Table 3 Example quotes organised thematically and mapped to CFIR domain and construct base on barrier and facilitator

Intervention Characteristic

Design Quality and Packaging

Perceived facilitators: dedicated team for NCD Management

If we are to truly focus on NCD services for patients, a dedicated team should be developed at the clinic. (paramedic, 34 years old)

Outer Setting

Patient Needs and Resources

Perceived barrier: non-compliance to appointment time

Most of our patients [here] are elderly. Their children will drop them off early in the morning before going off to work. They [elderly patients] will congregate [at the clinic] at the same time. We cannot implement the staggered-time appointment, even when we emphasised it. [That is why] the small OPD [outpatient department] area is congested [because] many patients are waiting there. (professional, 33 years old)

Perceived barrier: patients’ beliefs

People always have this concept about KK [health clinic], it’s a place to take medicine and medical certificate [MC]. But they never thought of KK as a place [for] health [improvement] opportunity. (professional, 36 years old)

Perceived facilitators: clinic location

Most patients love to come here [clinic] because it’s near to town and is easy since consultation, blood tests and analyses can be completed within one day. (professional, 49 years old)

Cosmopolitanism

Perceived barrier: lack of inter-facility networking

Whenever patient [is] discharged from a hospital, they will bring a [referral] letter from the hospital to come to the clinic. That is the only thing [document]...we do not have any other way [to access information]. Sometimes, the letter might not complete, investigations done might not be there (professional, 28 years old)

Perceived facilitators: relationship and networking with NGO and community

If that is true [collaborating with KOSPEN], it [will be] very helpful because we do not have [the] opportunity [to perform] screening. Sometimes, a patient, especially elderly, is afraid of the clinics [staff]. But if its KOSPEN, [patients] will come [for screening] (professional, 42 years old)

External Policy and Incentives

Perceived barrier: top-down mandates with new unplanned programme

Sometimes the programmes [directives from top management] come suddenly and they want the result immediately...it is disruptive, given [short] period of time and we have to rush. (paramedic, 32 years old)

Inner Setting

Structural Characteristics

Perceived barrier: physical space constraints to deliver services

We are sharing room for fundus assessment with dental services. Because dental officers will come our clinic once a month. So, when there is an appointment for dental, the room becomes a dental room and will not be open for fundus assessment. So when a patient comes for a fundus appointment that coincidentally clashes with a dentist slot, his/her assessment will be postponed to another day. (paramedic, 27 years old)

Networks and Communications

Perceived facilitators: Information sharing

If we need [something], we just can talk [share the information] …. If not, during the morning briefing, anything urgent we can discuss with the head of unit [about] any problem or current issues, and they will highlight [and] go through it. (professional, 56 years old)

Culture

Perceived facilitators: teamwork

Relationship [between staff] is better, good, because we have no blocks [no barrier] here. I mean, the last time we have an OPD [outpatient department] wing and a MCH [Maternal Child Health] wing. Now, no [more]...we are all under one clinic. (professional, 55 years old)

Perceived barrier: divided zone leads to silos working culture

We are divided into two zones/areas here [for family doctor concept]—a blue zone and a pink zone. Previously, there were no zones, only one area; we would automatically help each other. But when there are zones like this, there’s no initiative from staffs at the pink zone to help the blue zone or vice versa (paramedic, 31 years old)

Implementation Climate

i) Tension for Change

Perceived facilitators: increasing service demand

Increase in population... currently around 50 thousand. Before, there are around 20 thousand [patients]. The number grew a lot. (professional, 33 years old)

Perceived facilitators: Standardisation of work process

Work process. The patient flow... That’s why things are not standardised. (laboratory technician, 36 years old)

Perceived facilitators: Improving documentation process

For every single thing you have to documentation … documentation … documentation.... But you are doing the repetitive work...for the medical assistants or nurses every month, they have to repeatedly key-in all these work into their computers to send to the [state] office. (professional, 40 years old)

Perceived facilitators: Improving consultation time

We don’t have enough time to counsel patients. Because when the number of patients increases, everyone wants to be fast and we are unable to focus. NCD has lots of factors [things to talk about] but we only have five minutes to counsel [patients]. (professional, 27 years old)

Implementation Climate

ii) Compatibility

Perceived barrier: lack of proper tracking mechanism

We have received referrals from KOSPEN, but the issue is patient does not come [for appointments] sometimes … there is no mechanism that states how we want to cater [to all referrals]. (Professional, 42 years old)

Implementation Climate

iii) Relative Priority

Perceived facilitators: accepting the concept family doctor

The same doctor [for a patient], the doctors will understand and be more familiar about their [patients’] health. (paramedic, 42 years old)

Implementation Climate

iv) Organisation Incentives and Rewards

Perceived facilitators: services performance recognition

I think it’s like a reward...we receive a plaque and the staffs were happy...we [our clinic] are the best maternal child health [performance] in this state; so we are proud. (professional, 42 years old)

Implementation Climate

v) Learning Climate

Perceived facilitators: avenue for discussion

He [medical officer in charge] is great. If anything goes wrong … he’ll call all of us [and] discuss. (paramedic, 32 years old)

Readiness for Implementation

i) Leadership Engagement

Perceived facilitators: involvement of leaders with implementation

They [leaders] are willing to look at it [problem] and try to solve [it]. They are very approachable. (professional, 30 years old)

Readiness for Implementation

ii) Available Resources

Perceived barrier: minimal manpower

We only have two staff at the community clinic, one working at the clinic and the other one does home visits. So the one who is out for home visit, even in an isolated area, will be working alone as we only have one transportation. (paramedic, 45 years old)

Readiness for Implementation

iii) Access to Knowledge and Information

Perceived facilitators: SOP and guidelines made available

Now there’s a SOP that everyone supposed to know. They should know what readings should be read; what to do about it … meaning there is already a guideline. It makes its easier to handle NCD cases. (paramedic, 45 years old)

Perceived barrier: insufficient information to introduce new programme

An example of programmes that I would like to mention is the FDC [family doctor concept]—it was not proper, not clear. We forced ourselves to make it clear for us because we have to implement the program. (professional, 32 years old)

Characteristic of Individual

Knowledge and Beliefs

Perceived facilitators: regular updating knowledge

To me, [the proposed] EnPHC has many good sides. When we take good care of our patients, their health will improve. In the end, it will benefit us [providers] too, as indirectly, our patient load will be reduced. We think in future, the workload will be diminished. No more people will suffer from diabetes, high blood pressure. (paramedic, 45 years old)

Self-efficacy

Perceived facilitators: own capability to perform

Why are we so eager about it? One, we have an indicator that needs to be pursued. The second one, one of the main duties of the assistance medical officer is a prevention programme. So, I take as my responsibility to make sure the programme is running. (paramedic, 30 years old)

Individual Stage of Change

Perceived facilitators: embrace new ideas for improvement

I prefer when a new person comes to the clinic, he has a new idea. So, there may be new ways to implement....we can try and improve our programme. Because sometimes when an outsider comes in, we have new ideas. (paramedic, 30 years old)

Individual Identification with Organisation

Perceived facilitators: work commitment

Like me, whenever I am given a task, I will do it. I would not decline [the task], but I may take some time. (paramedic, 41 years old)

Other Personal Attributes

Perceived facilitators: professionalism and value

We actually want to give more [health education] to patients, but we don’t have enough [time] since many patients are waiting, so we have to make the consultation short...I will usually try to extend time [for] each session. I do not mind skipping my lunch, as long my patients are okay. (professional, 32 years old)