Table 3.

Themes and Quotes that Emerged from Formative Interviews about the Hypertension Extension for Community Health Outcomes Program among Frontline Healthcare Workers in the Federal Capital Territory, Nigeria.

CFIR DOMAINS AND THEMES	IDENTIFIER	QUOTE	BARRIER (–) OR FACILITATOR (+)
Characteristics of Intervention
Availability of Well-Recognized Experts
	KII1	“We [The Hub] just tried to build a multi-disciplinary hub. So we tried to have MDs on there with certain skill sets. For diabetes [a] diabetes educator, nutritionists, even social work or case manager or something of those sorts.”	+
	KII5	“We [The Hub] have Dr. [REDACTED] who is well known and his credentials are just phenomenal. In regards to high blood pressure and management.”	+
	KII5	“He is such a fabulous teacher, you can tell when he is in the zone when he does these echoes he is just right in that zone and the conversations that he can generate with the members is really pretty phenomenal.”	+
	KII4	“Our program is housed here in the Department of Pediatrics in [University] […] we [The Hub] do partner with over 60 facilitators who are within different departments”	+
	KII7	“We [The Hub] want to make sure we get really good didactic presenters that encourage good attendance and give the best education possible”	+
	KII4	“They [The Participants] are not just hearing from a specialist, but they’re also learning from the experiences of all of these other providers from different organizations.”	+
Relative Advantage of In-Person vs. Online Training
	KII7	“And so ECHO really fits in nicely into that reaching out to practices across huge geographic distances and providing education in a way that general practice likes to receive education rather than a complete didactic session, giving them lots of space and comfort to contribute their knowledge.”	+
	FGD5	“Then once in a while, we [HCWs] can have the kind of training like this, let it not be only online. Because you know when you were asking some questions, you elaborated on it before we can answer it. So, sometimes, face-to-face discussions too will help.”	+/–
	FGD2	“Classroom training is always the best because there are possible interactions.”	–
	FGD2	“I will also prefer the classroom training because in the classroom, after the teaching, we [HCWs] can ask questions. Whatever we don’t understand, we can easily ask questions and get the answer back. I prefer that one.”	–
	FGD4	“I like that idea of staying alone to listen to it [training], rather than gathering.”	+
	FGD2	“I will suggest both classroom and Zoom because it is good to learn some things. You don’t remain in classroom all the time. It is good because even in that Zoom learning, you can ask questions. You can raise your hand and ask questions.”	+/–
Outer setting
Participation is Voluntary
	KII2	“People choose to show up […] right now most are monthly and kind of open, and you know, just kind of come when you can.”	+
	KII7	“We [The Hub] were seen to be a lot of effort. A lot of advertising for I think we had 21 people attend. We had over 40 register and then we got 21.”	–
	KII6	“It is hard to get them [The Participants] to participate, get their opinions and questions.”	–
	KII6	“Rural doctors are hard to convince, it’s sometimes hard to get cases to study, they don’t easily understand that these discussions will help to solve a life.”	–
One of Many Ad-Hoc Programs Implemented by External Bodies
	FGD2	“They [Program Managers] should integrate hypertension program with diabetes program.”	–
	FGD7	“We [HCWs] are used to different trainings being organized online from time to time. So once we hear any program, as long as we are available, most often we key in because we know it’s still another avenue to improve our knowledge.”	+
Presence of a Functional ECHO Hub
		A key finding during our conduct of KIIs was that numerous ECHO hubs listed by Project ECHO were non-functional at the time we contacted and surveyed them.	+
Inner Setting
Availability of Adequate Resources
	KII3	“We [The Hub] eventually overcame those [technological issues] and our technology now is much better.”	+
	KII2	“We [The Hub] just need a little bit more staff support […] it’s a lot nicer when you have more people obviously.”	+/–
	KII6	“We [The Hub] need a strong communications support.”	+/–
	FGD1	“This online training needs data. So if they [ECHO Program] can provide data to CHEWs, I think they [CHEWs] will be happy because the knowledge they will get is more than the financial aspect they will think of. But if they have data that they can connect, I think it will help.”	–
	FGD5	“If they [ECHO Program] can provide a tablet to use in facilitating information […] A tablet, mobile devices, it will help […] for the online, they will need a laptop or a tablet for that online meeting.”	+/–
	FGD5	“About the online training, it must not really be the laptop, it can be an android phone or something and you know, you can’t just use it like that without data, there must be data”	+/–
	FGD5	“What I know is that we [HCWs] need an android phone or a tablet or something if it will be individual. Like me now I don’t have an android phone and if anything is coming online I can’t afford it, so if it is individual, I won’t be able to participate, but if it is a group one, since you said our PHC has one, we will be able to do it together, so far as there is data for it.”	–
	FGD7	“The major challenge in participating in the online program is actually network fluctuations and power failure. Because some gadgets may not be able to go an hour or two online without the battery being drained. Whereas, when the network is not stable, especially during rainy season being the month of June-July, once it’s raining, definitely our [HCWs] ability to browse or assess online activity goes off.”	–
Conducive Environment
	KII1	“The biggest barrier across all hubs, not even just endocrine is time, you know when’s the best time to have the sessions and then can the providers get off that time. It’s always the biggest barrier.”	–
	KII1	“You might have weeks that you [The Hub] might not get a case. And that’s typically just because the folks [The Participants] don’t have time to submit them or they cancel on you last second, or something like that because they can’t come to the session.”	–
	KII3	“Early on I think we [The Hub] noticed the attendance went down during the summer months because of vacations […] So we, at times would decide to take a break during the summer to allow summer vacations to occur.”	+/–
	KII6	“Sessions are delivered by Zoom synchronously. The sessions are not pre-recorded, and participants are supposed to participate live as that is better for overall participation and engagement.”	+
	FGD7	“The disadvantage, I will not say that I have any major disadvantage, but the timing of listening to that was an issue to me [Prior ECHO Participant]. People learn better early morning. Early morning when you wake up, you come by 8:00 a.m. If the presentation is delivered early and we come face-to-face early, you tend to listen more and you tend to understand more.”	–
	FGD7	“The advantages from the training that I [Prior ECHO Participant] had is that the timing is after the normal facility work, from 2:00 down, because we close by 2:00. From that 2:00 to 4:00, sometimes we’ll be free and we can now attend the meetings and listen.”	+
	FGD7	“And the place, like my [Prior ECHO Participant] PHC, where we gather to listen sometimes, maybe they might use the office. And then they will say, ‘We want to use this place for another thing.’ Then we’ll now begin to look for where to stay.”	–
	FGD7	“When it’s [The ECHO Program] coming, the person [Participant] should be left alone to join fully. Less work, less problem with less headache. You just concentrate and do it. We need time.”	+/–
	FGD7	“For those of us in the tertiary center, reminders, motivation, and encouraging us to join in the online program will go a long way to help us get interested and to participate fully in the program.”	+
Health Workers Have Many Competing Demands
	KII4	“They [HCWs] were not interested in the topic, but because they had to commit some time to participate in the series and that time was the time away from their clinics and the patients.”	–
	KII3	“And they [HCWs] have a full day patient panel and one hour of a lecture was viewed by some as just an extension and one hour lost in the day to do my clinical work, so that was that was the tension within sort of our region.”	–
	FGD6	“And sometimes one of the challenges that it may not make it [ECHO Program] effective is when you [HCW] are in your facility and probably you are connected online receiving the training, you might have a patient that is coming to see you for one reason or the other.”	–
Characteristics of Individuals
Ongoing and Broader Training is Needed
	KII3	“I’ve [Hub Administrator] been practicing now thirty years and when I first started as a specialist there were specialists they dealt with the more challenging difficult cases.”	+
	KII6	“The curricula are developed in consultation with key stakeholders based on knowledge gaps within the community of practitioners.”	+
	FGD3	“We [HCWs] will need training in resuscitation of a patient that just suddenly falls down. That training is key […] If we’re trained on how to handle such cases, we will reduce sudden cases of death.”	+
	FGD3	“I [HCW] want to improve on pregnant women […] if you notice any pregnant woman who are hypertensive, we refer them to [REDACTED] and they may not go. Most of them don’t go. Immediately you refer them, they will just go and sit at home. So, I don’t know if there is anything you people will do, on that aspect, so that we can give them something, instead of referring them.”	+
	FGD5	“Most of us [HCWs] don’t even know the complication that may arise from hypertension. And most of them, you know some drugs are contraindicated, so they wouldn’t, up to now, some people will still be giving some drugs to pregnant women and not knowing it’s contraindicated to the pregnancy. So that is why they need this training.”	+
	FGD3	“Yes, 100 percent need. We [HCWs] need more training. If I should score it, 100 percent more training. The reason why [training should continue] is because we, as the CHEWs, our primary assignment, 70 percent is in the rural community. And most of these clients are in the community, so we are always with them, we are always at their doorstep, we are always the entry point to the healthcare system, so there is need.”	+
Health Workers are Eager to Learn
	FGD3	“If there will be more programs or trainings, we’ll [HCWs] be grateful to acquire more knowledge.”	+
	FGD3	“Knowledge is always increased, and it will also help us [HCWs] handle our patients very well.”	+
	FGD1	“Also, much training based on Zoom. As we say, we’ll [HCWs] be given more training. This time they will make the training to be six months. They will make the training basically six months. I think it will be good so that it will boost the knowledge of us working in the PHCs.”	+
	FGD3	“There is that need [to continue training] because health is teamwork. There is that need that all other health professional to be also trained, so that we go with a very nice target to cover, in hypertensive treatment.”	+
	FGD7	“One, it’s an opportunity to connect with other facilities beside my primary facility. Secondly, we also cut across primary, secondary, and tertiary health institutions. Thirdly, it’s still another avenue to increase knowledge and impact one another. Fourthly, my patients will also benefit too, not only waiting until I have been seen, knowing fully well that other people will also do the same thing.”	+
Process
Partner With a Functional ECHO Hub
	KII6	“Connect with the Project ECHO team and use their resources and knowledge for building a hub.”	+

Abbreviations: CFIR, Consolidated Framework for Implementation Research; CHEW, Community Health Extension Worker; ECHO, Extension for Community Health Outcomes; FGD, Focus Group Discussion; HCW, Healthcare Worker; KII, Key Informant Interview; PHC, Primary Healthcare Centers.