Measuring Context: Balancing Implementation Research and Practice
By Dr. Sobia Khan, Director of Implementation
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We tell people frequently that they should have a way of assessing context; this is inevitably followed up with the question – “so how do we measure it?” That’s an excellent question for which we tend to have both a short and a long answer. The short answer is we often “use the Consolidated Framework for Implementation Research (CFIR)” which is, to be frank, not the most ideal response because the CFIR is a framework, not an assessment tool. This means that people using the CFIR as a context assessment tool have to figure out how to operationalize a method of assessment (e.g, transforming items into survey items, developing an interview guide, having informal conversations etc.). We recommend the CFIR because it is one of the most common implementation framework used right now (Promoting Action on Research Implementation in Health Services or PARiHS is the other commonly used context framework). Plus CFIR is a meta-framework which means that it was informed by many other frameworks for implementation. The “inner setting” domain in particular is quite helpful to people who are thinking about assessing context.
What is the implementation context?
The long answer is this. Assessing context requires that you have a general understanding of what context means to you in your implementation system. Context is such a nebulous term that we often use in reference to all things external to the people involved in implementation. The first step of reining in this concept of context is having a sense of what level of implementation constitutes the primary implementation setting (e.g., organization or agency, community, wider system); this helps to distinguish between the more immediate context and peripheral context. Once you identify the level of your primary implementation setting, you can find a framework or tool that targets this level. Going back to the CFIR, this framework is useful when your immediate context is at the level of the organization (“inner setting”) and the extra-organizational space is your peripheral context (“outer setting”). In fact, in implementation science we tend to know most about contexts within organizations. A note, however, is that when you define your immediate context as something outside of the organization (a community, an interorganizational network, an entire “big-S” System), assessing context becomes more and more difficult. We won’t discuss this at length in this bulletin, but there is still a lot to be explored on this topic.
How do you assess the implementation context?
The next hurdle that people run into is, how exactly do we assess context in a comprehensive way, without overburdening both the implementation team and the people involved in the assessment? There is the issue of operationalizing an assessment I spoke of briefly above; in implementation practice many people want to be able to comprehensively collect information on context through surveys, interviews, focus groups, etc., but just don’t have the resources to do so. Here, we often recommend you embed context assessment into the things you do anyway – things like meetings, huddles, or training sessions. Use a framework or tool to guide you on what kinds of questions you should ask about context, and perform these kinds of “pulse checks” throughout implementation. There is also the issue of “how comprehensive do you get” – if you have looked at context frameworks and tools, there are numerous factors that relate to context because remember, context is nebulous. Often what’s helpful is to “weight” the context factors in terms of what will be especially important in general for your setting, as well as for the specific initiative you have selected.
Linking context assessments, readiness assessments, and sustainability tools
Finally, there is the issue of assessment fatigue. Implementation practitioners are told that they have to do a readiness assessment, a context assessment, a sustainability assessment…the list goes on. A tip is that many of these frameworks and tools actually measure similar things. We have compared the CFIR to readiness assessment tools and sustainability planning tools and find that there is immense overlap. Pick one framework or tool and use that before, during and after implementation.
Ariadne Labs in Boston have delved deep into the context world from a research perspective, and have come out on the other side from the practice perspective. I had the opportunity to work with them and other experts in research, practice and implementation in 2019 to think about how to more practically measure context. The themes that staff at Ariadne Labs brought up in discussion resonated so greatly with the ones I mentioned above. They took this information and developed a context assessment tool that is shorter, more practically focused, looks at contextual factors that are commonly important in organizational change.
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