Conceptual Frameworks

Consolidated Framework for Implementation Research (CFIR)

The CFIR is a compilation of organized terminology and definitions related to effective implementation that was created by implementation researchers in 2009 [3] . It is a theoretical framework that categorizes the different elements that may impact implementation success according to five constructs:
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Intervention characteristics: attributes of the proposed intervention, including complexity and adaptability. 
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Inner setting: recognized as an active factor rather than a backdrop in implementation [4] and considers structural characteristics, culture, and readiness for implementation. 

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Outer setting: external factors that influence the intervention, such as policies, incentives, networking with other organizations. 
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Individuals involved: considers how individual actions and behaviors impact implementation success. 
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Implementation process: defines four components of implimentation: planning, engaging, executing, and reflecting. 

How was CFIR applied?

We reference the glossary of implementation research terms provided by the CFIR throughout the four phases of the INSPIRE model. This helps us to ensure we are comprehensive in our discussions and that we are able to plan ahead and consider the repercussions of specific decisions. The components defined in the CFIR’s implementation process are nearly synonymous with the four phases of the INSPIRE model. In Phase 1, “understand the system”, we focused on exploring and understanding the elements within three of the CFIR constructs: inner setting, outer setting, and individuals involved. In phase 2, “find leverage”, we considered the implications of intervention design decisions. In phase 3, “act strategically,” and 4, “learn & adapt,” we reflected on all five constructs to decide how to best take action and then to proactively identify the sources of successes and failures to make informed adjustments. 

WHO Health Systems 

This conceptual framework, also called the “building blocks framework” was developed by the WHO and defines six core elements of a health system  [5] :
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Service delivery: considers demand for services, package of integrated services, organization of provider network, management, and infrastructure & logistics. 
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Health workforce: considers availability and distribution of health workers across levels of the system, access to education/training programs, and workforce retention.
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Health information system: considers availability of population and facility-based data and the capacity to analyze and promote/act on collected information.
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Medical products, vaccines & technologies: considers the availability of evidence-based and cost-effective health commodities. 
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Financing: considers reliance on out-of-pocket payments, vulnerable populations’ financial access to healthcare, transparency & accountability in financing systems, among others.  
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Leadership & governance: considers health system design, accountability, regulation, policy guidance, and oversight. 
These building blocks help to evaluate how specific parts of an existing health system might impact the success of a health intervention, and by doing so, they speak to the CFIR’s “inner setting” construct.

How was this framework applied?

Since Proyecto Precáncer seeks to facilitate the implementation of a health intervention, we needed to address the health system that is expected to embrace it. The health system building blocks make this task approachable by providing us with a checklist of health systems elements to explore in phase 1 of INSPIRE in order to truly understand the current system. We studied the screening & treatment services offered throughout the continuum of care, including the location of these services, who offers them, and how they are explained to the women. We developed different ways to keep track of the health workforce related to cervical cancer prevention over time, including their levels of training. We studied the existing health information system and identified gaps that needed to be sustainably filled. We identified the supplies necessary to provide relevant services and became familiar with procurement and disposal challenges. We also explored when financial barriers to care impede coverage or continuum of care completion. Our constant contact with representatives from the regional and national ministries of health as well as the directors of local health institutions have given us an intimate understanding of the role of leadership & governance in the system. Investing time to achieve a complete understanding of these six health system elements made us more effective and better equipped to facilitate health system strengthening as it relates to cervical cancer prevention. 
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RE-AIM 

RE-AIM is a framework that was created in 1999 by Russ Glasgow, Shawn Boles, and Tom Vogt to guide evaluation of implementation success [6] . The acronym reflects the five dimensions it seeks to measure:


- Reach: How do we reach those who need this intervention?

- Effectiveness: How do we know our intervention is working?

- Adoption: How do we develop organizational support to deliver our intervention?

- Implementation: How do we ensure the intervention is delivered properly?

- Maintenance: How do we incorporate the intervention so it is delivered over the long-term?

RE-AIM has since been referred to in a variety of health interventions and has more recently been applied in efforts to translate research findings into real-world settings. The framework seeks to bring attention to these five program elements in order to assure sustainable implementation success. 

How was RE-AIM applied?

The RE-AIM dimensions were primarily referenced early on to develop the project’s monitoring and evaluation metrics and to establish continuous data collection activities. We use quantitative metrics to keep track of what happens to key elements of system behavior and supplement that information with qualitative research to understand why the system is behaving that way.  To measure reach, we are looking at screening coverage—how many eligible women are getting screened? For effectiveness, we track a screen-positive woman’s completion of the continuum of care—does she get treated, or does she drop out prematurely? This quantitative data is supplemented by focus group discussions and interviews with women in the community to gain a better understanding of barriers to care.  We measure adoption by keeping track of what types of services are offered over time. This includes the type of screening test administered and how screen-positive women are managed and/or treated. We also determine if these align with the agreed upon intervention. Implementation is measured by keeping track of time delays that may impede program effectiveness through a comprehensive time & motion study. Maintenance is measured by comparing quarterly M&E reports and keeping track of major external events that influence time trends. 
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Soft Systems Methodology (SSM)

Soft Systems Methodology was first introduced by developer Peter Checkland and practitioner John Poulter. It is an action-oriented approach for undertaking complex social situations that relies on accepting and understanding conflicting perspectives of the individuals involved. Every individual will have their own perspective on a situation which is reflected in their actions. Checkland proposes an iterative, seven-step approach to inform the SSM process [7]
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Since SSM focuses on social behaviors, it responds to the CFIR construct “Individuals involved”. It provides a logical roadmap for understanding behaviors and facilitating goal-oriented problem solving. It also recognizes the “softness” of social systems, in other words, that these systems are constantly evolving as they are highly dependent on individuals’ thoughts and actions [8]

How was SSM applied?

SSM guided interactions with stakeholders/collaborators throughout phases 1 and 2 of the INSPIRE model. It outlined two unique concepts that supplemented our participatory approach:  
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Stakeholders in the system hold diverse values and perspectives which guide their behavior in meeting common system goals
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The interactions between the stakeholders with these diverse perceptions and values propagate the dynamic and non-linear systems behavior that impact the “problematical situation”
We recognize the importance of understanding diverse worldviews as they relate to the same common goal of decreasing cervical cancer morbidity and mortality, and we seek to incorporate this understanding when collaboratively selecting an implementation strategy that is both desirable and feasible. 
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Systems Thinking

Systems thinking is a problem-solving approach characterized by a desire to improve system behavior toward a purposeful goal. To achieve this, interconnected system elements are identified & localized within the problem situation. How these elements contribute to ineffective system behavior is then considered, and actionable interventions to move the system behavior towards its purposeful goal are developed and tested.  Systems thinking recognizes that to improve a system, it is essential to understand how these human elements view the system goals and operations and how they are interconnected. 
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