Health Research Program

Selecting and using a framework to guide your IR project

When you embark on a new journey, some sort of roadmap is useful to guide the way—in IR these roadmaps are called theories, models, or frameworks. While there are some distinctions between them (see this – Nilsen, 2015 – article), they are collectively referred to as ‘frameworks’ here as all of them in some way capture the logic behind how an intervention or strategy is expected to function, how it leads to change, and what factors  may affect how it works.

There is nothing so practical as a good theory.”
– Kurt Lewin, 1951

Why use a framework?

Frameworks are important for IR projects.  A framework is intended to guide the process of designing, planning, implementing, and evaluating an intervention. In IR, frameworks can map out or break apart complex processes to better understand the factors that influence implementation.  In focusing on a framework, assumptions and complex processes are made more explicit for all involved in the IR project. Frameworks help to ensure the findings can be used for program improvement. Frameworks can help to:

  • Point to reasons why an intervention works or doesn’t work (explanations)
  • Highlight implementation strategies essential to study (process)
  • Show what is important to measure (outcomes)
  • Enhance how study findings are interpreted (analysis)

How to select or develop a useful framework?

With the abundance of IR frameworks that exist, selecting an appropriate one for your research can be a daunting task. Defining preliminary study aims and research questions (see TIP #6—Formulating research questions) will help determine which framework is most appropriate. The chosen framework will then help to refine and finalize the research questions.  Resources such as the Dissemination & Implementation Models in Health Research and Practice interactive webtool are designed to help you through this process.

1. Map out what you want to study.

A first step is to map out the overall logic of the health intervention and corresponding program under study. This will help identify key elements of the program you are studying and the factors that are known to influence it.  Tools such as the Dissemination and Implementation logic model sheet can guide this process. Figure 7.1 shows an example of how it can be applied to the malaria treatment example discussed in TIP #2.

TIP#7_Figure 7.1_Sept 14

2. Search existing frameworks to find a good match.

You can then use this ‘map’ to determine which existing implementation framework addresses the needs of your proposed study. While this repository of frameworks is quite comprehensive, a brief review of the literature may also be useful, depending on your research topic. There may be multiple frameworks that could potentially be used and fit the research purpose.  Stakeholders can be consulted for experience with and preferences for frameworks they may have utilized in the past.

Two of the frameworks commonly used are discussed briefly in Box 7.1

Box 6.2: How IR was used to Strengthen Financing Reforms in Indonesia4 In 2014, Indonesia began implementing a national health insurance initiative (JKN) aimed at covering the country’s entire population by 2019. IR was undertaken to provide crucial information about whether JKN was being implemented as intended. A consultative process with key stakeholders, including national and local policymakers and implementers, contributed to defining the IR questions. The first one-year cycle assessed how JKN regulations were being interpreted and implemented and implications for effectiveness. The second cycle sought to investigate health worker satisfaction and opportunities to strengthen the links that lead to improved service delivery.

3. Assess the “fit” of a framework.

Once you have a short list of viable options, you can use a tool such as the Theory, Model, and Framework Comparison and Selection Tool (T-CaST) for Implementation Practitioners which provides guidance on assessing the “fit” of a framework based on its usability, validity, applicability, and acceptability.  See Figure 7.2 for additional suggestions on what to consider when selecting a framework.

TIP#7_Figure 7.2_Sept 14

 

4. Tailor the framework.

Often, it is useful to adapt an existing framework (i.e. make minor adjustments based on the focus of your questions, the local context, the nature of the specific intervention you are studying, etc.). See this example of how the CFIR was utilized to identify implementation performance drivers for Human papillomavirus vaccine delivery in Mozambique.  It is important to document the steps taken in this selection process and the reasoning behind your decisions.

How to use the framework in a meaningful way? 

You can use frameworks during the initial conceptualization of IR and throughout the full effort (Figure 7.3).

TIP#7_Figure 7.3_Sept 14

Key resources


References
  1. Birken SA, et al. T-CaST: an implementation theory comparison and selection tool. Implementation Sci 13, 143 (2018).
  2. National Cancer Institute, Division of Cancer Control and Population Studies. https://cancercontrol.cancer.gov/is/tools.
  3. Damschroder LJ (2020). Clarity out of chaos: use of theory in implementation research. Psychiatry research, 283.
  4. Nilsen P. Making sense of implementation theories, models and frameworks.Implementation Science 2015;10:53.
  5. Tabak RG, Khoong EC, Chambers DA, Brownson RC. Bridging research and practice: models for dissemination and implementation researchAm J Prev Med. 2012;43(3):337-50.
  6. Kirk MA, et al. (2016). A systematic review of the use of the Consolidated Framework for Implementation Research. Implementation Science, 11(1), 72.
  7. Kirchner JE, Smith JL, Powell BJ, Waltz TJ, & Proctor, E. K. (2019). Getting a clinical innovation into practice: An introduction to implementation strategies. Psychiatry research, 283.
  8. Soi, C., Gimbel, S., Chilundo, B. et al.Human papillomavirus vaccine delivery in Mozambique: identification of implementation performance drivers using the Consolidated Framework for Implementation Research (CFIR). Implementation Sci 13, 151 (2018).
  9. VanDevanter, N., Kumar, P., Nguyen, N. et al.Application of the Consolidated Framework for Implementation Research to assess factors that may influence implementation of tobacco use treatment guidelines in the Viet Nam public health care delivery systemImplementation Sci 12, 27 (2017).
  10. Rabin et al, 2019. Workshop at the 12th Annual Conference on the Science of Dissemination and Implementation in Health.