Evaluating applications of the CFIR in low- and middle-income countries Arianna Rubin Means, Christopher Kemp , Marie Claire Gwayi-Chore, Sarah Gimbel, Kenneth Sherr, Brad Wagenaar, Judith Wasserheit, Bryan J. Weiner December 3, 2018
Introduction to the CFIR Characteristics of Inner Individuals Implementation Outer the intervention Setting Setting involved process • Intervention • Structural • Patient needs and • Knowledge and • Planning source characteristics resources beliefs about the • Engaging • Evidence strength • Networks and • Cosmopolitanism intervention • Execution and quality communications • Peer pressure • Self-efficacy • Reflection and • Relative • Culture • External policies • Individual stage of evaluation advantage • Implementation and incentives change • Adaptability climate • Individual • Trialability identification with • Complexity organization • Design quality • Other personal • Cost attributes Source : Damschroder, Laura J., et al. "Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science." Implementation science 4.1 (2009): 50.
Rapid Growth in Use of CFIR 80 Publications with CFIR in 60 Title/Abstract 40 20 0 2009 2011 2013 2015 2017
HICs LMICs • More resources • Fewer resources • Individualist • Collectivist • Multiple health systems • National health system • Not donor-driven • Donor-driven
Objectives • Characterize application of the CFIR in LMICs • Assess compatibility and relevance of CFIR domains and constructs in these settings • Identify opportunities to refine the CFIR to optimize utility in these settings
Methods • Systematic review • February 1, 2018 • SCOPUS • PubMed, EMBASE, CINAHL, PsycINFO • Included peer-reviewed studies using CFIR in LMICs Data abstraction informed by Kirk et al. (2015) 1 • • Survey to corresponding authors: 1) Why they chose the CFIR as a guiding framework 2) Which domains and constructs were compatible, incompatible, or irrelevant and why 3) Ways in which the authors believe that the CFIR could be optimized or updated for use in global health contexts, if any 1 Kirk et al. 2015. A systematic review of the use of the consolidated framework for implementation research.
Results: PRISMA flow diagram Databases 374 Non-duplicates 166 Screened Excluded 166 68 Full-text review Excluded 98 71 48 Did not use CFIR Studies included 10 Not LMIC 27 5 Not peer reviewed 4 Multiple reasons 4 Not primary research
Results: study descriptive statistics • 20 LMICs and territories • Diverse health topics – Chronic disease, clinical practice guidelines generally, health policy, hepatitis C, HIV, immunizations, maternal health, obesity, pediatric inpatient care, pediatric mental health, primary healthcare, surgery, tobacco cessation, and tuberculosis • Most applied CFIR post-implementation (14, 52%) • Most used CFIR to: – Guide data analysis (14, 52%) – Contextualize findings (14, 52%) • Only 2 (7%) investigated outcomes linked to CFIR constructs • Unit of analysis: – Health providers (13, 48%) – Organizations (11, 41%)
Results: constructs used Adaptability Complexity Cost Design Quality & Packaging Evidence Strength & Quality Intervention Source Relative Advantage Trialability Access to Knowledge & Information Available Resources Compatibility Culture Goals and Feedback Leadership Engagement Learning Climate Networks & Communications Organizational Incentives & Rewards Relative Priority Structural Characteristics Tension for Change Cosmopolitanism Intervention characteristics External Policy & Incentives Patient Needs & Resources Peer Pressure Inner setting Individual Identification with Organization Individual Stage of Change Outer setting Knowledge & Beliefs about the… Other Personal Attributes Characteristics of individuals Self-efficacy Champions Engaging Process of implementation Executing External Change Agents Formally Appointed Internal… Opinion Leaders Planning Reflecting & Evaluating 0 2 4 6 8 10
Results: construct compatibility Domain Construct Compatible (n) Incompatible (n) Irrelevant (n) Adaptability 16 0 1 Complexity 16 1 0 Cost 12 2 3 Design Quality & Packaging 12 2 3 Intervention Evidence Strength & Quality 13 3 1 Intervention Source 16 0 1 Relative Advantage 10 2 5 Trialability 9 3 5 Culture 17 0 0 Implementation Climate 16 0 1 Inner setting Networks & Communications 12 2 3 Readiness for Implementation 15 1 1 Structural Characteristics 14 0 3 Cosmopolitanism 12 1 4 External Policy & Incentives 16 0 1 Outer setting Patient Needs & Resources 9 6 2 Peer Pressure 14 1 2 Individual Identification with Org 10 4 2 Individual Stage of Change 9 5 2 Characteristics of Knowledge & Beliefs about Interv. 16 0 0 individuals Other Personal Attributes 10 4 2 Self-efficacy 13 2 1 Engaging 17 0 0 Executing 16 0 1 Process Planning 16 0 1 Reflecting & Evaluating 16 0 1
Results: incompatible constructs Domain Construct Author feedback examples Health care settings in these contexts are not patient-centered or do not have that focus. Patient Needs & Therefore, it's difficult to apply this construct. Outer setting Resources No patients are involved in the intervention at the level of the health system in LMICs The concept of individuality within the health care team was not compatible with the countries and settings where this study was conducted Individual Stage of Characteristics of individuals Change These interventions look not at individuals but at teams and organizations involved in the implementation
Results: CFIR relevance in LMICs In some settings health policy decisions are made from top down, and recipient will not have much option nor alternatives. In such conditions, CFIR individual and process domains might reflect Circumstances in which skewed and over optimistic results CFIR is not relevant in LMICs Contexts vary largely such as the health systems and not only internally but the social norms, culture of the people and the political environment/economy...Therefore, it might be good to consider the macro-level factors as well
Results: adaptations or improvements It will be good if the CFIR can communicate more on how it can be used or applied in larger scale of actions such as implementation of national policy and strategy, not only at an intervention level Possible adaptations or improvements to the CFIR I think there should be an emphasis on resource in LMICs constraints as they exist in both the inner and outer setting. This was a common theme that is not very explicitly presented in the CFIR
Results: additions to domains & constructs More systems-based domains and constructs could be added in response to national and global actions such as accountability, governance & politics (both national and international) and legal and regulatory process. These factors play an Domains or constructs important role in influencing the implementation of that should be added to national policy increase relevancy of CFIR in LMICs It would be excellent if it could be adapted for use in researching health systems. In addition, if rather than, individuals there could be a domain for teams…I believe adding the domain of collective efficacy to characteristics of individuals would be useful
Results: additions to domains & constructs More systems-based domains and constructs could be added in response to national and global actions such as accountability, governance & politics (both national and international) and legal and regulatory process. These factors play an Domains or constructs important role in influencing the implementation of that should be added to national policy increase relevancy of CFIR in LMICs It would be excellent if it could be adapted for use in researching health systems. In addition, if rather than, individuals there could be a domain for teams…I believe adding the domain of collective efficacy to characteristics of individuals would be useful. But also: I don't think any more should be added, it is already complex enough
Main messages from author responses Implementation research in LMICs often requires study of 1 health systems , at multiple operational and administrative levels that do not necessarily fit within existing Inner and Outer setting domains Many LMICs have hierarchical structures that are not 2 compatible with Western conceptualizations of the role of the individual in affecting implementation Due to the resource constraints facing LMICs, sustainability 3 of interventions as well as resource source and flow must also be accounted for
Limitations • Missing perspectives of those who chose not to use CFIR • No comparison against other determinants frameworks e.g. COACH, developed for use in LMICs 2 – 2 Bergstrom et al. 2015. Health system context and implementation of evidence-based practices…
CFIR (now) CHARACTERISTICS OF SYSTEMS OUTER SETTING INTERVENTION INTERVENTION (unadapted) (adapted) INNER SETTING Core components Core components INDIVIDUALS Adaptable periphery Adaptable periphery INVOLVED PROCESS
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