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Using the consolidated framework for implementation research (CFIR) to assess the implementation context of a quality improvement program to reduce missed opportunities for vaccination in Kano, Nigeria: a mixed methods study.

ABSTRACT: Background: Although understanding implementation context is essential, there is a dearth of research on how to systematically explore it in quality improvement (QI) programs. Therefore, in this study, we used the consolidated framework for implementation research (CFIR) to guide a systematic evaluation of the implementation context of an ongoing QI program in order to generate rapid site-specific feedback that can be used to improve subsequent plan-do-study-act (PDSA) cycles.Methods: Formative cross-case evaluation was conducted using convergent mixed methods design. The study was conducted in five primary health care (PHC) facilities (PHC 1, PHC 3, PHC 5, PHC 9 and PHC 10) implementing the QI program. Health workers in those facilities formed the study population. Quantitative data were collected using a self-administered, Likert-based rating tool, while qualitative data collection was guided by an interview guide. The interviews were transcribed verbatim, and thematic analysis was performed. Raw median score and factor scores were computed. Methodological integration occurred at the design, analysis and reporting stage.Results: A total of 165 health workers were included in this study with a mean age of 33.43 years (standard deviation of 7.15). Majority were females and they all had post-secondary education. Health workers in two facilities; PHC 1 and PHC 5, reported higher score for the QI program across all five domains of CFIR. Implementation facilitators included intervention flexibility, relative advantage, self-efficacy among health workers, health workers confidence in the intervention, services integration. While implementation barriers included vaccine stock out, faulty cold chain infrastructure, lack of incentives, and socio-cultural beliefs.Conclusion: This study demonstrated that theory-driven formative evaluation can be integrated in QI programs in a low resource setting. It buttressed the value in conducting such assessment as they can be used to generate rapid feedback on factors that influence implementation success which can then be addressed in subsequent cycles.

SUBMITTER: Adamu AA

PROVIDER: S-EPMC7062445 | biostudies-literature | 2020

REPOSITORIES: biostudies-literature

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Using the consolidated framework for implementation research (CFIR) to assess the implementation context of a quality improvement program to reduce missed opportunities for vaccination in Kano, Nigeria: a mixed methods study.

Adamu Abdu A AA Uthman Olalekan A OA Gadanya Muktar A MA Wiysonge Charles S CS

Human vaccines & immunotherapeutics 20190923 2

<b>Background</b>: Although understanding implementation context is essential, there is a dearth of research on how to systematically explore it in quality improvement (QI) programs. Therefore, in this study, we used the consolidated framework for implementation research (CFIR) to guide a systematic evaluation of the implementation context of an ongoing QI program in order to generate rapid site-specific feedback that can be used to improve subsequent plan-do-study-act (PDSA) cycles.<b>Methods</ ...[more]

PMID: 31424313

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Project description:BackgroundQualitative approaches, alone or in mixed methods, are prominent within implementation science. However, traditional qualitative approaches are resource intensive, which has led to the development of rapid qualitative approaches. Published rapid approaches are often inductive in nature and rely on transcripts of interviews. We describe a deductive rapid analysis approach using the Consolidated Framework for Implementation Research (CFIR) that uses notes and audio recordings. This paper compares our rapid versus traditional deductive CFIR approach.MethodsSemi-structured interviews were conducted for two cohorts of the Veterans Health Administration (VHA) Diffusion of Excellence (DoE). The CFIR guided data collection and analysis. In cohort A, we used our traditional CFIR-based deductive analysis approach (directed content analysis), where two analysts completed independent in-depth manual coding of interview transcripts using qualitative software. In cohort B, we used our new rapid CFIR-based deductive analysis approach (directed content analysis), where the primary analyst wrote detailed notes during interviews and immediately "coded" notes into a MS Excel CFIR construct by facility matrix; a secondary analyst then listened to audio recordings and edited the matrix. We tracked time for our traditional and rapid deductive CFIR approaches using a spreadsheet and captured transcription costs from invoices. We retrospectively compared our approaches in terms of effectiveness and rigor.ResultsCohorts A and B were similar in terms of the amount of data collected. However, our rapid deductive CFIR approach required 409.5 analyst hours compared to 683 h during the traditional deductive CFIR approach. The rapid deductive approach eliminated $7250 in transcription costs. The facility-level analysis phase provided the greatest savings: 14 h/facility for the traditional analysis versus 3.92 h/facility for the rapid analysis. Data interpretation required the same number of hours for both approaches.ConclusionOur rapid deductive CFIR approach was less time intensive and eliminated transcription costs, yet effective in meeting evaluation objectives and establishing rigor. Researchers should consider the following when employing our approach: (1) team expertise in the CFIR and qualitative methods, (2) level of detail needed to meet project aims, (3) mode of data to analyze, and (4) advantages and disadvantages of using the CFIR.

Project description:BackgroundSince 2012 Gavi, the Vaccine Alliance has provided financial support for HPV vaccine introduction in low- and middle-income countries (LMICs); however, funding has been contingent on establishing a demonstration project prior to national scale-up, in order to gauge effectiveness of delivery models. Although by 2016, most beneficiary countries had completed demonstration projects, few have scaled up delivery nationwide. An important barrier was the dearth of published, country-specific implementation recommendations. We employed the Consolidated Framework for Implementation Research (CFIR) as a lens to identify drivers of heterogeneous (dissimilar) implementation performance during Mozambique's 2-year demonstration project. Mozambique presents a compelling example as the country conducted demonstration projects in three different districts with extremely different economic resources and sociocultural practices.MethodsA post implementation interpretive evaluation was undertaken. Forty key informant interviews were conducted with district and health facility immunization staff, Ministry of Education managers, and teachers across the three demonstration districts, central level informants from MOH, research institutes, and immunization program partners. We compared valence and strength ratings of CFIR constructs, across diverse implementation sites, so as to explain drivers and barriers to implementation success. Two researchers coded separately, and subsequent content analysis followed pre-defined CFIR construct themes.ResultsEighteen constructs emerged from informants' responses as implementation influencers. Adaptability was identified as an important construct because delivery modalities needed to meet differing levels of girls' school attendance. Expanding outside of school-based delivery was needed in the low-performing district, making the vaccine delivery process more complex. Available resources varied across the three sites, with one site receiving direct Gavi support, while others received primarily state-based support. These latter sites reported considerably more implementation bottlenecks, in part related to weaker infrastructural characteristics and insufficient organizational incentives. Health workers' beliefs in importance of vaccines and an organizational culture of making personal sacrifice for immunization program activities drove implementation performance. Advocacy and social mobilization through the right opinion leaders and champions generated higher demand.ConclusionHPV vaccination presents a pertinent opportunity for the prevention of cervical cancer in Mozambique, sub-Saharan Africa, and other LMICs. However, important barriers to broad-scale implementation exist. We recommend the development of local and global strategies to overcome barriers and facilitate its expanded utilization.

Project description:BackgroundIn the United States, as in many other parts of the world, the prevalence of overweight/obesity is at epidemic proportions in the adult population and even higher among Veterans. To address the high prevalence of overweight/obesity among Veterans, the MOVE!(®) weight management program was disseminated nationally to Veteran Affairs (VA) medical centers. The objective of this paper is two-fold: to describe factors that explain the wide variation in implementation of MOVE!; and to illustrate, step-by-step, how to apply a theory-based framework using qualitative data.MethodsFive VA facilities were selected to maximize variation in implementation effectiveness and geographic location. Twenty-four key stakeholders were interviewed about their experiences in implementing MOVE!. The Consolidated Framework for Implementation Research (CFIR) was used to guide collection and analysis of qualitative data. Constructs that most strongly influence implementation effectiveness were identified through a cross-case comparison of ratings.ResultsOf the 31 CFIR constructs assessed, ten constructs strongly distinguished between facilities with low versus high program implementation effectiveness. The majority (six) were related to the inner setting: networks and communications; tension for change; relative priority; goals and feedback; learning climate; and leadership engagement. One construct each, from intervention characteristics (relative advantage) and outer setting (patient needs and resources), plus two from process (executing and reflecting) also strongly distinguished between high and low implementation. Two additional constructs weakly distinguished, 16 were mixed, three constructs had insufficient data to assess, and one was not applicable. Detailed descriptions of how each distinguishing construct manifested in study facilities and a table of recommendations is provided.ConclusionsThis paper presents an approach for using the CFIR to code and rate qualitative data in a way that will facilitate comparisons across studies. An online Wiki resource (http://www.wiki.cfirwiki.net) is available, in addition to the information presented here, that contains much of the published information about the CFIR and its constructs and sub-constructs. We hope that the described approach and open access to the CFIR will generate wide use and encourage dialogue and continued refinement of both the framework and approaches for applying it.

Project description:Much research does not address the practical needs of stakeholders responsible for introducing health care delivery interventions into organizations working to achieve better outcomes. In this article, we present an approach to using the Consolidated Framework for Implementation Research (CFIR) to guide systematic research that supports rapid-cycle evaluation of the implementation of health care delivery interventions and produces actionable evaluation findings intended to improve implementation in a timely manner.To present our approach, we describe a formative cross-case qualitative investigation of 21 primary care practices participating in the Comprehensive Primary Care (CPC) initiative, a multi-payer supported primary care practice transformation intervention led by the Centers for Medicare and Medicaid Services. Qualitative data include observational field notes and semi-structured interviews with primary care practice leadership, clinicians, and administrative and medical support staff. We use intervention-specific codes, and CFIR constructs to reduce and organize the data to support cross-case analysis of patterns of barriers and facilitators relating to different CPC components.Using the CFIR to guide data collection, coding, analysis, and reporting of findings supported a systematic, comprehensive, and timely understanding of barriers and facilitators to practice transformation. Our approach to using the CFIR produced actionable findings for improving implementation effectiveness during this initiative and for identifying improvements to implementation strategies for future practice transformation efforts.The CFIR is a useful tool for guiding rapid-cycle evaluation of the implementation of practice transformation initiatives. Using the approach described here, we systematically identified where adjustments and refinements to the intervention could be made in the second year of the 4-year intervention. We think the approach we describe has broad application and encourage others to use the CFIR, along with intervention-specific codes, to guide the efficient and rigorous analysis of rich qualitative data.NCT02318108.

Project description:The importance of providing evidence-based palliative care for people with dementia is increasingly acknowledged as important for patient outcomes. In Ireland, evidence-based guidance has been developed in order to address key features of dementia palliative care, including the management of pain, medications and hydration and nutrition. The aim of this study was to identify and explore the factors affecting the implementation of evidence-based guidance on dementia palliative care. The Consolidated Framework for Implementation (CFIR) guided a mixed-method pre-post study. One guidance document pertaining to the management of pain, medication or hydration and nutrition was implemented in three long-term care facilities. Participatory action research in the form of work-based learning groups was used to implement the guidance, drawing on a situational analysis (pre-implementation). Staff questionnaires and audits were conducted pre- and post-implementation while champion interviews were also conducted post-implementation. Features of the guidance, the inner setting components such as readiness to change, and the process of implementation were most frequently identified as impacting implementation. Components of the outer setting, such as external policy incentives and individual characteristics, featured less commonly. Data from qualitative interviews revealed that the guidance was perceived as advantageous or complimentary to previous care provided. Within the inner setting, leadership and support from other colleagues facilitated implementation. However, limited availability of other healthcare professionals to assist with carrying out guidance actions presented a barrier in some facilities. The external facilitators of the work-based learning groups (WBLGs) were perceived as experienced and encouraged active participation and reflection on practices. Despite the challenge of releasing staff to attend the WBLGs, quantitative data demonstrated reduced staff de-motivation amongst those who did attend was noted post-implementation (pre-Mdn = 19.50 versus post-Mdn = 22.00, U = 497.00, p = 0.07). A situational analysis informed by the CFIR framework in conjunction with a participatory action research approach helped to advance the implementation of the guidance. The progress of implementation depended on the extent to which evidence-based care was previously being implemented at each site. Post-implementation analysis using CFIR identified challenges to address in future projects such as staff cover and timing of training to facilitate attendance for staff with different working hours. Facilitators included multidisciplinary engagement with the intervention and champions at each site to support the implementation process.

Project description:BACKGROUND:Amid the current burden of non-communicable (NCD) diseases in Malaysia, there is a growing demand for more efficient service delivery of primary healthcare. A complex intervention is proposed to improve NCD management in Malaysia. This exploratory study aimed to assess primary healthcare providers' receptiveness towards change prior to implementation of the proposed complex intervention. METHOD:This study was conducted using an exploratory qualitative approach on purposely selected healthcare providers at primary healthcare clinics. Twenty focus group discussions and three in-depth interviews were conducted using a semi-structured interview guide. Consent was obtained prior to interviews and for audio-recordings. Interviews were transcribed verbatim and thematically analysed, guided by the Consolidated Framework for Implementation Research (CFIR), a framework comprised of five major domains promoting implementation theory development and verification across multiple contexts. RESULTS:The study revealed via CFIR that most primary healthcare providers were receptive towards any proposed changes or intervention for the betterment of NCD care management. However, many challenges were outlined across four CFIR domains-intervention characteristics, outer setting, inner setting, and individual characteristics-that included perceived barriers to implementation. Perception of issues that triggered proposed changes reflected the current situation, including existing facilitating aspects that can support the implementation of any future intervention. The importance of strengthening the primary healthcare delivery system was also expressed. CONCLUSION:Understanding existing situations faced at the primary healthcare setting is imperative prior to implementation of any intervention. Healthcare providers' receptiveness to change was explored, and using CFIR framework, challenges or perceived barriers among healthcare providers were identified. CFIR was able to outline the clinics' setting, individual behaviour and external agency factors that have direct impact to the organisation. These are important indicators in ensuring feasibility, effectiveness and sustainability of any intervention, as well as future scalability considerations.

Project description:Faith-based organizations, with broad reach and trust, are well-positioned to promote health. The purpose of the study was to examine 12-month implementation and its predictors in the statewide Faith, Activity, and Nutrition (FAN) dissemination and implementation (D&I) study. Churches (n = 93; 42% predominantly African American) in the [South Carolina] Conference of the United Methodist Church trained by Community Health Advisors participated in the study. Church FAN coordinators (n = 92) completed implementation surveys regarding opportunities, policies, messages, and pastor support for physical activity (PA) and healthy eating (HE) at baseline and 12 months. FAN coordinators and pastors (n = 93) completed CFIR-based measures at baseline, immediate post-training, and 12 months. Repeated measures ANOVAs tested change in PA and HE implementation composite scores; Cohen's d indicated magnitude of change. Mixed model linear regression tested whether CFIR items predicted 12-month implementation, controlling for baseline implementation. PA (d = 1.42) and HE (d = 2.05) implementation increased significantly over time. PA and HE implementation were significantly greater in predominantly African American (versus White) congregations, and HE implementation was greater in churches with <500 members. FAN coordinators' ratings of the inner setting (networks/communication, culture, tension for change, organizational rewards, readiness, and congregant needs) and implementation process (engaging opinion leaders and champions) domains were most predictive of implementation outcomes. Few pastor ratings related to implementation outcomes. This study identified constructs, guided by CFIR, that may be important for understanding PA and HE implementation in churches. Future studies will need to test them for replication. Greater changes in implementation outcomes among African American churches underscores the potential of promoting health equity through this setting.

Dataset Information

Using the consolidated framework for implementation research (CFIR) to assess the implementation context of a quality improvement program to reduce missed opportunities for vaccination in Kano, Nigeria: a mixed methods study.

Publications

Using the consolidated framework for implementation research (CFIR) to assess the implementation context of a quality improvement program to reduce missed opportunities for vaccination in Kano, Nigeria: a mixed methods study.

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