We interviewed 12 participants from July 2022 to November 2022. There were 36 eligible individuals approached in person, email, text, or a combination of methods and 24 did not respond to outreach. Stakeholders from the jail included 2 members of the administration/custody leadership, 3 healthcare leaders/staff, 1 member of the maintenance team leadership, and 3 correctional officers, as well as 2 participants from Northwell Lab, and 1 contracted healthcare provider employee.
In the sections below, we present key CFIR domains and related constructs organized according to those that were mentioned most frequently by participants. Tables 1–3 below define the CFIR constructs within each domain, N is the total number of times excerpts from key informant interviews were coded as a construct and includes the total number of times an interview excerpt was categorized as either a barrier, familiar, or neutral; in addition to, a representative quote from interviews. A supplemental table includes additional domains and corresponding constructs. Notably, some excerpts were shared amongst the domains, but quotes were only included once within our tables.
Table 1
Intervention Characteristics Domain: CFIR-informed barriers to and facilitators of wastewater-based surveillance and nasal self-testing in the Fulton County Jail.
Identified constructs per CFIR domain | N | Barrier | Neutral | Facilitator | Representative quotes |
A. INTERVENTION CHARACTERISTICS | | | | | |
1. Relative Advantage ‘Individuals’ shared perception of the importance of implementation within the organization.’ | 10 | 2 | 3 | 5 | I guess a truth of the measurements or the testing compared to what we have -- whether it’s the measurements are high but we have a small number of positive cases or if the measurement is low and we have a higher number of positive cases inside the facility, just kind of compare the apples to the oranges and see what it looks like. Facilitator to WBS and NST, FCJ Sherriff’s Leadership Office |
2. Adaptability ‘The degree to which an intervention can be adapted, tailored, refined, or reinvented to meet local needs.’ | 17 | 7 | 4 | 6 | We had to get very creative because our facility for the most part is max to capacity, so we did a lot of movement around trying to get our inmates – create space. We had to create space to do isolations from the other general population. Of course, with staff we had to get creative – when COVID first came, we just didn’t know, the 14 days – people were out 14 days at a time. That hurt us with trying to keep normal operations going, so we really, really kind of had to dig into the trenches. For the most part we had to create space, and we just kind of improvised where we had to just to continue our day-to-day operations. So, every day may have been different for us, you know? Whatever the situation was, we had to kind of accommodate. Facilitator to NST, FCJ Sherriff’s Office Leadership |
3. Complexity “Perceived difficulty of the intervention, reflected by duration, scope, radicalness, disruptiveness, centrality, intricacy and number of steps required to implement.” | 13 | 7 | 4 | 2 | Well, this is a bit more complicated because this is a – you know, this jail system and Emory are in another state, so they’re not here. So, we had state boundary, you know, distance issues I suppose. You know, the jail was difficult because we couldn’t do our usual process which is conduct it by Wi-Fi, it would be real time that they would scan in samples right after the person’s done collecting. Instead, they were collecting and then having to take them somewhere else to scan them in, so that created difficulty. Barrier to WBS, Northwell Health, Senior Project Manager |
Table 3
Process Domain: CFIR-informed barriers to and facilitators of wastewater-based surveillance and nasal self-testing in the Fulton County Jail.
Identified constructs per CFIR domain | N | Barrier | Neutral | Facilitator | Representative quotes |
E. PROCESS | | | | | |
1. Planning “The degree to which a scheme or method of behavior or task for implementing an intervention are developed in advance and the quality of those schemes or methods.” | 12 | 2 | 2 | 8 | We set up a process early on that, once we got the protocol down, I think it went fairly smoothly. I think certainly from our perspective, for lots of reasons, the laboratory pieces are regulated, so we had limited flexibility in making modifications. From a pure testing perspective, we had no modifications to the protocol over the course of the study, because that would obviously have all sorts of other downstream implications. So it was just working through the protocol to meet [the study’s] needs – how to get individual sample, how to get patients or participants registered, how to get individual sample, how to get the results back to the individuals. Facilitator to WBS and NST, Northwell Health, Chief Medical Information Officer |
2. Engaging “Attracting and involving appropriate individuals in the implementation and use of intervention combined strategy of social marketing, education, role modeling, training and other similar activities.” | 16 | 5 | 1 | 10 | I stepped in. The way you congregate now. You won’t be able to do it unless we can keep you safe in this environment. Explain won’t have movement. The ventilation is not that great. You are co-herding around the table. You don’t have face coverings on that we gave you. This is the best way to ensure that we don’t have a widespread outbreak. If [you] sell it that way, they’re generally agreeable. Facilitator to NST, FCJ Sherriff’s Office Leadership |
Additional Material |
• File Name: Additional File 1 |
• File format: pdf (Link: https://drive.google.com/file/d/1m85jiwYGaFjeLkOKyggL2fuqrBrll_5-/view?usp=sharing) |
• Supplemental Table 1. CFIR-informed barriers to and facilitators of wastewater-based surveillance and nasal self-testing in the Fulton County Jail. |
Themes related to the adaptability and complexity constructs within the Intervention Characteristics domain were the most frequently mentioned and deemed to be barriers despite the perceived relative advantage conferred by WBS and NST. Other constructs that were mentioned frequently from the Inner Setting domain, included networks & communication and culture, which were classified as facilitators, and available resources, which was identified to be a barrier. In the Process domain, both the engaging and planning constructs were deemed to be facilitators. Other CFIR constructs including Formally appointed internal implementation leaders, External change agents, Evidence, strength and quality, Leadership engagement, Peer pressure, and Structural characteristics were mentioned less frequently during the analysis.
Intervention characteristics domain
According to participants, adaptability and complexity, which describe the ability to tailor an intervention to meet specific needs and the difficulty of its implementation, respectively, were interrelated with one another and deemed to be overall barriers to WBS and NST. Multiple participants noted challenges related to their ability to modify the intervention based on situational factors in comparison to other interventions. For example, Northwell Health had implemented COVID-19 testing and the dissemination of results in other non-carceral congregate settings prior to this project; however, previous initiatives included access to cell phones for communication of results. Because cell phones are not permitted for residents of carceral facilities, the SWANSS project was their first experience in which individuals were not able to receive their results. As such, a portal system needed to be implemented that was monitored by jail healthcare staff as discussed in Table 1.A3.
Similar perspectives were voiced in relation to complexity. Multiple participants including the Maintenance Team Leadership noted that they were not able to fulfill every call or request required to sustain WBS and NST. Other stakeholders voiced experiences regarding the complexities in coordinating with the study team. Officers’ bandwidth during scheduled hours were limited, requiring overtime on off days or before/after shifts to assist with testing for same/next day compensation. Overall, stakeholders felt the program might be adoptable for less complex jails than FCJ.
Despite challenges with adaptability and complexity, multiple stakeholders acknowledged the relative advantage or perceived importance of self-collected NST at FCJ when compared to testing led by medical staff. Participants felt self-collected nasal tests were more efficient due to the quick turnaround time of results and not having to wait on the availability of a provider to administer a test. Also considering that the NST and PCR methods were engineered to cost less than tests traditionally used for mass screening in jails (Table 1.A4). Stakeholders referred to the possibility of officers being trained to collect and complete regular testing if the SWANSS partnership concluded. Noting, the NST used does not require a healthcare provider to be present. The test also does not require deep nasopharyngeal samples, which residents prefer.
While stakeholders recognized the relative advantage associated with WBS for surveillance, they did express concern about its sustainability due to the novel and complex way in which it is implemented. Compared to other congregate settings, the intricacy of the jail highlighted the need for FCJ partners to be involved in this type of implementation strategy for sustainability purposes. Moreover, jail staff explained that movement of residents after positive wastewater and PCR tests to a designated pod is challenging and sometimes not feasible at a jail such as FCJ where populations is usually at or above capacity. A participant specifically noted how they had to create space to isolate residents (Table 1.A2). A COVID isolation zone for those who tested positive could house up to 32 individuals during their isolation periods, but this could not always be implemented, given security and other considerations governing housing.
(Table 1 here)
Inner setting domain
Networks & Communication, defined briefly as the quality of networks within an organization and the communication that ensues within those networks was deemed to be an overall facilitator in the implementation of WBS and NST. Among facility staff, discussion of COVID-19 mitigation efforts in response to WBS and NST results were incorporated at multiple touchpoints. For example, the facility has different communication channels accessible by all staff. Among residents, interactions with healthcare staff, signage, and resident briefings during officer shift changes were intended to keep them informed. However, stakeholders mentioned a lack of WBS specific reports following testing results, which was an area needing perceived improvement. Jail management specified that ideally these reports would be accompanied by an impression of findings to stay informed on the wastewater signal in regular meetings with department heads. On the other hand, in terms of sustainability, participants shared it could be challenging for external stakeholders to get buy in for jail staff to be responsible for managing and reviewing the WBS results to further consistent internal communication.
Culture such as norms and values within the organization was another facilitator within the inner setting. Participants endorsed these initiatives to improve the quality of health within the institution as well as their own health. Participants recognized the risk of residents contracting COVID-19, and communal efforts were thought to be important to mitigate this risk. Cleaning the living quarters, isolating symptomatic residents, and vaccination requirements were all viewed to promote the prevention of disease spread.
Access to knowledge & information, described as the availability of necessary, quality information and its relevance to daily work, appeared to be a facilitator. One stakeholder provided their outlook on the sustainability of the intervention recognizing that the ability of comparing wastewater testing results to the number of positive cases in the facility could provide “truth of measurements” (Table 1.A1). Another stakeholder pointed out potential future changes in testing and using WBS as a tool for an additional data source (Table 2.C6).
Table 2
Inner settings Domain: CFIR-informed barriers to and facilitators of wastewater-based surveillance and nasal self-testing in the Fulton County Jail.
Identified constructs per CFIR domain | N | Barrier | Neutral | Facilitator | Representative quotes |
C. INNER SETTING | | | | | |
1. Networks & Communications “The nature and quality of webs of social networks and the nature and quality of formal and informal communication within an organization.” | 26 | 6 | 9 | 14 | We have daily toolbox talks and also monthly safety meetings, and I’m also a part of the safety committee – I get all these documentations from CDC about COVID. So we share this stuff with the staff pretty much daily. You know, I’m always telling people, because we do a turnover talk every day at 3:00 and one in the morning and I say be safe, where your mask. You know, so COVID has changed the dynamics when it comes to safety around here because at the end of the day that’s the hot topic. So I want to make sure that my team is aware that people got a little comfortable because they’re thinking it was over. But what you do outside of here, that’s different than what’s going on over here. This building here – I would never step foot up on that floor without a mask on. You know, I might come in here and take my mask off, but if I get on that elevator and go to a floor, I’m putting a mask on. But my team is very knowledgeable and very aware of COVID. It’s preached and practiced here daily. So there’s no misunderstanding. You know, I don’t want anybody on my staff to ever say I didn’t know that, because my team knows. Facilitator to WBS and NST, Maintenance Team Leadership |
2. Culture “Norms, values and basic assumptions of a given organization.” | 22 | 5 | 5 | 12 | As long as they don’t see people getting really, really sick, they say ‘whatever.’ But we can certainly encourage it, almost require it. Just can’t come out and commune with the rest of the group if you don’t participate. Facilitator to NST + WBS, FCJ Sherriff’s Office Leadership |
3. Tension for Change “The degree to which stakeholders perceive the current situation as intolerable or needing change.” | 8 | 3 | 3 | 2 | It just kind of – I think our practices never really changed. We’ve always – We know that COVID still exists in our communities. So we still do things on an air of caution because everybody’s still required to wear their masks, staff and inmates when they’re back there in direct contact. So that’s never changed. We still do our sanitizing. We still do our decontaminations with our sprayers. So none of that has changed. But it just continued to let us know that it’s still existing. Barrier to WBS and NST, FCJ Sherriff’s Leadership Office |
4. Relative Priority “Individuals’ shared perception of the importance of implementation within the organization.” | 6 | 5 | 0 | 1 | I don’t think that surveillance is realistic right now. I think that people have veered away from that. I think that that’s important during the acute phase of a pandemic, but I think that we’re over that bump. I think now with the pandemic, it’s kind of socially endemic, we’re living with COVID and there’s less surveillance and more just treating people as they’re actually ill from COVID, not just when they have COVID, but if they’re actually ill. More like the flu. Barrier to WBS and NST, Northwell Health, Senior Project Manager |
5. Available Resources “The level of resources dedicated for implementation and on-going operations, including money, training, education, physical space, and time.” | 26 | 4 | 2 | 2 | If we had more nurses, we can tackle more floors or more areas at a faster rate opposed to hitting one floor, maybe a floor and a half once a week. We can have more staff when we deal with certain floors, because certain floors with different inmates, more staffing helps, period. The more you’ve got, it makes everyone’s job easier. Barrier to NST, FCJ Healthcare Staff |
6. Access to Knowledge & Information “Ease of access to digestible information and knowledge about the intervention and how to incorporate it into work tasks.” | 9 | 3 | 1 | 4 | I wasn’t really familiar with wastewater testing until I started hearing about it, and then once I started hearing [study staff] talk about it, it became more prevalent to me, because I started hearing it in the news media. And then when I started seeing the results come back and there was some COVID – positive COVIDness in the wastewater I was like, wow, this is interesting, and it really became relevant, because I noticed that yes, COVID was still here in the building when we was getting the positive results back from the wastewater. So when it decreased I didn’t hear anything about the positives being in the wastewater. So now in our facility today we see some spikes of COVID coming back in our inmate population, I’m really curious if there’s any positive COVIDness in the wastewater. Since then we just recently have some inmates here now that are COVID positive. And it just kind of stopped at a moment, and then I can tell it’s starting to pick back up. Facilitator to WBS, FCJ Healthcare Staff |
Available resources inclusive of space, time, money, staff, and supplies was a barrier. Most jail staff agreed that there is not much space within the facility. Overcrowding leads to residents living in communal spaces rather than an enclosed cell. Therefore, NST requires more security to control zones to test residents. If there was more cell space, testing cells door-to-door would be more secure. In addition to this being a safety concern when gathering NST, it makes it difficult to dedicate zones for the movement of positive COVID-19 cases that arise resulting in an infected resident living amongst other uninfected residents often. Furthermore, stakeholders noted that the facility is always experiencing staffing challenges. When visiting certain floors of the jail, there is a needed amount of security that was not regularly available during testing times.
Relative priority, another assessment of importance, was also a barrier. Similar to concerns about sustainability of WBS, as discussed by the interviewee in Table 2.C4, participants felt the prioritization of WBS may waver during different phases of the COVID-19 pandemic. Consistent with all of the above, Tension for change or the shared perspective that change is required was a borderline barrier or neutral. Within the jail setting, adoption of new interventions like WBS and NST over traditional surveillance methods could be hindered by other priorities that require more attention when the status of jail activities is more intense.
(Table 2 here)
Process domain
Both the planning and engaging constructs, defined as the quality preparation of intervention plans ahead of implementation and the involvement of appropriate stakeholders, respectively, were determined to be facilitators. Before the SWANSS study, surveillance was based off entry screening and residents reporting symptoms to staff. Opt-out testing for the entire jail population then became available. Jail administrators encouraged officers to engage with residents and explain the purpose of testing to address those who may be reluctant to participate week-to-week (Table 3.E2).
It was suggested by the Maintenance Team Leadership that the study team engage more with the maintenance staff by meeting them for an informational session, so they understand the purpose of WBS and its extension beyond opening a manhole to test the wastewater. With WBS, someone in a managerial position needs to delegate which contracted maintenance worker is assigned to accompany study team. The current stakeholder in the role suggested that the SWANSS team share testing plans with jail partners sooner to improve engagement. Participants mentioned that more than a 24-hour notice is needed for WBS coordination between the maintenance team, study staff, and the sheriff’s department to prevent partners from coming on site and not having escorts to complete sampling or testing.
During the initial phases of the study, the SWANSS team worked closely with a laboratory to develop protocols and plan testing strategies. Throughout the study, there was more flexibility for protocol changes to fit the study team’s needs during deployment such as how to register individual residents, how to organize residents as samples were taken, and how to report results to individuals. For example, the SWANSS team adjusted their NST strategy by using electronic real time recording instead of printed materials to effectively screen and test as many people as possible. But there was less flexibility for modifications of the laboratory protocol to follow typical regulations.
(Table 3 here)