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Table 1 Summary of main themes based on CFIR domains and associated constructs

From: Facilitators and barriers to HIV pre-exposure prophylaxis (PrEP) uptake through a community-based intervention strategy among adolescent girls and young women in Seme Sub-County, Kisumu, Kenya

Definitions of CFIR domains used and associated construct definitions (CFIRguide.org) which emerged as main themes Facilitators Barriers
Inner Setting: Characteristics of the implementing organization such as team culture, relative priority of the intervention, leadership engagement, and the compatibility of the intervention with the organization  
Compatibility: “The degree of tangible fit between meaning and values attached to the intervention and how the intervention fits in with the existing goals, workflows, and systems of the organization.” Pamoja staff believed that the implementation of PrEP through the DREAMS Initiative was critical in achieving the goal of reducing the amount of new HIV amongst adolescent girls and young women in their community.
Relative Priority: “Individuals’ shared perception of the importance of the implementation within the organization.” Pamoja staff, health care providers, and local chiefs and assistant chiefs recognized the vulnerability of adolescent girls and young women to new HIV infections, acknowledging the necessity of rapid PrEP implementation and scale-up.
Intervention Characteristics: Aspects of an intervention that may impact implementation success such as relative advantage, complexity   
Adaptability: The degree to which an intervention can be adapted, tailored, refined, or reinvented to meet local needs.” The implementation of PrEP through the DREAMS Initiative by Pamoja was adapted to increase PrEP accessibility and decrease community stigma surrounding PrEP. Increased accessibility to PrEP was achieved by allowing PrEP refills to take place at the safe space. Decreased community stigma was achieved through hosting PrEP sensitization meetings for parents and male sexual partners.
Complexity: Perceived difficulty of implementation, reflected by duration, scope, disruptiveness, and intricacy and number of steps required to implement. The side effects of PrEP was a barrier to implementation, medication uptake and persistence. Some of the adolescent girls and young women reported poor appetite, dizziness, nausea, vomiting, and stomachaches as reasons why their peers have defaulted from PrEP or decided not to be initiated on the medication.
Characteristics of Individuals: Individuals’ beliefs, knowledge, self-efficacy, and personal attributes that may affect implementation of people implementing or receiving the intervention.   
Knowledge and Beliefs about the Intervention:
Attitudes towards and value placed on the intervention as well as familiarity with facts, truths, and principles related to the intervention
Adolescent girls and young women and PrEP implementers, such as Pamoja staff members and health care providers, recognized the value of PrEP, acknowledging that adolescent girls and young women were at increased risk of new HIV infections. They referenced many risk factors such as poverty, multiple sexual partners, wife inheritance, and boda boda drivers.
Outer Setting: External influences on intervention implementation including patient needs and resources, external policies and incentives, community culture and attitudes.   
Patient needs and resources: “The extent to which patient needs, as well as barriers and facilitators to meet those needs, are accurately known and prioritized by the organization.” Through the utilization of the safe spaces, the use of peer mentors and close communication with local community chiefs and assistant chiefs, Pamoja has been able to better understand the challenges to PrEP implementation in addition to the barriers and facilitators to PrEP initiation and persistence among adolescent girls and young women. Community stigma against PrEP and the frequent relocation of adolescent girls and young women away from DREAMS associated areas continues to remain a barrier to medication uptake and persistence.
  Continuous sensitization meeting surrounding the benefits of PrEP, cultivating positive attitudes around the PrEP use and HIV risk factor reduction among the adolescent girls and young women proved to be a facilitator to medication initiation and persistence. The health care providers mentioned limited financial and humans resources as barriers to PrEP implementation. They mentioned limited resources in clinics to provide proper testing and follow-up screening for patients on PrEP and the inability to attend safe space meetings due to staff shortages.
Process: Strategies used, the presence of key intervention stakeholders and influencers including opinion leaders, stakeholder engagement, and project champions.   
Engaging: “Attracting and involving appropriate individuals in the implementation and use of the intervention through a combined strategy of social marketing, education, role modeling, training, and other similar activities” Pamoja engaged MoH health care providers, peer mentors and community chiefs and assistant chiefs to help facilitate PrEP implementation. These individuals helped conduct community sensitization meetings, educational sessions with adolescent girls and young women around PrEP and served as role models for PrEP use.
Reflecting and Evaluating: “Quantitative and qualitative feedback about the progress and quality of implementation accompanied with regular personal and team debriefing about progress and experience.” Through the oversight of the MoH, Pamoja created a database to track the amount of adolescent girls and young women initiated on PrEP and monitor the persistence rates within the PrEP program. This information was used to better understand the areas of strength and the areas in which the PrEP implementation strategy by Pamoja could be improved.