We developed a semi-structured interview guide based on conversations with individuals involved in community screening programs, clinical experience, and a review of implementation science literature. Although informed by CFIR, the interview guide was not explicitly mapped to individual constructs, and instead, CFIR served as an overarching framework to guide question development. Our objective was to explore individual leaders’ experiences of designing and implementing community-based eye screening interventions. To ensure content and face validity, the interview guide was pilot-tested and refined with feedback from qualitative experts at the University of Michigan’s Institute for Health Policy and Innovation Qualitative Research Group. The final guide maintained a standardized structure while incorporating open-ended prompts and flexible probes to encourage elaboration on relevant issues. This allowed us to achieve consistency across interviews while preserving responsiveness to participant perspectives. At the end of the interview, we elicited a few participant demographic characteristics. This was kept minimal both to ensure participant confidentiality and because it was not relevant to the purpose of the study. The full interview guide is available in Supplemental Text 1.

We employed purposive snowball sampling to identify and recruit individuals with experience designing and implementing varied vision screening initiatives. A targeted literature review identified key US-based community eye screening programs from 1995 to 2025, and principal investigators of these programs were invited via email to participate. Subsequent participants were recommended by initial respondents. We aimed to recruit 15 to 20 participants, based on sample size conventions in similar qualitative implementation science studies, ^,, and anticipated thematic saturation across diverse program contexts. Inclusion criteria required participants to be aged 18 or older, have an academic affiliation, and possess first-hand knowledge of their organization’s eye-screening efforts. Eighteen individuals were contacted, and 17 agreed to participate.

One interviewer (R.R.) conducted all semi-structured interviews between May and August 2024. Prior to data collection, the interviewer completed a brief training session in qualitative interviewing techniques led by a qualitative expert at the University of Michigan. Interviews ranged from 50 to 75 minutes and were conducted via Zoom. All interviews were audio-recorded and professionally transcribed verbatim using NVivo Transcription (Lumivero Inc.). Before beginning each interview, participants were provided with an information sheet, and verbal informed consent was obtained. This study was conducted in accordance with the Declaration of Helsinki and was reviewed and approved by the Institutional Review Boards at the University of Michigan and the University of Pennsylvania, reflecting a change in principal investigator’s affiliation during the study.

All transcripts were imported into NVivo 12 for thematic analysis. A subset was double-coded by the principal investigator and a researcher at Penn’s Mixed Methods Research Lab (D.B.), who collaboratively developed a codebook. CFIR 2.0 was used as the guiding determinant framework. Coding was done iteratively, using Grounded Theory, allowing themes to emerge from the data. These codes were then deductively organized into CFIR constructs via consensus. As analysis progressed, new codes were added when concepts were not captured by the CFIR framework, resulting in a hybrid coding framework combining deductive CFIR constructs with inductively derived codes. To maintain validity, coding discrepancies were resolved through consensus, and interrater reliability exceeded κ > 0.8. The remaining transcripts were coded independently. Using the quality criteria for qualitative research defined by Lincoln and Guba, trustworthiness was maintained through investigator triangulation (credibility), review of data before theoretical organization (credibility), iterative code refinement through consensus (credibility), maintenance of an audit trail of research activities (confirmability/dependability), and discussions of possible biases and assumptions throughout the study (reflexivity).

We identified 22 constructs across the 5 CFIR domains as follows: (1) innovation (screening program) characteristics; (2) outer setting; (3) inner setting; (4) individuals involved; (5) process of implementation. Definitions of the constructs and notable quotations are provided in Tables 3 and 4 , respectively.

TABLE 3

Codebook of CFIR Constructs, Definitions, and Notes

	Construct Name	Final Construct Definition: “The degree to which….”	Notes
I. Innovation	Motivation/Evidence-basis a	There is clear motivation for why the innovation was pursued.	Why did they pursue the development of this program?
	Relative advantage	The innovation is better than other available innovations or current practice.	What is the advantage/importance of developing this program?
	Adaptability	The innovation can be modified, tailored, or refined to fit local context or needs.	How is implementation tied to local context? (Mentions of local context, geography, etc.)
	Trialability	The innovation can be tested or piloted on a small scale and undone.	How can implementation be trialed on a small scale and broken down?
	Complexity	The innovation is complicated, which may be reflected by its scope and/or the nature and number of connections and steps.	What makes executing the innovation complex?
II. Outer Setting	Partnerships and connections	The Inner Setting is networked with external entities, including referral networks, academic affiliations, and professional organization networks.	How are community partners and affiliates engaged? Who are they?
	Policies and laws	Legislation, regulations, professional group guidelines and recommendations, or accreditation standards support implementation and/or delivery of the innovation.	Guidelines, legislation, etc. related to the implementation
	Financing	Funding from external entities (e.g., grants, reimbursement) is available to implement and/or deliver the innovation.
	Government funding	Funding from federal/governmental agencies is available to implement and/or deliver the innovation.	Government grants, loans, and things required by the Govt. for funding (e.g. demographic data)
	Grant funding	Funding from federal or private grants is available to implement and/or deliver the innovation.	Funded by grant.
	Philanthropic funding	Funding from donors and philanthropic organizations is available to implement and/or deliver the innovation.	In-kind donations, donations from clients/community partners.
	Foundational funding	Funding from foundations is available to implement and/or deliver the innovation.	Specific funding from a foundation.
	Competing priorities a	Goals and missions of various stakeholders drive implementation and/or delivery of the innovation.
	Institution	Goals and missions of the academic institution drive implementation and/or delivery of the innovation.	Engagement/support (or lack of) from the institution.
	Community	Goals and missions of the local community drive implementation and/or delivery of the innovation.	Mention of the community’s priorities
	Funding source	Goals and missions of the funding sources drive implementation and/or delivery of the innovation.	Mention of goals or expectations from a funding source and how it drives design or implementation.
	Provider	Goals and missions of the clinician and providers drive implementation and/or delivery of the innovation.	How did interviewees balance research goals and providing clinical care or personal and professional goals
	Patients	Goals and missions of the patients drive implementation and/or delivery of the innovation.	What patients are hoping to receive from screening initiatives
	Clinic	Goals and missions of the clinical setting drive implementation and/or delivery of the innovation.	Mentions of other health care services being offered in the clinic or the goals/mission of the clinic where the program is taking place
III. Inner Setting	Structural characteristics	Infrastructure components support functional performance of the Inner Setting. Note: Use this construct to capture themes related to structural characteristics that are not included in the subconstructs below.	Discussions about the design of the program including how and when the program should run, workflow, and on the ground operations.
	Physical infrastructure	Layout and configuration of space and other tangible material features support functional performance of the inner setting.	Discussions about where the screening were occurring, what the physical layout of the space looked like, what diagnostic equipment was used, costs involved, etc.
	Information technology	Technological systems for tele-communication, electronic documentation, and data storage, management, reporting, and analysis support functional performance of the inner setting.	Any discussion of telemedicine, generally or related to program.
	Work infrastructure	Organization of tasks and responsibilities within and between individuals and teams, and general staffing levels, support functional performance of the Inner Setting.	Discussion regarding members of the screening team and their responsibilities.
	Culture	There are shared values, beliefs, and norms across the Inner Setting.	Culture of inner setting, what culture is the implementation trying to foster?
	Access to knowledge b	Discussions relating to education or knowledge of pertinent issues	This includes discussions about glasses or any other cause of vision impairment.
IV. Individuals	High-level leaders	Individuals with a high level of authority, including key decision-makers, executive leaders, or directors.	Mentions of authority figures and decision makers.
	Opinion leaders	Individuals with informal influence on the attitudes and behaviors of others.	Mentions of community leaders.
	Implementation team members	Individuals who lead efforts to implement the innovation.	Feedback from on-the ground workers and staff.
	Innovation recipients	Individuals who are directly or indirectly receiving the innovation.	Feedback from patients/patient stories.
V. Implementation Process	Assessing needs	Collect information about priorities, preferences, and needs of people. Note: Use this construct to capture themes related to Assessing Needs that are not included in the subconstructs below.	Mentions of care navigation and/or how the eye program helps patients connect to other health care resources/follow-up care, mentions of ADA accessibility and other forms of accessibility for those disabled, mentions of language resources for non-English speakers.
	Assessing context	Collect information to identify and appraise barriers and facilitators to implementation and delivery of the innovation.	Patient barriers (any obstacles that keep patients from getting eye care or glasses). Any discussion of insurance, insurance status, or reimbursement. Obstacles that hinder program development.
	Planning	Identify roles and responsibilities, outline specific steps and milestones, and define goals and measures for implementation success in advance.	Discussions regarding data collection. How are demographic data and other data from participants collected? What is collected?
	Tailoring strategies	Choose and operationalize implementation strategies to address barriers, leverage facilitators, and fit context.	Suggestions to improve community eye programs OR things interviewee would do differently for their program.
	Reflecting and evaluating	Collect and discuss quantitative and qualitative information about the success of implementation. Note: Use this construct to capture themes related to Reflecting & Evaluating that are not included in the subconstructs below.	What defines success? How do you measure it?
	Adapting	Modify the innovation and/or the Inner Setting for optimal fit and integration into work processes.	How were decisions and changes made based on past experiences or feedback received?

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