Using the consolidated framework for implementation research (CFIR) to assess the implementation context of a quality improvement program to reduce missed opportunities for vaccination in Kano, Nigeria: a mixed methods study

Abstract

Background: Although understanding implementation context is essential, there is a dearth of research on how to systematically explore it in quality improvement (QI) programs. Therefore, in this study, we used the consolidated framework for implementation research (CFIR) to guide a systematic evaluation of the implementation context of an ongoing QI program in order to generate rapid site-specific feedback that can be used to improve subsequent plan-do-study-act (PDSA) cycles. Methods: Formative cross-case evaluation was conducted using convergent mixed methods design. The study was conducted in five primary health care (PHC) facilities (PHC 1, PHC 3, PHC 5, PHC 9 and PHC 10) implementing the QI program. Health workers in those facilities formed the study population. Quantitative data were collected using a self-administered, Likert-based rating tool, while qualitative data collection was guided by an interview guide. The interviews were transcribed verbatim, and thematic analysis was performed. Raw median score and factor scores were computed. Methodological integration occurred at the design, analysis and reporting stage. Results: A total of 165 health workers were included in this study with a mean age of 33.43 years (standard deviation of 7.15). Majority were females and they all had post-secondary education. Health workers in two facilities; PHC 1 and PHC 5, reported higher score for the QI program across all five domains of CFIR. Implementation facilitators included intervention flexibility, relative advantage, selfefficacy among health workers, health workers confidence in the intervention, services integration. While implementation barriers included vaccine stock out, faulty cold chain infrastructure, lack of incentives, and socio-cultural beliefs. Conclusion:This study demonstrated that theory-driven formative evaluation can be integrated in QI programs in a low resource setting. It buttressed the value in conducting such assessment as they can be used to generate rapid feedback on factors that influence implementation success which can then be addressed in subsequent cycles.

Implementation research approaches to promoting universal health coverage in Africa: a scoping review

“…There were ten distinct UHC-related themes of focus across the articles, including HIV ( n = 8) [ 54 , 56 , 60 , 61 , 65 , 67 , 68 , 70 ], maternal and child health ( n = 4) [ 55 , 59 , 69 , 73 ], immunisation ( n = 3) [ 50 , 51 , 72 ], voluntary male medical circumcision ( n = 2) [ 63 , 71 ], healthcare financing ( n = 2) [ 66 , 75 ], healthcare data quality ( n = 2) [ 62 , 64 ], primary health care quality improvement ( n = 2) [ 57 , 58 ], malaria diagnosis ( n = 1) [ 52 ], surgery ( n = 1) [ 74 ] and typhoid fever ( n = 1) [ 53 ].…”

“…Broadly, implementation research was used to guide the design, implementation and evaluation of health programmes and services as well as the contextualisation of evaluation findings to improve future implementation outcomes. Implementation research was most frequently used for post-implementation evaluation of implemented health programmes or activities [ 51 , 53 , 55 , 56 , 61 , 62 , 66 – 68 , 70 – 73 , 75 ]. Four studies used implementation research approaches for pre-implementation assessment, piloting and planning [ 50 , 59 , 65 , 69 ]; while four studies involved mid-implementation evaluation [ 54 , 60 , 63 , 74 ].…”

“…The most commonly reported contextual facilitators were political support for programme funding and implementation [ 51 , 53 , 55 , 56 , 61 , 62 , 66 – 68 , 70 – 73 , 75 ]; strong and sustained collaborations among stakeholders [ 59 , 65 , 69 ]; goal sharing among stakeholders [ 51 , 55 ], effective leadership and administrative support for frontline personnel, peer-support [ 73 ] and staff motivation [ 74 , 75 ]. Others included intervention flexibility [ 51 , 55 ], health workers’ confidence in the intervention [ 51 ]; supportive leadership [ 59 , 70 ]; implementing a pilot project before the actual implementation [ 75 ]; and performance appraisal with remedial feedback [ 59 , 63 ]. The most commonly reported barriers included inadequate human resource and other health care resource and infrastructural gaps, lack of leadership [ 74 ], lack of incentives, perception of implementation as additional work burden by personnel [ 74 ] and socio-cultural barriers.…”

Using Household Surveys to Assess Missed Opportunities for Simultaneous Vaccination: Longitudinal Examples from Colombia and Nigeria

“…The choice of health facilities to include in such a study can be informed by stratum-specific results from the household survey (if it is large enough). In countries such as Nigeria where it is clear that MOVs are a problem (from the analyses reported here and from in-depth work in Kano state) [ 52 , 68 ], the WHO MOV strategy suggests that country stakeholders might skip the clinic-based assessment and move directly to brainstorming about interventions [ 2 , 12 , 69 , 70 ].…”

Challenges and lessons learned during the planning and early implementation of the RTS,S/AS01E malaria vaccine in three regions of Ghana: a qualitative study

“…As an additional analysis, the challenges and lessons learned were coded onto the Consolidated Framework of Implementation Research (CFIR) [ 14 ]. The CFIR was selected as it is a commonly used, broad, theoretical framework that was developed to guide systematic assessment of factors that affect implementation across multi-level implementation contexts and which is being increasingly used in low- and middle-income countries, including implementation of vaccination programmes in Africa [ 15 – 18 ]. Using the CFIR as a guiding theoretical framework for the analysis allows the conceptualization of the challenges and lessons learned in a comprehensive, systematic and organized manner.…”