TABLE 3.

Facilitators, barriers, and neutral factors summarized following CFIR constructs.

Domain and construct
I. Intervention characteristics
A	Intervention source		Facilitators	The overall intervention and the screening were externally designed by the research team but adapted with the local stakeholders.
			Barriers	A barrier for internal development was the distance between the premises of the research team and the COB area.
B	Evidence strength and quality		Facilitators	Stakeholders perceived the project as innovative, carrying human values. The project was complementary of other preventative health actions launched in the territory. An intervention on cardiovascular risk was deemed appropriate to health problems of inhabitants.
			Barriers	Despite the research team communications, some stakeholders remained unfamiliar with the project or disinterested.
C	Relative advantage		Facilitators	The project was perceived as addressing the lack of prevention in France. Cardiovascular prevention fit to the populations’ health. Stakeholders expressed that hosting the project improved the image of the COB territory. The deployment of screeners and the publicity around the project valorized the COB territory. The screening was deemed acceptable by the screeners. The screening was perceived as an introduction to further deeper preventive actions. The population was receptive to the SPICES project and adhered to screening. Participating in the project led the health students to discover the COB territory.
			Barriers	Some screeners described preventive professional skills as something new in their practice. Screeners felt announcing a high cardiovascular risk was challenging. Finally, some participants had requests beyond the screening and brief advice that could lead to discomfort for screeners.
D	Adaptability		Facilitators	During the events, some screeners organized spontaneously a new position of canvasser which referred potential participants to screeners and increased participation to the screening. For health professionals, shifts in screening, use of waiting time in queues at pharmacies, creation of dedicated times were innovations to perform the screening. Some nurses integrated screening in their routine care. In local events, organizers were facilitators by placing signs, setting up a booth and making announcements on the microphone. At times, screeners used the consent form within groups to promote screening. Some screeners printed a paper version of the NL-IHRS to deal with the tablet remotely.
			Barriers	Barriers to adaptability were shortness of the recruitment period for health professionals, and rigidity of European funding which complicated the purchase of equipment, the compensations for screeners. The rigidity of the European financial lines prevented reallocations while the research team refined study needs. Calendar constraints frustrated preventative health service students, encroaching on weekends, holidays, summer jobs. The geographic exclusion criterion for participants was annoying according to preventative health service screeners as foreigners to the COB area participated to COB events and were disappointed that they could not participate.
F	Complexity		Facilitators	Supervision of screeners by junior researchers was perceived as a strength for facing complexity as they could solve tablet problems, communication issues, personal health problems brought by participants. Screeners used social networks to facilitate deployment of screeners. The NL-IHRS was perceived by screeners as representative of cardiovascular risk.
			Barriers	Unexpectedly, screeners discovered that the population was redundant from an event to the next. For health professional, recruiting during summer was arduous because of colleagues’ vacations inducing extra-work. Some screeners feared biases in the NL-IHRS because of embellishment of answers by participants and the absence of questions about alcohol.
			Neutrals	Duration of the training, content of the training, handling of the tablets during the screening, recruitment duration and some considerations about the NL-IHRS (classification of the answers, feasibility of the measure) were considered either barriers or facilitators.
G	Design quality and packaging		Facilitators	The NL-IHRS and the brief advice were easy and short to deliver. The brief automated advice gave meaning to the NL-IHRS for participants. Using a tablet was acceptable for participants. The auxiliary material was small enough to allow screeners autonomy and ambulation in events. The SPICES windbreakers made screeners visible and attracted people to the screeners. Wording of the NL-IHRS questions was clear. Posters created by the research team were effective in attractiveness. Some events had specific signaling, even a specific booth or room dedicated to the screening which improved attractiveness of screening.
			Barriers	When walking around, it was difficult to handle simultaneously the tablet sleeve, the tablet, and the tape measure. Due to lack of supply, windbreakers were navy-blue instead of red, which reduced visibility of the screeners. Regulatory content in the consent form made the consent form overly complex to understand for participants. Several tablet bugs were encountered: touch screen malfunction, tablet failures, random switch of software from French to English. Tablets were new supports for patients. Tablets could disrupt interactions between screeners and participants. There was a need for spare tablets. The software was found to be unintuitive with a long connection delay. The Redcap application was judged as poorly coded with imprecise wording of application menus. Data transfer suffered from the lack of acknowledgment of receipt of the data, low internet speed and a difficulty to handle data transfer procedure. Some screeners regretted the absence of pictures to illustrate the NL-IHRS questions.
H	Cost		Facilitators	The European funding was perceived as a strength as the COB stakeholders did not have to clear a budget to deploy the screening.
			Barriers	Some costs were not anticipated, as a financial compensation for COB structures which were involved in publicizing the project in the COB area.
II. Outer setting
A	Needs and resources of those served by the organization		Facilitators	Many screeners perceived this was their role to address health prevention. They described a professional consistency in being engaged as screeners. Participants declared a particular interest in their health. Relatives could press participants for screening. Participants shared their knowledge in cardiovascular health with screeners. Participants expressed they were looking for solutions to improve their health.
			Barriers	Screeners felt there was not public demand for screening in events. When screening in companies, the screening was in competition with working time or break time. Due to the very low medical density of the territory, some participants had no doctor to refer and to handle elevated NL-IHRS result.
B	Cosmopolitanism		Facilitators	Health professional screeners expressed a sense of belonging to the community. Participating to the screening provoked a federation of the professionals around the project. For health professionals, the pre-existing relationship was a facilitator to propose the screening.
			Barriers	Screeners perceived some events were not suitable for screening, for example a community garage-sale. An organizer tried to hijack the screeners to perform first aid in his event. In some pharmacies, partial involvement of the team was a barrier to perform screenings in large numbers.
III. Inner setting
A	Structural characteristics		Facilitators	Events took place in a good atmosphere; screeners received a warm welcome. Some specific logistics in events were particularly suitable as visible layout in the event, dedicated room for screening, prior internal promotion to the screening, dedicated oral announcements in the event and hierarchical incentive for screening in some companies.
			Barriers	Some failures in the organization of the events themselves had repercussions on screening: signage of the event itself, signage of the screening in the event, late promotion of the screening in the event, lack of electricity, lack of privacy. Large events were difficult to canvass for screeners. Movement of people in some events prevented screeners to catch participants. Some screeners felt populations were selected according to the theme of the events. Some events suffered unexpected low attendance.
B	Networks and communications		Facilitators	The research team, the stakeholders and the screeners used diversified means of communication as text messages, WhatsApp, Google drive, physical meetings. The research team promoted the project using paper media and radio. Screeners described a group dynamic among themselves. They planned carpooling to events. Screeners pointed out effective support from supervising junior researchers. Screeners identified team spirit, mutual aid, and emulation in the group. Screeners organized peripheral convivial moments, they described bonding together. Good relations existed within and with the research team. Research team members knew each other well. The research team was available to the stakeholders and the screeners. Junior researchers appreciated their back-up groups that got them support and enhanced their work.
			Barriers	In some events, screeners did not organize themselves, and distributed no dedicated roles leading to relative inefficiency.
C	Culture		Facilitators	Screening was felt by screeners like the continuity of usual talks between health professionals and patients. Many screeners related this experience with previous trainings in cardiovascular prevention. The topic of cardiovascular prevention was already an interest of screeners. Screeners felt they had a role in health promotion. They felt they created a possibility to continue prevention beyond brief advice.
			Barriers	None
D	Implementation climate		Facilitators	The screening was strongly welcomed by local stakeholders, local associations, and screeners. Screening plus brief advice was perceived as a human sharing. Trust was a value commonly shared within the study: between health students and junior researchers, between patients and health professionals, within the research team and between local actors and the research team.
			Barriers	Preventative health service students took the training in a bad mood because of the encroachment of the project on their schedules. Some screeners had non-professional behaviors: absence to the training, absence to the screenings, lateness to events, hangovers, and alcoholism. Some participants rejected the screeners by mentioning an inappropriate expertise, a difference in social class, conspiracy, and lassitude. Some participants expressed bad emotions. Some screeners expressed doubts about the interest of the study. The risk announcement could be badly experienced, participants could be disappointed by exclusion and reassurance for an unexpected score could be difficult. Some participants were not paying attention to the screening. Some people got aggressive talking about low medical demography. Participants could feel an intrusion with the NL-IHRS or initiate off-topic discussions.
	1	Tension for change	Facilitators	Screening was perceived by screeners as an opportunity to listen to participants. The screening was experienced as a reward for both the screener and the participant. Participants were curious about the assessment. Participants expressed a benefit to get a contact with a caregiver. Screeners and participants were interested in participating to a clinical study. Some participants were searching for the follow-up of the second SPICES phase. Screeners expressed a pleasure in carrying out the screening.
			Barriers	As an unusual task, health professionals could forget to offer the screening. In events, screening was an unusual proposal and participants could express reluctance to be canvassed. Screeners felt excessive expectations from some people local to the area. Population could have in contrast a lack of interest about cardiovascular prevention or a lack of motivation to improve their health. Some participants argued they already had a follow-up or had competing priorities to cardiovascular health for not carrying out the screening.
	2	Compatibility	Facilitators	The screening was a continuity of usual conversations. The topic of cardiovascular prevention was already an interest of screeners. Many screeners perceived this was their role to address health prevention.
			Barriers	However, screeners underlined the lack of institutional recognition of prevention and the lack of financial valorization of prevention. Medical students underlined their lack of awareness of prevention entailed by their current training.
	3	Relative priority	Facilitators	None
			Barriers	Expressed barriers were the competitive professional priorities for health professionals, competitive personal priorities for professionals, students, and research team.
			Neutrals	Time to allocate to the screening and current health professionals’ workload were perceived either as facilitators or barriers.
	5	Goals and feedback	Facilitators	None
			Barriers	Thinking about recruitment goals frightened some screeners as they felt they could not fulfill this objective. Preventative health service students deplored the lack of feedback of screening results from the research team. Imprecisions in the grant protocol hindered a clear communication of goals to stakeholders and led to an initial blurred communication from the research team.
	6	Learning climate	Facilitators	Screeners described a progressive empowerment during the screening. Being involved in the project resulted in a gain of knowledge, skills, and legitimacy for the screeners. Gradually, screeners expressed a familiarity with the NL-IHRS. They gained confidence in screening and expressed a progressive empowerment. Screeners developed recruitment strategies as the creation of the canvasser, effective presentation speech, search for areas of affluence, taking advantage of a snowball effect for attracting participants, the targeting of groups in events, a splitting of screeners, some staying in the booths and some wandering. The research team expressed an important collaboration within it. A specific recruitment was realized to focus on organization tasks in the research team (research internship plus secretary). Collaboration between junior researchers and the research team was appreciated on both sides. Consultation of local actors by the research team was appreciated by local stakeholders.
			Barriers	The research team was frequently on a rush with precipitations in the organization. In screening groups, some mutual unfamiliarity of the members could be uncomfortable. Screeners expressed some dissatisfaction because of the geographical remoteness and the obligation to participate. From the participant’s point of view, facing a group of screeners could generate a feeling of oppression.
E	Readiness for implementation		Facilitators	Health professionals volunteered to screen. Screeners expressed voluntarism in recruiting people and screening people. Local associations, work supervisors and families encouraged participants to perform the screening. The welcome on the events was benevolent with dedicated announcements and dedicated booths. Health professionals, declared a legitimacy in the screening and pharmacies were especially accessible for participants.
			Barriers	The participation of the screeners to a single event was forgotten by the organizers of the event despite reminders of the research team.
	1	Leadership engagement	Facilitators	The research team members were very available and deeply involved in the study. Human qualities of the doctors involved in the research team were esteemed. The research team engaged in regular communication with local stakeholders. The research team had respect for the privacy of team members. Research staff described less stress than hospital projects. In the COB, there was a local attractiveness of SPICES.
			Barriers	There was a competition in the researchers’ agenda and an overflow on researchers’ personal time.
	2	Available resources	Facilitators	The specific resources available for the study which were: - Two specific recruitments in the research team including a student for his research internship and a secretary - Junior researchers - Screeners - Tablets - The Redcap application and its remote data backup - The automated brief advice was efficient. - The consent form and the small auxiliary material - Lent equipment for screeners by events’ organizers - SPICES flocked windbreaker - Posters - A paper version of the NL-IHRS was added by some screeners
			Barriers	Researchers and screeners complained about the lack of research staff, no specific premises in some events, a lack of booths or shelters against the rain, a clutter by personal belongings, an absence of a standard rationale, the overly complex consent form, and the absence of a printed questionnaire.
	3	Access to knowledge and information	Facilitators	The training was appreciated by screeners for its presentation of the project, the peer training, the group training and the NL-IHRS self-scoring during the training.
			Barriers	However, screeners regretted that the training did not mention more on the expectations of the population of the COB area, methods for canvassing, deeper experience of the NL-IHRS, cues for good relationship with participants. Some screeners needed more precisions about the objective of the study. Some screeners found that trainers had excessive assumptions about their digital skills. For the first trainings, the definitive version of the French NL-IHRS was not available. Screeners had new needs which appeared between training and screening and had new technical needs when they manipulated the tablets, these needs were not covered by the training.
			Neutrals	Cardiovascular knowledge provided by the training, duration of the training and the handling of the tablets were either considered as facilitators or barriers.
IV. Characteristics of individuals
A	Knowledge and beliefs about the innovation		Facilitators	The screening was attractive because screeners could be part of a research project. Screeners felt they mastered the topic, and it was reassuring for patients to face a health professional for such a screening. Junior researchers expressed belonging to the SPICES project was rewarding.
			Barriers	On the other side, some professional inconsistency could arise as some screeners felt their professional skills were limited to handle cardiovascular screening. For preventative health students, the screening appeared too early in their training course. Some screeners felt incompetent in canvassing. Screeners and junior researchers were inexperienced. Some screeners had no digital skills.
B	Self-efficacy		Facilitators	Screeners described themselves as having a quality of contact. They were able to adapt themselves to the participant’s personality and to use humor wisely.
			Barriers	On the other side, some screeners considered they lacked self-confidence, and motivation. Some screeners were shy. Some screeners had fears of refusal, fear of facing the participants’ answer, fear of announcing the results, fear of breaking the equipment, fear of filling error, fear of being intrusive. Communication could be difficult, some screeners lacked clarity, made offensive formulations, experienced discomfort in facing people at risk, had difficulties in popularizing medical information. Accumulation of refusals and repetition of tiresome screenings led some screeners to discouragement.
C	Individual stage of change		Facilitators	Screeners met participants who initiated the screening. Some participants expressed attraction and curiosity for the screening. Participants were interested in their health and were searching for health solutions. The questionnaire was perceived by the participants as a mark of interest from the screeners. They perceived a benefit from a contact with a caregiver.
			Barriers	Some people did not want to participate. Some expressed they did have no time to undergo the score. Some participants expressed they had other concerns. Some denied the risk they were facing. Some participants expressed to fear their NL-IHRS result. Some participants expressed resistance to change and contemplation. Some alleged they preferred to ignore their cardiovascular status.
V. Process
A	Planning		Facilitators	Organization of the screening was generally satisfactory. Support from junior researchers was appreciated. The planning of screening allowed deployment of screeners in every event. Presentation of the study became fluent. The media coverage was extensive.
			Barriers	Screeners ignored how the project continued after screening. Some unforeseen events appeared during the screening phase: programming difficulties, acceptances to the events were known last-minute. Sometimes, workforce was inadequate to the needs of the events. Screeners underlined that catering could be an issue if no dining area existed or when the provided food was unhealthy compared to cardiovascular disease prevention. Coordination of FP interns could be impaired with lack of anticipation among screeners. A significant time was required from the research team for media coverage.
B	Engaging		Facilitators	None
			Barriers	Expressed barriers to engaging were the organization with students of the preventative health service. They were not involved in the planning construction. The research team provided no feedback to the screeners. The preventative health service was mandatory, so that some students felt forced to participate to the screening.