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Table 2 Feasibility testing results, summarized by themes and representative quotations

From: Human-centered implementation research: a new approach to develop and evaluate implementation strategies for strengthening referral networks for hypertension in western Kenya

Feasibility Testing

Domain

Key Theme

Quotation

Active Peer Engagement

Effective Patient Navigation

Peers provided logistical support and oriented patients to unfamiliar health facilities

Someone like me, if am told to go to Referral [Moi Teaching and Referral Hospital], where would I start from to get to the doctor? Because in Referral people are many and you can’t even know which room you will go to so that you be served immediately. [I] am thankful, that program [STRENGTHS] is good. (Patient, Turbo Secondary Level Facility)

Improved Patient Advocacy

Patients felt comfortable talking with peer navigators, who functioned as patient advocates and often accompanied patients into their clinician visits

The patient is more free to explain himself to the peer navigator whom he seems to see as a normal person…when the patients knows that he is going to talk to the Doctor, he thinks to prepare him so much that sometimes he ends up forgetting other things but when he is talking to the peer navigator, he feels very free…but when with the Doctor, the patient may come out and say I had forgotten to tell the provider A, B, C, D. And so mostly the patient feels comfortable with the peer navigators when they are explaining their thoughts. (peer navigator, Moi Teaching and Referral Hospital)

Active Peer Follow-up

Active follow up from peer “challenged” patients to overcome barriers that may have prevented them from completing referrals

I am grateful because [the Peer Navigator] will even challenge you. If you have lacked money you will run to the neighbor and say, ‘there is someone somewhere who wants to help me.’ So I run and found the transport and I went. (Patient, Turbo Secondary Level Facility).

Prohibitive Costs

Remaining challenges of referral completion included high cost of transport, drugs, and tests

Sometimes money becomes a challenge. I went [to the hospital] and [the] doctor wanted to do some tests...I was told one is 1800 KSH and the other is 900 KSH and I didn’t have that money. I had to go back home. (Patient, Cheramei Primary Level Facility)

Limited Scope of Patient Education

Peers lacked training to counsel patients with multiple comorbidities or educate on topics other than HTN

They say [my] eyes have been bad because of hypertension and because of diabetes. So mostly you are told [by peer navigators] that [they] have nothing to do on the side of the eyes. It’s better you go check on the eyes in Nairobi or where you will go. So what I can suggest is that diabetes and [high blood] pressure it affects the eyes, so they bring again here an optician so that he can direct us as well. (Patient, Turbo Secondary Level Facility)

Enhanced Communication

Timely Referral Updates

Peers effectively communicated referral updates with clinicians and patients

Communication was effective, was good communication. I think when you have a case to refer it was good to go to the desk where the peer is and the good thing she was always available, so we actually had no problem to go there. So, at times she can just come and explain this is a referral from the facility so we could give them a priority. So communication is very effective. (Clinician, Turbo Secondary Level Facility)

Improved Patient Understanding of Reason for Referral

Peers helped explain the reason for referral and convinced patient of the benefits of referral completion

After being told from the doctor [that they must go to a referral facility], they end up not realizing really the exact meaning. But when we impact on them and explain more about why, in fact they end up realizing that we, they have understood the reason for referral. (peer navigator, Moi Teaching and Referral Hospital)

Convenient Access to Peers via Phone

Phone calls were most convenient means of planning and following up with patients

[The peer navigator] took my phone number and I went home and she has been following me up from home...she calls me, she asks me how things are, even when I come here she asks me, “you have come, how are going on with your clinic?.” So they help so much. (Patient, Turbo Secondary Level Facility)

Successful Integration with Clinic Staff

Peers integrated well with clinic staff and assisted in other clinic tasks (e.g. triage vitals and patient education)

We also engage the peer in providing health education to our clients and they also assisted us in working in other areas in the facility. (FGD, Providers, Turbo)

Reinforced Referral Practices

The presence of peers seemed to reinforce adherence to clinical protocols and increase clinicians’ awareness of referral resources

After the providers understood the referral network, for the first weeks we didn’t have so many referrals but as time went by, they understood our role in the clinic…So, our communication was really good. Yes. They even come and look for me because am always at the front desk, they have a referral, the doctor comes to me and tells me I have such a referral. If I need them, I also go to their offices, I tell them what I need from them so, it was a two-way traffic.” (Peer Navigator, Turbo Secondary Level Facility)

Interruption of Clinic Workflow

Peers sometimes interfered with clinic flow if they spend too much time with the patient

Patients have a priority to be seen by the consultant and then probably the consultant to the clerks and then to go home and then this peer educator comes in between. The patient is not ready for his or her service, so this navigator must be very convincing and actually bring the patient closer so that the patient can be able to give him or her time. (Clinician, Moi Teaching and Referral Hospital)

Difficulty Finding & Identifying Peers

Providers sometimes struggled to identify peer navigators in busy clinics without an established work station or uniform

But my challenge has always been, how will this be a navigator be identified? (Clinician, Moi Teaching and Referral Hospital)

Referral Data Integration

Fast Retrieval of Clinical Information

Use of a tablet enabled fast retrieval of referral information (when EMR available)

From the word “go,” when a patient is referred we are able to know why the patient is referred from the [health record] system…it makes work easier. Yes. You don’t have to make phone calls [or] ask so many questions. (peer navigator, Turbo Secondary Level Facility).

Utility of Encounter Forms

Encounter forms provided some useful information that was referenced by other peers (even though most information sharing occurred over phone)

[The HIT package] helped. You see, when the peer navigator was at [the] other facility [you] could click and see the updates about the patient. Then from there one could be able to know what is supposed to do next about the patient. (Peer Navigator, Moi Teaching and Referral Hospital)

Reliability of Network and HIT Package

Peer navigators had consistent access to the HIT package via a tablet and mobile data network

For my case, there [was] no time [when I couldn’t use the electronic form] because...we used to have the [mobile data] bundles, which we were to buy and use it to fill the forms. So, I never [had problems with the network] but some other people experienced the same problems because the [clinic’s wifi] network was down. (peer navigator, Moi Teaching and Referral Hospital)

Lack of Physical Patient Reminders

Keeping track of paper referral forms, slips, or clinic booklets was challenging for patients

If you are given that small card [referral appointment card] I can put in this bag. And tomorrow I want to go to the hospital [and] I have forget it was in another bag...now you find there is challenges because you will forget [the card]. (Patient, Cheramei Primary Level Facility)

Integration Barriers with Paper Record System

Some clinicians still used paper encounter forms due to simplicity, reliability, and availability (some clinics did not have access to EMR), which limited clinical information available in the EMR

We used the written [paper] forms, up to now as am talking. The forms are in the POC [EHR], but finding them is a problem. But when you click you need to add “Sending to MTRH” in that form you are referring...now from Moi Teaching and Referral Hospital we need to add where specifically we need--is eye clinic, is renal unit--[the electronic form] doesn’t have that specification. Is it to oncology? You need to specify you are sending to oncology and a bit of notes what are you going to do. (FGD, Provider, Turbo)

Limited Provider Use of Referral Forms

Some clinicians were unaware of a standard referral form (instead used a freehand note), limiting referral information available in the EMR

We use the internal consultation forms [for referrals]...But I have seen there are those [clinicians] who don’t want to use the consultation forms from MTRH and so we just write a letter which will be stamped by the hospital...But we don’t have a specific referral form for referring patients” (FGD, Provider, Turbo)

Limited Utility of HIT Package in Paper-based Clinics

It was difficult to use tablets in paper-based clinics (when the patient’s information was held in paper charts or not recorded in a standard way)

The patient could just be written something on a paper [e.g. when clinicians did not use the standard referral form]. Yes. But no more information...You just get a written document that they have been referred for investigations. (peer navigator, Turbo Secondary Level Facility)