Conclusion
We have developed and validated a systematic tool for context-mapping, enabling to design context-driven implementation strategies for (lung) health interventions in low-resource settings. Its application to the FRESH AIR project demonstrated that the SETTING-tool is highly feasible, acceptable, and effective in facilitating context-driven adaptations to implementation strategies in six diverse settings across the globe.
The SETTING-tool was cocreated by an international expert panel and local end-users. Development was both theory driven and practice driven. Concepts from a rich diversity of relevant fields were consolidated, ranging from implementation science to global health. Additionally, the methodology was prospectively validated in six diverse settings in four countries on three continents: from deprived Ugandan slums, to rapidly developing Vietnamese villages, to austerity-impacted rural Greece and highly risk-burdened Kyrgyzstan. Feasibility, acceptability and effectiveness of the tool were consistently high. This demonstrates its global applicability.
However, it is difficult to assess whether better alternatives would have been available to the components included in our tool. In our pragmatic literature searches, there were no studies comparing the effectiveness of different components and certainly not across contexts. In this practice paper, we also did not compare our context-mapping outcomes against those of a control group. Lastly, although application of the SETTING-tool was feasible, the overall feasibility of working with certain populations should remain of consideration. For example, the tool’s feasibility was also high in the Roma camp, yet working with the Roma population generally required more time than working in other settings.
Existing studies, frameworks and toolkits emphasised the need for context-driven implementation strategies and repetitive calls highlighted the need for evidence on how to design those.5 6 9 16 17 19 The SETTING-tool addresses these calls by guiding the researcher step-by-step through the context-mapping process. Other than existing approaches such as Community-Based Participatory Research,50 this tool is developed as a practical guide in the field. It covers the entire context-mapping process, including for example developing the research materials and promoting uptake of the findings. Each step is easily reproducible. Key elements for successful completion of the steps are highlighted. This structured guidance can particularly serve clinical researchers without implementation expertise.18
The SETTING-tool is particularly relevant as it was developed for low-resource settings, where the burden of disease is highest, while the means to combat disease and evidence on how to do so are scarcest.5 9 19 22 51 52 Furthermore, the tool addresses two important issues that contribute to the avoidable loss of 85% of investments in health and biomedical research (US$200 billion lost in 2010 alone): (1) failure to establish priorities based on stakeholders’ needs and (2) poorly designed research methods.53 54
The SETTING-tool can be used flexibly; it can be adapted according to local needs, as long as the core elements (the six steps) remain intact and the tool remains simple to use.7 55 Researchers should also ensure to continuously collaborate closely with the stakeholders (box 2). Flexible aspects are, for example, that not every health topic requires the use of a vignette to avoid stigmatisation. Use of the tool across diverse contexts, for other health topics and by researchers that were not involved in its development, could provide further insight on the generalisability of the tool. This would also allow for assessing the importance of individuals components depending on the setting or targeted disease. Although validated in LMICs, the tool might also be transferable to high-income settings.
Box 2Main lesson learnt
Continuous collaboration between the researchers and the stakeholders was vital for successful completion of every step of the Setting-Exploration-Treasure-Trail-to-Inform-implementatioN-strateGies-tool. The close collaboration helped to align the study aim with the actual needs, to promote compatibility of methods and materials with the local reality, to identify the right community researchers to join the team and to promote uptake of the findings. Additional lessons learnt are detailed in online supplemental appendix 9.
Notably, the tool focuses on local beliefs and behaviours, and it is important to remain aware of other elements that shape context.8 Systematically assessing a context on multiple elements (beliefs and behaviour, physical environment, organisational structures, etc) would require a substantial amount of resources. We would then recommend to conduct the tool’s steps more pragmatically; particularly the in-depth analyses in step 5 as they are most time-consuming.
To conclude, the SETTING-tool can support researchers, policy-makers, health workers, NGOs and other implementers to apply evidence-based methods in context-mapping. This can facilitate them to design context-driven implementation strategies to increase implementation success of their health interventions, potentially avoiding the widescale waste of scarcely available resources. Ultimately, this could improve health outcomes.