Table 1 Elements of the conceptual framework supported with quotes and how they relate to CIFR domains

SYSTEM

i. Clinic characteristics

Inner setting

Clinic organization is varied among the different disciplines.

-“Like every year, they used to rotate [crosstalk].... I work in pediatric ward, of course now, and I have the knowledge, maybe by the time they do the reshufflement and I have been taken away from that ward, another set of people will have to be given that knowledge. But that will not stop if there is need for me when the need comes, I should go and help in that section.” (Nurses Focus Group)

ii. Resource availability

Inner setting

In some clinics staff are rotated, while in some, they are left on permanent basis.

-“Like, we have the TB unit, the TB unit in this center is head by a nurse. The eye center, and they are permanent. Malaria unit, they are permanent nurses there. They don't shift.” (Doctors Focus Group)

Low remuneration, increased staff turnover, insufficient number of staff.

-“The payment is very poor, so that is the ... like last year, we had more than 10 nurses that left this hospital, not to talk of the doctors.” (Nurses Focus Group)

-“One doctor see over 400 and something patients.” (Doctors Focus Group)

iii. Tension for change

Inner setting

Greatest tension was around staff shortage.

“There are times when we used to have 37 doctors here. There was a time. But they all left....The pay is better than here. They leave.” (Doctors Focus Group)

iv. Implementation climate

Inner setting

The participants showed evidence of the organization climate to support change and importance of creating new programs that meet the long- term needs of patients.

-“Patients are permanent. So, you should try a solution that is lasting to them....And we know that once we start this program, we're going to identify a lot of acute patients, and more people are going to be coming.” (Doctors Focus Group)

Emphasis was also made on planning and to anticipate barriers and overcoming them.

-“See what is available, how can we enhance what we have to ensure the success of the program, and the anticipated barriers that will have affect the success, so that you try and address them. So, whatever solution, you need to put it in that context....So that you are able to solve a perceived problem or an anticipated problem.” (Doctors Focus Group)

INDIVIDUAL

i. Normative beliefs

Characteristics of the individual

Agree task shifting is a good idea.

-“In places of this task shifting, I believe it's because of the shortage of hand among the doctors. So that's why we are shifting it to the nurses. I think if that is the case, I quite tend to agree that I think the nurses can be trained and they can do it. And if they are trained, they can take results on that. I don't see an issue with that.” (Doctors Focus Group)

TCD is a good intervention.

-“Yeah, it's good to bring interventions, it should be sustained and be sustainable, and people should learn. And they should learn properly, and they should [inaudible] without any bias. As many people as they could should know what is done correctly and rightly.” (Administrator)

ii. Behavioural beliefs

Characteristics of the individual

How best to conduct TCD screening is to explain the importance and the procedure to parents.

-“I know basically what you explain to the parent is that this scanning entails putting a probe on the head of your child to tell us if the pressure going to the brain is very high or not because the sickle cell we have now, it narrowed the blood [vessel] going to the brain. So, as it narrowed, the pressure going into the brain of your child is very, very high. And if we leave it like that, it will expose your child to having stroke.” (Doctors Focus Group)

Train nurses and supervise them.

-“No, I think you can supervise maybe twice or three times. And if you're sure of their judgment and of the specific person doing it, from that time, you can trust anything. You know, this one I've seen him doing, I've seen her or seen him doing this for many days and I know that there is no problem.” (Doctors Focus Group)

Trust nurses on the ability to do TCD.

iii. Control beliefs

Characteristics of the individual

Willingness of both doctors and nurses to work together

-“No. It's not like that. We trust them nurses working [inaudible]. And they do everything, all what doctors do, they can also do it. And if they can take care of a baby and unit, we can trust their judgment.” (Doctors Focus Group)

“It will work if we put hand together” (Administrator)

PROCESS

i. Engage

Process

Levels of engagement

 i. At the hospital by engaging pediatricians and involving other departments.

-“The need, especially the pediatricians, I think they should be the frontline.” (Doctors Focus Group)

 ii. At the ministry by engaging the policymakers.

-“This is a policy now; policies are done from the ministry. You have a Commissioner, you have a Permanent Secretary. So, the hierarchy says, ‘If you want to get something, you have to apply through the Ministry of Health.’ So, the Ministry of Health are in charge of policy. And then they'll tell you, you could go ahead and implement it. So, I believe the right thing to do is to write to the Commissioner through the ministry, then the ministry will tell you, ‘Fine, the thing is applicable.’” (Administrator)

 iii. At the community by engaging the parents and other community leaders

“Giving health talks. In church and any other religious [setting]. You can also go through that route because the people tend to listen to them.” (Doctors Focus Group)

“Like the radio. Most of our setting, people that talk to this hospital from the low socioeconomic class. So, the radio is the best according to my opinion.” (Doctors Focus Group)

“Most of them listen to the radio. So, the radio is the best according to my opinion.” (Doctors Focus Group)

“Right from the beginning, as I have said, the Medical Director actually has his management team which all the head of departments are part of. They have management meetings actually every month or twice. So, everybody has to [inaudible] be told exactly this is what is happening and expect so, so, so and so working in this environment and [inaudible]. So, I think right from the start. That's why I said the ministry should be aware, then the MD, then his management, then it drops to staff and then community.” (Administrator)

ii. Implement

Inner setting (implementation climate)

Emphasis was on staffing (through employment) and training.

“If you can employ more people, good. If you say you can employ more nurses, employ more doctors there will be more hands to take and even man somebody permanently.” (Doctors Focus Group)

Setting a start date.

iii. Adopt

Process (executing)

Willingness of the leadership of the hospital to adopt the program.

“I believe our management will support this program, even the nursing department will support this program. And since it is coming down to us, we'll also support the program.” (Administrator)

“Because we have already give you the rooms...We have already give all what you want...so we're waiting for you.” (Administrator)

MODERATORS

i. External factors

Outer settings

 □ Patient needs and resources (cost)

The cost of providing care for a child with sickle cell disease was seen as an important aspect of family needs.

“It affect them morally and economically, because I can say, economically, they will always be in the hospital, spending money for blood, drugs. If they didn't walk to the actual place to look for help. Sometimes they will advise them to go to the medical, traditional medicine, looking for help. Spending money.” (Administrator)

Lack of male partner support.

“Mostly, it's the women, because some of the fathers, they don't even care to come to the hospital with their...their wives.” (Administrator)

Cosmopolitanism

External support from NGOs and other support groups like Friends of the Hospital.

“That why they have associations and some NGO even like one in Badarawa to makes the health care delivery to them, to the cost implication, to lessen it. That's the essence of all these NGO. So that if you go to any private hospital for admission, it's money all the time. But all these NGO whatever, they can form a support group so that....Just like those who are outside, they're HIV...so, they can also do that for the...sickle cell.” (Administrator)

 □ External policies and incentives

Strengthening the primary health care system.

“We're only encouraging, because the primary health, we cannot refer the patient from the secondary health facility to the primary health facility....The only thing we normally encourage them is, let's say the antenatal care or the immunization. Then we always encourage them that it's not necessary for them that they should come here. If they have primary health sectors in their places, let them be attending so that at least they will reduce the workload on us. So, by the time they are attending the...if there is anything that is bigger than them, then they will refer them to come to us.” (Administrator)

ii. Caregiver

Patients’ needs and resources (education)

How the caregiver understands sickle cell disease, stroke risk, and stroke screening may influence utilization of the program.

“So, use the language, very simple and clear language that the child or the mother, if it is a very small baby that cannot understand you're saying, you talk to the parents. If it means even bringing both parents, the father and the mother together so that—so that you can be able to at least give them the information so that they will know how to take care of the child.” (Administrator)

iii. Teams

Inner setting (Networks and communication; Implementation climate, Tension for change) and Characteristics of individuals.

Some people talked about the importance of all team members having common knowledge about the body and the importance of learning TCD, as well as the consequences of stroke.

-“Not waiting until we look for somebody that knows how to operate the machine. So, the best thing, like the nurses that are here, everybody should be given the knowledge. If everybody have the knowledge, you will not wait until the person that have the knowledge come and take care of the patient. Once you have the knowledge you will know what to do without even waiting.” (Administrator)

-“Stroke is a very serious medical issue. When you have stroke, you lose function. So, by losing function, it means you're not capable of doing a lot of things, even your thinking, your rationale, your movements, your coordination.” (Administrator)

iv. Intervention

Intervention characteristics

The potential barriers to the implementation of the intervention were identified: (1) prior experience, (2) complexity, and (3) cost.

-“From the start, it will become very difficult. When you're starting something new, but every time there is going to be some adjustment ... So, by the time we are used to it, we'll be able to adjust to combine the two together, but…we are willing to adjust.” (Nurses Focus Group)

-“My question here is the TCD, is it going to be free for the... for the patients? That's very good.” (Nurses Focus Group)

-“So, anything you want to do, you should also consider the financial aspects.” (Administrator)