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Table 3 CFIR constructs associated with PVS performance

From: The implementation of health promotion in primary and community care: a qualitative analysis of the ‘Prescribe Vida Saludable’ strategy

CFIR Constructs Cases
High implementation: Center A Medium implementation: centers B and C Low implementation: center D
Intervention characteristics
Intervention source It was a collaborative effort at all levels; everyone had internalized their commitment to health promotion. (+2) We have adhered voluntarily and we have joined because we want to respond to the challenge (of making prevention effective in increasing healthy habits). (+1) This is something that we initially did voluntarily but then all sorts of demands were placed on us at the same time. (0)
Evidence strength and quality We are seeing how our patients are changing their habits, similar to how we have seen a change in our own. (+2) This is a priority, in other words, it is so important because of the impact it has. (+1) Coming from pediatrics, I think other types of things could be done to make things better because this tool doesn't fit very well. (+1) Everyone as much as they can (…). Haven’t they told you that many folks say that five fruit or veg. portions can make you fat? (−1)
Adaptability The method, in itself, is not bad. The problem is how fast. They are demanding a 95% and we are going at full speed, we can’t keep up with that for a long time. (−2) For this outcome data to be useful, I would have to reach 4 or 5 daily, with each consultation being half an hour, there is not enough time for me and I create a waiting list for other demands. (0) The surveys are a little complicated for people, aren’t they? About the portions and having to write it down every time, and all that; I think it doesn't reflect reality very well. (−2)
Design quality & packaging (…) we thought, “that’s fantastic, we are going to have a tool that’s going to help us, and not the other way around, …” and gives us many, too many problems (−1) You’re working with a tool that you know doesn't work; we are even having trouble printing the prescriptions (−1) The tools didn’t work from the start, not theirs (the nurses) or ours (admission); I’m talking about the assessment too (−1) We should have better things that can help us, with this, I don't know where to fit it in (−1) The computer platform is amazing as a model (…) But when you want to give advice, you cannot print; it often fails completely or doesn’t work properly and it could be improved. I guess… 80% of my expectations are fulfilled while 20% aren’t because there are a lot of things that could be improved. We have to be positive, I think the tool we have is very good. In the long term, it is going to reap results (…) but it is a question of years. (+1) For instance, physical exercise: I have always prescribed physical exercise; but to have the tool, the information sheets, the specifics and ways of telling individuals how much to do, in what ways, and how to orient patients about physical exercise. (+2)
Inner setting: Implementation climate
Tension for change We have committed to this and have internalized that it is not only about addressing the pathology but also about promoting health across the various levels of care. (+1) We have to be positive and I think the tool is terrific. I think, in the long term, we will have good results. (+2) I do tobacco prevention too (…) indeed this year, I have two or three of my patients have quit smoking; I have not managed the problem well because I don't feel comfortable with the program. I have not done the program with the patients. (−2)
Learning climate All the time, we are trying to do more because everyone is saying ‘let’s do it, let’s do it’. (+2) We have to do it gradually, without stressing, and always making it better. (0) I haven’t got as involved as him. (0) I joined in December and until now I have not done anything. (−1)
Characteristics of individuals
Self-efficacy This is part of an effort on the part of the whole group and totally a personal effort, without support. (+2) Going at the speed of a cruise ship, for how long do I go? Because I may not be able to. (−1) I am flexible with the people that really want to (…). If the patient works in the morning and wants to stop smoking, we move the appointment to the afternoon and out of the usual times; we try to do that. (+1) It is very hard for me to prescribe the physical activity; it is very hard. (−2)
Process
Planning Our actions have to be organized, with everyone and directed to the patient. (0) I don't know where we are and where we are going; I just don't know. Sometimes we feel like we lose sight of the goal, ‘listen, what do we need to do now?’. (0) Our goal as professionals is to change patient lifestyle habits. If we can agree on that goal and can do it within a timeframe, that’s perfect; but if not, then we will have to set other timelines. (0) Since during the assessment time we were getting little out of it, we told ourselves: ‘let’s assess here, in this other room’. That way we get to the patient in a different way and increase the rate of assessment. (0) Ah, ok, later on you tell me how this is done. (−1) When you tell the patient, what exercise, then you write it down on a piece of paper: ‘this patient is interested in doing physical exercise, please help him’. If you send them with that, the gym will pay attention and the patient will get to the appropriate person. You didn't know this? No, no, I didn't know that, that you have to write it down and send the patient out with that. (−1) At the beginning, there was talk of making more time available for PVS but I haven’t done it, from the beginning I refused to do that. (−2)
Engaging Champions This is a team effort, totally personal, without any support; we don’t have anyone who can support it. Then, from primary care, we have been figuring out how to do it. (+1) In any case, these data can be useful to check where we are, but I’m hoping it will not become a burden in our work. (+2) Our team coordinator is really motivated. I am with the coordinator. I don't know how to put this, but I have been surprised by the beneficial impact of PVS on our patients. (+2) NA
Executing I have the impression that we are making it better in each of our meetings and that it becomes clearer. (+1) You make the patient fill out the survey at the reception area, because if you don't, then he goes home and doesn't come back. (+1) At the beginning, we felt a bit like: damn, it is difficult to introduce changes, and let’s try to do this slowly, making changes at our own pace, bit by bit. (0) Me, the goals, the ones I set are not the ones defined by PVS. To me if someone eats an apple when they don't have anything to eat, I know it will not be counted by PVS but it is an achievement from my perspective. (−1) We are so focused on the health problem and we are not accustomed to working through the healthy themes and how to work with them. (−2) In recent months, we have been doing much less assessment and this is because we show up as not doing anything. It is a failing of the computer technology; I don't know really, it is really annoying and it makes me angry that our activity is not being recognized. (−2)
Reflecting & evaluating It would be interesting, even if they are very preliminary data, to have an evaluation of the first semester of the pilot and the changes that we have achieved. (+1) We have to look at the outcomes so that we can plan on our own, to be able to see if we are having an impact in the future. (+1) I think we need to put the data in context. The data is a start of the reflection. It is to say: ‘hey, how could we increase the number of patients participating?’ (+1) Sure, but we’re not sure what the “n” (the expected outcome) means, we don´t understand. (−1) I realized that I was advising patients but I wasn't writing it down (…). It means that if you don't write it down, it is as if you’re not doing anything. (−2) I don't know how the indicators are created but other information should emerge from all that, right? (−2)
Organizational tracking We are running around to reach a 95% rate; if it is a pilot, why do we have to reach 95%? (−2) At times, we had to make decisions so that the program works and that you have been around to just bring up the statistics. (−2) Man, the statistical part and all that, it is really a pain in the neck, a real drag. (0) It is very stressful; it doesn't, really, reflect reality. (−2) NA