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Table 4 SCC implementation challenges and successful strategies with associated Consolidated Framework for Implementation Research challenge construct and domain

From: Adaptation and implementation of the WHO Safe Childbirth Checklist around the world

Intervention challenges

CFIR challenge construct

 Dependence on external funding for sustainability (NGOs)

Intervention source

Cost

 Funding for ongoing mentorship/coaching

Intervention source

Cost

 Effective coordination and structure of mentorship/coaching

Design quality and packaging

 SCC not designed for teams

Adaptability

 SCC not integrated into medical record

Adaptability

 SCC perceived to be tool for LMICs only

Relative advantage

 Cost of printing SCC and missing SCC

Complexity

Cost

 Inability to adapt SCC due to government mandate

Adaptability

Outer setting challenges

CFIR challenge construct

 Government does not enforce or support SCC

External policy and incentives

 Patient care seeking behavior and preferences

Patient needs and resources

 Lack of timely referral system

Patient needs and resources

Cosmopolitanism

 Incentives required for motivation

Peer pressure

External policy and incentives

 Tension between data collection for research and sustainable implementation

Cosmopolitanism

Patient needs and resources

External policy and incentives

Inner setting challenges

CFIR challenge construct

 Tension and interpersonal dynamics between different cadres

Networks and communications

Culture

 Lack of leadership support for SCC

Readiness for implementation

 Staff turnover

Readiness for implementation

 Lack of required infrastructure (personnel, supplies, space)

Structural characteristics

Readiness for implementation

 Quality of care not perceived as a priority

Implementation climate

Readiness for implementation

Characteristics of individuals challenges

CFIR challenge construct

 Lack of motivation and perceived burden of SCC

Knowledge and beliefs about the intervention

Other personal attributes

 Gaps in technical knowledge/skills in labor management

Self-efficacy

Other personal attributes

 Resistance to behavior change

Individual stage of change

Process challenges

CFIR challenge construct

 No clear process for evaluation or audit of individuals

Reflecting and evaluating

 Difficult to use SCC in emergency situations

Executing

 SCC not integrated into routine workflow

Planning

Executing

 No clear mechanism for identifying once practices have become habit without SCC

Reflecting and evaluating

Successful strategies

CFIR domain

Incorporate accountability into SCC documentation and implementation

Intervention

Government policy or mandate for SCC

Outer setting

Include birth companions in care delivery

Link SCC implementation to other structural changes at facility

Strengthen health facility infrastructure to accomplish SCC behaviors

Inner setting

Develop motivational strategy around SCC

Long-term external coach/supervisor who has support from leadership and frontline clinicians

Include ongoing technical training to address gaps in knowledge/skills

Characteristics of individuals

Embed oversight of SCC to ensure it is used with high quality

Create supporting documentation to facilitate SCC use (discharge warning signs)

Engage leaders at facility and district levels before implementation

Learn from a model facility where SCC was implemented successfully (either locally or internationally)

Mentoring/coaching system to support ongoing SCC use

Incorporate feedback continuously

Integrate SCC into workflow

Integrate SCC into medical record

Process