Development of a coding frame for context analysis in implementation: Insights from Sumamos Excelencia project

Development of a coding frame for context analysis in implementation: Insights from Sumamos Excelencia project | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Development of a coding frame for context analysis in implementation: Insights from Sumamos Excelencia project Leticia Bernués-Caudillo, Amanda Drury, Esther Gonzalez-María, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5676060/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background The selection, application and reporting of theories, models, and frameworks in implementation science can be challenging, hindering study comparisons and the advancement of science. Context analysis is a critical but underdeveloped area in implementation research. Structured approaches, such as coding frames informed by implementation science, can enhance methodological rigor and transparency. This study, part of the Sumamos Excelencia project, addresses these challenges by applying implementation frameworks to assess implementation context developing a coding frame to analyze qualitative interviews conducted during the project. The project implemented evidence-based recommendations in Spanish healthcare units using a multifaceted implementation strategy. Methods A literature review guided theories, models, and frameworks selection, integrating the Consolidated Framework for Implementation Research, Tailored Implementation for Chronic Diseases checklist, Expert Recommendations for Implementing Change, and Exploration, Preparation, Implementation, Sustainment framework. A coding frame was developed adhering to the content-driven process phases of Schreier’s methodology (selecting, structuring and generating, revising and expanding) and considering its requirements for a coding frame (unidimensionality, mutual exclusiveness, exhaustiveness, and saturation). Results Each framework provided valuable insights into the coding frame, complementing each other and enabling a comprehensive analysis of the complexity and multi-level aspects of context and implementation process. The integration of the results of the data-driven and concept-driven strategies resulted in a coding frame composed of 4 levels, 11 sublevels, 16 categories, and 82 contextual factors. The levels include factors related to the individuals involved in the implementation, factors related to the characteristics of the unit (internal context), factors related to the external context of the unit and factors related to the project's global implementation strategy. The strategies and the temporal phases were also incorporated into the coding frame. Conclusion This coding frame systematically captures context complexity, integrating constructs from multiple theories, models, and frameworks. It supports rigorous, standardized context analysis that is applicable beyond this project. This framework also offers a practical tool for mixed-method implementation studies, enabling novice researchers and healthcare professionals to analyze context comprehensively. Future research should validate and refine this framework across diverse settings to enhance its utility in advancing implementation science. Implementation science Coding Frame Contextual factors Context analysis Qualitative methods Qualitative analysis Figures Figure 1 Figure 2 Figure 3 Contributions to the literature This work: Contributes to implementation science by developing a coding frame for qualitative data that helps to capture context complexity across different implementation phases, enabling a holistic understanding of implementation. Demonstrates a novel and replicable approach to integrating multiple implementation science frameworks into a unified coding frame and advances systematic analysis of contextual factors. Enables standardized, rigorous context analysis and reporting that is applicable across diverse projects and ensures accessibility by using clear, user-friendly language suitable for healthcare professionals and novice researchers. BACKGROUND Explaining the rationale behind the selection of one or more theories, models and frameworks (TMFs) and detailing how they were applied in the study can be complex. Over the past few decades, the field of implementation has rapidly advanced, leading to numerous TMFs for implementation [ 1 , 2 , 3 , 4 ]. Despite this growth, a common concern among researchers engaged in implementation science is that many implementation papers fail to cite appropriately the TMFs employed, specify the phase of the study in which they were applied, or describe how they were used [ 1 , 5 , 6 , 7 , 8 ]. This issue may be attributed to the challenges of selecting an appropriate implementation framework for a specific study [ 9 ]. Researchers frequently find that no single TMF is fully suited to their project, necessitating the combination of multiple frameworks [ 9 , 10 ]. Inadequate reporting of methods or rationale for using TMFs limits the advancement of implementation science, impedes the synthesis and comparison of findings across studies [ 8 , 11 ], and contributes to the “paradoxical gap” between implementation research and practice [ 12 ]. It has been emphasized that providing detailed information on how implementation theory is applied in practice could enhance the consistency and rigor with which theory is applied [ 6 , 7 , 11 ]. Furthermore, the value of describing the process of developing coding frames for single research projects has been highlighted [ 13 , 14 ]. According to Schreier, a coding frame provides a structured approach to organizing data. It is composed of primary categories that delineate key aspects, along with subcategories that define specific meanings relevant to those aspects [ 15 ]. Coding frames have the potential to facilitate the management of large amounts of data throughout their analysis and interpretation, ensuring that attention remains focused on addressing the research questions. Moreover, they improve the consistency, rigor, and transparency of the coding process by offering precise definitions and criteria for researchers [ 13 , 14 , 15 ]. In light of these advantages, we conclude that a coding frame is essential for conducting a robust context analysis, as it ensures a comprehensive examination of the dynamic, multi-dimensional, and multi-level interactions between context, the implementation process, and the strategies employed. Context, as defined by Rogers et al. [ 16 ], as “a multi-dimensional construct encompassing micro, meso, and macro-level determinants that are pre-existing, dynamic, and emergent throughout the implementation process.” Understanding the influence of context is critical to the understanding of successful implementation [ 14 , 16 , 17 , 18 , 19 ], yet it is often overlooked in implementation studies. This oversight is partially due to the absence of a clear methodology for assessing, analyzing, and reporting on context [ 14 , 16 , 17 ]. As a result, there is significant variability in how context is defined, analyzed, and reported across studies, which hampers the understanding of implementation processes and outcomes [ 16 , 17 , 18 ]. Therefore, it is recommended to follow TMFs when conducting context analysis and provide detailed descriptions of the methods used, the factors assessed, and how this information influenced subsequent phases of the study [ 17 ]. For this purpose, some implementation researchers have remarked on the need for pragmatic methods to assess context [ 20 ]. In this paper, we aim to describe how we used implementation TMFs to develop a coding frame that allowed us to analyze the context, assess the implementation process and understand the reciprocal influences and evolution of these elements over time, also considering the implementation strategies applied. Study background This study is part of the Sumamos Excelencia project [ 21 ], which aims to implement evidence-based recommendations within healthcare units providing direct patient care. It encompasses a multicentric quasi-experimental before-and-after implementation study, with data collection at four time points: baseline, 3, 6, and 12 months, to evaluate the effects of implementing specific recommendations through a multifaceted strategy. This strategy combines discrete approaches (training, ongoing support, facilitation, audits, context analysis, tailored strategy design at the units) organized on two levels: one led by the global coordinating team and the other by the local implementation team at each unit. The project is conducted in hospitals, primary care centres, and nursing homes within the Spanish National Health System. It involves three types of participants: (1) Clinical units, (2) Health professionals, and (3) Patients who participate indirectly. Each unit forms a local implementation team of up to five members, led by a nurse, to carry out the implementation and selects one of four intervention packages to implement recommendations: pain assessment and management, conservative management of urinary incontinence, prevention of childhood obesity, or promotion of breastfeeding. Additionally, all units implement hand hygiene recommendations. Patients are included consecutively based on discharge dates, clinic visits, or residence, according to specific inclusion criteria of each package. One of the foundational pillars of the Sumamos Excelencia project is context analysis to identify barriers to implementation in each unit and design tailored strategies to overcome them, thereby ensuring successful implementation. To conduct the context analysis, local implementation teams completed a barriers questionnaire based on the comprehensive, integrated checklist of determinants of practice developed for the project Tailored Implementation for Chronic Diseases (The TICD checklist) [ 22 ]. To evaluate the project and analyze the evolution of contextual factors, in-depth interviews were conducted with leaders from some units implementing recommendations on pain assessment and management during the second half of the project. When the project was finished, a focus group was held with non-leader team members of the units implementing recommendations on the same topic. Sample selection was done for convenience, seeking a representative sample of participating units. The project lasted 15 months, from February 2022 to May 2023, was approved by the ethics committee of the Carlos III Health Institute (CEI_PI_18_2022) and registered in clinicaltrials.gov (NCT05466656) [ 23 ]. METHODS Theoretical Approach Considering the specific characteristics of the Sumamos Excelencia project, we define context as a comprehensive set of characteristics, conditions, and relationships within which an intervention is implemented. This broad interpretation includes not only the physical environment but also social roles, interactions, and organizational structures at multiple levels. These factors actively interact with the intervention, influencing its process and outcomes. Context, therefore, represents a dynamic and multilayered framework that shapes implementation and contributes to variations in its effectiveness across different settings [ 19 , 24 ]. We reviewed the implementation literature and identified theories, models and frameworks that align with our project methodology and research objectives. Based on the results of this literature review, our experience in implementation projects, and the criteria proposed by Birken et al. for selecting an appropriate TMF (usability, testability, applicability, and acceptability) [ 25 ], we chose a combination of the Consolidated Framework for Implementation Research (CFIR) [ 26 , 27 ] and the TICD checklist [ 22 ] to develop a comprehensive coding frame that enables us to explore the factors (barriers and facilitators) influencing the implementation process and outcomes during the Sumamos Excelencia Project. Furthermore, we utilized the Expert Recommendations for Implementing Change (ERIC list) [ 28 , 29 ] to map the strategies developed by the participating units and the Exploration, Preparation, Implementation, Sustainment (EPIS) framework [ 30 ] to divide the project into different phases and to identify changes in factors and strategies throughout these phases (Table 1 ). The Tailored Implementation for Chronic Disease ( TICD) checklist [ 22 ]: We developed a barriers questionnaire based on The TICD checklist because it straightforwardly collects all possible determinants of practice in the healthcare setting, aligning with our project scope and methodology. The TICD checklist was developed through a systematic review and a consensus process among implementation researchers within the framework of the Tailored Implementation for Chronic Disease project. It aims to provide insights into methods for tailoring implementation programs according to the determinants of evidence-based clinical practice for patients with chronic diseases. The original and the updated Consolidated Framework for Implementation Research (CFIR) [26, 27]: From month 6 to month 12 of the project, individual interviews and a focus group were conducted to analyze determinants encountered by the units, using a CFIR-based interview guide. CFIR, a widely used metatheoretical framework, was developed through a systematic review of the TMFs in implementation science, primarily within the healthcare sector, with the goal of integrating all published theories on implementation science into a single framework to guide implementation research. It was updated in 2022 based on user feedback [ 27 ]. The Expert Recommendations for Implementing Change (ERIC) list [28, 29]: Local implementation teams in Sumamos Excelencia design their own strategies after conducting context analysis. Consequently, the project's coordinating team does not control them, although we are convinced that strategies developed during the implementation significantly influence context. To analyze them, we integrated categories and strategies from the Expert Recommendations for Implementing Change (ERIC) list into the coding frame. ERIC was developed through a literature review, Delphi study, concept mapping and scoring process conducted by implementation experts. The Exploration, Preparation, Implementation, Sustainment (EPIS) framework [7, 30]: Sumamos Excelencia context analysis is longitudinal. To examine how context evolves over time during the implementation, we utilized the EPIS framework, adapting it to our project. EPIS, developed for the public service sector, outlines four well-defined phases (exploration, preparation, implementation, and sustainment) that guide the implementation process and identify levels within and between the external and internal contexts, as well as intermediate and innovation factors that interact with both contexts and the innovation or practice being implemented. Table 1 : Characteristics, components, advantages and limitations of the implementation frameworks used in Sumamos Excelencia. Development coding frame In developing this coding frame, we first used an inductive approach followed by a deductive approach, adhering to a content-driven process and considering the requirements of a coding frame highlighted by Schreier [ 15 ] (Fig. 1). Schreier's methods have previously been employed to develop the Normalization Process Theory coding manual for qualitative research [ 13 ]. 1. Selecting : We conducted a literature review and considered our experience in implementation to select the TMFs used in the coding frame: the TICD checklist, CFIR framework, ERIC list, and EPIS framework. 2) Structuring and generating: Data-driven strategy : We employed an inductive coding approach to capture factors related to the context and the implementation process that were not anticipated in the existing frameworks. This involved thematic line-by-line coding of qualitative interviews, resulting in codes and subcodes associated with the contextual factors (barriers and facilitators), strategies utilized, and the implementation process. Concept-driven strategy : Following the inductive approach, we planned a deductive analysis. TICD and CFIR frameworks were examined to identify similarities and overlaps in their constructs and factors, subsequently mapping TICD determinants onto CFIR domains. After this arrangement, we reviewed TICD determinants alongside CFIR sub-constructs, removing redundant categories and adding relevant information, which resulted in a code for deductively analyzing contextual factors. We modified the definitions and statements for each category and factor to align with the Sumamos Excelencia project methodology, leading to a reorganization of CFIR constructs by eliminating irrelevant categories to the context of the study. Inductively identified strategies were also mapped to the ERIC list. Additionally, we adapted the EPIS framework to the project and conducted an analysis of the interviews to capture mentions of time and phases of the implementation process, aiming to understand how the context evolved as implementation progressed. 3. Defining : After mapping frameworks, we integrated the categories and subcategories obtained from the inductive analysis with those from the deductive analysis. For instance, we added two categories to reflect the distinct influence of mid-level and senior leaders, acknowledging that their commitment could differently affect the implementation of recommendations across units. Subsequently, we defined each factor by adapting the definitions to the context and process of the Sumamos Excelencia. This involved combining various definitions provided by the frameworks and modifying them based on the inductive analysis results. For example, we included the patients’ support network in the contextual factors related to patients, as it was identified as an important factor for compliance with the recommendations. Each factor was assigned a label, a description, indicators specifying what would be considered a barrier or a facilitator, and a code, with illustrative examples drawn from interviews or constructed hypothetically. 4. Revising and expanding : Once the initial coding frame was created, it was reviewed to detect overlapping categories and collapse similar factors where possible. At this stage, the coding frame was piloted with qualitative interviews collected during the project. Two researchers experienced in the project recorded the interview transcripts and assessed whether the results obtained inductively could be enriched. Their feedback was discussed and incorporated into the framework. In a later phase of the analysis, we plan to expand the coding frame by incorporating quantitative data collected in the study, facilitating a mixed-methods analysis and evaluation of the implementation process. Figure 1: Coding frame construction process following Schreier's methodology. This systematic approach ensured that the coding frame was robust, adaptable, and reflective of the dynamic context in which the implementation was embedded, facilitating a deeper understanding of the factors influencing the success of the implementation process. RESULTS After reviewing the literature, and based on our judgment and experience as healthcare professionals, implementation researchers, and facilitators in various projects, we selected four implementation frameworks to develop our coding frame. We found that each framework provided valuable insights to the coding frame and that they complemented each other, enabling a comprehensive analysis of the complexity and multi-level aspects of context and implementation process. The inductive analysis of interviews resulted in 26 codes for contextual factors grouped as barriers and/or facilitators, as well as 13 different strategies. The concept-driven strategy for developing the coding frame resulted in a framework with 66 contextual factors structured within four CFIR domains (innovation domain, outer setting domain, inner setting domain, and individual’s domain). Reviewing CFIR constructs and TICD determinants of practice, we identified many similitudes, with some differences in their labels and definitions. Some constructs were unique to one framework, while others were related to multiple constructs in the other or expanded in our coding frame for greater specificity (see Additional file 1 for factors’ definitions with their references in CFIR and TICD and adapted ERIC strategies, and Additional file 2 for examples of each contextual factor). The ERIC strategies and the modified phases of EPIS were incorporated into the coding frame after contextual factors were described. The definition phase, where the results of the data-driven and concept-driven strategies were integrated, resulted in a coding frame composed of 4 levels, 11 sublevels, 16 categories, and 82 contextual factors. The levels include: A) Factors related to the individuals involved in the implementation; B) Factors related to the characteristics of the unit (internal context); C) Factors related to the external context of the unit; D) Factors related to the project global implementation strategy. Levels and sublevels were inspired by both the domains, constructs, and subconstructs of CFIR and the domains and categories of TICD (Fig. 2). Figure 2: Representation of the coding frame’s levels and sublevels and their relationships. All codes extracted inductively were previously included in the CFIR framework or the TICD checklist, except one: Professional stability. When incorporating the results of the inductive analysis, the most significant modifications were made to the coding frame's structure. Adjustments to the CFIR domains, constructs and/or subconstructs were necessary to accommodate certain contextual factors directly related to them. Although all the category definitions were initially informed by the CFIR framework, the definition of motivation was revised and replaced during the final phase, revising and expanding, with the one proposed in the COM-B model [ 31 ] as it was considered broader than the CFIR definition. Individual-Level Factors The level of factors related to the individuals involved in the implementation contains the most factors: 45, distributed across 12 categories. This is due to the consideration of five different sublevels: Local Implementation Team; professionals who must comply with the recommendations; unit leaders and/or managers; institution leaders and/or high-level managers; and patients and their support network. Several categories and factors from these sublevels are repeated, with adaptations based on the sublevel to which they refer. This organization is inspired by the relevant results of the inductive coding of the interviews. Another change derived from the interview’s inductive analysis is the inclusion of the patient support network within the sublevel related to patient factors. Internal Context Factors The second level corresponds to factors related to the unit’s characteristics, which we consider the internal context. We understand the internal context as all characteristics and factors belonging to the unit where the recommendations are implemented, including the physical environment, culture, and available resources. We include in the internal context those characteristics of the unit that can influence how the evidence-based recommendations proposed in Sumamos Excelencia are aligned with unit culture or whether they are suitable for the unit itself. This level considers four sublevels: alignment between recommendations and unit organization, factors related to unit management characteristics; resources available to implement the recommendations; and relationships between unit members. In total, this level comprises 24 factors. External Context Factors The third level pertains to the unit’s external context. We define external context as all characteristics and factors that do not directly belong to the unit but can influence the outcomes of the implementation. This level includes two sublevels: the context of the institution where the unit is located and the sociopolitical context. Each sublevel consists of two categories, which together provide ten factors. Global Implementation Factors Finally, the fourth level encompasses the factors related to the global implementation strategy of the project and consists of three factors that were consistently identified as relevant throughout the qualitative interviews (Fig. 3). Figure 3: Schematic Representation of Coding Frame Contextual Factors Levels, Sublevels, and Categories. All factor definitions were developed considering the definitions of the CFIR or TICD frameworks and adapted to the Sumamos Excelencia project. Considering Sumamos Excelencia project characteristics, where evidence-based recommendations are selected and evaluated by a group of experts, and due to voluntary participation, we consider that constructs related to CFIR’s innovation domain and the TICD guideline factors were not pertinent in this coding frame. However, we retained those factors related to professional’s perceptions of the recommendations, creating a dedicated category for these at the level of factors related to the individuals involved in the implementation. We also kept those related to the recommendation’s adaptability to the context, which were transferred to the level of factors related to the unit’s characteristics. CFIR domain related to the implementation process was also removed from our coding frame, considering that factors related to this domain are already included in the level of the global implementation strategy, as well as the ERIC strategies and the phases of the EPIS framework. ERIC strategies were added with some modifications in their descriptions. To code strategies, we followed Proctor’s definition of strategy as “methods or techniques used to enhance the adoption, implementation, and sustainability of a clinical program or practice” [ 32 ]. Only one strategy was added to the ERIC list: informing professionals involved in the implementation. The implementation phases inspired by the EPIS framework are intended to mark factors transversally, which is another axis to consider during the coding. Following this framework, Sumamos Excelencia methodology, and the inductive analysis of qualitative interviews, we can divide the project into four distinct phases: Exploration, Preparation, Implementation, and Evaluation and sustainability (Table 2). Table 2: Implementation Phases of the Sumamos Excelencia Project based on EPIS framework. The contextual factors influencing implementation outcomes can be organized according to these phases, allowing for an observation of when certain factors are more relevant than others or how factors influence change over time. DISCUSSION The aim of developing this coding frame was to demonstrate how the implementation science has been used to codify data and analyze context in the Sumamos Excelencia project. Integrating different constructs from multiple TMFs enables us to clearly and systematically represent the complexity of context and the implementation process at various levels. This approach avoids oversimplifying the multifaceted processes and factors that can influence implementation. According to Schroeder et al., utilizing different TMFs to investigate how innovations are implemented is a complex process, but it adds significant value to the research [ 33 ]. On the other hand, is been discussed that employing multiple TMFs for coding data can increase time, resources, and project management complexity. This problem arises especially when researchers code the data separately for each framework [ 34 ]. However, mapping the frameworks first and then coding data using a unified coding frame reduces the time required for coding, avoiding the need to code data multiple times with different frameworks. In our study, combining various determinant frameworks and taxonomies is compelling because it enables us to describe the contextual factors influencing implementation and the processes followed by participating units in greater depth. This approach illustrates complexity in an easily understandable manner for all stakeholders involved and reflects the strategies that units employ to overcome these factors at each implementation phase. Furthermore, our coding frame aims to enhance understanding of the dynamic and evolving relationship between context and the implementation process by systematically illuminating how these two elements influence each other over time. Mielke et al. highlighted the issue of vague definitions in conceptualizing context and their negative consequences, such as limiting opportunities to understand, summarize, or compare contextual analysis results [ 17 ]. Another issue in context analysis is that the tools designed for this purpose often use highly technical language, which frequently requires researchers with expertise in implementation science to conduct the analysis [ 20 ]. However, no one understands context better than the professionals working on it. To address this, we ensured that the levels, sublevels, categories, and factors were structured and described using accessible language suitable for healthcare professionals and researchers with limited knowledge of implementation science, while maintaining precise, detailed definitions for each element. Therefore, we considered it essential to develop a user-friendly coding frame for healthcare professionals and novice researchers, enabling standardized and rigorous context assessments and coding that are applicable not only to the Sumamos Excelencia project but also to other implementation projects. This decision aligns with recommendations from other authors who have emphasized the importance of connecting implementation research with implementation practice as a key step in bridging the gap between research evidence and practical application [ 24 ]. Previous studies have successfully combined CFIR with the Theoretical Domains Framework (TDF) to address different conceptual levels and determinants [ 34 , 35 ]. However, we selected TICD instead of TDF. We believe that TICD, in combination with CFIR, sufficiently addresses the main levels and factors influencing implementation for our research purpose, with fewer domains and factors (14 domains and 84 constructs in TDF vs. seven domains and 57 determinants in TICD). Moreover, while TDF focuses on behavioural factors, TICD offers a comprehensive checklist considering a wide array of determinants, including guideline, social, political, and legal factors, which we found ideal for complementing CFIR domains. While some CFIR constructs and definitions are considered too broad [ 34 ], potentially complicating coding and data interpretation, the TICD checklist offers concrete factors definitions, including questions for detecting them, examples, and related strategies. Combining these two frameworks results in a comprehensive list of factors with detailed definitions and examples, which, used as a coding frame, facilitates the identification and classification of data. Rogers et al. [ 16 ] emphasized the importance of reporting not only the factors analyzed in the context analysis but also the levels at which they operate. Adhering to this recommendation, we provide detailed information about the levels, sublevels, and categories in our coding frame. Context has been conceptualized in many implementation frameworks (TMFs) as a key category in implementation studies. Some of them use categories for different levels of context, while others employ subcategories within a broad context category. For certain TMFs, context is one of the categories that influence the implementation, along with other categories of determinants of practice [ 16 ]. Context is often defined as everything surrounding the implementation, except the intervention itself [ 16 , 18 ]; consequently, in this definition, we decided to exclude intervention characteristics from the context analysis. Another CFIR domain that we did not include in our coding frame was the "implementation process". We believe the implementation process is adequately addressed by considering the factors related to the overall implementation strategy, the ERIC strategy list, and the phases of implementation over time. Adding the implementation process construct would introduce unnecessary complexity and redundancy to our coding frame. Our coding frame includes individual stakeholder characteristics (e.g., professionals or patient factors) as part of the context, although many TMFs consider them separately from context [ 16 ]. We argue that these individual factors can significantly influence both internal and external contexts, as well as the implementation process. They should be considered alongside other important factors, such as resource availability and organizational priorities in any context analysis. Additionally, we incorporated factors related to the implementation phases and strategies into our context analysis. These elements constantly interact during implementation, and their boundaries often remain unclear. Understanding changes in context or the success or failure of implementation requires considering all of them together. The updated CFIR version [ 27 ] introduces several constructs in the individual factors domain to consider their roles and characteristics. This revised version includes roles such as high- and mid-level leaders, Implementation Team Members, and Implementation Facilitators. We adapted these roles for our project, but instead of including them as constructs in our coding frame, we added them as sublevels within the individual level. These sublevels were further organised into the categories of capability, relationships, perceptions, and motivation. Not all sublevels include the same categories, as these were defined based on the factors identified as relevant during the inductive analysis of the qualitative interviews. The only categories common to all sublevels are capability and motivation. While the development of the definitions for these categories adhered to the CFIR framework, the definition of motivation was drawn from the COM-B model [ 31 ]. This choice was made because the broader scope of the COM-B definition allowed for a more detailed breakdown of this category into specific factors. For each category, we identified the most significant factors where these roles can influence the implementation, guided by the inductive interview analysis. In developing their pragmatic context assessment tool (pCAT), Robinson and Damschroder [ 20 ] utilized the think-aloud technique to include feedback from the frontline improvement team. In this process, professionals suggested some important factors and considerations, such as the differentiation between different levels of leadership and time as a resource to make the change happen. Time was also one of the most frequently mentioned factors in the inductive analysis of our qualitative interviews. Accordingly, we add a factor in the sublevel of the local implementation team: “Time available to develop the implementation”. Lack of time was also one of the most cited reasons for professionals not to comply with recommendations. However, in our data, professionals lack of time was never identified as a standalone factor but always in relation to other issues, such as staff shortages, patient care complexity, or slow technological equipment. Considering this, we decided not to include a specific factor referring solely to lack of time. We believe that doing so could oversimplify the coding of underlying factors contributing to time constraints, thereby reducing analysis depth and richness. In our coding frame, we identified two sublevels within the external context. One sublevel addresses factors outside the unit but still within the institution, while the other pertains to the sociopolitical context beyond the organization. Researchers often overlook the barriers and facilitators outside organizations [ 17 , 36 ]. However, it is crucial to consider these factors as they likely influence implementation [ 7 , 36 ], especially when political factors (e.g., nurse-patient ratios) or social aspects (e.g., breastfeeding social media campaigns) come into play. Sumamos Excelencia’s specific characteristics require the ERIC strategy list to be included in the coding frame. Although the project applies a multifaceted strategy uniformly across all units, local implementation teams must design strategies tailored to their contexts to facilitate the implementation of the intervention package. These strategies are coded using the ERIC list, a comprehensive, widely used tool [ 37 , 38 ]. This choice allows us to compare our results with other studies. Additionally, considering contextual factors alongside strategies across different implementation phases enables us to analyse when and why certain strategies are employed and the contextual changes they produce throughout the project [ 14 ]. In other implementation projects where all strategies are known in advance, including this aspect may not be necessary. For the development of this coding frame, we followed Schreier’s methodology [ 15 ]. Schreier proposes that coding frames must comply with the requirements of unidimensionality, mutual exclusiveness, exhaustiveness, and saturation. Unidimensionality suggests that a coding frame should consist of a single dimension. However, our framework includes some repetition of factor labels across different levels (e.g., leadership style appearing in unit leaders, institutional leaders, and implementation team members). We repeat factors at different levels when the levels were sufficiently distinct, so the same factor influenced implementation in different ways and required different strategies. This repetition may make the coding frame less parsimonious than it should be [ 35 ], but it clarifies the different influences the factor can have when acting at various levels. Though it results in a more extensive framework, it is worth it to directly distinguish the level at which the factors operate and their influence within the context. This approach simplifies data analysis, making it easier for novice researchers or those less familiar with implementation science. Mutual Exclusiveness ensures that each coding unit is assigned to only one subcategory. We carefully built definitions to differentiate factors across levels, sublevels, categories, and factors, minimizing ambiguity. When similar factor definitions were found, we combined them into one to prevent confusion. This attention to definition wording ensures that each factor in the framework is clearly distinguishable from others, supporting accurate data coding. Exhaustiveness requires that all relevant factors are captured by at least one subcategory of the coding frame. By mapping the different frameworks and incorporating the results from the inductive analysis of interviews conducted during the project, we aimed to ensure that the coding frame is both exhaustive and comprehensive. We also included a "miscellaneous" subcategory at each level to account for any factors not represented within the main subcategories. Saturation demands that each subcategory be used at least once during analysis. This criterion does not apply to our approach, as we used a data-driven approach. Limitations A limitation of this coding frame is the possibility of researcher bias, as it emerged organically during a doctoral thesis without a protocol, potentially affecting its transparency and replicability. Efforts to mitigate this bias included consulting experienced researchers. Another limitation is that the frameworks used lack in-depth explanations of how implementation occurs in specific contexts. To achieve this, a theory such as the Normalization Process Theory (NPT) [ 39 ] would have been more appropriate. Finally, this coding frame does not consider the sustainability of the implementation of recommendations, as qualitative interviews were conducted during or immediately after the project. CONCLUSION The development of this coding frame offers valuable insights into the contextual factors and their evolution during the implementation process. By adapting established TMFs to the specific needs of the Sumamos Excelencia project, we have created a tool that provides a detailed, structured approach to analysing context, applicable not only to this project but also to other implementation efforts seeking a comprehensive context analysis. This coding frame facilitates the structured organization of factors in a meaningful and relevant way, enabling a deeper understanding of the implementation process in future research. Its adaptability makes it useful for healthcare professionals and novice researchers, ensuring rigorous, standardized coding while maintaining clarity and accessibility. Furthermore, it could be used to integrate qualitative and quantitative data into mixed-method analyses, enhancing the understanding of context at various levels. Future research should focus on refining and validating this approach to verify coding patterns across multiple studies. This process will help establish the benefits of combining these frameworks and support linking coding to theory. Ultimately, this coding frame holds the potential to evolve into a practical tool for future editions of Sumamos Excelencia and beyond, helping to bridge the gap between implementation research and practice. Table 1 Characteristics, components, advantages and limitations of the implementation frameworks used in Sumamos Excelencia. Framework’s name Characteristics Components Advantages Limitations TICD checklist Developed through a systematic review and a consensus process among implementation researchers aimed to provide insights on methods to tailor implementation programs according to the determinants of evidence-based clinical practice for patients with chronic diseases. 57 determinants of practice divided into seven domains (guideline factors; individual health professional factors; patient factors; professional interactions; incentives and resources; capacity for organizational change; social, political and legal factors. Represents a comprehensive list of determinants of healthcare practice relevant for effecting changes in such practice, applicable across various settings and practices. For Sumamos Excelencia project, the domains’ organization does not allow us to locate where each of the factors occur (different levels of context). CFIR framework Metatheoretical framework, including constructs from a synthesis of existing theories, without representing specific interrelations, ecological levels, or concrete hypotheses. It was developed through a systematic review of the FMTs in the field of implementation science, primarily within the healthcare sector, with the goal of integrating all published theories on implementation science into a single framework to guide implementation research. It was updated in 2022 based on user feedback. Original CFIR : 39 constructs organized into 5 domains (intervention characteristics domain, outer setting domain, inner setting domain, characteristics of individuals, process) Updated CFIR : 48 constructs and 19 subconstructs across 5 domains (innovation domain, outer setting domain, inner setting domain, individuals domain, implementation process domain) Is one of the most employed frameworks in implementation science, applicable across settings and innovations, useful for reporting determinants and designing implementation strategies and the domains and constructs are easy to understand. The updated version overcomes some of the problems of the previous version, such as the difficulty of understanding the meaning of some constructs and adds determinants identified by the users. Domains structure, with some changes, is in line with the structure we have identified during Sumamos Excelencia. Is a generalized framework, needing adaptation. It is not considered easy to use by non-researchers and has been criticised for being more complicated than necessary. We consider constructs organization too complex to be used in Sumamos Excelencia without adaptation, as its structure does not adequately represent the organizational structures of the healthcare units participating in the project. Furthermore, this organisation does not allow us to identify the level of the context in which the determinants occur. ERIC list The ERIC list provides a compilation of discrete strategies that can be used to build tailored multifaceted strategies for implementation. Was developed by a review of health and mental health literature, a modified Delphi process and concept mapping, 73 implementation strategies, 9 thematic groups: Use evaluative and iterative strategies, Provide interactive assistance, Adapt and tailor to context, Develop stakeholder interrelationships, Train and educate stakeholders, Support clinicians, Engage consumers, Utilize financial strategies, Change infrastructure. This list of strategies is recommended to standardize the way in which strategies used in implementation projects and research are described and reported. It provides clear labels and detailed definitions for implementation strategies, it is applicable to health and mental health settings and it is based on consensus of implementation experts. Some strategies used in Sumamos Excelencia were not included in the list. It had to be completed and adapted for use in the Sumamos Excelencia project. EPIS framework The EPIS framework is a comprehensive, standalone implementation framework developed based on review of the literature on implementation in public sector social and allied health service systems in the USA. Four phases: exploration, preparation, implementation, and sustainment. Identifies levels within and between the external and internal contexts, intermediate and innovation factors that interact with both contexts and the innovation or practice being implemented. It is one of the most used implementation frameworks in public sector settings. It has broad applicability in different countries and Health or allied health settings. EPIS offer a multi-level conceptualization of the implementation process, including factors at the individual, organizational, and systems levels. The four phases of EPIS, with some modifications, were considered useful to organize Sumamos Excelencia project factors in a temporary manner and evaluate their changes according to the different phases of the project. Designed for specific use in the public service sector. Needed adaptation to fit with Sumamos Excelencia phases. Table 2: Implementation Phases of the Sumamos Excelencia Project based on EPIS framework. Phase Description Exploration The unit expresses interest in the project or receives encouragement from its institution to participate. The most suitable intervention package, based on the unit's needs is selected, and the implementation team is formed. Finally, the unit completes and formalizes its application to participate in the project. Preparation The local implementation team receives training about the project and conducts a baseline audit and context analysis. Following this, they design implementation strategies tailored to the unit in accordance with the context analysis. Implementation Once the local implementation team designs the strategies , the implementation phase begins, and the strategies must be developed. This phase is divided into: Initial Implementation (0 to 3 months): where the local implementation teams within the units start to implement the strategies, seek support, and gather resources. Consolidation of Implementation (3 to 6 months): Following the initial period, the local implementation team conducts the second audit and context analysis. After the initial phase, the team may discover new barriers or need to adjust the strategies. After the second audit, the planning becomes more stable, and the team gains confidence in their actions. Maintenance of Implementation (6 to 12 months): after the first six months, most strategies have been developed, and the local implementation team within the units seeks to maintain compliance with the recommendations. Evaluation and Sustainability After 12 months of implementation, units review their achievements and consider how compliance with the recommendations will continue when the project concludes. Abbreviations TMF: theories, models and frameworks TICD: Tailored Implementation for Chronic Diseases CFIR: Consolidated Framework for Implementation Research ERIC: Expert Recommendations for Implementing Change EPIS: Exploration, Preparation, Implementation, Sustainment TDF: Theoretical Domains Framework pCAT: pragmatic context assessment tool NPT: Normalization Process Theory Declarations Ethics approval and consent to participate: Not applicable Consent for publication: Not applicable Availability of data and materials: Not applicable Competing interests: The authors declare no competing interest. Funding: Partially financed by Spanish Centre for Evidence-Based Nursing and Healthcare: A Joanna Briggs Institute Centre of Excellence. Contributions : AD proposed the study and initial design. All authors contributed to the theoretical conceptualization of the manuscript. LBC wrote the main manuscript text. AD, TMC, EGM and LBC reviewed the manuscript and made important contributions. The authors have read and approved the final manuscript. Acknowledgements: Research reported in this publication is supported by the Spanish Centre for Evidence Based Nursing and Healthcare (Nursing and Health Care Research Unit, ISCIII). The content is solely the responsibility of the authors and does not necessarily represent the official views of the Spanish Centre for Evidence Based Nursing and Healthcare. The authors thank Dr. Azucena Pedraz-Marcos for her support in the development of this study, as well as the Dublin City University for their collaboration in this research. Authors' information: Leticia Bernués-Caudillo, BSN, MSc, RN, is Predoctoral Nurse Researcher at the Spanish Centre for Evidence Based Nursing and Healthcare: A Joanna Briggs Institute Centre of Excellence (Madrid, Spain). Amanda Drury, MSc, PhD, RN, is associate Professor in General Nursing at the School of Nursing, Psychotherapy and Community Health, Dublin City University, Glasnevin. (Dublin, Ireland) Esther González-María, MSc, PhD, RN, and M. Teresa Moreno-Casbas, PhD, FEAN, FAAN, RN, are Senior Researchers at the Nursing and Health Research Unit (Investén-isciii), the Spanish Center for Evidence-Based Nursing and Healthcare: A Joanna Briggs Institute Centre of Excellence; and the Biomedical Research Network Centre on Frailty and Healthy Ageing (CIBERFES ISCIII) (Madrid, Spain). References Birken SA, Powell BJ, Shea CM, Haines ER, Alexis Kirk M, Leeman J, et al. Criteria for selecting implementation science theories and frameworks: Results from an international survey. Implement Sci. 2017;12(1):124. https://doi.org/10.1186/s13012-017-0656-y. Lynch EA, Mudge A, Knowles S, Kitson AL, Hunter SC, Harvey G. “there is nothing so practical as a good theory”: A pragmatic guide for selecting theoretical approaches for implementation projects. BMC Health Serv Res. 2018;18(1):857. https://doi.org/10.1186/s12913-018-3671-z. Nilsen P. Making sense of implementation theories, models and frameworks. Implement Sci. 2015;10:53. https://doi.org/10.1186/s13012-015-0242-0. Villalobos Dintrans P, Bossert TJ, Sherry J, Kruk ME. A synthesis of implementation science frameworks and application to global health gaps. Glob Health Res Policy 2019;4:25. https://doi.org/10.1186/s41256-019-0115-1. Field B, Booth A, Ilott I, Gerrish K. Using the Knowledge to Action Framework in practice: a citation analysis and systematic review. Implement Sci 2014;9:172. https://doi.org/10.1186/s13012-014-0172-2. Mcevoy R, Ballini L, Maltoni S, O’donnell CA, Mair FS, Macfarlane A. A qualitative systematic review of studies using the normalization process theory to research implementation processes. Implement Sci 2014;9:2. doi:10.1186/1748-5908-9-2. Moullin JC, Dickson KS, Stadnick NA, Rabin B, Aarons GA. Systematic review of the Exploration, Preparation, Implementation, Sustainment (EPIS) framework. Implement Sci 2019;14:1. https://doi.org/10.1186/s13012-018-0842-6. Skolarus TA, Lehmann T, Tabak RG, Harris J, Lecy J, Sales AE. Assessing citation networks for dissemination and implementation research frameworks. Implement Sci 2017;12:97. https://doi.org/10.1186/s13012-017-0628-2. Moullin JC, Sabater-Hernández D, Fernandez-Llimos F, Benrimoj SI. A systematic review of implementation frameworks of innovations in healthcare and resulting generic implementation framework. Health Res Policy Syst 2015;13:16. https://doi.org/10.1186/s12961-015-0005-z. Tabak RG, Khoong EC, Chambers DA, Brownson RC. Bridging research and practice: Models for dissemination and implementation research. Am J Prev Med 2012;43:337–50. https://doi.org/10.1016/j.amepre.2012.05.024. Kirk MA, Kelley C, Yankey N, Birken SA, Abadie B, Damschroder L. A systematic review of the use of the Consolidated Framework for Implementation Research. Implement Sci 2016;11:72. https://doi.org/10.1186/s13012-016-0437-z. Westerlund A, Sundberg L, Nilsen P. Implementation of Implementation Science Knowledge: The Research-Practice Gap Paradox. Worldviews Evid Based Nurs 2019;16:332–4. https://doi.org/10.1111/wvn.12403. May CR, Albers B, Bracher M, Finch TL, Gilbert A, Girling M, et al. Translational framework for implementation evaluation and research: a normalisation process theory coding manual for qualitative research and instrument development. Implement Sci 2022;17:19. https://doi.org/10.1186/s13012-022-01191-x. Rogers L, De Brún A, McAuliffe E. Development of an integrative coding framework for evaluating context within implementation science. BMC Med Res Methodol 2020;20:158. https://doi.org/10.1186/s12874-020-01044-5. Schreier M. Qualitative content analysis in practice. London: SAGE; 2012. Rogers L, De Brún A, McAuliffe E. Defining and assessing context in healthcare implementation studies: A systematic review. BMC Health Serv Res 2020;20:591. https://doi.org/10.1186/s12913-020-05212-7. Mielke J, Brunkert T, Zúñiga F, Simon M, Zullig LL, De Geest S. Methodological approaches to study context in intervention implementation studies: an evidence gap map. BMC Med Res Methodol 2022;22:320. https://doi.org/10.1186/s12874-022-01772-w. Nilsen P, Bernhardsson S. Context matters in implementation science: A scoping review of determinant frameworks that describe contextual determinants for implementation outcomes. BMC Health Serv Res 2019;19:189. https://doi.org/10.1186/s12913-019-4015-3. Pfadenhauer LM, Gerhardus A, Mozygemba K, Lysdahl KB, Booth A, Hofmann B, et al. Making sense of complexity in context and implementation: The Context and Implementation of Complex Interventions (CICI) framework. Implement Sci 2017;12:21. https://doi.org/10.1186/s13012-017-0552-5. Robinson CH, Damschroder LJ. A pragmatic context assessment tool (pCAT): using a Think Aloud method to develop an assessment of contextual barriers to change. Implement Sci Commun 2023;4:3. https://doi.org/10.1186/s43058-022-00380-5. Bernués-Caudillo L, González-María E, Albornos-Muñoz L, Moreno-Casbas T. A multifaceted implementation strategy to enhance the uptake of evidence-based nursing recommendations in Spain: implementation project protocol. Rev Esp Salud Publica 2024;98: e202409053. Flottorp SA, Oxman AD, Krause J, Musila NR, Wensing M, Godycki-Cwirko M, et al. A checklist for identifying determinants of practice: A systematic review and synthesis of frameworks and taxonomies of factors that prevent or enable improvements in healthcare professional practice. Implement Sci 2013;8:35. https://doi.org/10.1186/1748-5908-8-35. Moreno-Casbas MT, González-María E, Bernués-Caudillo L, Cameselle-Lago C, Albornos-Muñoz L. SUMAMOS EXCELENCIA Project: Assessment of Implementation of Best Practices in a National Health System (Second Edition) [Internet]. ClinicalTrialsGov. NCT05466656; 2022 [cited 2024 Nov 30]. Available from: https://clinicaltrials.gov/study/NCT05466656?term=Sumamos%20Excelencia&rank=1 Harvey G, Rycroft-Malone J, Seers K, Wilson P, Cassidy C, Embrett M, et al. Connecting the science and practice of implementation – applying the lens of context to inform study design in implementation research. Front Health Serv 2023;3:1162762. https://doi.org/10.3389/frhs.2023.1162762. Birken SA, Rohweder CL, Powell BJ, Shea CM, Scott J, Leeman J, et al. T-CaST: An implementation theory comparison and selection tool. Implement Sci 2018;13:143. https://doi.org/10.1186/s13012-018-0836-4. Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science. Implement Sci 2009;4:50. https://doi.org/10.1186/1748-5908-4-50. Damschroder LJ, Reardon CM, Widerquist MAO, Lowery J. The updated Consolidated Framework for Implementation Research based on user feedback. Implement Sci 2022;17:75. https://doi.org/10.1186/s13012-022-01245-0. Powell BJ, Waltz TJ, Chinman MJ, Damschroder LJ, Smith JL, Matthieu MM, et al. A refined compilation of implementation strategies: Results from the Expert Recommendations for Implementing Change (ERIC) project. Implement Sci 2015;10:21. https://doi.org/10.1186/s13012-015-0209-1. Waltz TJ, Powell BJ, Matthieu MM, Damschroder LJ, Chinman MJ, Smith JL, et al. Use of concept mapping to characterize relationships among implementation strategies and assess their feasibility and importance: Results from the Expert Recommendations for Implementing Change (ERIC) study. Implement Sci 2015;10:109. https://doi.org/10.1186/s13012-015-0295-0. Aarons GA, Hurlburt M, Horwitz SMC. Advancing a conceptual model of evidence-based practice implementation in public service sectors. Adm Policy Ment Health 2011;38(1):4-23. https://doi.org/10.1007/s10488-010-0327-7. Michie S, van Stralen MM, West R. The behaviour change wheel: A new method for characterising and designing behaviour change interventions. Implement Sci 2011;6:42. https://doi.org/10.1186/1748-5908-6-42. Proctor EK, Powell BJ, McMillen JC. Implementation strategies: Recommendations for specifying and reporting. Implement Sci 2013;8:139. https://doi.org/10.1186/1748-5908-8-139 Schroeder D, Luig T, Finch TL, Beesoon S, Campbell-Scherer DL. Understanding implementation context and social processes through integrating Normalization Process Theory (NPT) and the Consolidated Framework for Implementation Research (CFIR). Implement Sci Commun 2022;3:13. https://doi.org/10.1186/s43058-022-00264-8. O’Donovan B, Kirke C, Pate M, McHugh S, Bennett K, Cahir C. Mapping the Theoretical Domain Framework to the Consolidated Framework for Implementation Research: do multiple frameworks add value? Implement Sci Commun 2023;4:100. https://doi.org/10.1186/s43058-023-00466-8. Birken, SA, Powell, BJ, Presseau, J, Kirk, MA, Lorencatto, F, Gould, NJ, et al. Combined use of the Consolidated Framework for Implementation Research (CFIR) and the Theoretical Domains Framework (TDF): A systematic review. Implement Sci 2017;12:2. https://doi.org/10.1186/s13012-016-0534-z Watson DP, Adams EL, Shue S, Coates H, McGuire A, Chesher J, et al. Defining the external implementation context: An integrative systematic literature review. BMC Health Serv Res 2018;18:209. https://doi.org/10.1186/s12913-018-3046-5. Lovero KL, Kemp CG, Wagenaar BH, Giusto A, Greene MC, Powell BJ, et al. Application of the Expert Recommendations for Implementing Change (ERIC) compilation of strategies to health intervention implementation in low- and middle-income countries: a systematic review. Implement Sci 2023;18:56. https://doi.org/10.1186/s13012-023-01310-2. Yakovchenko V, Chinman MJ, Lamorte C, Powell BJ, Waltz TJ, Merante M, et al. Refining Expert Recommendations for Implementing Change (ERIC) strategy surveys using cognitive interviews with frontline providers. Implement Sci Commun 2023;4:42. https://doi.org/10.1186/s43058-023-00409-3. May CR, Mair F, Finch T, MacFarlane A, Dowrick C, Treweek S, et al. Development of a theory of implementation and integration: Normalization Process Theory. Implement Sci 2009;4:29. https://doi.org/10.1186/1748-5908-4-29. Supplementary Files Additionalfileslegends.docx 7.Additionalfile1.docx 8.Additionalfile2.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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frame and advances systematic analysis of contextual factors.\u003c/li\u003e\n \u003cli\u003eEnables standardized, rigorous context analysis and reporting that is applicable across diverse projects and ensures accessibility by using clear, user-friendly language suitable for healthcare professionals and novice researchers.\u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"BACKGROUND","content":"\u003cp\u003eExplaining the rationale behind the selection of one or more theories, models and frameworks (TMFs) and detailing how they were applied in the study can be complex. Over the past few decades, the field of implementation has rapidly advanced, leading to numerous TMFs for implementation [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Despite this growth, a common concern among researchers engaged in implementation science is that many implementation papers fail to cite appropriately the TMFs employed, specify the phase of the study in which they were applied, or describe how they were used [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. This issue may be attributed to the challenges of selecting an appropriate implementation framework for a specific study [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Researchers frequently find that no single TMF is fully suited to their project, necessitating the combination of multiple frameworks [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eInadequate reporting of methods or rationale for using TMFs limits the advancement of implementation science, impedes the synthesis and comparison of findings across studies [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], and contributes to the \u0026ldquo;paradoxical gap\u0026rdquo; between implementation research and practice [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. It has been emphasized that providing detailed information on how implementation theory is applied in practice could enhance the consistency and rigor with which theory is applied [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Furthermore, the value of describing the process of developing coding frames for single research projects has been highlighted [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAccording to Schreier, a coding frame provides a structured approach to organizing data. It is composed of primary categories that delineate key aspects, along with subcategories that define specific meanings relevant to those aspects [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Coding frames have the potential to facilitate the management of large amounts of data throughout their analysis and interpretation, ensuring that attention remains focused on addressing the research questions. Moreover, they improve the consistency, rigor, and transparency of the coding process by offering precise definitions and criteria for researchers [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. In light of these advantages, we conclude that a coding frame is essential for conducting a robust context analysis, as it ensures a comprehensive examination of the dynamic, multi-dimensional, and multi-level interactions between context, the implementation process, and the strategies employed.\u003c/p\u003e \u003cp\u003eContext, as defined by Rogers et al. [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], as \u0026ldquo;a multi-dimensional construct encompassing micro, meso, and macro-level determinants that are pre-existing, dynamic, and emergent throughout the implementation process.\u0026rdquo; Understanding the influence of context is critical to the understanding of successful implementation [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], yet it is often overlooked in implementation studies. This oversight is partially due to the absence of a clear methodology for assessing, analyzing, and reporting on context [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. As a result, there is significant variability in how context is defined, analyzed, and reported across studies, which hampers the understanding of implementation processes and outcomes [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Therefore, it is recommended to follow TMFs when conducting context analysis and provide detailed descriptions of the methods used, the factors assessed, and how this information influenced subsequent phases of the study [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. For this purpose, some implementation researchers have remarked on the need for pragmatic methods to assess context [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn this paper, we aim to describe how we used implementation TMFs to develop a coding frame that allowed us to analyze the context, assess the implementation process and understand the reciprocal influences and evolution of these elements over time, also considering the implementation strategies applied.\u003c/p\u003e\n\u003ch3\u003eStudy background\u003c/h3\u003e\n\u003cp\u003eThis study is part of the Sumamos Excelencia project [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], which aims to implement evidence-based recommendations within healthcare units providing direct patient care. It encompasses a multicentric quasi-experimental before-and-after implementation study, with data collection at four time points: baseline, 3, 6, and 12 months, to evaluate the effects of implementing specific recommendations through a multifaceted strategy. This strategy combines discrete approaches (training, ongoing support, facilitation, audits, context analysis, tailored strategy design at the units) organized on two levels: one led by the global coordinating team and the other by the local implementation team at each unit.\u003c/p\u003e \u003cp\u003eThe project is conducted in hospitals, primary care centres, and nursing homes within the Spanish National Health System. It involves three types of participants: (1) Clinical units, (2) Health professionals, and (3) Patients who participate indirectly. Each unit forms a local implementation team of up to five members, led by a nurse, to carry out the implementation and selects one of four intervention packages to implement recommendations: pain assessment and management, conservative management of urinary incontinence, prevention of childhood obesity, or promotion of breastfeeding. Additionally, all units implement hand hygiene recommendations. Patients are included consecutively based on discharge dates, clinic visits, or residence, according to specific inclusion criteria of each package.\u003c/p\u003e \u003cp\u003eOne of the foundational pillars of the Sumamos Excelencia project is context analysis to identify barriers to implementation in each unit and design tailored strategies to overcome them, thereby ensuring successful implementation. To conduct the context analysis, local implementation teams completed a barriers questionnaire based on the comprehensive, integrated checklist of determinants of practice developed for the project Tailored Implementation for Chronic Diseases (The TICD checklist) [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. To evaluate the project and analyze the evolution of contextual factors, in-depth interviews were conducted with leaders from some units implementing recommendations on pain assessment and management during the second half of the project. When the project was finished, a focus group was held with non-leader team members of the units implementing recommendations on the same topic. Sample selection was done for convenience, seeking a representative sample of participating units.\u003c/p\u003e \u003cp\u003eThe project lasted 15 months, from February 2022 to May 2023, was approved by the ethics committee of the Carlos III Health Institute (CEI_PI_18_2022) and registered in clinicaltrials.gov (NCT05466656) [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003cdiv id=\"Sec4\" class=\"Section3\"\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"METHODS","content":"\u003ch2\u003eTheoretical Approach\u003c/h2\u003e\n\u003cp\u003eConsidering the specific characteristics of the Sumamos Excelencia project, we define context as a comprehensive set of characteristics, conditions, and relationships within which an intervention is implemented. This broad interpretation includes not only the physical environment but also social roles, interactions, and organizational structures at multiple levels. These factors actively interact with the intervention, influencing its process and outcomes. Context, therefore, represents a dynamic and multilayered framework that shapes implementation and contributes to variations in its effectiveness across different settings [\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eWe reviewed the implementation literature and identified theories, models and frameworks that align with our project methodology and research objectives. Based on the results of this literature review, our experience in implementation projects, and the criteria proposed by Birken et al. for selecting an appropriate TMF (usability, testability, applicability, and acceptability) [\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e], we chose a combination of the Consolidated Framework for Implementation Research (CFIR) [\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e] and the TICD checklist [\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e] to develop a comprehensive coding frame that enables us to explore the factors (barriers and facilitators) influencing the implementation process and outcomes during the Sumamos Excelencia Project. Furthermore, we utilized the Expert Recommendations for Implementing Change (ERIC list) [\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e] to map the strategies developed by the participating units and the Exploration, Preparation, Implementation, Sustainment (EPIS) framework [\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e] to divide the project into different phases and to identify changes in factors and strategies throughout these phases (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThe\u003c/em\u003e Tailored Implementation for Chronic Disease (\u003cem\u003eTICD) checklist\u003c/em\u003e [\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e]:\u003c/p\u003e\n\u003cp\u003eWe developed a barriers questionnaire based on The TICD checklist because it straightforwardly collects all possible determinants of practice in the healthcare setting, aligning with our project scope and methodology. The TICD checklist was developed through a systematic review and a consensus process among implementation researchers within the framework of the Tailored Implementation for Chronic Disease project. It aims to provide insights into methods for tailoring implementation programs according to the determinants of evidence-based clinical practice for patients with chronic diseases.\u003c/p\u003e\n\u003ch3\u003eThe original and the updated Consolidated Framework for Implementation Research (CFIR) [26, 27]:\u003c/h3\u003e\n\u003cp\u003eFrom month 6 to month 12 of the project, individual interviews and a focus group were conducted to analyze determinants encountered by the units, using a CFIR-based interview guide. CFIR, a widely used metatheoretical framework, was developed through a systematic review of the TMFs in implementation science, primarily within the healthcare sector, with the goal of integrating all published theories on implementation science into a single framework to guide implementation research. It was updated in 2022 based on user feedback [\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eThe Expert Recommendations for Implementing Change (ERIC) list [28, 29]:\u003c/h3\u003e\n\u003cp\u003eLocal implementation teams in Sumamos Excelencia design their own strategies after conducting context analysis. Consequently, the project\u0026apos;s coordinating team does not control them, although we are convinced that strategies developed during the implementation significantly influence context. To analyze them, we integrated categories and strategies from the Expert Recommendations for Implementing Change (ERIC) list into the coding frame. ERIC was developed through a literature review, Delphi study, concept mapping and scoring process conducted by implementation experts.\u003c/p\u003e\n\u003ch3\u003eThe Exploration, Preparation, Implementation, Sustainment (EPIS) framework [7, 30]:\u003c/h3\u003e\n\u003cp\u003eSumamos Excelencia context analysis is longitudinal. To examine how context evolves over time during the implementation, we utilized the EPIS framework, adapting it to our project. EPIS, developed for the public service sector, outlines four well-defined phases (exploration, preparation, implementation, and sustainment) that guide the implementation process and identify levels within and between the external and internal contexts, as well as intermediate and innovation factors that interact with both contexts and the innovation or practice being implemented.\u003c/p\u003e\n\u003cp\u003eTable\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e: \u003cstrong\u003eCharacteristics, components, advantages and limitations of the implementation frameworks used in Sumamos Excelencia.\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n \u003ch2\u003eDevelopment coding frame\u003c/h2\u003e\n \u003cp\u003eIn developing this coding frame, we first used an inductive approach followed by a deductive approach, adhering to a content-driven process and considering the requirements of a coding frame highlighted by Schreier [\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e] (Fig.\u0026nbsp;1). Schreier\u0026apos;s methods have previously been employed to develop the Normalization Process Theory coding manual for qualitative research [\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e\u003cspan\u003e\n \u003cp\u003e\u003cstrong\u003e1. Selecting\u003c/strong\u003e: We conducted a literature review and considered our experience in implementation to select the TMFs used in the coding frame: the TICD checklist, CFIR framework, ERIC list, and EPIS framework.\u003c/p\u003e\n \u003c/span\u003e\n\u003c/div\u003e\n\u003ch3\u003e2) Structuring and generating:\u003c/h3\u003e\n\u003cul\u003e\n \u003cli\u003e\n \u003cp\u003e\u003cstrong\u003eData-driven strategy\u003c/strong\u003e: We employed an inductive coding approach to capture factors related to the context and the implementation process that were not anticipated in the existing frameworks. This involved thematic line-by-line coding of qualitative interviews, resulting in codes and subcodes associated with the contextual factors (barriers and facilitators), strategies utilized, and the implementation process.\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003e\u003cstrong\u003eConcept-driven strategy\u003c/strong\u003e: Following the inductive approach, we planned a deductive analysis. TICD and CFIR frameworks were examined to identify similarities and overlaps in their constructs and factors, subsequently mapping TICD determinants onto CFIR domains. After this arrangement, we reviewed TICD determinants alongside CFIR sub-constructs, removing redundant categories and adding relevant information, which resulted in a code for deductively analyzing contextual factors. We modified the definitions and statements for each category and factor to align with the Sumamos Excelencia project methodology, leading to a reorganization of CFIR constructs by eliminating irrelevant categories to the context of the study. Inductively identified strategies were also mapped to the ERIC list. Additionally, we adapted the EPIS framework to the project and conducted an analysis of the interviews to capture mentions of time and phases of the implementation process, aiming to understand how the context evolved as implementation progressed.\u003c/p\u003e\n \u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003e3. Defining\u003c/strong\u003e: After mapping frameworks, we integrated the categories and subcategories obtained from the inductive analysis with those from the deductive analysis. For instance, we added two categories to reflect the distinct influence of mid-level and senior leaders, acknowledging that their commitment could differently affect the implementation of recommendations across units. Subsequently, we defined each factor by adapting the definitions to the context and process of the Sumamos Excelencia. This involved combining various definitions provided by the frameworks and modifying them based on the inductive analysis results. For example, we included the patients\u0026rsquo; support network in the contextual factors related to patients, as it was identified as an important factor for compliance with the recommendations. Each factor was assigned a label, a description, indicators specifying what would be considered a barrier or a facilitator, and a code, with illustrative examples drawn from interviews or constructed hypothetically.\u003c/p\u003e\n\u003cp\u003e\u003cspan\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4. Revising and expanding\u003c/strong\u003e: Once the initial coding frame was created, it was reviewed to detect overlapping categories and collapse similar factors where possible. At this stage, the coding frame was piloted with qualitative interviews collected during the project. Two researchers experienced in the project recorded the interview transcripts and assessed whether the results obtained inductively could be enriched. Their feedback was discussed and incorporated into the framework. In a later phase of the analysis, we plan to expand the coding frame by incorporating quantitative data collected in the study, facilitating a mixed-methods analysis and evaluation of the implementation process.\u003c/p\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFigure 1: Coding frame construction process following Schreier\u0026apos;s methodology.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis systematic approach ensured that the coding frame was robust, adaptable, and reflective of the dynamic context in which the implementation was embedded, facilitating a deeper understanding of the factors influencing the success of the implementation process.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eAfter reviewing the literature, and based on our judgment and experience as healthcare professionals, implementation researchers, and facilitators in various projects, we selected four implementation frameworks to develop our coding frame. We found that each framework provided valuable insights to the coding frame and that they complemented each other, enabling a comprehensive analysis of the complexity and multi-level aspects of context and implementation process.\u003c/p\u003e \u003cp\u003eThe inductive analysis of interviews resulted in 26 codes for contextual factors grouped as barriers and/or facilitators, as well as 13 different strategies. The concept-driven strategy for developing the coding frame resulted in a framework with 66 contextual factors structured within four CFIR domains (innovation domain, outer setting domain, inner setting domain, and individual\u0026rsquo;s domain). Reviewing CFIR constructs and TICD determinants of practice, we identified many similitudes, with some differences in their labels and definitions. Some constructs were unique to one framework, while others were related to multiple constructs in the other or expanded in our coding frame for greater specificity (see Additional file 1 for factors\u0026rsquo; definitions with their references in CFIR and TICD and adapted ERIC strategies, and Additional file 2 for examples of each contextual factor). The ERIC strategies and the modified phases of EPIS were incorporated into the coding frame after contextual factors were described.\u003c/p\u003e \u003cp\u003eThe definition phase, where the results of the data-driven and concept-driven strategies were integrated, resulted in a coding frame composed of 4 levels, 11 sublevels, 16 categories, and 82 contextual factors. The levels include: A) Factors related to the individuals involved in the implementation; B) Factors related to the characteristics of the unit (internal context); C) Factors related to the external context of the unit; D) Factors related to the project global implementation strategy. Levels and sublevels were inspired by both the domains, constructs, and subconstructs of CFIR and the domains and categories of TICD (Fig.\u0026nbsp;2).\u003c/p\u003e \u003cp\u003e \u003cb\u003eFigure 2: Representation of the coding frame\u0026rsquo;s levels and sublevels and their relationships.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eAll codes extracted inductively were previously included in the CFIR framework or the TICD checklist, except one: Professional stability. When incorporating the results of the inductive analysis, the most significant modifications were made to the coding frame's structure. Adjustments to the CFIR domains, constructs and/or subconstructs were necessary to accommodate certain contextual factors directly related to them.\u003c/p\u003e \u003cp\u003eAlthough all the category definitions were initially informed by the CFIR framework, the definition of motivation was revised and replaced during the final phase, revising and expanding, with the one proposed in the COM-B model [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] as it was considered broader than the CFIR definition.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eIndividual-Level Factors\u003c/h2\u003e \u003cp\u003eThe level of factors related to the individuals involved in the implementation contains the most factors: 45, distributed across 12 categories. This is due to the consideration of five different sublevels: Local Implementation Team; professionals who must comply with the recommendations; unit leaders and/or managers; institution leaders and/or high-level managers; and patients and their support network. Several categories and factors from these sublevels are repeated, with adaptations based on the sublevel to which they refer. This organization is inspired by the relevant results of the inductive coding of the interviews. Another change derived from the interview\u0026rsquo;s inductive analysis is the inclusion of the patient support network within the sublevel related to patient factors.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eInternal Context Factors\u003c/h2\u003e \u003cp\u003eThe second level corresponds to factors related to the unit\u0026rsquo;s characteristics, which we consider the internal context. We understand the internal context as all characteristics and factors belonging to the unit where the recommendations are implemented, including the physical environment, culture, and available resources. We include in the internal context those characteristics of the unit that can influence how the evidence-based recommendations proposed in Sumamos Excelencia are aligned with unit culture or whether they are suitable for the unit itself. This level considers four sublevels: alignment between recommendations and unit organization, factors related to unit management characteristics; resources available to implement the recommendations; and relationships between unit members. In total, this level comprises 24 factors.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eExternal Context Factors\u003c/h2\u003e \u003cp\u003eThe third level pertains to the unit\u0026rsquo;s external context. We define external context as all characteristics and factors that do not directly belong to the unit but can influence the outcomes of the implementation. This level includes two sublevels: the context of the institution where the unit is located and the sociopolitical context. Each sublevel consists of two categories, which together provide ten factors.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eGlobal Implementation Factors\u003c/h2\u003e \u003cp\u003eFinally, the fourth level encompasses the factors related to the global implementation strategy of the project and consists of three factors that were consistently identified as relevant throughout the qualitative interviews (Fig.\u0026nbsp;3).\u003c/p\u003e \u003cp\u003e \u003cb\u003eFigure 3: Schematic Representation of Coding Frame Contextual Factors Levels, Sublevels, and Categories.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eAll factor definitions were developed considering the definitions of the CFIR or TICD frameworks and adapted to the Sumamos Excelencia project.\u003c/p\u003e \u003cp\u003eConsidering Sumamos Excelencia project characteristics, where evidence-based recommendations are selected and evaluated by a group of experts, and due to voluntary participation, we consider that constructs related to CFIR\u0026rsquo;s innovation domain and the TICD guideline factors were not pertinent in this coding frame. However, we retained those factors related to professional\u0026rsquo;s perceptions of the recommendations, creating a dedicated category for these at the level of factors related to the individuals involved in the implementation. We also kept those related to the recommendation\u0026rsquo;s adaptability to the context, which were transferred to the level of factors related to the unit\u0026rsquo;s characteristics.\u003c/p\u003e \u003cp\u003eCFIR domain related to the implementation process was also removed from our coding frame, considering that factors related to this domain are already included in the level of the global implementation strategy, as well as the ERIC strategies and the phases of the EPIS framework.\u003c/p\u003e \u003cp\u003eERIC strategies were added with some modifications in their descriptions. To code strategies, we followed Proctor\u0026rsquo;s definition of strategy as \u0026ldquo;methods or techniques used to enhance the adoption, implementation, and sustainability of a clinical program or practice\u0026rdquo; [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Only one strategy was added to the ERIC list: informing professionals involved in the implementation.\u003c/p\u003e \u003cp\u003eThe implementation phases inspired by the EPIS framework are intended to mark factors transversally, which is another axis to consider during the coding. Following this framework, Sumamos Excelencia methodology, and the inductive analysis of qualitative interviews, we can divide the project into four distinct phases: Exploration, Preparation, Implementation, and Evaluation and sustainability (Table\u0026nbsp;2).\u003c/p\u003e \u003cp\u003e \u003cb\u003eTable\u0026nbsp;2: Implementation Phases of the Sumamos Excelencia Project based on EPIS framework.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe contextual factors influencing implementation outcomes can be organized according to these phases, allowing for an observation of when certain factors are more relevant than others or how factors influence change over time.\u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe aim of developing this coding frame was to demonstrate how the implementation science has been used to codify data and analyze context in the Sumamos Excelencia project. Integrating different constructs from multiple TMFs enables us to clearly and systematically represent the complexity of context and the implementation process at various levels. This approach avoids oversimplifying the multifaceted processes and factors that can influence implementation.\u003c/p\u003e \u003cp\u003eAccording to Schroeder et al., utilizing different TMFs to investigate how innovations are implemented is a complex process, but it adds significant value to the research [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. On the other hand, is been discussed that employing multiple TMFs for coding data can increase time, resources, and project management complexity. This problem arises especially when researchers code the data separately for each framework [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. However, mapping the frameworks first and then coding data using a unified coding frame reduces the time required for coding, avoiding the need to code data multiple times with different frameworks.\u003c/p\u003e \u003cp\u003eIn our study, combining various determinant frameworks and taxonomies is compelling because it enables us to describe the contextual factors influencing implementation and the processes followed by participating units in greater depth. This approach illustrates complexity in an easily understandable manner for all stakeholders involved and reflects the strategies that units employ to overcome these factors at each implementation phase. Furthermore, our coding frame aims to enhance understanding of the dynamic and evolving relationship between context and the implementation process by systematically illuminating how these two elements influence each other over time.\u003c/p\u003e \u003cp\u003eMielke et al. highlighted the issue of vague definitions in conceptualizing context and their negative consequences, such as limiting opportunities to understand, summarize, or compare contextual analysis results [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Another issue in context analysis is that the tools designed for this purpose often use highly technical language, which frequently requires researchers with expertise in implementation science to conduct the analysis [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. However, no one understands context better than the professionals working on it. To address this, we ensured that the levels, sublevels, categories, and factors were structured and described using accessible language suitable for healthcare professionals and researchers with limited knowledge of implementation science, while maintaining precise, detailed definitions for each element. Therefore, we considered it essential to develop a user-friendly coding frame for healthcare professionals and novice researchers, enabling standardized and rigorous context assessments and coding that are applicable not only to the Sumamos Excelencia project but also to other implementation projects. This decision aligns with recommendations from other authors who have emphasized the importance of connecting implementation research with implementation practice as a key step in bridging the gap between research evidence and practical application [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePrevious studies have successfully combined CFIR with the Theoretical Domains Framework (TDF) to address different conceptual levels and determinants [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. However, we selected TICD instead of TDF. We believe that TICD, in combination with CFIR, sufficiently addresses the main levels and factors influencing implementation for our research purpose, with fewer domains and factors (14 domains and 84 constructs in TDF vs. seven domains and 57 determinants in TICD). Moreover, while TDF focuses on behavioural factors, TICD offers a comprehensive checklist considering a wide array of determinants, including guideline, social, political, and legal factors, which we found ideal for complementing CFIR domains. While some CFIR constructs and definitions are considered too broad [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e], potentially complicating coding and data interpretation, the TICD checklist offers concrete factors definitions, including questions for detecting them, examples, and related strategies. Combining these two frameworks results in a comprehensive list of factors with detailed definitions and examples, which, used as a coding frame, facilitates the identification and classification of data.\u003c/p\u003e \u003cp\u003eRogers et al. [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] emphasized the importance of reporting not only the factors analyzed in the context analysis but also the levels at which they operate. Adhering to this recommendation, we provide detailed information about the levels, sublevels, and categories in our coding frame. Context has been conceptualized in many implementation frameworks (TMFs) as a key category in implementation studies. Some of them use categories for different levels of context, while others employ subcategories within a broad context category. For certain TMFs, context is one of the categories that influence the implementation, along with other categories of determinants of practice [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Context is often defined as everything surrounding the implementation, except the intervention itself [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]; consequently, in this definition, we decided to exclude intervention characteristics from the context analysis.\u003c/p\u003e \u003cp\u003eAnother CFIR domain that we did not include in our coding frame was the \"implementation process\". We believe the implementation process is adequately addressed by considering the factors related to the overall implementation strategy, the ERIC strategy list, and the phases of implementation over time. Adding the implementation process construct would introduce unnecessary complexity and redundancy to our coding frame.\u003c/p\u003e \u003cp\u003eOur coding frame includes individual stakeholder characteristics (e.g., professionals or patient factors) as part of the context, although many TMFs consider them separately from context [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. We argue that these individual factors can significantly influence both internal and external contexts, as well as the implementation process. They should be considered alongside other important factors, such as resource availability and organizational priorities in any context analysis. Additionally, we incorporated factors related to the implementation phases and strategies into our context analysis. These elements constantly interact during implementation, and their boundaries often remain unclear. Understanding changes in context or the success or failure of implementation requires considering all of them together.\u003c/p\u003e \u003cp\u003eThe updated CFIR version [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] introduces several constructs in the individual factors domain to consider their roles and characteristics. This revised version includes roles such as high- and mid-level leaders, Implementation Team Members, and Implementation Facilitators. We adapted these roles for our project, but instead of including them as constructs in our coding frame, we added them as sublevels within the individual level. These sublevels were further organised into the categories of capability, relationships, perceptions, and motivation. Not all sublevels include the same categories, as these were defined based on the factors identified as relevant during the inductive analysis of the qualitative interviews. The only categories common to all sublevels are capability and motivation. While the development of the definitions for these categories adhered to the CFIR framework, the definition of motivation was drawn from the COM-B model [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. This choice was made because the broader scope of the COM-B definition allowed for a more detailed breakdown of this category into specific factors. For each category, we identified the most significant factors where these roles can influence the implementation, guided by the inductive interview analysis.\u003c/p\u003e \u003cp\u003eIn developing their pragmatic context assessment tool (pCAT), Robinson and Damschroder [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] utilized the think-aloud technique to include feedback from the frontline improvement team. In this process, professionals suggested some important factors and considerations, such as the differentiation between different levels of leadership and time as a resource to make the change happen. Time was also one of the most frequently mentioned factors in the inductive analysis of our qualitative interviews. Accordingly, we add a factor in the sublevel of the local implementation team: \u0026ldquo;Time available to develop the implementation\u0026rdquo;. Lack of time was also one of the most cited reasons for professionals not to comply with recommendations. However, in our data, professionals lack of time was never identified as a standalone factor but always in relation to other issues, such as staff shortages, patient care complexity, or slow technological equipment. Considering this, we decided not to include a specific factor referring solely to lack of time. We believe that doing so could oversimplify the coding of underlying factors contributing to time constraints, thereby reducing analysis depth and richness.\u003c/p\u003e \u003cp\u003eIn our coding frame, we identified two sublevels within the external context. One sublevel addresses factors outside the unit but still within the institution, while the other pertains to the sociopolitical context beyond the organization. Researchers often overlook the barriers and facilitators outside organizations [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. However, it is crucial to consider these factors as they likely influence implementation [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e], especially when political factors (e.g., nurse-patient ratios) or social aspects (e.g., breastfeeding social media campaigns) come into play.\u003c/p\u003e \u003cp\u003eSumamos Excelencia\u0026rsquo;s specific characteristics require the ERIC strategy list to be included in the coding frame. Although the project applies a multifaceted strategy uniformly across all units, local implementation teams must design strategies tailored to their contexts to facilitate the implementation of the intervention package. These strategies are coded using the ERIC list, a comprehensive, widely used tool [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. This choice allows us to compare our results with other studies. Additionally, considering contextual factors alongside strategies across different implementation phases enables us to analyse when and why certain strategies are employed and the contextual changes they produce throughout the project [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. In other implementation projects where all strategies are known in advance, including this aspect may not be necessary.\u003c/p\u003e \u003cp\u003eFor the development of this coding frame, we followed Schreier\u0026rsquo;s methodology [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Schreier proposes that coding frames must comply with the requirements of unidimensionality, mutual exclusiveness, exhaustiveness, and saturation.\u003c/p\u003e \u003cp\u003eUnidimensionality suggests that a coding frame should consist of a single dimension. However, our framework includes some repetition of factor labels across different levels (e.g., leadership style appearing in unit leaders, institutional leaders, and implementation team members). We repeat factors at different levels when the levels were sufficiently distinct, so the same factor influenced implementation in different ways and required different strategies. This repetition may make the coding frame less parsimonious than it should be [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e], but it clarifies the different influences the factor can have when acting at various levels. Though it results in a more extensive framework, it is worth it to directly distinguish the level at which the factors operate and their influence within the context. This approach simplifies data analysis, making it easier for novice researchers or those less familiar with implementation science.\u003c/p\u003e \u003cp\u003eMutual Exclusiveness ensures that each coding unit is assigned to only one subcategory. We carefully built definitions to differentiate factors across levels, sublevels, categories, and factors, minimizing ambiguity. When similar factor definitions were found, we combined them into one to prevent confusion. This attention to definition wording ensures that each factor in the framework is clearly distinguishable from others, supporting accurate data coding.\u003c/p\u003e \u003cp\u003eExhaustiveness requires that all relevant factors are captured by at least one subcategory of the coding frame. By mapping the different frameworks and incorporating the results from the inductive analysis of interviews conducted during the project, we aimed to ensure that the coding frame is both exhaustive and comprehensive. We also included a \"miscellaneous\" subcategory at each level to account for any factors not represented within the main subcategories.\u003c/p\u003e \u003cp\u003eSaturation demands that each subcategory be used at least once during analysis. This criterion does not apply to our approach, as we used a data-driven approach.\u003c/p\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eA limitation of this coding frame is the possibility of researcher bias, as it emerged organically during a doctoral thesis without a protocol, potentially affecting its transparency and replicability. Efforts to mitigate this bias included consulting experienced researchers. Another limitation is that the frameworks used lack in-depth explanations of how implementation occurs in specific contexts. To achieve this, a theory such as the Normalization Process Theory (NPT) [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e] would have been more appropriate. Finally, this coding frame does not consider the sustainability of the implementation of recommendations, as qualitative interviews were conducted during or immediately after the project.\u003c/p\u003e \u003c/div\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThe development of this coding frame offers valuable insights into the contextual factors and their evolution during the implementation process. By adapting established TMFs to the specific needs of the Sumamos Excelencia project, we have created a tool that provides a detailed, structured approach to analysing context, applicable not only to this project but also to other implementation efforts seeking a comprehensive context analysis.\u003c/p\u003e \u003cp\u003eThis coding frame facilitates the structured organization of factors in a meaningful and relevant way, enabling a deeper understanding of the implementation process in future research. Its adaptability makes it useful for healthcare professionals and novice researchers, ensuring rigorous, standardized coding while maintaining clarity and accessibility. Furthermore, it could be used to integrate qualitative and quantitative data into mixed-method analyses, enhancing the understanding of context at various levels.\u003c/p\u003e \u003cp\u003eFuture research should focus on refining and validating this approach to verify coding patterns across multiple studies. This process will help establish the benefits of combining these frameworks and support linking coding to theory. Ultimately, this coding frame holds the potential to evolve into a practical tool for future editions of Sumamos Excelencia and beyond, helping to bridge the gap between implementation research and practice.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics, components, advantages and limitations of the implementation frameworks used in Sumamos Excelencia.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFramework\u0026rsquo;s name\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eComponents\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAdvantages\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLimitations\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eTICD checklist\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDeveloped through a systematic review and a consensus process among implementation researchers aimed to provide insights on methods to tailor implementation programs according to the determinants of evidence-based clinical practice for patients with chronic diseases.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e57 determinants of practice divided into seven domains (guideline factors; individual health professional factors; patient factors; professional interactions; incentives and resources; capacity for organizational change; social, political and legal factors.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRepresents a comprehensive list of determinants of healthcare practice relevant for effecting changes in such practice, applicable across various settings and practices.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFor Sumamos Excelencia project, the domains\u0026rsquo; organization does not allow us to locate where each of the factors occur (different levels of context).\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eCFIR framework\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMetatheoretical framework, including constructs from a synthesis of existing theories, without representing specific interrelations, ecological levels, or concrete hypotheses. It was developed through a systematic review of the FMTs in the field of implementation science, primarily within the healthcare sector, with the goal of integrating all published theories on implementation science into a single framework to guide implementation research. It was updated in 2022 based on user feedback.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eOriginal CFIR\u003c/b\u003e: 39 constructs organized into 5 domains (intervention characteristics domain, outer setting domain, inner setting domain, characteristics of individuals, process)\u003c/p\u003e \u003cp\u003e\u003cb\u003eUpdated CFIR\u003c/b\u003e: 48 constructs and 19 subconstructs across 5 domains (innovation domain, outer setting domain, inner setting domain, individuals domain, implementation process domain)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIs one of the most employed frameworks in implementation science, applicable across settings and innovations, useful for reporting determinants and designing implementation\u003c/p\u003e \u003cp\u003estrategies and the domains and constructs are easy to understand.\u003c/p\u003e \u003cp\u003eThe updated version overcomes some of the problems of the previous version, such as the difficulty of understanding the meaning of some constructs and adds determinants identified by the users.\u003c/p\u003e \u003cp\u003eDomains structure, with some changes, is in line with the structure we have identified during Sumamos Excelencia.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eIs a generalized framework, needing adaptation. It is not considered easy to use by non-researchers and has been criticised for being more complicated than necessary.\u003c/p\u003e \u003cp\u003eWe consider constructs organization too complex to be used in Sumamos Excelencia without adaptation, as its structure does not adequately represent the organizational structures of the healthcare units participating in the project. Furthermore, this organisation does not allow us to identify the level of the context in which the determinants occur.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eERIC list\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe ERIC list provides a compilation of discrete strategies that can be used to\u003c/p\u003e \u003cp\u003ebuild tailored multifaceted strategies for implementation. Was developed by a review of health and mental\u003c/p\u003e \u003cp\u003ehealth literature, a modified Delphi process and concept mapping,\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e73 implementation strategies, 9 thematic groups: Use evaluative and iterative strategies, Provide interactive assistance, Adapt and tailor to context, Develop stakeholder interrelationships, Train and educate stakeholders, Support clinicians, Engage consumers, Utilize financial strategies, Change infrastructure.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eThis list of strategies is recommended to standardize the way in which strategies used in implementation projects and research are described and reported. It provides clear labels and\u003c/p\u003e \u003cp\u003edetailed definitions for implementation\u003c/p\u003e \u003cp\u003estrategies, it is applicable to health and mental health settings and it is based on consensus of implementation experts.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSome strategies used in Sumamos Excelencia were not included in the list. It had to be completed and adapted for use in the Sumamos Excelencia project.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eEPIS framework\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe EPIS framework is a comprehensive, standalone\u003c/p\u003e \u003cp\u003eimplementation framework developed based on review\u003c/p\u003e \u003cp\u003eof the literature on implementation in public\u003c/p\u003e \u003cp\u003esector social and allied health service systems in the USA.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFour phases: exploration, preparation, implementation, and sustainment. Identifies levels within and between the external and internal contexts, intermediate and innovation factors that interact with both contexts and the innovation or practice being implemented.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIt is one of the most used implementation frameworks in public sector settings. It has broad applicability in different countries and\u003c/p\u003e \u003cp\u003eHealth or allied health settings. EPIS offer a multi-level conceptualization of the implementation process, including factors at the individual,\u003c/p\u003e \u003cp\u003eorganizational, and systems levels.\u003c/p\u003e \u003cp\u003eThe four phases of EPIS, with some modifications, were considered useful to organize Sumamos Excelencia project factors in a temporary manner and evaluate their changes according to the different phases of the project.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDesigned for specific use in the public service sector. Needed adaptation to fit with Sumamos Excelencia phases.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eTable\u0026nbsp;2: Implementation Phases of the Sumamos Excelencia Project based on EPIS framework.\u003c/b\u003e \u003c/p\u003e\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 21.9081%;\"\u003e\n \u003cp\u003ePhase\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78.0919%;\"\u003e\n \u003cp\u003eDescription\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 21.9081%;\"\u003e\n \u003cp\u003eExploration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78.0919%;\"\u003e\n \u003cp\u003eThe unit \u003cstrong\u003eexpresses\u003c/strong\u003e interest in the project or \u003cstrong\u003ereceives encouragement from\u003c/strong\u003e its institution to participate. The most suitable intervention package, \u003cstrong\u003ebased on\u003c/strong\u003e the unit\u0026apos;s needs is selected, and the implementation team is formed. Finally, the unit completes and formalizes its application to participate in the project.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 21.9081%;\"\u003e\n \u003cp\u003ePreparation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78.0919%;\"\u003e\n \u003cp\u003eThe local implementation team receives training about the project and \u003cstrong\u003econducts\u003c/strong\u003e a baseline audit and context analysis. Following this, they design implementation strategies tailored to the unit \u003cstrong\u003ein accordance with\u003c/strong\u003e the context analysis.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 21.9081%;\"\u003e\n \u003cp\u003eImplementation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78.0919%;\"\u003e\n \u003cp\u003eOnce the local implementation \u003cstrong\u003eteam designs the strategies\u003c/strong\u003e, the implementation phase begins, and the strategies must be developed. This phase is divided into:\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eInitial Implementation (0 to 3 months): where the local implementation teams within the units start to implement the strategies, seek support, and gather resources.\u003c/li\u003e\n \u003cli\u003eConsolidation of Implementation (3 to 6 months): Following the initial period, \u003cstrong\u003ethe local implementation team conducts the\u003c/strong\u003e second audit and context analysis. \u003cstrong\u003eAfter the initial phase, the team may discover new barriers or need to adjust the strategies. After the second audit, the planning becomes more stable, and the team gains confidence in their actions.\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003eMaintenance of Implementation (6 to 12 months): after the first six months, most strategies have been developed, and the local implementation team within the units seeks to maintain compliance with the recommendations.\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 21.9081%;\"\u003e\n \u003cp\u003eEvaluation and Sustainability\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78.0919%;\"\u003e\n \u003cp\u003eAfter 12 months of implementation, units review their achievements and consider how compliance with the recommendations will continue when the project concludes.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eTMF: theories, models and frameworks\u003c/p\u003e\n\u003cp\u003eTICD: Tailored Implementation for Chronic Diseases\u003c/p\u003e\n\u003cp\u003eCFIR: Consolidated Framework for Implementation Research\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eERIC: Expert Recommendations for Implementing Change\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEPIS: Exploration, Preparation, Implementation, Sustainment\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTDF: Theoretical Domains Framework\u003c/p\u003e\n\u003cp\u003epCAT: pragmatic context assessment tool\u003c/p\u003e\n\u003cp\u003eNPT: Normalization Process Theory\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interest.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePartially financed by Spanish Centre for Evidence-Based Nursing and Healthcare: A Joanna Briggs Institute Centre of Excellence.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eContributions\u003c/strong\u003e:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAD proposed the study and initial design. All authors contributed to the theoretical conceptualization of the manuscript. LBC wrote the main manuscript text. AD, TMC, EGM and LBC reviewed the manuscript and made important contributions. The authors have read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eResearch reported in this publication is supported by the Spanish Centre for Evidence Based Nursing and Healthcare (Nursing and Health Care Research Unit, ISCIII). The content is solely the responsibility of the authors and does not necessarily represent the official views of the Spanish Centre for Evidence Based Nursing and Healthcare. The authors thank Dr. Azucena Pedraz-Marcos for her support in the development of this study, as well as the Dublin City University for their collaboration in this research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; information:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLeticia Bernu\u0026eacute;s-Caudillo, BSN, MSc, RN, is Predoctoral Nurse Researcher at the Spanish Centre for Evidence Based Nursing and Healthcare: A Joanna Briggs Institute Centre of Excellence (Madrid, Spain).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAmanda Drury, MSc, PhD, RN, is associate Professor in General Nursing at the School of Nursing, Psychotherapy and Community Health, Dublin City University, Glasnevin. (Dublin, Ireland)\u003c/p\u003e\n\u003cp\u003eEsther Gonz\u0026aacute;lez-Mar\u0026iacute;a, MSc, PhD, RN, and M. Teresa Moreno-Casbas, PhD, FEAN, FAAN, RN, are Senior Researchers at the Nursing and Health Research Unit (Invest\u0026eacute;n-isciii), the Spanish Center for Evidence-Based Nursing and Healthcare: A Joanna Briggs Institute Centre of Excellence; and the Biomedical Research Network Centre on Frailty and Healthy Ageing (CIBERFES ISCIII) (Madrid, Spain).\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBirken SA, Powell BJ, Shea CM, Haines ER, Alexis Kirk M, Leeman J, et al. Criteria for selecting implementation science theories and frameworks: Results from an international survey. Implement Sci. 2017;12(1):124. https://doi.org/10.1186/s13012-017-0656-y.\u003c/li\u003e\n\u003cli\u003eLynch EA, Mudge A, Knowles S, Kitson AL, Hunter SC, Harvey G. \u0026ldquo;there is nothing so practical as a good theory\u0026rdquo;: A pragmatic guide for selecting theoretical approaches for implementation projects. BMC Health Serv Res. 2018;18(1):857. https://doi.org/10.1186/s12913-018-3671-z.\u003c/li\u003e\n\u003cli\u003eNilsen P. Making sense of implementation theories, models and frameworks. Implement Sci. 2015;10:53. https://doi.org/10.1186/s13012-015-0242-0.\u003c/li\u003e\n\u003cli\u003eVillalobos Dintrans P, Bossert TJ, Sherry J, Kruk ME. A synthesis of implementation science frameworks and application to global health gaps. Glob Health Res Policy 2019;4:25. https://doi.org/10.1186/s41256-019-0115-1.\u003c/li\u003e\n\u003cli\u003eField B, Booth A, Ilott I, Gerrish K. Using the Knowledge to Action Framework in practice: a citation analysis and systematic review. Implement Sci 2014;9:172. https://doi.org/10.1186/s13012-014-0172-2.\u003c/li\u003e\n\u003cli\u003eMcevoy R, Ballini L, Maltoni S, O\u0026rsquo;donnell CA, Mair FS, Macfarlane A. A qualitative systematic review of studies using the normalization process theory to research implementation processes. Implement Sci 2014;9:2. doi:10.1186/1748-5908-9-2. \u003c/li\u003e\n\u003cli\u003eMoullin JC, Dickson KS, Stadnick NA, Rabin B, Aarons GA. Systematic review of the Exploration, Preparation, Implementation, Sustainment (EPIS) framework. Implement Sci 2019;14:1. https://doi.org/10.1186/s13012-018-0842-6.\u003c/li\u003e\n\u003cli\u003eSkolarus TA, Lehmann T, Tabak RG, Harris J, Lecy J, Sales AE. Assessing citation networks for dissemination and implementation research frameworks. Implement Sci 2017;12:97. https://doi.org/10.1186/s13012-017-0628-2.\u003c/li\u003e\n\u003cli\u003eMoullin JC, Sabater-Hern\u0026aacute;ndez D, Fernandez-Llimos F, Benrimoj SI. A systematic review of implementation frameworks of innovations in healthcare and resulting generic implementation framework. Health Res Policy Syst 2015;13:16. https://doi.org/10.1186/s12961-015-0005-z.\u003c/li\u003e\n\u003cli\u003eTabak RG, Khoong EC, Chambers DA, Brownson RC. Bridging research and practice: Models for dissemination and implementation research. Am J Prev Med 2012;43:337\u0026ndash;50. https://doi.org/10.1016/j.amepre.2012.05.024.\u003c/li\u003e\n\u003cli\u003eKirk MA, Kelley C, Yankey N, Birken SA, Abadie B, Damschroder L. A systematic review of the use of the Consolidated Framework for Implementation Research. Implement Sci 2016;11:72. https://doi.org/10.1186/s13012-016-0437-z.\u003c/li\u003e\n\u003cli\u003eWesterlund A, Sundberg L, Nilsen P. Implementation of Implementation Science Knowledge: The Research-Practice Gap Paradox. Worldviews Evid Based Nurs 2019;16:332\u0026ndash;4. https://doi.org/10.1111/wvn.12403.\u003c/li\u003e\n\u003cli\u003eMay CR, Albers B, Bracher M, Finch TL, Gilbert A, Girling M, et al. Translational framework for implementation evaluation and research: a normalisation process theory coding manual for qualitative research and instrument development. Implement Sci 2022;17:19. https://doi.org/10.1186/s13012-022-01191-x.\u003c/li\u003e\n\u003cli\u003eRogers L, De Br\u0026uacute;n A, McAuliffe E. Development of an integrative coding framework for evaluating context within implementation science. BMC Med Res Methodol 2020;20:158. https://doi.org/10.1186/s12874-020-01044-5.\u003c/li\u003e\n\u003cli\u003eSchreier M. Qualitative content analysis in practice. London: SAGE; 2012.\u003c/li\u003e\n\u003cli\u003eRogers L, De Br\u0026uacute;n A, McAuliffe E. Defining and assessing context in healthcare implementation studies: A systematic review. BMC Health Serv Res 2020;20:591. https://doi.org/10.1186/s12913-020-05212-7.\u003c/li\u003e\n\u003cli\u003eMielke J, Brunkert T, Z\u0026uacute;\u0026ntilde;iga F, Simon M, Zullig LL, De Geest S. Methodological approaches to study context in intervention implementation studies: an evidence gap map. BMC Med Res Methodol 2022;22:320. https://doi.org/10.1186/s12874-022-01772-w.\u003c/li\u003e\n\u003cli\u003eNilsen P, Bernhardsson S. Context matters in implementation science: A scoping review of determinant frameworks that describe contextual determinants for implementation outcomes. BMC Health Serv Res 2019;19:189. https://doi.org/10.1186/s12913-019-4015-3.\u003c/li\u003e\n\u003cli\u003ePfadenhauer LM, Gerhardus A, Mozygemba K, Lysdahl KB, Booth A, Hofmann B, et al. Making sense of complexity in context and implementation: The Context and Implementation of Complex Interventions (CICI) framework. Implement Sci 2017;12:21. https://doi.org/10.1186/s13012-017-0552-5.\u003c/li\u003e\n\u003cli\u003eRobinson CH, Damschroder LJ. A pragmatic context assessment tool (pCAT): using a Think Aloud method to develop an assessment of contextual barriers to change. Implement Sci Commun 2023;4:3. https://doi.org/10.1186/s43058-022-00380-5.\u003c/li\u003e\n\u003cli\u003eBernu\u0026eacute;s-Caudillo L, Gonz\u0026aacute;lez-Mar\u0026iacute;a E, Albornos-Mu\u0026ntilde;oz L, Moreno-Casbas T. A multifaceted implementation strategy to enhance the uptake of evidence-based nursing recommendations in Spain: implementation project protocol. Rev Esp Salud Publica 2024;98: e202409053. \u003c/li\u003e\n\u003cli\u003eFlottorp SA, Oxman AD, Krause J, Musila NR, Wensing M, Godycki-Cwirko M, et al. A checklist for identifying determinants of practice: A systematic review and synthesis of frameworks and taxonomies of factors that prevent or enable improvements in healthcare professional practice. Implement Sci 2013;8:35. https://doi.org/10.1186/1748-5908-8-35.\u003c/li\u003e\n\u003cli\u003eMoreno-Casbas MT, Gonz\u0026aacute;lez-Mar\u0026iacute;a E, Bernu\u0026eacute;s-Caudillo L, Cameselle-Lago C, Albornos-Mu\u0026ntilde;oz L. SUMAMOS EXCELENCIA Project: Assessment of Implementation of Best Practices in a National Health System (Second Edition) [Internet]. ClinicalTrialsGov. NCT05466656; 2022 [cited 2024 Nov 30]. Available from: https://clinicaltrials.gov/study/NCT05466656?term=Sumamos%20Excelencia\u0026amp;rank=1 \u003c/li\u003e\n\u003cli\u003eHarvey G, Rycroft-Malone J, Seers K, Wilson P, Cassidy C, Embrett M, et al. Connecting the science and practice of implementation \u0026ndash; applying the lens of context to inform study design in implementation research. Front Health Serv 2023;3:1162762. https://doi.org/10.3389/frhs.2023.1162762.\u003c/li\u003e\n\u003cli\u003eBirken SA, Rohweder CL, Powell BJ, Shea CM, Scott J, Leeman J, et al. T-CaST: An implementation theory comparison and selection tool. Implement Sci 2018;13:143. https://doi.org/10.1186/s13012-018-0836-4.\u003c/li\u003e\n\u003cli\u003eDamschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science. Implement Sci 2009;4:50. https://doi.org/10.1186/1748-5908-4-50.\u003c/li\u003e\n\u003cli\u003eDamschroder LJ, Reardon CM, Widerquist MAO, Lowery J. The updated Consolidated Framework for Implementation Research based on user feedback. Implement Sci 2022;17:75. https://doi.org/10.1186/s13012-022-01245-0.\u003c/li\u003e\n\u003cli\u003ePowell BJ, Waltz TJ, Chinman MJ, Damschroder LJ, Smith JL, Matthieu MM, et al. A refined compilation of implementation strategies: Results from the Expert Recommendations for Implementing Change (ERIC) project. Implement Sci 2015;10:21. https://doi.org/10.1186/s13012-015-0209-1.\u003c/li\u003e\n\u003cli\u003eWaltz TJ, Powell BJ, Matthieu MM, Damschroder LJ, Chinman MJ, Smith JL, et al. Use of concept mapping to characterize relationships among implementation strategies and assess their feasibility and importance: Results from the Expert Recommendations for Implementing Change (ERIC) study. Implement Sci 2015;10:109. https://doi.org/10.1186/s13012-015-0295-0.\u003c/li\u003e\n\u003cli\u003eAarons GA, Hurlburt M, Horwitz SMC. Advancing a conceptual model of evidence-based practice implementation in public service sectors. Adm Policy Ment Health 2011;38(1):4-23. https://doi.org/10.1007/s10488-010-0327-7.\u003c/li\u003e\n\u003cli\u003eMichie S, van Stralen MM, West R. The behaviour change wheel: A new method for characterising and designing behaviour change interventions. Implement Sci 2011;6:42. https://doi.org/10.1186/1748-5908-6-42.\u003c/li\u003e\n\u003cli\u003eProctor EK, Powell BJ, McMillen JC. Implementation strategies: Recommendations for specifying and reporting. Implement Sci 2013;8:139. https://doi.org/10.1186/1748-5908-8-139\u003c/li\u003e\n\u003cli\u003eSchroeder D, Luig T, Finch TL, Beesoon S, Campbell-Scherer DL. Understanding implementation context and social processes through integrating Normalization Process Theory (NPT) and the Consolidated Framework for Implementation Research (CFIR). Implement Sci Commun 2022;3:13. https://doi.org/10.1186/s43058-022-00264-8.\u003c/li\u003e\n\u003cli\u003eO\u0026rsquo;Donovan B, Kirke C, Pate M, McHugh S, Bennett K, Cahir C. Mapping the Theoretical Domain Framework to the Consolidated Framework for Implementation Research: do multiple frameworks add value? Implement Sci Commun 2023;4:100. https://doi.org/10.1186/s43058-023-00466-8.\u003c/li\u003e\n\u003cli\u003eBirken, SA, Powell, BJ, Presseau, J, Kirk, MA, Lorencatto, F, Gould, NJ, et al. Combined use of the Consolidated Framework for Implementation Research (CFIR) and the Theoretical Domains Framework (TDF): A systematic review. Implement Sci 2017;12:2. https://doi.org/10.1186/s13012-016-0534-z\u003c/li\u003e\n\u003cli\u003eWatson DP, Adams EL, Shue S, Coates H, McGuire A, Chesher J, et al. Defining the external implementation context: An integrative systematic literature review. BMC Health Serv Res 2018;18:209. https://doi.org/10.1186/s12913-018-3046-5.\u003c/li\u003e\n\u003cli\u003eLovero KL, Kemp CG, Wagenaar BH, Giusto A, Greene MC, Powell BJ, et al. Application of the Expert Recommendations for Implementing Change (ERIC) compilation of strategies to health intervention implementation in low- and middle-income countries: a systematic review. Implement Sci 2023;18:56. https://doi.org/10.1186/s13012-023-01310-2.\u003c/li\u003e\n\u003cli\u003eYakovchenko V, Chinman MJ, Lamorte C, Powell BJ, Waltz TJ, Merante M, et al. Refining Expert Recommendations for Implementing Change (ERIC) strategy surveys using cognitive interviews with frontline providers. Implement Sci Commun 2023;4:42. https://doi.org/10.1186/s43058-023-00409-3.\u003c/li\u003e\n\u003cli\u003eMay CR, Mair F, Finch T, MacFarlane A, Dowrick C, Treweek S, et al. Development of a theory of implementation and integration: Normalization Process Theory. Implement Sci 2009;4:29. https://doi.org/10.1186/1748-5908-4-29.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Implementation science, Coding Frame, Contextual factors, Context analysis, Qualitative methods, Qualitative analysis","lastPublishedDoi":"10.21203/rs.3.rs-5676060/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5676060/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe selection, application and reporting of theories, models, and frameworks in implementation science can be challenging, hindering study comparisons and the advancement of science. Context analysis is a critical but underdeveloped area in implementation research. Structured approaches, such as coding frames informed by implementation science, can enhance methodological rigor and transparency. This study, part of the Sumamos Excelencia project, addresses these challenges by applying implementation frameworks to assess implementation context developing a coding frame to analyze qualitative interviews conducted during the project. The project implemented evidence-based recommendations in Spanish healthcare units using a multifaceted implementation strategy.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA literature review guided theories, models, and frameworks selection, integrating the Consolidated Framework for Implementation Research, Tailored Implementation for Chronic Diseases checklist, Expert Recommendations for Implementing Change, and Exploration, Preparation, Implementation, Sustainment framework. A coding frame was developed adhering to the content-driven process phases of Schreier\u0026rsquo;s methodology (selecting, structuring and generating, revising and expanding) and considering its requirements for a coding frame (unidimensionality, mutual exclusiveness, exhaustiveness, and saturation).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eEach framework provided valuable insights into the coding frame, complementing each other and enabling a comprehensive analysis of the complexity and multi-level aspects of context and implementation process. The integration of the results of the data-driven and concept-driven strategies resulted in a coding frame composed of 4 levels, 11 sublevels, 16 categories, and 82 contextual factors. The levels include factors related to the individuals involved in the implementation, factors related to the characteristics of the unit (internal context), factors related to the external context of the unit and factors related to the project's global implementation strategy. The strategies and the temporal phases were also incorporated into the coding frame.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThis coding frame systematically captures context complexity, integrating constructs from multiple theories, models, and frameworks. It supports rigorous, standardized context analysis that is applicable beyond this project. This framework also offers a practical tool for mixed-method implementation studies, enabling novice researchers and healthcare professionals to analyze context comprehensively. Future research should validate and refine this framework across diverse settings to enhance its utility in advancing implementation science.\u003c/p\u003e","manuscriptTitle":"Development of a coding frame for context analysis in implementation: Insights from Sumamos Excelencia project","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-01-23 06:38:32","doi":"10.21203/rs.3.rs-5676060/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e128bcab-0be5-46eb-ba6a-2bb93d8f8e56","owner":[],"postedDate":"January 23rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-04T16:23:17+00:00","versionOfRecord":[],"versionCreatedAt":"2025-01-23 06:38:32","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5676060","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5676060","identity":"rs-5676060","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}