Table 2 Summary of TMFs and their operationalisation
Name | Author | Origin/location | Purpose | Type | Description | Equity focus* (explicit/implicit/applied) | Systems focus | Operationalisation |
|---|---|---|---|---|---|---|---|---|
Determinant frameworks | ||||||||
Consolidated Framework for Implementation Research (CFIR) | Gordon et al. [68], Gordon et al. [69], Goff et al. [70], Lam et al. [71] | All USA | To identify facilitators and barriers to implementation | Established [79] | Five domains of factors that determine implementation success: (1) Intervention characteristics; (2) Outer setting; (3) Inner setting; (4) Characteristics of individuals; (5) Process | Applied | Fully considered Micro-level: Characteristics of Individuals Meso-level: Inner setting Macro-level: Outer setting | Culturally appropriate kidney transplant programme for Hispanic people [68, 69]. CFIR used prior to implementation to identify key stakeholders’ perceptions of the facilitators and barriers to implementation. Post-partum depression screening protocol delivered in practices that serve minoritised ethnic and racial groups [70]. CFIR used prior to implementation to identify perceived facilitators and barriers to screening and referral. Interventions to increase colorectal cancer screening in clinics serving predominately (> 82%) minoritised ethnic and racial groups [71]. CFIR used post-implementation for evaluation. |
Health Equity Implementation Framework (HEIF) | Woodward et al. [66] | USA | To identify health equity determinants so that interventions and implementation strategies can be tailored or adapted to advance health equity | Adapted | Five domains of factors influencing implementation outcomes and health equity: (1) Characteristics of the Innovation; (2) Clinical Encounter; (3) Patient & Provider Factors; (4) Inner & Outer Context; (5) Societal Influence | Explicit Identifies factors that explain the causes of health equities across multiple levels (patients, providers, clinical encounters and the health system) | Fully considered Micro-level: Clinical Encounter and Patient and Provider Factors Meso-level: Inner context Macro-level: Outer context, Societal influence | Hepatitis C treatment in Black veterans [66]. HEIF used to explore patient-identified barriers and facilitators to treatment. Social needs screening survey in a primary care clinic serving predominantly minoritised ethnic and racial groups [80]. HEIF used to identify clinician and patient perspectives on facilitators and barriers to implementing the screening survey. Adapted for use in the field of paediatric rheumatology where inequities in patient care and health outcomes are evident [81]. This adaptation retains the same five overarching domains of HEIF with a focus in the long-term nature of caring for paediatric rheumatology patients. |
Integrated Practical, Robust Implementation and Sustainability Model (PRISM) and Socio-Ecological Model (SEM) framework | Henderson et al. [65] | USA | To guide development and implementation of a breast screening programme | Novel | Integrated framework combining PRISM (an implementation science framework) and SEM (a behavioural health framework) | Implicit Framework developed to guide design and implementation of a screening and navigation programme to address breast cancer disparities | Fully considered Micro-level: Patient perspectives and characteristics (PRISM); individual and interpersonal levels (SEM) Meso-level: Organisational perspectives and characteristics, Implementation and Sustainability Infrastructure and External Environment (PRISM); Community and Organisation levels (SEM) Macro-level: policy level (SEM) | Breast cancer screening programme (Mi-MAMO) for underserved populations (58% Hispanic/Latina, 34% non-Hispanic Black) [65]. Programme design and implementation addressed factors affecting breast cancer screening, early detection and treatment that were identified across the different levels of the integrated framework. |
He Pikinga Waiora (HPW) Implementation Framework | Oetzel et al. [61] | Aotearoa New Zealand | Provide a theoretical foundation and guide for designing and implementing effective and culturally-appropriate interventions for communities experiencing health inequities | Novel | Comprises four elements: Community Engagement; Cultural Centredness; Systems Thinking; Integrated Knowledge Translation. These elements are underpinned by a Kaupapa Māori approach, which prioritises indigenous history, development and aspirations. | Explicit Each element included has been identified as important for advancing Indigenous health equity | Fully considered Captured primarily in the Systems Thinking element Micro-level: Cultural Centeredness Meso-level: Community Engagement and Integrated Knowledge Translation | Retrospective analysis of lifestyle interventions for diabetes prevention in Indigenous communities in Australia, Canada, New Zealand and the USA [61]. Co-design of lifestyle interventions for Māori communities in New Zealand [75, 76]. Evaluation of two researcher-community partnerships that were engaged to co-deign and implementation of lifestyle interventions for diabetes prevention [77]. |
Implementation theories | ||||||||
Capability, Opportunity, Motivation and Behaviour (COM-B) | USA, Australia | Model for understanding behaviour; used as a basis for designing interventions that aim to change behaviour | Established [82] | COM-B helps to identify possible behavioural targets for interventions across three domains: Capability, Opportunity and Motivation. Forms part of the Behaviour Change Wheel | Applied | Partially considered Micro-level: Motivation The Opportunity domain could include consideration of meso- and/or macro-factors influencing behaviours | Health IT coaching and resource programme for Latina women with recent gestational diabetes [72]. COM-B used to analyse data relating to barriers and facilitators for post-partum women. engaging with diabetes prevention behaviours Smoking cessation service for pregnant Indigenous Australian women [73]. COM-B was used to inform intervention design. N.B. This study also used the TDF (a determinant framework) to provide examples of other domains that aligned with the COM-B model. | |
Process models | ||||||||
Equity-based Framework for Implementation Research (EquIR) | Eslava-Schmalbach et al. [58] | Latin America | Reduce or prevent the increase of existing inequalities during the implementation of equity-focused health programs, policies or interventions | Novel | Five steps: (1) Population's health status; (2) Planning the programme; (3) Designing equity-focused implementation research; (4) Implementing equity-focused implementation research; (5) Equity focused implementation outcomes | Explicit Each step of the framework has an equity lens applied. Includes gathering data on inequities, identifying strategies to reduce inequities, involving key stakeholders, identifying facilitators and barriers to implementation and equity-focused evaluation. | Partially considered Multi-level systems factors are not explicitly described, but the framework prompts users to identify facilitators and barriers to implementation, and design strategies to overcome these, which, depending on the intervention, could include micro-, meso- and macro-factors | Implementation of a programme in a population of disadvantaged children in Bolivia [58]. An equity lens was provided to the programme using the EquIR. Steps were revised based on equity considerations. |
Intervention and Research Readiness Engagement and Assessment of Community Health Care (I-RREACH) tool | Maar et al. [59] | Canada, Tanzania | Guide implementation of interventions in low-resource settings to ensure the intended health benefits are achieved | Novel | The tool includes three phases: (1) A community fact sheet to determine if the characteristics are suitable for implementation of the intervention; (2) A key informant interview guide to gather practical information on what is required for successful implementation; (3) A focus group interview guide to gather information on the lived experience of the intended recipients of the intervention | Implicit Guides the process of identifying factors that influence implementation in low-resource settings (low- and middle-income countries and disadvantaged populations in high-income countries) | Partially considered Micro-level: Perceptions of key informants and community members about implementation Meso-level: gathers information on a range of meso-level factors relevant to the implementation context | Text messaging service to encourage blood pressure measurement and feedback between patients and health providers [59]. The tool was developed through participatory research prior to implementation of the trial. |
Transcreation Framework | Nápoles and Stewart, [60] | USA | Step-by-step guide to intervention design and implementation to reduce health disparities, in partnership with the target community | Novel | Seven-step process for implementation: (1) Identify community infrastructure and engage partners; (2) Specify theory; (3) Identify multiple inputs for new programme; (4) Design intervention prototype; (5) Design study, methods and measures for community setting; (6) Build community capacity for delivery; (7) Deliver ‘transcreated’ intervention and evaluate implementation processes | Explicit Focuses on community partnership to reduce inequities in intervention adaptation and delivery | Partially considered Primarily focuses on the meso-level, i.e. the community setting and its capacity for the intervention | Development of a stress management intervention for Latina cancer survivors [83]. The framework facilitated community engagement and programme adaptation, enabling recruitment goals to be exceeded and the intervention to be implemented successfully. |
Indigenous Health Promotion Tool Implementation Model | Percival et al. [62] | Australia | Provide a framework for Indigenous health promotion tool implementation planning, documentation and evaluation | Novel | The model describes the: (1) Conditions influencing implementation (Reciprocity, Change agents, Governance and resources); (2) Four processes guiding implementation (Engaging and relating, Developing and using evidence, tailoring for diverse groups, programmes and settings, Strengthening capacity); (3) Benefits (Participant satisfaction and control, Workforce recruitment and capacity, Organisational resources, systems and partnerships, Programme sustainability and spread) | Implicit Each aspect of the model has been identified as important for culturally responsive health promotion in Indigenous peoples | Partially considered Primarily focuses on the micro- and meso-levels Micro-level: Reciprocity and Change agents Meso-level: Governance and resources | Not operationalised |
ConNECT Framework | Alcaraz et al. [57] | USA | Link behavioural medicine and health equity science to achieve equitable health outcomes | Novel | Five interrelated principles: (1) Integrating Context; (2) Fostering a Norm of Inclusion; (3) Ensuring Equitable Diffusion of Innovations; (4) Harnessing Communication Technology; (5) Prioritising Specialised Training The principles are applied across the research to practice continuum through the phases of Discovery, Development, Delivery and Dissemination | Explicit All principles have an equity lens applied. Includes appreciating the situational and interactive influences on health, engaging with and examining diverse groups, facilitating equitable intervention dissemination, utilising communication strategies to enhance reach, and workforce development through integrating education, training, and mentoring approaches. | Partially considered Systems level factors are not explicitly described, however, the Integrating Context, Fostering a Norm of Inclusion and Ensuring Equitable Diffusion of Innovations domains could reasonably include consideration of micro-, meso- and macro-factors | Not operationalised |
Collaborative Intervention Mapping Framework | USA | Overcome barriers to the modification, pre-implementation, and use of evidence-based approaches in real-world settings by using a collaborative approach | Novel | Combines Community-Based Participatory Research (CBPR) principles (shared health concern, ownership, co-learning and capacity building) with Intervention Mapping (IM). IM comprises six steps: (1) Problem analysis; (2) Review of intervention objectives and theoretical foundations; (3) Modification of intervention methods and strategies; (4) Development of revised intervention; (5) Development of adoption and implementation plan; (6) Evaluation | Implicit Uses CBPR principles to ensure sociocultural and system factors are considered when translating interventions to new contexts | Partially considered Primarily considers factors at the meso-level of influence, i.e. focus on community engagement and modifying the intervention to ensure it is appropriate for the community context | Health care manager intervention (PCARE – care coordination and patient activation) for Hispanic people with serious mental illness [84]. The collaborative framework was used to adapt the intervention to improve its reach in the local community and reduce health disparities. | |
Evaluation frameworks | ||||||||
Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) | Glasgow et al. [74] | USA | Plan and evaluate implementation of interventions across five key dimensions | Established [85] | RE-AIM comprises five dimensions: Reach, Effectiveness, Adoption, Implementation, Maintenance | Applied | Partially considered Primarily focuses on the micro- and meso-levels Micro-level: Reach and Effectiveness Meso-level: Adoption, Implementation and Maintenance | Weight loss and hypertension management intervention targeting a high-risk population (70% African-American, 13% Hispanic) [74]. RE-AIM used to identify equity issues across the different domains relating to implementation and dissemination if the intervention. |
Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) extension for sustainability | Shelton et al. [67] | USA | Guide planning, measurement, evaluation and adaptation of evidence-based interventions with a focus on sustainability | Adapted | Extension of the RE-AIM framework to enhance sustainability, by focusing on Dynamic Context and Culture, Health Equity, and Costs, Resources and Capacity across the implementation cycle and RE-AIM domains | Explicit The framework includes a health equity domain that prompts users to consider health equity across each of the RE-AIM domains | Partially considered Micro-level: Reach and Effectiveness Meso-level: Adoption, Implementation and Maintenance Macro-level influences are captured by the Costs, Resources and Capacity domain | Not operationalised |
Adaptation of Proctor et al. framework | Baumann and Cabassa, [11] | USA | To illustrate how application of an equity lens can help to integrate the implementation science and health inequities research fields | Adapted | Equity-focused adaptation of Proctor et al.’s implementation outcomes framework [86], focusing on five elements: (1) Focus on reach from the beginning; (2) Design and select interventions for vulnerable populations with implementation in mind; (3) Implement what works and develop implementation strategies that can help reduce inequities in care; (4) Develop the science of adaptation; (5) Use an equity lens for implementation outcomes | Explicit The framework applies an equity lens across each element | Partially considered Emphasises Reach (micro-level) and focusing on the implementation context, which, depending on the intervention, could include micro-, meso- and macro-level factors | Not operationalised |
Hybrid frameworks | ||||||||
EQ-DI | Yousefi et al. [63] | USA | To illustrate the interaction between the fields of health equity and D&I science | Novel | Health equity sensitises D&I planning and evaluation frameworks. D&I science operationalises EBIs to promote health equity by providing tools, methods and approaches for planning and evaluation | Explicit Health equity sensitises D&I science by identifying, acknowledging and addressing the conditions in which inequities are created and perpetuated across multiple levels (individuals, relationships, community and system-levels) | Fully considered Prompts users to consider the multiple levels and complex dynamics that influence equitable implementation | Not operationalised |