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Table 3 Summary of emergent themes from qualitative interviews that influence referral system implementation

From: What will it take? Using an implementation research framework to identify facilitators and barriers in implementing a school-based referral system for sexual health services

CFIR ConstructThemesQuotations
I. Intervention Characteristics
 Evidence Strength and Quality-Schools are an ideal location to address the epidemic of STIs, HIV, and unintended pregnancy“Schools represent… a really important social institution in the lives of young people and means by which we can get young people aware about resources in the community, I think that they’re a key player.” (Interviewee 07—CBHP)
-The referral system can help students achieve better academic outcomesWhen students can access SHS referrals from school staff, they “have the ability to focus more on what they are here to do every day, which is to get their education.” (Interviewee 16—District Staff)
 Complexity-There is a moderate level of difficulty felt when implementing an referral system because of the many layers of bureaucracy“It’s such a huge system that is very cumbersome and kind of in a transition mode. So there’s a fair amount of chaos, in my experience, in just dealing with the system” (Interviewee 3 – CBHP)
II. Outer Domain
 Needs and Resources-There is high need for an referral system because of high STI rates among adolescent populations and adolescents are misinformed about the risks.They’ve all got experience, they’ve all done everything, if you listen to their stories. But they don’t even know basics about female and…. male anatomy.” Interviewee 14 – School Building Referral Staff)
 Cosmopolitanism-The local health department and CBHP emerged as two main types of crucial partners for these school districts“We have a fantastic relationship with the health department…We work hand-in-hand.” (Interviewee 18 –District Staff)
 State and District Policies-State and district policies can be important facilitators or barriers to implementing an referral system. Furthermore, although supportive policies may be in place, implementation may be hindered by lack of knowledge or awareness of the policies.“I think sometimes policy creates, or has the potential to create, barriers because people don’t understand realistically what the policy is saying.” (Interviewee 16 –District Staff)
III. Inner Setting
 Networks and Communications-Sites drew from existing staffing structures and developed innovative marketing and communication tools (e.g., palm-sized chat cards)The nursing staff “are broken into clusters…I think I have more actual discussion of how to handle [SHS referrals] at our cluster level than I do at the district level, just because those are the nurses I see more often, and we have the same student populations.” (Interviewee 15 – School Building Referral Staff)
 Organizational Culture and Access to Knowledge and Information-Culturally conservative climate impacts the referral system in many ways. Although a school district may be located in a more liberal city, conservative attitudes at the individual level can still affect the referral system“It’s such a culturally conservative environment that most people who work with teenagers and young people are really afraid of sexuality, and they’re afraid to really go there. (Interviewee 3 – CBHP)
 Leadership Engagement-Principals have a lot of authority on the day-to-day operation of schools but their acceptance and commitment to implementing a sexual health referral system varies“The principals still almost have reign over their school… And the principals can decide the way that things run in their school. And they could be, for instance, homophobic or even sex negative versus sex positive.” (Interviewee 4 – District Staff)
- District-level leadership (e.g., superintendent) and community-based health service providers were described as supportive, involved, and motivated“The leaders here are really on board with [the referral system], and they really encourage us to do a lot more and get the program really out there to do a lot for the students. They’re very supportive” (Interviewee 8 – School Building Referral Staff)
 Available Resources-A full-time referral staff as crucial in the success of the referral system
-SBHC were identified as important resources
“Knowing that [the referral staff] is there five days a week and knowing the level of conversations that she has with kids …and the time that she spends linking and connecting families to services, I know why kids are doing better in her school.” (Interviewee 16 – District Staff)
IV. Characteristics of Individuals
 Knowledge and Belief-Staff who were actively involved were most knowledgeable about the logistics of referral-making and the policies. School staff and students have a general knowledge of the staff to refer to for health-related questions.“…Our school staff are pretty well-informed about the services that the [SBHC] offers. They may not know how the logistics works off campus…And I don’t think they really know all of the law surrounding [state’s family planning law].” (Interviewee 19-CBHP)
V. Process
 Engaging-The role of formally appointed implementation leader was essential in supporting implementation, especially in engaging key stakeholders and provision of professional development“Well, without somebody advocating for [the SHS referral system] in the school district, I don’t think it would have ever happened. So I give [Program Coordinator] a lot of credit.” (Interviewee 13—CBHP)
 Reflecting and Evaluating-Tracking referrals was identified as challenging as current data collection systems do not capture passive referrals or efforts that don’t necessarily result in a referral“So I think probably…some of the referrals aren’t being tracked the way that they should be. But we don’t really have systems in place that would support that process” (Interviewee 2-CBHP)