the Consolidated Framework for Implementation Research to identify - - PowerPoint PPT Presentation

HPV vaccine demonstration project in Mozambique: Applying the Consolidated Framework for Implementation Research to identify drivers of implementation performance

Caroline Soi, Sarah Gimbel, Baltazar Chilundo, Vasco Muchanga, Luisa Matsinhe, Kenneth Sherr

10th Dissemination and Implementation Science Conference Arlington, Virginia December 5th, 2017

Background

Global HPV Prevalence & Cervical Cancer Incidence

http://www.nature.com/nature/journal/v488/n7413_supp/full/488S2a.html

Mozambique cervical cancer burden and HPV attribution

• Second on global cervical cancer

burden ranking

• 65.0 per 100,000 Incidence
• 49.2 per 100,000 Mortality
• 78% HPV 16 and 18 infection in

cervical cancer biopsies

Gavi model of HPV vaccine support

• Demonstration projects

prior to national scale-up Rationale - No health care delivery system for target age group Aim - Assess feasibility of possible delivery model/s 2011 - Gavi decision to fund HPV vaccine introduction in LMICs

Implementation Challenge: Slow Adoption

Gavi programs

Plan

By 2015 21 demonstration projects 8 national programs

Current Status

2017 23 demonstration projects 3 national programs

Mozambique

Plan

2015 Demonstration Project 2018 National scale up

Current Status

2017 Demonstration completed in 2015 National Scale-up postponed 2019

Methods

Research Question Study Design

What factors affected the implementation performance observed across the diverse HPV vaccine delivery demonstration sites in Mozambique? Post Implementation Interpretive Evaluation

Developmental

• Identify potential barriers /

facilitators

• Integrate findings into

intervention design and refinement prior to implementation

Implementation-Focused

• Assess discrepancies between

implementation plan and execution.

• Progress-Focused
• Monitor impacts and indicators
• f progress toward project goals
• Interpretive
• Explain success or

failure

Summative

• Determine degree of

success

Stages of Formative Evaluation

Post- Implementation Pre- Implementation Implementation

Adapted from: Stetler, Legro, Smith et al (2006)

Consolidated Framework for Implementation Research (CFIR)

Domain

• No. of

Constructs Constructs Intervention characteristics

8

Intervention Source, Trialability, Adaptability, Evidence Strength & Quality, Cost, Design Quality & Packaging, Relative Advantage, Complexity Outer setting

4

Patient Needs & Resources, Cosmopolitanism, Peer Pressure, External Policy & Incentives Inner setting

13

Structural Characteristics, Networks & Communication, Culture, Tension for change, Organizational Incentives & Rewards, Goals and Feedback, Learning Climate, Readiness for Implementation, Leadership engagement, Access to Knowledge and Information, Relative Priority, Available resources, Compatibility, Implementation Climate Characteristics

• f individuals

5

Knowledge & Beliefs about the Intervention, Self-efficacy, Individual Stage of Change, Individual Identification with Organization, Other Personal Attributes Process

9

Planning, Engaging Opinion Leaders, Formally Appointed Internal Implementation Leaders, Champions, External Change Agents, Key Stakeholders, Innovation Participants, Executing, Reflecting & Evaluating

Damschroder et al. 2009.

Qualitative methods

Definition of unit of analysis & performance criteria Initial construct selection Data collection through KIIs Final construct selection through thematic coding Valence and strength rating

Damschroder et al.2009 http://cfirguide.org/

Unit of analysis - District

Socio-demographic Indicators South (Gavi) Central (MOH) North (MOH) Proportion of girls aged 6 years or more who enrolled in primary schools 64.7 63.5 46.8 Under-five mortality 96 114 116 Contraceptive prevalence rate among women 15-49 years old (married or in union) 32.8 12.5 2.9 Proportion of households with access to portable water 85.1 84.1 37.1 Wealth quintile (proportion in poorest quintile) 1.2 5.5 23.8

Performance criteria – Proportion of eligible girls who completed all vaccination doses

17 % Moçimboa da Praia - Low 47% Manica - Intermediate 73.3% Manhiça - High

Data Collection

40 respondents from implementing entities Key Informant Interviews CFIR guided semi- structured interview guide

Immunization staff 55% Ministry of Education 15% NGO 10% Multilateral 7% Research Institute 7% Bilateral 3% Pharmaceutical 3%

Data Analysis

• Transcription
• Nvivo coding using CFIR codebook

2 coders - inter coder reliability - kappa statistic at 80% threshold

Construct Selection

Innovation Characteristics Outer Setting Inner Setting Process

1.Adaptability 4.Patient Needs & Resources 5.Structural Characteristics 13.Planning 2.Complexity 6.Networks & Communications 14.Opinion Leaders 3.Design Quality & Packaging 7.Culture 15.Champions 8.Relative priority 16.Key stakeholders 9.Organizational Incentives 17.Innovation participants 10.Learning climate 18.Executing 11.Available resources 19.Reflecting 12.Access to knowledge & Info

Valence and Strength Rating

• 2
• Negative

Influence

• Explicit

Examples

• 1
• Negative

Influence

• General

mention

• Neutral

+1

• Positive

Influence

• General

Mention +2

• Positive

Influence

• Explicit

Examples

Results and Discussion

Results

Distinguishing Constructs

strongly

weakly

12

11

1

Valence Evaluated Constructs Distinguishing High Intermediate Low

Innovation Characteristics

Adaptability Strongly +2

• 2
• 2

Complexity Strongly

• 1
• 2
• 2

Design Quality & Packaging Not +2 +2 +2

Outer setting

Patient Needs & Resources Strongly +2

• 2
• 2

Inner Setting

Structural Characteristics Strongly +2

• 2
• 2

Networks & Communications Weakly

• 1
• 2
• 2

Culture Not +2 +2 +2 Relative Priority Not +2 +2 +2

• Org. Incentives & rewards

Strongly

• 2
• 2

Learning Climate Strongly +2 Available Resources Strongly

• 2
• 2

Access to knowledge and info Strongly +2

• 1
• 1

Process

Planning Not

• 1
• 2
• 2

Opinion leaders Strongly +2

• 2
• 2

Champions Not +2 +1 +1 Key stakeholders Strongly +2 Innovation participants Strongly +2

• 2

Executing Neutral Reflecting &Evaluating Not +2 +2 +2

Valence Evaluated Constructs Distinguishing High Intermediate Low Innovation Characteristics Adaptability Strongly +2

• 2
• 2

Complexity Strongly

• 1
• 2
• 2

Design Quality & Packaging Not +2 +2 +2

Delivery model needs to be adaptable

Consider context with fewer girls in school

Address complexity where possible

Providing the vaccine

• ut of the health

facility means relying

• n non health workers

Valence Evaluated Constructs Distinguishing High Intermediate Low Inner Setting Structural Characteristics Strongly +2

• 2
• 2

Culture Not +2 +2 +2 Relative Priority Not +2 +2 +2

• Org. Incentives & rewards

Strongly

• 2
• 2

Available Resources Strongly

• 2
• 2

Access to knowledge and info Strongly +2

• 1
• 1

Allocation of sufficient financial resources Worst performance was in poorest district Organizational workers’ work ethic & beliefs Belief in vaccines, health workers sacrificed Training for all implementers Teachers were not trained in the int. and lower performing sites

Valence Evaluated Constructs Distinguishing High Intermediate Low Outer Setting Patient Needs & Resources Strongly +2

• 2
• 2

Process Planning Not

• 1
• 2
• 2

Opinion leaders Strongly +2

• 2
• 2

Champions Not +2 +1 +1 Key stakeholders Strongly +2 Innovation participants Strongly +2

• 2

Executing Neutral Reflecting &Evaluating Not +2 +2 +2

Intervention recipients’ perceptions, beliefs & attitudes Address these in social mobilization messages, longer period Advocacy and Social mobilization Identify context specific opinion leaders Planning and reflecting & evaluating Decentralize these process components sooner

Reflection on CFIR

Standardized terminology and methodology allows for comparison with

• ther studies

CFIR’s broadness allows for flexibility without compromise

Thank you

Quotations

• Adaptability (Strongly Distinguishing Construct)
• Complexity (Strongly Distinguishing Construct)
• Needs & Resources of those Served by the Organization (Strongly Distinguishing

Construct

Quotations

• Networks & Communications (Weakly Distinguishing Construct)
• Organization Culture (Not a Distinguishing Construct)
• Planning (Not a Distinguishing Construct)

Research questions?