Table 4 Quotes on CFIR constructs

 Relative advantage

This is more effective than leaving it to health workers from the hospital to go to the community to educate the PLWD, for that is not always feasible (MoH national representative)

The training we received was very good. People appreciate my work when I give them talks… (Peer supporter)

The referral card…have a look (showing the card)…it has my name, and the date of my next clinic … at the clinic I just showed it (to the staff) and I was attended (FGD participant who attended clinic)

I still have my referral card … I never leave it behind…so I know that the day I go to the eye clinic I will show it and get checked (FGD participant who did not attend clinic)

 Complexity

Training the peer supporters was not difficult, the training slides are easy to use (trainer)

We are not doing things that are very different from what is usually done …[in DSGs]…we were already familiar with group talks, what we have not been doing was the telephone reminders...and giving referrals, but that is not burdensome (peer supporter)

When I learnt the reason for the test, and was given the referral card…all I needed was to present myself at the clinic. You could go even the following day, anytime…and you only needed to go once. We went together several of us. Can anyone say that it is difficult? (FGD participant who had screening)

 Adaptability and flexibility

I wanted the PLWD to go to the eye clinic as soon as possible…so if I could not reach them on phone because they had put off the phone, I took it upon myself to go to their homes (peer supporter)

We carry out the DURE activities because they fit well with our other activities…I go on with my usual work on the farm except for the DSG meetings (peer supporters)

During recruitment, we realized that we needed additional personnel in the recruitment team, so we expanded the team (member of research team)

 Cost

The intervention uses existing resources in the community and in the hospital…this is the biggest advantage because it can scaled up without cost limitations…(MoH county representative)

People’s pockets are different…when I went there I had only 100 shillings … I paid 50 for registration. They asked me to pay another 50 for eye examination. I paid it because I had to get the screening. But someone else will just say they will come next week. (FGD participant who attended screening)

 Relative disadvantage

The only problem is that at both the diabetes clinic and the eye clinic they make you wait… queuing two times…then in the eye clinic they put some medicine in your eyes and ask you to wait again…you can end of wasting a lot of time waiting. Why should I que twice? (FGD participant who attended screening)

But why don’t you focus on preventing the complications, rather than just screening? For me I have begun with doing exercises, but later I will go for the screening. [names peer supporter] will take me there… (FGD participant who did not attend screening)

 Diabetes as a health priority

We are keen on sustainable interventions for NCDs and we have to go to where the patients are found…We should not wait for patients to come but go to them. This is sustainable because the trained peer educators will remain in the DSG to educate more people. We will work with them more. (MoH representative at national level)

 Clinical guidelines for DR are used as a national governance tool that is also useful for resource mobilization

The clinical guidelines have been very helpful. Earlier on I did not routinely screen those who have good vision. Now I dilate and screen all those that come here. We also order more dilating drops (eye health worker)

 Peer supporters mitigated potential implementation challenges such as political events

The presidential elections were nullified, everyone left the (DSG) meeting to go and watch the news… and had I not been passionate to mobilise members there would have been very poor attendance at the next meeting… (peer supporter)

 Intervention fits within the norms of the health care system

The county health services, including eye care and diabetes care services supported this innovative involvement of peer supporters because we all want to improve quality of life for PLWD (MoH representative at county level)

 External outreach camps

There were two external mobile outreach camps organized at a church by a private care provider…some of the people preferred to go for the screening here because it was nearer

(DSG county lead)

With the mobile outreach clinic, you know it is only for one day, so you don’t want to miss the opportunity. For the hospital, some of the people, even if they live near, do not attend… They keep on postponing because the eye clinic will always be here… (Peer supporter)

 Tension for change

I know someone who doesn’t go out of his home now, because he can’t see…that is why we have been told not to wait till we have eye problems (FGD participant who took screening)

I have never had my eyes checked…. Can you check me today? Or give us the referral cards so we can go [to the eye clinic] tomorrow (FGD participant from control arm)

We have to find a way of easily identifying those any diabetes patient who has not been screened. May be label their files so that they can easily identified (eye health worker)

We have seen people going blind…nobody will come from outside to stop it… we have to do something ourselves (KDDA county representative)

 Compatibility

We give the group talks as part of the monthly DSG meetings (peer supporter)

We want to have all PLWD screened for DR, thus this intervention is contributing to that mandate (eye care worker)

 DSG Organisational Culture

For us we are always open to new things that can help us who live with diabetes, so we are happy to work with you on this…it empowers us to not just to go for screening, but to engage in advocacy for diabetes eye health (KDDA local representative)

In DSGs, we know about volunteering … and for the good of our people, we all have to work together to ensure everyone goes for the eye check… I do not mind giving my time to do this, though of course it requires extra time … I am happy people got tested

(peer supporter)

At the DSG I tell them my experience with screening…we don’t hide things from one another…(PLWD who has taken screening)

In some of the DSGs, participants came together…we would have a large group turn up at one go…they would tell me they all agreed to come together (eye health worker)

Here we like to share about ourselves openly, we don’t hide things, we are not afraid to open up or keep reminding one another about attending screening (FGD participant who attended screening)

 Incentives and rewards

We do not get paid for this work, it is about volunteer work, people who do not want to volunteer their time cannot do this work (peer supporter)

But since we are doing good work, and we spend a lot of time on it, if we were paid we could do even more (peer supporter)

 Readiness for implementation

We are planning a peer supporter training in [names county]…we want you to come and train them so that they start doing the same in [names county]… (KDDA national representative)

Now that you have done this with some groups, you also have to come to our groups and give us the intervention, … you should not leave us out (PLWD from control group)

 Adjustments in the eye health system

Sometimes, people did not screen for diabetic retinopathy if the patient’s vision was good. But now we have been reminded to screen all PLWD annually and we have started doing that

(eye health worker)

The eye clinic has recently been renovated, we saw the governor launch it and we heard that it has all the equipment, so we are now happy to go there. (FGD participant who attended screening)

 Community volunteers (CVs) reinforced key messages

Community volunteers really support us…because they reinforce what we say. In our DSG, we have a member who is a community volunteer… I usually call her to speak after I given the group talk...it is better when the message comes from two people. (peer supporter)

 Geographical barriers hinder uptake of screening

Getting to the eye clinic is a problem because the easiest way is to take a boda boda (motorbike taxi) to the main road and then wait for a matatu (public van). I avoid boda boda because I have a back problem, so I just wait for the outreach camp. (FGD participant who has not attended screening)

From this experience, the cost of mobility must be borne by the provider, not the PLWD. We must find a way of going to the DSG for screening, rather than asking them to come. (member of the steering team)

For me, I haven’t gone to the eye clinic. I am looking for the fare. Why can’t you come to do the test here? (FGD participant who has not attended screening)

 Knowledge and beliefs about the intervention

The peer supporter at [DSG] informed me that they have started a WhatsApp group for peer supporters…to discuss how they can do more to prevent diabetes complications in general…they feel the work they are doing with DURE can be expanded (PI field notes)

I observed that the peer supporters enjoyed giving the group talks, and the key messages were easy to explain and it was a social activity, unlike the paper work which was more of an individual task. They still did the documentation since they were trained to do it. (research assistant)

 Individual identification with the role of PS

In our support group, most people have gone to the eye clinic, because [names peer supporter] is very active, and he makes us laugh when he is giving the talk…you cannot get tired…and every time he meets you he will remind you, even at church… (FGD participant who attended clinic)

I always see [name] here in the diabetes clinic, bringing his DSG members. Then he also takes them to the eye clinic. Sometimes they tell him they do not have the money for the hospital fee but he insists and they pay (diabetes care worker)

 Individual stage of change

All the peer supporters had already taken screening so they must have been good role models (KDDA national representative)

None of the peer supporters had any previous training on delivering a diabetes eye health intervention, you could tell that they liked it…the novelty of the information seems to have been a motivator… (Trainer)

 Personal attributes

“I did not do as much work as [name], though he and I are the supporters in our group. But he did very well…you know he is younger, ‘sharp sharp’ (slang for exuberance) and men can do this work more easily…” (Female peer supporter)

[Name] is ever punctual so we know (DSG) meetings will run on time. She is a teacher so she explains very well. That is why many people don’t miss the meetings, and most of us got tested the very first month (FGD participant who attended screening)

What I have seen, is that he [peer supporter] is self-sacrificing…from the heart … he closes his business of selling clothes to bring PLWD to both the diabetes clinic and the eye clinic (diabetes clinician)

We did not know whether keeping the peer supporters engaged over six months would be challenging…I would say selection of peer supporters is important as they have to be highly motivated and committed (member of steering team)

 Self-efficacy of peer supporters

He took me to the eye clinic, together with others… he did not feel bothered about waiting in the queue with us… (FGD participant who attended screening)

When I saw that the first five members had gone for screening right after I gave the first talk, I knew I was doing it right, I felt motivated me to continue with the work (peer supporter)

When I observed [names peer supporters giving the talk], they performed so well, they answered all the questions. I think it is because they were trained well… (research assistant)

 Planning

We were very happy to be involved from the beginning…we have always insisted on being involved as equal partners in things that concern us, so we participated (KDDA national representative)

I remember the meeting we had at the beginning…when our chairman of KDDA came and introduced the project…we agreed to support… (peer supporter)

 Engaging

The research team was really committed…they were always available and we worked so well together, it made us not to leave the work half- way (peer supporter)…we even took lots of photos

The community volunteers, they really embrace us…we support one another in the work (peer supporter)

I looked forward to the call from the PI every week – it gave me motivation (peer supporter)

Regular briefing helped us to keep involved (steering committee member)

 Executing

We were of course concerned about the feasibility of the intervention since we have not used the DSG platform before. But we had success with the pilot trial, so this proved not to be a major issue (member of project steering group)

The DSGs in the control arm are left out, but we have understood that they can get the intervention thereafter (peer supporter)

 Evaluating

I am looking forward to the findings of the study (research nurse)

You need to give us a copy of the results…(MoH county representative)

We will organize a forum to share the results with the stakeholders (MoH national representative)