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Mapping ERIC Implementation Strategies to Context

Implementation scientists have long recognized the need to assess context and then tailor implementation strategies to fit. The CFIR is often used to identify contextual determinants (barriers and facilitators) that can then be used to guide selection of appropriate strategies. Our team, led by Dr. Tom Waltz, published results from 169 self-identified implementation experts who selected strategies most likely to address each CFIR barriers. Each expert identified up to 7 strategies for an average of 6.1 barriers based on CFIR constructs. Mappings were highly heterogenous; each CFIR barrier had an average 47 different strategies endorsed by at least one expert. With 73 ERIC strategies and 39 CFIR constructs, there are 2847 possible unique combinations of strategy-construct mappings. Level 1 endorsements (i.g., strategy selections that were endorsed by at least 50% of respondents for a specific CIFR barrier) comprised 33 combinations (e.g., over half of respondents agreed that “Audit and Provide Feedback” was highly likely to address lack of “Reflecting and Evaluating”). Level 2 strategies (n=332) were endorsed by 20-49% of respondents. One reason for the diversity of recommendations may have been rooted in the diversity of assumed underlying mechanisms of change. ERIC strategies are not operationalized for specific scenarios and may be enacted under an array of assumptions driving their selection. We have posted a tool that users can apply based on results from this work. Dr. Maria Fernandez and colleagues recently published a 5-step Implementation Mapping process that can be used to operationalize strategy choices based on the Strategy Matching Tool, by explicitly identifying and designing based on hypothesized underlying change theories.

French Translation of CFIR used for evaluation in Burkina

Dr. Valéry Ridde has provided a French translation of the CFIR, which is now available online along with a brief illustration; scroll to the bottom of the Constructs page. This translation was developed to support her work with Mc Sween-Cadieux and colleagues, who published a paper in PLoS ONE describing their experience implementing a knowledge-brokering intervention in Burkina Faso. Knowledge brokers (KBs) seek to establish links between researchers, practitioners, and decision-makers by helping these key individuals better understand each other’s goals, culture, to initiate and build partnerships, to influence each other’s’ work and ultimately, increase their use of research-based evidence (RBE). The stated goals of this project were to establish a KB intervention within a Burkino Faso healthcare district to identify RBE that meets the needs of these individuals and to facilitate transfer and application of RBE generated by researchers across a range of topics. The authors identified six levels of determinants guided by the CFIR and Durlak and Dupre’s Ecological Framework (outer setting, inner setting (2 levels), support system, individuals, intervention, and process). The KB was successful in generating early enthusiasm and support and provided multiple levels of support. However, the intervention was terminated because of a lack of decisional power among district stakeholders and absence of organizational resources or incentives to support and encourage participation. Efforts to relocate the intervention at the national level failed in part because of unstable political context. The authors recommend using a conceptual framework like the CFIR to plan and evaluate interventions like this. This article is a great read and to be commended for important insights within context of a negative trial of a challenging KB intervention.

Quantitative measures of CFIR Inner Setting Constructs​

Maria Fernandez and colleagues developed quantitative measures for 7 constructs within the Inner Setting. Five exist within CFIR: Culture Overall (9 items), Implementation Climate (4 items), Learning Climate (4 items), Leadership Engagement (4 items), and Available Resources (7 items). Items were drawn from the Practice Adaptive Reserve instrument (Jaen et al, 2010), The Organizational Readiness for Change Assessment (Helfrich et al, 2009), Clinical Oncology Program Survey (Weiner et al, 2011), and a single item from the Implementation Climate Assessment (Konn et al, 2001). Two constructs are not included in CFIR but included in measure development: Culture Stress (4 items) and Culture Effort (5 items). These latter two constructs are conceptualized as distinct from general Culture. Culture Effort is based on the work of Patterson et al and measures how hard people work toward achieving goals and includes items like, “People in this clinic always want to perform to the best of their abilities.” Culture Stress, based on the work of Lehman et al, measures perceived strain, stress, and role overload and includes items like, “Staff frustration is common here.” They chose to focus on these 7 constructs based on the degree to which they fit CFIR definitions, salience for health-related settings, achieved survey goals for FQHCs within a cancer control network, and had some evidence of reliability and validity.

All scales exhibited acceptable/good scale reliability, model fit, discriminant validity and interrater reliability. Analyses revealed that individual responses to survey items can be aggregated to the clinic level, which is great news. In separate analyses (not included in this article), they found that rolling up the 38 items into a single measure did exhibit properties supporting the notion of a latent class related to Inner Setting. These measures are available for use. We have posted the instrument under our Quantitative Measures page and included links from the individual construct pages. To compute each subscale, compute the mean response by unit (e.g., clinic) and average the items for each subscale (construct). They were not able to provide recommendations on minimum number of individuals needed to reliably assess organization-level constructs.

If you use the Strategy Matching Tool, we welcome your feedback. Please contact us.

If you have a translation of the CFIR you are willing to share, please contact us.

Measures are available for review here.

For permission to use, please email Dr. Fernandez at: Maria.E.Fernandez at uth-dot-tmc-dot-edu