of imple-mentation of a community CVD prevention programmein Mukono and Buikwe districts in Uganda using theCFIR. The framework enabled the systematic and compre-hensive identification of drivers of implementation successor failure across its domains to inform and improve inter-vention implementation for impact and scale-up. The bar-riers to intervention implementation were the complexityof the intervention leading to high opportunity costs,some aspects of the intervention not being compatiblewith community culture, the lack of an enabling environ-ment for behaviour change and community memberssometimes mistrusting CHWs. Moreover, the low com-munity awareness of CVD, CHW factors such as theirdemographics and competing demands and unfavourablepolicies impeded intervention implementation. On theother hand, the intervention was facilitated by availabilityof inputs and protective equipment which also acted as in-centives, adequate training of CHWs, working with com-munity structures including leaders and groups, frequentsupport supervision and engagements, CHW attributessuch as motivation and commitment and access to goodquality health services. These barriers and facilitators arein line with those that had been anticipated by the com-munity and CHWs at the start of the intervention [18],those reported by a systematic review in China [21]
and experiences from Bangladesh, China, Nepal andViet Nam [35].In implementation of a multi-component community
CVD prevention programme, the complexity of theintervention needs careful consideration especially be-cause CHWs are lay persons with no specialised CVDknowledge and skills and usually have low literacy levels[28–30, 36]. Moreover, the more complex an interven-tion is, the higher the opportunity cost to CHWs espe-cially in terms of time and resources which may impactintervention fidelity [37]. Therefore, in addition to con-text, designed interventions should be adapted to CHW’sabilities to enhance intervention ownership, acceptabilityand success. Potential adjustments could include omit-ting certain intervention components or reducing theirduration, simplifying implementation tools includingthose for training or education or setting manageabletargets. However, where complex interventions areinvolved, a selection criterion that requires a higher edu-cation level would help to increase efficiency and impact.Indeed, higher education levels are associated withimproved knowledge and performance among CHWs[38, 39] though they may come with higher attritionlevels [40] and thus should be considered cautiously.Uganda’s CHW is voluntary with no remuneration [28–30]and CHWs continue to face other competing demands dueto personal and social responsibilities [18, 41]. It is thus keythat costs for CHWs are minimised as much as possiblesuch as through providing transportation mechanisms.Moreover, in recruiting CHWs to support such demandinginterventions, their other commitments need to be realistic-ally examined to avoid those with many responsibilitieswho may not create time for the intervention. Beyondworkload, CHW self-efficacy, motivation and commitmentare key attributes that should be explored a priori duringrecruitment in line with the World Health Organization(WHO) guidelines on health policy and system support tooptimise CHW programmes [40]. Motivated CHWs aremore likely to be performers and invest time in supportingintervention implementation [38, 42] though motiv-ation avenues should be continually incorporatedwithin programmes. During intervention implementa-tion, CHWs also reported some forms of mistrust bycommunity members which although had been antici-pated [18] is a concern for the success of communityinterventions. Mistrust could be related to the lowcommunity awareness on CVD and its risk factors [8]hence the low relative priority some members at-tached to it. Trust and respect are cornerstones ofcommunity health work [40, 42–44] and have beenreported as a facilitator for CHW engagement inNCD prevention programmes [21, 35]. Overall, in-creasing community CVD awareness, relative priorityand community ownership of programmes and
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support of the local structures would go a long wayin increasing trust of CHWs [41–44].Culture in terms of community attitudes and beliefs is
another key factor that can bar or skew intervention im-plementation if not well managed. It is thus importantthat the compatibility of an intervention with commu-nity culture is ascertained in advance. In our pre imple-mentation study, some of the discussed aspects of theintervention were not very specific to elicit precise feed-back on the cultural aspects [18]. Trainings should payclose attention to any cultural aspects that may affectintervention implementation and prepare CHWs to ef-fectively deal with them. If left unattended, undesirableconsequences may arise for example CHWs finding theirown coping mechanisms such as selectively dealing withcommunity members of the same gender. Indeed, previ-ous literature has shown that sometimes CHWs find iteasier to deal with community members of their genderand similarly do community members [45] and sinceCHW programmes are usually dominated by females[36, 46], males—who rank higher in certain lifestylepractices such as smoking and alcoholism—may not befully impacted. Similarly, we found the CHW demo-graphic attributes to be an important factor in who theyreach out to. Community groups such as males andyouths were generally considered unwelcoming com-pared to females and the elderly which could largely bedependent on the demographic of the CHWs them-selves, usually female and older. This reiterates the needfor diversity of CHWs for effective intervention imple-mentation such that no groups are left behind [45].However, the WHO guidelines on health policy and sys-tem support to optimise CHW programmes downplaythe significance of factors such as age and gender as se-lection criteria for CHWs as they may promote unfairdiscrimination [40]. Moreover, it may be perceived thatCHWs are meant to attend to members of their genderthus creating unintended consequences. More proactivemeasures such as thorough training and empowermentof CHWs with skills to deal with the different groupsand manoeuvre-related cultural issues would be desir-able. The WHO guidelines however strongly recom-mend the need to remunerate CHWs based on theirtraining, duties and roles [40] which is still an impedi-ment in Uganda’s CHW programme [28, 29] and re-quires careful consideration in future programmes.Another external policy factor is the need to createan enabling environment for the practice of healthylifestyle factors. Sustainable initiatives such as thepromotion of vegetable gardens and usual physical ac-tivities that can be carried out in limited spaces wouldgo a long way in addressing such barriers creating an en-abling environment for behaviour change. CHWs shouldbe equipped with potential locally suitable options to
share with community members to overcome suchbarriers.Among the key facilitators for intervention implemen-
tation was the availability of key inputs such as inter-heart screening forms, referral forms and healtheducation leaflets. Weather challenges also required thatCHWs were provided with personal protective equip-ment including gumboots, umbrellas and t-shirts whichwere good motivation avenues and supported their iden-tification within communities. As with most previousprogrammes, training was a key facilitator of interven-tion implementation [21, 38, 42] as CHWs had notinterfaced with CVD interventions previously [18] sup-porting their understanding and contextualization of thedisease, its risk factors and intervention [22]. The CHWstraining programme was both didactic and experientialallowing CHWs to obtain the theoretical knowledge andfield experience while receiving important feedback toimprove, which was beneficial. Relatedly, during inter-vention implementation, frequent engagement withCHWs and goal setting helped to keep them on trackand support supervision motivated them. The role ofsupport supervision in CHW programmes has been welldocumented previously [21, 41, 42, 44, 47] and a strongcomponent of this is required for successful programmes.Community structures such as local and religious leadersand local saving groups were key facilitators of interven-tion as they supported mobilisation of the communityand/or were avenues through which members could bereached which CHWs took advantage of. As key compo-nents of a community health system, activating commu-nity interventions requires unlocking the potential of allcommunity structures as a springboard for self-care inter-ventions [15]. Another key advantage of the CVD preven-tion intervention was its outreach to build health facilitycapacity to deal with CVDs. Indeed, as had been antici-pated [18], a functional health facility with available andfriendly staff, drugs and equipment was a very importantfacilitator of the intervention. In their review of barriersand facilitators of CHWs engaging in NCD preventionand control in Asian countries, the integration of thehealth system with community CVD prevention interven-tions was key [21, 35]. Thus, a strengthened health systemis required for the effective functionality of a communityintervention.Exploring the acceptability of the proposed interven-
tion among the community and CHWs was an import-ant step in understanding the community dynamics,opportunity costs, and anticipated barriers and facilita-tors which guided intervention refinement and delivery[18]. Indeed, some of the identified gaps were bridgedprior to intervention implementation; however, othergaps were external and affected implementation. Basedon the lessons from the acceptability part of our study
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[18] and this exploration of barriers and facilitators, fu-ture community programmes should consider exploringthe prospective acceptability [48] of interventions anduse findings to guide intervention implementation.Moreover, during intervention implementation, it isimportant to continuously engage with CHWs andlocal stakeholders to generate contextually relevantand innovative adjustments to resolve some of theimpediments faced.In this study, through using CFIR, we elicited key
barriers and facilitators that spanned across the frame-work constructs thus furthering our understanding ofthe implementation process of a community-basedCVD prevention programme led by CHWs. Theframework also guided results presentation and com-prehensive synthesis highlighting key elements thatwould otherwise have been missed and allowing forcross setting evaluation and comparison in this inter-national project forming a key strength of this study.In addition, the study conducted a continuous processevaluation supporting timely reporting and discussionof barriers and facilitators and this together with thefocus group discussions held at the end of the imple-mentation cycle formed the study data enabling step-wise examination of the process and triangulation ofresponses. Moreover, all CHWs participated in theprocess evaluations and focus group discussions. Withthe increasing use of CFIR, there is an opportunity forcomparison of findings across studies. As opposed tomost previous studies that examined barriers andfacilitators post- or pre-intervention [49], this studyprovides information on drivers of implementation asprogramme implementation is ongoing. Thus, it wasnot possible to compare performance across cases, de-termine strength of given implementation drivers orhighlight magnitude of distinguishing parameters.Among the study weaknesses was the possibility ofCHWs providing desirable responses due to theirinvolvement in the study and their community-basedsupervisors being present during the discussions asnote takers. However, this was unlikely as CHWs wereusually upfront about the barriers they faced, and thesupport they felt they needed and efforts were furtherundertaken to re-assure CHWs to share any feedbackso that the team was better able to support them andthat their views would not influence their continuedengagement in the programme. This study did alsonot obtain views from community members and otherkey stakeholders such as programme managers whichwould have helped in triangulation of CHW responses.This study contributes important information regard-ing the implementation process of a community CVDprevention intervention which should inform otherprogrammes especially in low-income contexts.
ConclusionThe community CVD prevention programmes showedpromise within the context amidst implementation barriersand facilitators organised as per the CFIR. Indeed, factorssuch intervention complexity, cultural compatibility, enab-ling environment for behavioural change and CHW factorssuch as their demographics and competing demands re-quire significant attention especially during interventionplanning and implementation. On the other hand, strength-ening programme facilitators including availability of inputsand protective equipment, thorough training of CHWs,working with community structures, frequent supportsupervision and engagements, CHW attributes such as mo-tivation and commitment, and improving access to qualityhealth services is important for successful implementation.These drivers of implementation should inform the designof impactful, scalable and sustainable CHW programmesfor non-communicable diseases prevention and control.
Supplementary InformationThe online version contains supplementary material available at https://doi.org/10.1186/s13012-020-01065-0.
AbbreviationsCHWs : Community Health Workers; CVD : Cardiovascular disease; FGD: FocusGroup Discussion; NCDs: Non-communicable disease; SPICES: Scaling-upPackages of Interventions for Cardiovascular disease prevention in selectedsites in Europe and sub-Saharan Africa; WHO : World Health Organization
AcknowledgementsThe authors wish to thank the community health workers and community-based health promoters who support intervention implementation and con-tributed data for this study.
Authors’ contributionsRN contributed to the design of the study, data collection, led the analysisand drafting of the manuscript. RKW, FN, HB and GM contributed to thedesign of the study, analysis and critical review of the draft manuscript. Allauthors read and approved the final manuscript.
FundingThis study was funded under the SPICES project in Uganda which receivedfunding from the European Commission through the Horizon 2020 researchand innovation action grant agreement no. 733356 to implement andevaluate a comprehensive CVD prevention program in five settings: a ruraland semi-urban community in a low-income country (Uganda), middle-income (South Africa) and vulnerable groups in three high-income countries(Belgium, France and UK). The funder had no role in the design, decision topublish or preparation of the manuscript. The contents of this article are theviews of the authors alone and do not represent the views of the EuropeanUnion.
Availability of data and materialsThe data/transcripts used during the current study are available from thecorresponding author on reasonable request.
Ethics approval and consent to participateThis study obtained ethical approval from the Higher Degrees Research andEthics Committee of Makerere University School of public Health (protocol
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624) and was registered by the Uganda National Council for Science andTechnology (HS 2477). Permission to undertake the study was also obtainedfrom the district authorities. Study participants provided written informedconsent and their privacy and confidentiality was ensured.
Consent for publicationNot applicable
Competing interestsThe authors declare that they have no competing interests.
Received: 1 June 2020 Accepted: 29 November 2020
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