Abstract
Introduction: The use of models and frameworks to design and evaluate strategies to improve delivery of evidence-based interventions is a foundational element of implementation science. To date, however, evaluative implementation science frameworks such as Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) have not been widely employed to examine environmental health interventions. We take advantage of a unique opportunity to utilize and iteratively adapt the RE-AIM framework to guide NIH-funded case studies of the implementation of clean cooking fuel programs in eleven low- and middle-income countries.Methods: We used existing literature and expert consultation to translate and iteratively adapt the RE-AIM framework across several stages of the NIH Clean Cooking Implementation Science case study project. Checklists and templates to guide investigators were developed at each stage.Results: The RE-AIM framework facilitated identification of important emerging issues across this set of case studies, in particular highlighting the fact that data associated with certain important outcomes related to health and welfare are chronically lacking in clean fuel programs. Monitoring of these outcomes should be prioritized in future implementation efforts. As RE-AIM was not originally designed to evaluate household energy interventions, employing the framework required adaptation. Specific adaptations include the broadening of Effectiveness to encompass indicators of success toward any stated programmatic goal, and expansion of Adoption to include household-level uptake of technology.Conclusions: The RE-AIM implementation science framework proved to be a useful organizing schema for 11 case studies of clean fuel cooking programs, in particular highlighting areas requiring emphasis in future research and evaluation efforts. The iterative approach used here to adapt an implementation science framework to a specific programmatic goal may be of value to other multi-country program efforts, such as those led by international development agencies. The checklists and templates developed for this project are publicly available for others to use and/or further modify.
Highlights
The use of models and frameworks to design and evaluate strategies to improve delivery of evidence-based interventions is a foundational element of implementation science
In the initial checklist (Table 2), general RE-AIM indicators were combined with domain-specific information about clean fuel cooking programs and policies
The specific adaptations and templates developed for this project could be useful starting points to guide future researchers in the household energy domain who are interested in program planning and/or evaluation. Implementation science frameworks such as Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) have been shown to enhance the effectiveness of interventions and can be used to evaluate factors associated with implementation success
Summary
The use of models and frameworks to design and evaluate strategies to improve delivery of evidence-based interventions is a foundational element of implementation science. As the transition to cleaner cooking technologies has already occurred in higher-income countries, the existing imperative is one of implementation: how do we achieve the extension of what is known (clean fuels reduce air pollution and protect health) to what is practiced (sustained and exclusive use of clean fuels for cooking), in the variety of settings where people rely on polluting solid fuels to meet their cooking needs?. Many programs have promoted “improved” stoves that still use relatively unprocessed biomass fuels such as wood and charcoal. While they may reduce fuel use, often can be produced locally, and may provide some reduction in air pollution, these stoves generally do not reduce pollution to the guideline levels established by the World Health Organization (WHO) that are understood to be required to minimize adverse health impacts [2]. A shift in focus to stoves powered by “clean” fuels such as gas (biogas/LPG/natural gas), electricity, and in some cases processed biomass pellets [4] would help greatly in at least setting the stage for achieving the HAP reductions that are sought
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