Human papillomavirus vaccine delivery in Mozambique: identification of implementation performance drivers using the Consolidated Framework for Implementation Research (CFIR)

Abstract

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.Electronic supplementary materialThe online version of this article (10.1186/s13012-018-0846-2) contains supplementary material, which is available to authorized users.

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

“…CFIR constructs can be scored quantitatively and compared across cases according to strength and valence [44]. Quantitative scoring of constructs was employed in three studies [19,24,40]. Another study created a quantitative questionnaire to align with CFIR constructs, in which participants were asked to rate CFIR constructs on a 5-point Likert scale from "very unimportant" to "very important" for implementation success [10].…”

“…The unit of analysis for most of the articles was health providers in facilities or communities involved in implementation (n = 19), followed by organizations (e.g., health facilities, district health offices) involved in implementation (n = 12), patients benefiting from the intervention (n = 7), and policymakers and health system leaders at national or subnational levels (n = 5). Nine of the studies focused upon more than one unit of analysis [10,13,14,16,30,35,39,40,42].…”

“…Damschroder et al suggest that when the CFIR is applied post-implementation, it should be used to link determinants of implementation to targeted outcomes (e.g., intervention acceptability or effectiveness) [2]. However, only 6 (18%) studies reporting linking outcomes to specific CFIR constructs, all of which took place mid-or post-implementation [10,17,19,21,24,40]. These papers identified relationships between specific CFIR constructs and measures of high and low fidelity to the intervention [19], measures of high and low uptake of the intervention [21,24,40], successful implementation generally [10], as well as variations in implementation success, including successes in intervention management, supervision, and facilitation [17].…”

“…Used to interpret/ contextualize findings utilized constructs added to the CFIR within the process domain: key stakeholders and innovation participants. However, given that these constructs are not widely acknowledged as part of the CFIR, they are not included in the analysis for purposes of consistency [19,40]. Damschroder et al suggest that CFIR constructs be selected for use based on salience, level of application (ex., individual or health facility) and time point of application, and that researchers provide a rationale for why certain constructs were considered pertinent to the research question.…”

What will it take? Using an Implementation Research Framework to Identify Facilitators and Barriers in Implementing a School-Based Referral System for Sexual Health Services

“…Across the United States (U.S.), sexually transmitted infection (STI) and unintended pregnancy rates are alarmingly high for our nation's youth; young people aged 15-24 acquire half of all new STIs.1 Among this population from 2013-2017, syphilis cases have nearly doubled, gonorrhea cases have increased by 67%, and chlamydia remains the most common STI, with 45% diagnosed cases occurring among [15][16][17][18][19][20][21][22][23][24] year old females.2 Untreated, the sequalae of STIs include pelvic inflammatory disease, infertility, and cervical cancer.3 , 4 Additionally, among adolescents age 15-19, the unintended pregnancy rate is 41 per 1000 females, which is the second highest rate across all age groups. 5 Since almost 40% of high school students reported having engaged in sexual activity, the need for consistent and comprehensive STI and unintended pregnancy prevention services is high.6…”