Article Text

A systematic approach to context-mapping to prepare for health interventions: development and validation of the SETTING-tool in four countries
  1. Evelyn A Brakema1,
  2. Rianne MJJ van der Kleij1,
  3. Charlotte C Poot1,
  4. Niels H Chavannes1,
  5. Ioanna Tsiligianni2,
  6. Simon Walusimbi3,
  7. Pham Le An4,
  8. Talant Sooronbaev5,
  9. Mattijs E Numans1,
  10. Matty R Crone1,
  11. Ria R Reis1,6
  12. on behalf of the FRESH AIR collaborators
    1. 1Public Health and Primary Care, Leiden University Medical Center, Leiden, the Netherlands
    2. 2Clinic of Social and Family Medicine, School of Medicine, University of Crete, Heraclion, Crete, Greece
    3. 3Department of Medicine and Makerere Lung Institute, Makerere University Faculty of Medicine, Kampala, Uganda
    4. 4Center of Training Family Medicine, University of Medicine and Pharmacy, Ho Chi Minh City, Viet Nam
    5. 5Pulmonary Department, National Center of Cardiology and Internal Medicine, Bishkek, Kyrgyzstan
    6. 6The Children's Institute, University of Cape Town, Cape Town, South Africa
    1. Correspondence to Evelyn A Brakema; evelynbrakema{at}


    Effectiveness of health interventions can be substantially impaired by implementation failure. Context-driven implementation strategies are critical for successful implementation. However, there is no practical, evidence-based guidance on how to map the context in order to design context-driven strategies. Therefore, this practice paper describes the development and validation of a systematic context-mapping tool. The tool was cocreated with local end-users through a multistage approach. As proof of concept, the tool was used to map beliefs and behaviour related to chronic respiratory disease within the FRESH AIR project in Uganda, Kyrgyzstan, Vietnam and Greece. Feasibility and acceptability were evaluated using the modified Conceptual Framework for Implementation Fidelity. Effectiveness was assessed by the degree to which context-driven adjustments were made to implementation strategies of FRESH AIR health interventions. The resulting Setting-Exploration-Treasure-Trail-to-Inform-implementatioN-strateGies (SETTING-tool) consisted of six steps: (1) Coset study priorities with local stakeholders, (2) Combine a qualitative rapid assessment with a quantitative survey (a mixed-method design), (3) Use context-sensitive materials, (4) Collect data involving community researchers, (5) Analyse pragmatically and/or in-depth to ensure timely communication of findings and (6) Continuously disseminate findings to relevant stakeholders. Use of the tool proved highly feasible, acceptable and effective in each setting. To conclude, the SETTING-tool is validated to systematically map local contexts for (lung) health interventions in diverse low-resource settings. It can support policy-makers, non-governmental organisations and health workers in the design of context-driven implementation strategies. This can reduce the risk of implementation failure and the waste of resource potential. Ultimately, this could improve health outcomes.

    • diagnostics and tools
    • health policies and all other topics
    • public health
    • asthma
    • chronic obstructive pulmonary disease

    This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

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    • Handling editor Seye Abimbola

    • Collaborators On behalf of the FRESH AIR collaborators: Pham Le An, Marilena Anastasaki, Azamat Akylbekov, Andy Barton, Antonios Bertsias, Pham Duong Uyen Binh, Job FM van Boven, Evelyn A Brakema, Dennis Burges, Lucy Cartwright, Vasiliki E Chatzea, Niels H Chavannes, Liza Cragg, Tran Ngoc Dang, Ilyas Dautov, Berik Emilov, Irene Ferarrio, Frederik A van Gemert, Ben Hedrick, Le Huynh Thi Cam Hong, Nick Hopkinson, Elvira Isaeva, Rupert Jones, Corina de Jong, Sanne van Kampen, Winceslaus Katagira, Bruce Kirenga, Jesper Kjærgaard, Rianne MJJ van der Kleij, Janwillem Kocks, Le Thi Tuyet Lan, Tran Thanh Duv Linh, Christos Lionis, Kim Xuan Loan, Maamed Mademilov, Andy McEwen, Patrick Musinguzi, Rebecca Nantanda, Grace Ndeezi, Sophia Papadakis, Hilary Pinnock, Jillian Pooler, Charlotte C Poot, Maarten J Postma, Anja Poulsen, Pippa Powell, Nguyen Nhat Quynh, Susanne Reventlow, Dimitra Sifaki-Pistolla, Sally Singh, Talant Sooronbaev, Jaime Correia de Sousa, James Stout, Marianne Stubbe Østergaard, Aizhamal Tabyshova, Ioanna Tsiligianni, Tran Diep Tuan, James Tumwine, Le Thanh Van, Nguyen Nhu Vinh, Simon Walusimbi, Louise Warren, Sian Williams.

    • Contributors EB led the design, conduct and analyses of the research. EB, CP and RvdK performed the literature searches for the theoretical underpinning of the methodology. Together with all coauthors, the identified methodological components were discussed and selected for the tool. The country experts—IT, SW, PLA and TS—specifically focused on local acceptability and feasibility. RR trained the team and supervised application of the methodology on the ground in the first setting. Analyses were performed by all researchers. EB wrote the manuscript and RvdK provided feedback on each version. All authors provided input and approved the final manuscript.

    • Funding His study was funded by the EU Research and Innovation program Horizon2020 (Health, Medical research and the challenge of ageing) under grant agreement no. 680997.

    • Competing interests None declared.

    • Patient and public involvement statement This methodology was cocreated with local stakeholders, among others with district health officers, health workers and community members. We closely collaborated through face-to-face and digital meetings.

    • Patient consent for publication Not required.

    • Ethics approval The study was approved by the coordinating centre and by each local research ethical review board: the Medical Ethical Committee of the Leiden University Medical Centre (P16.063;04/15/2016), the Mulago Research and Ethics Committee (933;03/31/2016), the Ho Chi Minh City University of Medicine and Pharmacy (188/DHYD-HD;06/27/2016), the National Centre of Cardiology and Internal Medicine in Bishkek Ethics Committee (5;03/03/2016), and the 7th Health Region of Crete (protocol 6951;05/27/2016).

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data availability statement All data and meta-data which are not already included in the supplementary materials will be available upon reasonable request within a reasonable time frame.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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