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      Making sense of complexity in context and implementation: the Context and Implementation of Complex Interventions (CICI) framework

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          Abstract

          Background

          The effectiveness of complex interventions, as well as their success in reaching relevant populations, is critically influenced by their implementation in a given context. Current conceptual frameworks often fail to address context and implementation in an integrated way and, where addressed, they tend to focus on organisational context and are mostly concerned with specific health fields. Our objective was to develop a framework to facilitate the structured and comprehensive conceptualisation and assessment of context and implementation of complex interventions.

          Methods

          The Context and Implementation of Complex Interventions (CICI) framework was developed in an iterative manner and underwent extensive application. An initial framework based on a scoping review was tested in rapid assessments, revealing inconsistencies with respect to the underlying concepts. Thus, pragmatic utility concept analysis was undertaken to advance the concepts of context and implementation. Based on these findings, the framework was revised and applied in several systematic reviews, one health technology assessment (HTA) and one applicability assessment of very different complex interventions. Lessons learnt from these applications and from peer review were incorporated, resulting in the CICI framework.

          Results

          The CICI framework comprises three dimensions—context, implementation and setting—which interact with one another and with the intervention dimension. Context comprises seven domains (i.e., geographical, epidemiological, socio-cultural, socio-economic, ethical, legal, political); implementation consists of five domains (i.e., implementation theory, process, strategies, agents and outcomes); setting refers to the specific physical location, in which the intervention is put into practise. The intervention and the way it is implemented in a given setting and context can occur on a micro, meso and macro level. Tools to operationalise the framework comprise a checklist, data extraction tools for qualitative and quantitative reviews and a consultation guide for applicability assessments.

          Conclusions

          The CICI framework addresses and graphically presents context, implementation and setting in an integrated way. It aims at simplifying and structuring complexity in order to advance our understanding of whether and how interventions work. The framework can be applied in systematic reviews and HTA as well as primary research and facilitate communication among teams of researchers and with various stakeholders.

          Electronic supplementary material

          The online version of this article (doi:10.1186/s13012-017-0552-5) contains supplementary material, which is available to authorized users.

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          Most cited references70

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          Evaluating the successful implementation of evidence into practice using the PARiHS framework: theoretical and practical challenges

          Background The PARiHS framework (Promoting Action on Research Implementation in Health Services) has proved to be a useful practical and conceptual heuristic for many researchers and practitioners in framing their research or knowledge translation endeavours. However, as a conceptual framework it still remains untested and therefore its contribution to the overall development and testing of theory in the field of implementation science is largely unquantified. Discussion This being the case, the paper provides an integrated summary of our conceptual and theoretical thinking so far and introduces a typology (derived from social policy analysis) used to distinguish between the terms conceptual framework, theory and model – important definitional and conceptual issues in trying to refine theoretical and methodological approaches to knowledge translation. Secondly, the paper describes the next phase of our work, in particular concentrating on the conceptual thinking and mapping that has led to the generation of the hypothesis that the PARiHS framework is best utilised as a two-stage process: as a preliminary (diagnostic and evaluative) measure of the elements and sub-elements of evidence (E) and context (C), and then using the aggregated data from these measures to determine the most appropriate facilitation method. The exact nature of the intervention is thus determined by the specific actors in the specific context at a specific time and place. In the process of refining this next phase of our work, we have had to consider the wider issues around the use of theories to inform and shape our research activity; the ongoing challenges of developing robust and sensitive measures; facilitation as an intervention for getting research into practice; and finally to note how the current debates around evidence into practice are adopting wider notions that fit innovations more generally. Summary The paper concludes by suggesting that the future direction of the work on the PARiHS framework is to develop a two-stage diagnostic and evaluative approach, where the intervention is shaped and moulded by the information gathered about the specific situation and from participating stakeholders. In order to expedite the generation of new evidence and testing of emerging theories, we suggest the formation of an international research implementation science collaborative that can systematically collect and analyse experiences of using and testing the PARiHS framework and similar conceptual and theoretical approaches. We also recommend further refinement of the definitions around conceptual framework, theory, and model, suggesting a wider discussion that embraces multiple epistemological and ontological perspectives.
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            ABSORPTIVE CAPACITY: A REVIEW, RECONCEPTUALIZATION, AND EXTENSION.

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              Enabling the implementation of evidence based practice: a conceptual framework

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                Author and article information

                Contributors
                pfadenh@ibe.med.uni-muenchen.de
                ansgar.gerhardus@uni-bremen.de
                kati.mozygemba@uni-bremen.de
                k.b.lysdahl@medisin.uio.no
                a.booth@sheffield.ac.uk
                bjorn.hofmann@medisin.uio.no
                philip.wahlster@uni-bremen.de
                polus@ibe.med.uni-muenchen.de
                burns@ibe.med.uni-muenchen.de
                lbrereton@lincoln.ac.uk
                rehfuess@ibe.med.uni-muenchen.de
                Journal
                Implement Sci
                Implement Sci
                Implementation Science : IS
                BioMed Central (London )
                1748-5908
                15 February 2017
                15 February 2017
                2017
                : 12
                Affiliations
                [1 ]ISNI 0000 0004 1936 973X, GRID grid.5252.0, Institute for Medical Informatics, Biometry and Epidemiology, , LMU Munich, ; Munich, Germany
                [2 ]ISNI 0000 0001 2297 4381, GRID grid.7704.4, Institute of Public Health and Nursing Research, , University of Bremen, ; Bremen, Germany
                [3 ]ISNI 0000 0001 2297 4381, GRID grid.7704.4, Health Sciences Bremen, , University of Bremen, ; Bremen, Germany
                [4 ]ISNI 0000 0004 1936 8921, GRID grid.5510.1, Centre for Medical Ethics, , University of Oslo, ; Oslo, Norway
                [5 ]ISNI 0000 0004 1936 9262, GRID grid.11835.3e, School of Health and Related Research (ScHARR), , University of Sheffield, ; Sheffield, UK
                Article
                552
                10.1186/s13012-017-0552-5
                5312531
                28202031
                ac0eaea2-1cd9-417e-995f-89a87e998676
                © The Author(s). 2017

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                Funding
                Funded by: FundRef http://dx.doi.org/10.13039/501100004963, Seventh Framework Programme;
                Award ID: 306141
                Award ID: 306141
                Award Recipient :
                Categories
                Research
                Custom metadata
                © The Author(s) 2017

                Medicine
                context,implementation,complex intervention,concept analysis,systematic review,applicability,transferability,health technology assessment,public health

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