Evaluating and optimizing the consolidated framework for implementation research (CFIR) for use in low- and middle-income countries: a systematic review

Abstract

Background: The Consolidated Framework for Implementation Research (CFIR) is a determinants framework that may require adaptation or contextualization to fit the needs of implementation scientists in low-and middleincome countries (LMICs). The purpose of this review is to characterize how the CFIR has been applied in LMIC contexts, to evaluate the utility of specific constructs to global implementation science research, and to identify opportunities to refine the CFIR to optimize utility in LMIC settings.Methods: A systematic literature review was performed to evaluate the use of the CFIR in LMICs. Citation searches were conducted in Medline, CINAHL, PsycINFO, CINAHL, SCOPUS, and Web of Science. Data abstraction included study location, study design, phase of implementation, manner of implementation (ex., data analysis), domains and constructs used, and justifications for use, among other variables. A standardized questionnaire was sent to the corresponding authors of included studies to determine which CFIR domains and constructs authors found to be compatible with use in LMICs and to solicit feedback regarding ways in which CFIR performance could be improved for use in LMICs.Results: Our database search yielded 504 articles, of which 34 met final inclusion criteria. The studies took place across 21 countries and focused on 18 different health topics. The studies primarily used qualitative study designs (68%). Over half (59%) of the studies applied the CFIR at study endline, primarily to guide data analysis or to contextualize study findings. Nineteen (59%) of the contacted authors participated in the survey. Authors unanimously identified culture and engaging as compatible with use in global implementation research. Only two constructs, patient needs and resources and individual stages of change were commonly identified as incompatible with use. Author feedback centered on team level influences on implementation, as well as systems characteristics, such as health system architecture. We propose a "Characteristics of Systems" domain and eleven novel constructs be added to the CFIR to increase its compatibility for use in LMICs. Conclusions: These additions provide global implementation science practitioners opportunities to account for systemslevel determinants operating independently of the implementing organization. Newly proposed constructs require further reliability and validity assessments. Trial registration: PROSPERO, CRD42018095762

Beyond the Science: Advancing the "Art and Craft" of Implementation in the Training and Practice of Global Health

“…Take for example, a recent effort to optimize the consolidated framework for implementation research for use in LMICs. 18 The authors, recognizing the limitations of the existing framework, prescribe a new domain and eleven novel constructs for inclusion to the consolidated framework for implementation research to increase its compatibility for use in LMICs. But while frameworks developed from scientific approaches such as systematic reviews may broadly indicate areas or domains to be considered by researchers, policy-makers or implementers, they are insufficient to address real world challenges in complex adaptive systems.…”

Using implementation science theories and frameworks in global health

“…A recent systematic review showed that the CFIR is increasingly used worldwide, including in LMICs, where it was used 27 times. 72 Several researchers have adapted the CFIR to fit their contexts, showing that frameworks can be adjusted according to the research needs. The CFIR was for example adapted to study acceptability of a health intervention in Zambia 73 or to investigate sustainability in Ghana.…”

“…74 The CFIR may be mobilised to support data collection according to a deductive approach and/or at the data analysis stage to sort out data collected according to an inductive approach. 72 Besides descriptive frameworks, researchers may also use conceptual or theoretical frameworks, which are analytical. Such frameworks provide causal propositions for how different factors may influence-negatively or positively-implementation and outcomes.…”

Scaling Mhealth in Africa: Lessons From The Implementation of The MomConnect Program

“…A potential limitation was our selection of a determinate framework (CFIR) as they have been criticized for their inadequacy in addressing causal mechanisms or how change takes place (42). However, the use of the CFIR allowed the findings to be placed in the context of the wider implementation research literature (43,44).…”