the Consolidated Framework for Implementation Research to identify - PowerPoint PPT Presentation

HPV vaccine demonstration project in Mozambique: Applying the Consolidated Framework for Implementation Research to identify drivers of implementation performance Caroline Soi, Sarah Gimbel, Baltazar Chilundo, Vasco Muchanga, Luisa Matsinhe, Kenneth Sherr 10 th Dissemination and Implementation Science Conference Arlington, Virginia December 5 th , 2017

Background

Global HPV Prevalence & Cervical Cancer Incidence http://www.nature.com/nature/journal/v488/n7413_supp/full/488S2a.html

Mozambique • Second on global cervical cancer burden ranking cervical  65.0 per 100,000 Incidence cancer  49.2 per 100,000 Mortality burden and HPV • 78% HPV 16 and 18 infection in attribution cervical cancer biopsies

Gavi model of HPV vaccine support • Demonstration projects 2011 - Gavi prior to national scale-up decision to  Rationale - No health care fund HPV delivery system for target vaccine age group introduction  Aim - Assess feasibility of in LMICs possible delivery model/s

Implementation Challenge: Slow Adoption Mozambique Gavi programs Plan Plan 2015 By 2015 Demonstration Project 21 demonstration projects 2018 8 national programs National scale up Current Status Current Status 2017 2017 23 demonstration projects Demonstration completed in 2015 National Scale-up postponed 2019 3 national programs

Methods

Research What factors affected the implementation performance observed Question across the diverse HPV vaccine delivery demonstration sites in Mozambique? Post Implementation Study Design Interpretive Evaluation

Stages of Formative Evaluation Pre- Post- Implementation Implementation Implementation Developmental Implementation-Focused Interpretive • Identify potential barriers / • Assess discrepancies between • Explain success or facilitators implementation plan and failure • Integrate findings into execution. intervention design and • refinement prior to Progress-Focused Summative implementation • Determine degree of • Monitor impacts and indicators success of progress toward project goals • Adapted from: Stetler, Legro, Smith et al (2006)

Consolidated Framework for Implementation Research (CFIR) No. of Domain Constructs Constructs Intervention Intervention Source, Trialability, Adaptability, Evidence Strength & Quality, Cost, 8 characteristics Design Quality & Packaging, Relative Advantage, Complexity Patient Needs & Resources, Cosmopolitanism, Peer Pressure, External Policy & 4 Outer setting Incentives Structural Characteristics, Networks & Communication, Culture, Tension for change, Organizational Incentives & Rewards, Goals and Feedback, Learning 13 Inner setting Climate, Readiness for Implementation, Leadership engagement, Access to Knowledge and Information, Relative Priority, Available resources, Compatibility, Implementation Climate Characteristics Knowledge & Beliefs about the Intervention, Self-efficacy, Individual Stage of 5 of individuals Change, Individual Identification with Organization, Other Personal Attributes Planning, Engaging Opinion Leaders, Formally Appointed Internal Implementation 9 Process Leaders, Champions, External Change Agents, Key Stakeholders, Innovation Participants, Executing, Reflecting & Evaluating Damschroder et al. 2009.

Qualitative methods Definition of unit of analysis & performance criteria Initial construct selection Data collection through KIIs Final construct selection through thematic coding Valence and strength rating Damschroder et al.2009 http://cfirguide.org/

Unit of analysis - District Socio-demographic Indicators South Central North (Gavi) (MOH) (MOH) Proportion of girls aged 6 years or 64.7 63.5 46.8 more who enrolled in primary schools Under-five mortality 96 114 116 Contraceptive prevalence rate 32.8 12.5 2.9 among women 15-49 years old (married or in union) Proportion of households with 85.1 84.1 37.1 access to portable water Wealth quintile (proportion in 1.2 5.5 23.8 poorest quintile)

Performance criteria – Proportion of eligible girls who completed all vaccination doses 17 % Moçimboa da Praia - Low 47% Manica - Intermediate 73.3% Manhiça - High

Data Collection Research Bilateral Pharmaceutical Institute 3% 3% CFIR guided semi- 7% structured Multilateral interview guide 7% NGO Key Informant 10% Immunization Interviews staff 55% 40 respondents from Ministry of Education implementing 15% entities

Data Analysis • Transcription • Nvivo coding using CFIR codebook 2 coders - inter coder reliability - kappa statistic at 80% threshold

Construct Selection Innovation Characteristics Outer Setting Inner Setting Process 4.Patient Needs & 5.Structural 1.Adaptability Resources Characteristics 13.Planning 6.Networks & 2.Complexity Communications 14.Opinion Leaders 3.Design Quality & Packaging 7.Culture 15.Champions 8.Relative priority 16.Key stakeholders 9.Organizational 17.Innovation Incentives participants 10.Learning climate 18.Executing 11.Available resources 19.Reflecting 12.Access to knowledge & Info

Valence and Strength Rating -2 -1 0 +1 +2 • Negative • Negative • Neutral • Positive • Positive Influence Influence Influence Influence • Explicit • General • General • Explicit Examples mention Mention Examples

Results and Discussion

Results Valence Evaluated Constructs Distinguishing High Intermediate Low Innovation Characteristics Adaptability Strongly +2 -2 -2 12 Complexity Strongly -1 -2 -2 Design Quality & Packaging Not +2 +2 +2 Outer setting Distinguishing Patient Needs & Resources Strongly +2 -2 -2 Inner Setting Constructs Structural Characteristics Strongly +2 -2 -2 Networks & Communications Weakly -1 -2 -2 Culture Not +2 +2 +2 11 Relative Priority Not +2 +2 +2 Org. Incentives & rewards Strongly 0 -2 -2 Learning Climate Strongly +2 0 0 strongly Available Resources Strongly 0 -2 -2 Access to knowledge and info Strongly +2 -1 -1 Process Planning Not -1 -2 -2 1 Opinion leaders Strongly +2 -2 -2 Champions Not +2 +1 +1 weakly Key stakeholders Strongly +2 0 0 Innovation participants Strongly +2 0 -2 Executing Neutral 0 0 0 Reflecting &Evaluating Not +2 +2 +2

Valence Evaluated Constructs Distinguishing High Intermediate Low Innovation Characteristics Adaptability Strongly +2 -2 -2 Complexity Strongly -1 -2 -2 Design Quality & Packaging Not +2 +2 +2 Delivery model Address complexity needs to be where possible adaptable Providing the vaccine Consider context with out of the health facility means relying fewer girls in school on non health workers

Valence Evaluated Constructs Distinguishing High Intermediate Low Inner Setting Structural Characteristics Strongly +2 -2 -2 Culture Not +2 +2 +2 Relative Priority Not +2 +2 +2 Org. Incentives & rewards Strongly 0 -2 -2 Available Resources Strongly 0 -2 -2 Access to knowledge and info Strongly +2 -1 -1 Allocation of Organizational Training for all sufficient financial workers’ work ethic implementers resources & beliefs Worst performance Teachers were not Belief in vaccines, was in poorest trained in the int. and health workers district lower performing sites sacrificed

Valence Evaluated Constructs Distinguishing High Intermediate Low Outer Setting Patient Needs & Resources Strongly +2 -2 -2 Process Planning Not -1 -2 -2 Opinion leaders Strongly +2 -2 -2 Champions Not +2 +1 +1 Key stakeholders Strongly +2 0 0 Innovation participants Strongly +2 0 -2 Executing Neutral 0 0 0 Reflecting &Evaluating Not +2 +2 +2 Advocacy and Social Planning and reflecting Intervention recipients’ mobilization & evaluating perceptions, beliefs & attitudes Address these in social Decentralize these Identify context mobilization messages, process components specific opinion longer period sooner leaders

Reflection on CFIR Standardized terminology and CFIR’s broadness methodology allows allows for flexibility without compromise for comparison with other studies

Thank you

Quotations • Adaptability (Strongly Distinguishing Construct) • Complexity (Strongly Distinguishing Construct) • Needs & Resources of those Served by the Organization (Strongly Distinguishing Construct

Quotations • Networks & Communications (Weakly Distinguishing Construct) • Organization Culture (Not a Distinguishing Construct) • Planning (Not a Distinguishing Construct)

Research questions?