Table 3.

CFIR constructs and associated impacts on implementation*

CFIR construct [22]	Key informant group	Findings	Findings’ impact on implementation
I. Intervention characteristics (clients, SEP Staff, CBOs)
Relative advantage	Clients	• SEP is already a convenient location to receive services • Clients want RH services offered alongside wound-care services • Clients wish to avoid pregnancy until they are ready to parent	• Reinforced decision to provide services at SEP • Need for contraception and pregnancy options services for clients and counseling skills for staff
	Staff	• Unmet need for all health care services in this population, including RH • SEP is a trusted, safe place where people can enter without judgement • Desire to test expanding clinical services at SEP	• Motivated expansion of implementation beyond contraception to fuller RH services
	CBO	• Separate preventive visits are challenging for clients to attend, even with advocates or case managers	• Reinforced integration of RH services into primary/wound care services
Design quality & packaging	Clients	• Services should include contraception and well-woman care • Services should be offered on a walk-in basis with short wait times to be seen • Clients prefer a female provider trained in harm reduction/trauma-informed care • Site should be able to dispense Rx at time of appointment	• Focused training efforts on female provider • Offered several contraceptive methods on-site • Maintained walk-in model of care
	Staff	• Walk-in services • Focus on novel ways to advertise so clients become aware of services, e.g. use SEP peer-educators to advertise services. • Collect many forms of contact information for test follow-up, and give clients option to walk in for test results. • Provide prenatal care, contraception, well woman care.	• Advertised services via flyers, bulletin board in SEP, word of mouth from staff and volunteers • Utilized walk-in model for follow-up and results as well as care
	CBO	• Trauma-informed and harm reduction training for all providers involved in delivering care. • Walk-in services • Ability to provide same-day contraception, examinations, and testing. • Avoid stigmatizing women’s desire to be pregnant or parent	• Emphasized trauma-informed approach in clinical training • Pregnancy options counseling training for staff with emphasis on harm reduction
Cost	Staff	• Concern over funding to pay for extra providers’ time • Matching funding source with program mission (i.e. broader healthcare fund rather than STD/HIV prevention)	• Train current providers and provide ongoing mentorship using trainers’ research time
II. Outer setting (clients, SEP Staff, and CBOs)
Patient needs & resources	Clients	• Desired services: STD testing, contraception, pregnancy care, annual examinations, Pap smears	• Expansion from contraception to general RH care
	CBO	• Challenging to follow up with patients • Navigating consent with patients in the setting of active substance use and mental health diagnoses can be challenging	• Obtain multiple methods of contact, utilize non-traditional methods if client approves (e.g. leaving message for patient at shelter or day center) • Abstinence from substances is not a prerequisite for care or procedures; ability to express understanding for and desire for care/procedure is necessary
	Staff	• Clients need to develop relationships with staff in order to trust them • Pregnant clients are particularly likely to face judgment and barriers to care • Clients who do sex work need contraceptive methods other than condoms as condomless sex pays more • Contraceptive methods requiring daily or weekly user involvement are challenging • Living homeless and/or with substance use disorder means surviving takes up much of clients’ time, leaving less for preventive care	• Project staff spent weekly time assisting with syringe exchange to become familiar with clients • Acknowledge and combat the layered stigma of gender, pregnancy, and substance usage • Offer long-acting reversible contraception on-site • Make preventive services available where clients are seeking other services related to substance use disorder or living homeless
Peer pressure	CBO	• Few organizations work in the intersection of RH and substance use disorders • The nearest clinic has limited walk-in spots that may require an hours-long wait	• Reinforced need for integrating RH into SEP • Despite proximity of other clinics, lack of walk-in care is a barrier
	Staff	• Failure to treat patients’ substance use disorder with medication while inpatient frequently leads to adverse experiences and leaving against medical advice	• Emphasis on patient-centered care and therapeutic relationships
	Staff	• SEP cannot advertise any of its services on the sidewalk or outside of its building	• Unable to place poster or outward-facing advertisements for services
III. Inner setting (SEP staff)
Structural characteristics	Staff	• Most staff are comfortable making referrals within and outside the organization	• Planned staff education around RH topics and created referral list for RH care
Networks & communications	Staff	• Management is open to suggestions from staff	• Fully involve all types of staff in formative work and evaluation
Culture	Staff	• Harm reduction and relationship building with clients are highly valued	• Create low barrier, friendly services
Implementation climate—tension for change	Staff	• Client needs and staff’s perceptions of needed improvements drive change	• Harness staff’s interest in implementing services given client demand
Readiness for implementation— leadership engagement	Staff	• SEP manager highly engaged with staff and responsive to feedback	• Harness manager’s energy and interest in promoting implementation
Readiness for implementation—available resources	Staff	• Space is limited • Examination room has footrests for gynecologic examinations • Highly functional electronic medical record available	• Limit RH-specific equipment to avoid straining limited space
IV. Characteristics of individuals (SEP staff)
Knowledge & beliefs about the intervention	Staff	• Aware of increased effectiveness and lower user-related failure associated with IUDs and contraceptive implants • Desire for improved referral system for pregnancy options	• Designed referral brochure and educated staff on pregnancy options including abortion, adoption, parenting
Self-efficacy	Staff	• Very comfortable suggesting improvements and advocating for clients	• Utilized staff feedback in improving implementation

*Constructs without participant input or not impacting implementation are excluded from this table