Inge Petersen, Christopher G. Kemp, Deepa Rao, Bradley H. Wagenaar, Kenneth Sherr, Merridy Grant, Max Bachmann, Ruanne V. Barnabas, Ntokozo Mntambo, Sithabisile Gigaba, André Van Rensburg, Zamasomi Luvuno, Ishmael Amarreh, Lara Fairall, Nikiwe N. Hongo, & Arvin Bhana
University of Washington affiliated authors are displayed in bold.
Published: March 2021
Arianna Rubin Means, Christopher G. Kemp, Marie-Claire Gwayi-Chore, Sarah Gimbel, Caroline Soi, Kenneth Sherr, Bradley H. Wagenaar, Judith N. Wasserheit, & Bryan J. Weiner
University of Washington affiliated authors are displayed in bold.
Published: March 2020
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 middle-income 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.
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.
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.
These additions provide global implementation science practitioners opportunities to account for systems-level determinants operating independently of the implementing organization. Newly proposed constructs require further reliability and validity assessments.
PROSPERO, CRD42018095762
**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**
Bradley H. Wagenaar, Wilson H. Hammett, Courtney Jackson, Dana L. Atkins, Jennifer M. Belus, and Christopher G. Kemp
University of Washington affiliated authors are displayed in bold.
Published: March 2020
We systematically reviewed implementation research targeting depression interventions in low- and middle-income countries (LMICs) to assess gaps in methodological coverage.
PubMed, CINAHL, PsycINFO, and EMBASE were searched for evaluations of depression interventions in LMICs reporting at least one implementation outcome published through March 2019.
A total of 8714 studies were screened, 759 were assessed for eligibility, and 79 studies met inclusion criteria. Common implementation outcomes reported were acceptability (n = 50; 63.3%), feasibility (n = 28; 35.4%), and fidelity (n = 18; 22.8%). Only four studies (5.1%) reported adoption or penetration, and three (3.8%) reported sustainability. The Sub-Saharan Africa region (n = 29; 36.7%) had the most studies. The majority of studies (n = 59; 74.7%) reported outcomes for a depression intervention implemented in pilot researcher-controlled settings. Studies commonly focused on Hybrid Type-1 effectiveness-implementation designs (n = 53; 67.1), followed by Hybrid Type-3 (n = 16; 20.3%). Only 21 studies (26.6%) tested an implementation strategy, with the most common being revising professional roles (n = 10; 47.6%). The most common intervention modality was individual psychotherapy (n = 30; 38.0%). Common study designs were mixed methods (n = 27; 34.2%), quasi-experimental uncontrolled pre-post (n = 17; 21.5%), and individual randomized trials (n = 16; 20.3).
Existing research has focused on early-stage implementation outcomes. Most studies have utilized Hybrid Type-1 designs, with the primary aim to test intervention effectiveness delivered in researcher-controlled settings. Future research should focus on testing and optimizing implementation strategies to promote scale-up of evidence-based depression interventions in routine care. These studies should use high-quality pragmatic designs and focus on later-stage implementation outcomes such as cost, penetration, and sustainability.
**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**
Christopher G. Kemp, Bradley H. Wagenaar, and Emily E. Haroz
University of Washington affiliated authors are displayed in bold.
Published: November 2019
Successful implementation reflects the interplay between intervention, implementation strategy, and context. Hybrid effectiveness-implementation studies allow investigators to assess the effects of both intervention and implementation strategy, though the role of context as a third independent variable (IV) is incompletely specified. Our objective is to expand the hybrid typology to include mixtures of all three types of IVs: intervention, implementation strategy, and context.
We propose to use I to represent the IV of intervention, IS to represent implementation strategy, and C to represent context. Primary IVs are written first and in upper case. Secondary IVs are written after a forward slash and in lower case; co-primary IVs are written after a dash and in upper case. The expanded framework specifies nine two-variable hybrid types: I/is, I-IS, IS/i, IS/c, IS-C, C/is, C/i, I-C, and I/c. We describe four in detail: I/is, IS/c, IS-C, and C/is. We also specify seven three-variable hybrid types. We argue that many studies already meet our definitions of two- or three-variable hybrids.
Our proposal builds from the typology proposed by Curran et al. (1), but offers a more complete specification of hybrid study types. We need studies that measure the implementation-related effects of variations in contextual determinants, both to advance the science and to optimize intervention delivery in the real world. Prototypical implementation studies that evaluate the effectiveness of an implementation strategy, in isolation from its context, risk perpetuating the gap between evidence and practice, as they will not generate context-specific knowledge around implementation, scale-up, and de-implementation.
**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**
Christopher G. Kemp, Brooke A. Jarrett, Churl-Su Kwon, Lanxin Song, Nathalie Jetté, Jaime C. Sapag, Judith Bass, Laura Murray, Deepa Rao & Stefan Baral
University of Washington affiliated authors are displayed in bold.
Published: February 2019
Interventions to alleviate stigma are demonstrating effectiveness across a range of conditions, though few move beyond the pilot phase, especially in low- and middle-income countries (LMICs). Implementation science offers tools to study complex interventions, understand barriers to implementation, and generate evidence of affordability, scalability, and sustainability. Such evidence could be used to convince policy-makers and donors to invest in implementation. However, the utility of implementation research depends on its rigor and replicability. Our objectives were to systematically review implementation studies of health-related stigma reduction interventions in LMICs and critically assess the reporting of implementation outcomes and intervention descriptions.
PubMed, CINAHL, PsycINFO, and EMBASE were searched for evaluations of stigma reduction interventions in LMICs reporting at least one implementation outcome. Study- and intervention-level characteristics were abstracted. The quality of reporting of implementation outcomes was assessed using a five-item rubric, and the comprehensiveness of intervention description and specification was assessed using the 12-item Template for Intervention Description and Replication (TIDieR).
A total of 35 eligible studies published between 2003 and 2017 were identified; of these, 20 (57%) used qualitative methods, 32 (91%) were type 1 hybrid effectiveness-implementation studies, and 29 (83%) were evaluations of once-off or pilot implementations. No studies adopted a formal theoretical framework for implementation research. Acceptability (20, 57%) and feasibility (14, 40%) were the most frequently reported implementation outcomes. The quality of reporting of implementation outcomes was low. The 35 studies evaluated 29 different interventions, of which 18 (62%) were implemented across sub-Saharan Africa, 20 (69%) focused on stigma related to HIV/AIDS, and 28 (97%) used information or education to reduce stigma. Intervention specification and description was uneven.
Implementation science could support the dissemination of stigma reduction interventions in LMICs, though usage to date has been limited. Theoretical frameworks and validated measures have not been used, key implementation outcomes like cost and sustainability have rarely been assessed, and intervention processes have not been presented in detail. Adapted frameworks, new measures, and increased LMIC-based implementation research capacity could promote the rigor of future stigma implementation research, helping the field deliver on the promise of stigma reduction interventions worldwide.
**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**
Christopher G. Kemp & Jennifer Velloza
University of Washington affiliated authors are displayed in bold.
Published: September 2018
Christopher G. Kemp; Bryan J. Weiner; Kenneth H. Sherr; Linda E. Kupfer; Peter K. Cherutich; David Wilson; Elvin H. Geng; Judith N. Wasserheit
University of Washington affiliated authors are displayed in bold.
Published: July 2018
Christopher G. Kemp, Julia de Kadt, Erushka Pillay, Jennifer M. Gilvydis, Evasen Naidoo, Jessica Grignon and Marcia R. Weaver
University of Washington affiliated authors are displayed in bold.
Published: May 2017
Prevention interventions for people living with HIV/AIDS are an important component of HIV programs. We report the results of a pilot evaluation of a four-hour, clinic-based training for healthcare providers in South Africa on HIV prevention assessments and messages. This pre/post pilot evaluation examined whether the training was associated with providers delivering more prevention messages.
Seventy providers were trained at four public primary care clinics with a high volume of HIV patients. Pre- and post-training patient exit surveys were conducted using Audio-Computer Assisted Structured Interviews. Seven provider appropriate messaging outcomes and one summary provider outcome were compared pre- and post-training using Poisson regression.
Four hundred fifty-nine patients pre-training and 405 post-training with known HIV status were interviewed, including 175 and 176 HIV positive patients respectively. Among HIV positive patients, delivery of all appropriate messages by providers declined post-training. The summary outcome decreased from 56 to 50%; adjusted rate ratio 0.92 (95% CI = 0.87–0.97). Sensitivity analyses adjusting for training coverage and time since training detected fewer declines. Among HIV negative patients the summary score was stable at 32% pre- and post-training; adjusted rate ratio 1.05 (95% CI = 0.98–1.12).
Surprisingly, this training was associated with a decrease in prevention messages delivered to HIV positive patients by providers. Limited training coverage and delays between training and post-training survey may partially account for this apparent decrease. A more targeted approach to prevention messages may be more effective.
**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**
Jane M Simoni, Frances M Aunon, Christopher G Kemp, Bryan A Kutner, Megan K Ramaiya, Jennifer Velloza, & Joyce P Yang
University of Washington affiliated authors are displayed in bold.
Published: March 2017
Arianna R. Means, David E. Phillips, Grégoire Lurton, Anne Njoroge, Sabine M. Furere, Rong Liu, Wisal M. Hassan, Xiaochen Dai, Orvalho Augusto, Peter Cherutich, Gloria Ikilezi, Caroline Soi, Dong (Roman) Xu & Christopher G. Kemp
University of Washington affiliated authors are displayed in bold.
Published: November 2016
Bridging the ‘know-do gap’ is an enormous challenge for global health practitioners. They must be able to understand local health dynamics within the operational and social contexts that engender them, test and adjust approaches to implementation in collaboration with communities and stakeholders, interpret data to inform policy decisions, and design adaptive and resilient health systems at scale. These skills and methods have been formalized within the nascent field of Implementation Science (IS). As graduates of the world's first PhD program dedicated explicitly to IS, we have a unique perspective on the value of IS and the training, knowledge, and skills essential to bridging the ‘know-do gap’. In this article, we describe the philosophy and curricula at the core of our program, outline the methods vital to IS in a global health context, and detail the role that we believe IS will increasingly play in global health practice. At this junction of enormous challenges and opportunities, we believe that IS offers the necessary tools for global health professionals to address complex problems in context and raises the bar of success for the global health programs of the future.
**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**