Discussion
This study presents a unique contribution to implementation literature by applying quantitative CFIR measures to assess pre-implementation contextual data about three healthcare systems. Rather than focusing on a single aspect of the CFIR, the survey built on previous research to capture insights from each CFIR domain and added additional insights about stigma perceptions. Surveying staff in different roles allowed for a comprehensive view of clinic context, and the research team used the findings to inform the implementation.By understanding both weaknesses and strengths, these results provided useful feedback to the CLARO research team about the healthcare systems in the pre-implementation period. Overall, there were several consistencies across the three systems and across roles. Most areas for improvement at the system- and role-levels focused on inner setting (organizational focused) constructs whereas individual-level (staff focused) constructs tended to be areas of strength. Perceived community stigma also tended to score relatively high across systems and across roles. Some survey findings seem analogous to contextual factors identified in previous research such as concerns about resources.With regard to variation, system 2 results indicated some additional areas for improvement with inner setting and process constructs when compared to systems 1 and 3. Notably, as the CLARO RCT progressed, some challenges with system 2 gradually developed, shedding light on the pre-implementation survey findings. Emergent challenges included a complex and hierarchical leadership approach, combined with high staff burnout and patient skepticism about the health system and providers. As an example, in system 2, the research team eventually learned that while the population included many who could technically qualify for CLARO, many clinic staff believed they would not be able to recruit patients due to perceived stigma in the rural community (e.g., it was highly likely that a given patient would know everyone working in the clinic, from the front desk staff administrator to the pharmacist, so some worried patients may fear a damaged reputation). Implementation was later discontinued in system 2 due to low levels of adoption and fidelity to the intervention model.There was a fair amount of consistency when comparing survey data by role in that some inner setting and intervention constructs stood out across most roles similar to system-level results. In terms of variation, BHP results indicated that the process construct, engaging champions, was an area for further examination. Additionally, MPs seemed to have more favorable views about relative advantage as compared to BHPs and RNs. The possible reasons for those differences are less clear and would benefit from additional research.This research builds on the work of Fernandez et al.Discussions with clinic leaders focused on the many apparent strengths as well as areas for improvement including the topics, culture stress, resources, complexity, and perceived community stigma. Strengths were considered areas that clinic leaders and staff members could build on to support the CLARO RCT. For example, while many leaders might worry that employees will be resistant to something new, the high-scoring individual-level characteristic, openness to innovation, showed that staff members in these healthcare systems tended to be open to new initiatives. This finding provided a strong starting point for conversations with staff about CLARO as a new initiative.In a second example, in one healthcare system, discussions addressed how the survey findings related to ongoing concerns about employee burnout, and what that meant for implementation. CLARO team members met with clinic leaders to talk through the steps that clinic leaders planned to take to support their clinic staff members with issues related to stress, lack of resources, burnout, and related issues like leadership turnover.Additionally, because there were concerns about community-level stigma in all three healthcare systems, researchers spoke with leaders from each system about the nuances of what community stigma looked like in their geographic areas to help determine the biggest potential challenges related to implementation (e.g., if stigma was prominent among certain types of patients specifically, such as the unhoused).Through these types of conversations, CLARO team members were able to probe some of the nuances evidenced by survey data to support strategies for the implementation. The CLARO team did not change IRB-approved implementation protocols, but they were able to provide suggestions or ideas about aspects of the implementation that fell within the RCT’s control to some extent (e.g., ideas for champions and other coordinators), and suggestions for clinic leaders in support of their healthcare systems. Survey data discussions were also helpful in building relationships among the CLARO team and clinic leaders.