NCCMT Spotlight Webinar - The Consolidated Framework for Implementation Research (CFIR): Application and Tools
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This document summarizes a webinar presentation on the Consolidated Framework for Implementation Research (CFIR). The presentation was given by Laura Damschroder on November 12, 2015 through the National Centre for Methods and Tools. It provided an overview of the CFIR, including its five domains and 39 constructs. It then presented a case study applying the CFIR to analyze implementation of the VA MOVE! weight management program across several sites. Qualitative and quantitative data were collected and coded using the CFIR framework. Differences in implementation effectiveness across sites were explored in relation to ratings of CFIR constructs. The presentation concluded by discussing how findings can be built upon and compared across multiple studies to develop knowledge about implementation.
![Compatibility
• Negative Rating – e.g.,
– Only providers could refer to TLC in some sites
• Our nurses are specifically forbidden to write orders
…everything that gets written has to be written by a
physician[…] this has formed a really labor intensive
situation for practitioners, so they are super
rebelling against anything else coming down. [MOVE!
Coordinator, V02-6]
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NCCMT Spotlight Webinar - The Consolidated Framework for Implementation Research (CFIR): Application and Tools
- 1. Follow us @nccmt Suivez-nous @ccnmo Funded by the Public Health Agency of Canada | Affiliated with McMaster University Production of this presentation has been made possible through a financial contribution from the Public Health Agency of Canada. The views expressed here do not necessarily reflect the views of the Public Health Agency of Canada.. The Consolidated Framework for Implementation Research (CFIR): Application and Tools Presenter: Laura J. Damschroder, MS, MPH November 12, 2015 1:00 – 2:30 PM ET
- 2. Follow us @nccmt Suivez-nous @ccnmo Use Q&A to post comments / questions during the webinar • ‘Send’ questions to All (not privately to ‘Host’) Connection issues • Recommend using a wired Internet connection (vs. wireless), • WebEx 24/7 help line • 1-866-229-3239 Housekeeping 2 Q&A Participant Side Panel in WebEx
- 3. Poll Question #1 Where are you from? 1. BC 2. AB 3. SK 4. MB 5. ON 6. QC 7. NB 8. NS 9. PEI 10. NL 11. YK 11. NWT 12. NU 13. Outside Canada 3
- 4. Follow us @nccmt Suivez-nous @ccnmo Your profession? Put a √ on your answer (or RSVP via email) / Epidemiologist Management (director, supervisor, etc.) Allied health professionals (nurse, dietician, dental hygenist, etc.) Librarian Physician / Dentist Other 4
- 5. Follow us @nccmt Suivez-nous @ccnmo The Consolidated Framework for Implementation Research (CFIR): Application and Tools http://www.nccmt.ca/registry/view/eng/210.html Episode 20 5
- 6. NCC Infectious Diseases Winnipeg, MB NCC Methods and Tools Hamilton, ON NCC Healthy Public Policy Montreal, QC NCC Determinants of Health Antigonish, NS NCC Aboriginal Health Prince George, BC NCC Environmental Health Vancouver, BC 6
- 7. Follow us @nccmt Suivez-nous @ccnmo National Collaborating Centre for Methods and Tools • dedicated to improving access to, and use of, methods and tools that support moving research evidence into decisions related to public health practice, programs, and policy in Canada. 7
- 8. Poll Question #2 What sector are you from? 1. Public Health Practitioner 2. Health Practitioner (Other) 3. Education 4. Research 5. Provincial/Territorial/Government/Ministry 6. Municipality 7. Policy Analyst (NGO, etc.) 8. Other 8
- 9. Follow us @nccmt Suivez-nous @ccnmo Laura J. Damschroder, MS, MPH Research Scientist Ann Arbor Veteran’s Affairs, Center for Clinical Management Research and HSR&D Center of Excellence Presenter 9
- 10. Registry of Methods and Tools Online Learning Opportunities WorkshopsMultimedia Public Health+ Networking and Outreach NCCMT Products and Services 10
- 11. The Consolidated Framework for Implementation Research (CFIR): Application and Tools Laura J. Damschroder, MS, MPH November 12, 2015 National Centre for Methods and Tools (NCCMT) Webinar Series McMaster University The views expressed in this presentation are my own and do not reflect the position or policy of the Department of Veterans Affairs or the United States government
- 12. Poll Question #3 Have you heard of the CFIR? A. What is the CFIR? B. I am familiar with the CFIR C. I have thought about using the CFIR in my work D. None of the above 12
- 13. Goals for Implementation Research Case study: Application of the CFIR Building the knowledge-base Implementation Strategies Outline Roadmap for implementation science
- 14. • Science – Collaborative, systematic knowledge building • Praxis – Tools and processes for practitioners – Identify effective strategies • Tailored to context – Contribute to culture of learning healthcare system Dual Goals for Implementation ResearchIS Goals
- 15. Power of Theory • Organizing framework for research studies • Build scientific knowledge base • Context, mechanisms of action • Generalize through theory • Syntheses • Provides common terms & definitions • Efficient way to systematically build collective knowledge Colquhoun, H., Leeman, J., Michie, S., Lokker, C., Bragge, P., Hempel, S., … Grimshaw, J. (2014). Towards a common terminology: a simplified framework of interventions to promote and integrate evidence into health practices, systems, and policies. Implementation Science, 9, 51. Foy R, Ovretveit J, Shekelle PG, et al. The role of theory in research to develop and evaluate the implementation of patient safety practices. Quality & safety in health care. Feb 11 2011. IS Goals
- 16. Poll Question #4 Which of the following best describes your work? A. Developing and testing innovations B. Developing and testing implementation approaches C. Implement innovations D. All of the above E. Other 16
- 17. Innovations to Improve Patient Care 17 • “Active Ingredients” • Adaptability Innovation Science Goal: Improved health & well being of patients Colquhoun, H., Leeman, J., Michie, S., Lokker, C., Bragge, P., Hempel, S., … Grimshaw, J. (2014). Towards a common terminology: a simplified framework of interventions to promote and integrate evidence into health practices, systems, and policies. Implementation Science, 9, 51. Establishing “internal validity” is priority Control or ignore CONTEXT
- 18. Weight Loss Program Innovation • ASPIRE Comparative Effectiveness Trial – High fidelity coaching more weight loss • VA DPP Comparative Effectiveness Trial – DPP higher fidelity to ASPIRE-ID’d domains of coaching • Affirmed by patient ratings of delivery – National MOVE! program guidance updated • http://www.move.va.gov/GrpSessions.asp 18
- 19. Innovations to Improve Patient Care 19 • “Active Ingredients” • Adaptability Innovation: Improved health & well being of patients RCTs along do not provide sufficient information
- 20. Preparing for and Explaining Implementation 20 • Barriers & Facilitators • Why did/will it work? Implementation Science Goal: Drawing on knowledge about how an innovation will achieve expected benefits and the causes, effects, and factors that determine its success (or failure) in clinical practice Grol, et al. (2007). Planning and studying improvement in patient care: The use of theoretical perspectives. Milbank Quarterly, 85(1), 93–138. Establishing “external validity” is priority Embrace and understand CONTEXT …in all its wicked complexity
- 21. Use of theory in implementation Assess targeted Innovation and Context Sales A, Smith J, Curran G, Kochevar L. Models, strategies, and tools. Theory in implementing evidence-based findings into health care practice. J. Gen. Intern. Med. Feb 2006;21 Suppl 2:S43-49. Bartholomew, L. K., Parcel, G. S., & Kok, G. (1998). Intervention mapping: a process for developing theory- and evidence- based health education programs. Health Educ Behav, 25(5), 545-563. Use theory to guide assessment
- 22. Case Study VA MOVE! Weight Management Program 22 CFIR
- 23. Highly Variable Implementation MOVE!® 23 Number of Visits Reported by Study Site 1 & 2 Years Since Dissemination 0 10 20 30 40 50 60 70 FY 2007 FY 2008 #Visits/1000Veterans CFIR
- 24. Outcomes 24Proctor, E., H. Silmere, R. Raghavan, P. Hovmand, G. Aarons, A. Bunger, R. Griffey, and M. Hensley, Outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda. Administration and Policy in Mental Health, 2011. 38(2): p. 65-76.
- 25. Assess targeted EBP change and context French SD, Green SE, O'Connor DA, et al. Developing theory-informed behaviour change interventions to implement evidence into practice: a systematic approach using the Theoretical Domains Framework. Implement Sci. Apr 24 2012;7(1):38. Who needs to do what differently? Which barriers & facilitators need to be addressed? Applying Theory
- 26. Consolidated Framework for Implementation Research (CFIR) • A comprehensive framework to promote consistent use of constructs, terminology, and definitions – Five Domains – 39 Constructs 26 Damschroder L, Aron D, Keith R, Kirsh S, Alexander J, Lowery J: Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. 2009, 4:50. CFIR
- 27. OUTER CONTEXT INNER CONTEXT PRACTITIONER INNOVATION PROCESS SLIDE CREDIT: ©Dr. Melanie Barwick, SickKids / U Toronto, Canada 2015 Consolidated Framework for Implementation Research LOCAL REALITY CFIR
- 28. CFIR Consolidated Framework for Implementation Research Damschroder L, Aron D, Keith R, Kirsh S, Alexander J, Lowery J: Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. 2009, 4:50.
- 29. Poll Question #4 What types of data do you typically rely on in your work? A. Qualitative data e.g., interview transcripts, field notes B. Quantitative data e.g., surveys C. A lot of both D. Neither 29
- 30. Understanding Context • Qualitative Data – Interviews – Artifact data (e.g., P&Ps, journals, meeting notes) – Quantitative ratings 30
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- 36. Understanding Context • Qualitative Data – Interviews – Artifact data (e.g., P&Ps, journals, meeting notes) – Quantitative ratings • Quantitative Measures – Not well developed • Martinez, R., C. Lewis, and B. Weiner, Instrumentation issues in implementation science. Implementation Science, 2014. 9(1): p. 118 – Synthesis of measures – Chaudoir, S.R., A.G. Dugan, and C.H. Barr, Measuring factors affecting implementation of health innovations: A systematic review of structural, organizational, provider, patient, and innovation level measures. Implement Sci, 2013. 8(1): p. 22. – Assessment of measures – work in progress – REGISTRATION IS FREE BUT NECESSARY: http://www.societyforimplementationresearchcollaboration.org/sirc-projects/sirc-instrument- project/measures-collection/ – Lewis, C., C. Stanick, R. Martinez, B. Weiner, M. Kim, M. Barwick, and K. Comtois, The Society for Implementation Research Collaboration Instrument Review Project: A methodology to promote rigorous evaluation. Implementation Science, 2015. 10(1): p. 2. 36
- 37. Quantitative Measures http://cfirguide.org/quant.html CFIR 7th Annual D&I Conference December 2014
- 38. Inner Setting: Networks & Communications • HIGH IMPLEMENTATION SITES: – Both sites had a high degree of “teamness” – Meet regularly • LOW IMPLEMENTATION SITES – Did not have regular team meetings – Lack of effective communication • Patients confused about the program Damschroder, L.J. and J.C. Lowery, Evaluation of a large-scale weight management program using the consolidated framework for implementation research (CFIR). Implement Sci, 2013. 8: p. 51. CFIR
- 39. Data Collection, Coding, Rating • Coded qualitative data using CFIR as “codebook” • Rated strength and valence of each construct – Scale: -2 to +2 – By transcript – Rolled up ratings by sites • Blinded to site outcomes CFIR
- 40. Qualitative Data: Construct Ratings 40 Implementation Effectiveness: Low High I. INTERVENTION CHARACTERISTICS Relative advantage -2 1 2 2 II. OUTER SETTING Patient needs & resources -2 0 2 2 External Policy & Incentives -1 -2 0 1 III. INNER SETTING Networks and communications -2 -2 2 2 Implementation Climate Tension for change 0 0 1 1 Relative priority -1 -2 1 2 Goals and feedback -2 -1 1 2 Learning climate N/A -1 1 2 Readiness for Implementation Leadership Engagement -2 -1 2 2 Available resources -2 -2 1 -1 V. PROCESS Planning -1 N/A 1 1 Executing -2 1 2 2 Reflecting & Evaluating -1 -2 1 2 CFIR Goals and feedback
- 41. Number of Referrals per 1000 Veterans by Site Variable referral rates Follow-up Interviews CFIR
- 42. Site ID V03-3 V02-6 V03-4 V05-1 V01-2 V03-1 V01-4 V Referral Rate 2.0094 2.3236 2.5855 5.9953 6.0434 6.8834 7.7227 1 Structural Characteristics -2 -2 -2 -1 0 -1 -1 Networks & Communications -1 1 . . . -1 -1 Compatibility 1 -1 1 1 -1 1 -1 Referral rate & Construct Ratings by SiteCFIR
- 43. Compatibility • Correlation: 0.55 (p=0.08) 0 5 10 15 V03-3 V02-6 V03-4 V05-1 V01-2 V03-1 V01-4 V01-3 V02-2 V01-6 V02-3 Referred/1000 -2 -1 0 1 2 CFIR
- 44. Compatibility • Negative Rating – e.g., – Only providers could refer to TLC in some sites • Our nurses are specifically forbidden to write orders …everything that gets written has to be written by a physician[…] this has formed a really labor intensive situation for practitioners, so they are super rebelling against anything else coming down. [MOVE! Coordinator, V02-6] CFIR
- 45. Compatibility • Positive rating – e.g., – Perceived compatibility with clinical initiatives • …this …really helps the patient to have ownership for their processes and their living, and it definitely blends very nicely with the health coaching CFIR
- 46. BUILDING ON FINDINGS ACROSS STUDIES Knowledge
- 47. Comparing Findings Across Studies 47 Study: MOVE! TeleMOVE TLC Structural Characteristics Networks & Communications Tension for Change Compatibility Relative Priority Goals & Feedback Learning Climate Leadership Engagement Available Resources Strongly Distinguishes Weakly Distinguishes Not assessed
- 48. Knowledge
- 49. Causal complexity: Set Relations vs. Correlations: • Equifinality: Various (combinations of) conditions can lead to the same outcome. • Conjunctural causation: Conditions do not necessarily exert their impact on the outcome in isolation from one another, but sometimes have to be combined in order to reveal causal patterns. • Asymmetrical causation: The occurrence and non- occurrence of social phenomena require separate analysis – the presence versus absence of conditions might play crucially different roles in bringing about the outcome. 49 Knowledge
- 50. Qualitative Comparative Analysis • Case-oriented analysis – Rather than variable-oriented • Based on set theory and Boolean algebra • Appropriate when – The phenomenon of interest is best understood in terms of set relations – Evaluate configurations of conditions across cases • Describe causal complexity related to an outcome • Number of cases does not matter 50 Knowledge
- 51. Use QCA to Reveal Combinations of CFIR Constructs Success Studies Cases 7 53 • Behavioral Change Programs – Group-based weight management – Phone-based coaching for lifestyle change – Technology-enabled weight management program • TeleRetinopathy Program • Specialty Care – SCAN-ECHO – Specialty Care Neighborhood – E-Consults
- 52. What We Learned • Causal complexity confirmed • Different pathways lead to success • Analytical limitations – Solutions sets depended on the cases included – Must KNOW your data – link with qualitative data • A priori theories • Triangulate through different analyses, theories Knowledge
- 53. Preparing for and Explaining Implementation 53 • Barriers & Facilitators • Why did/will it work? Implementation: Theories about how an innovation will achieve expected benefits and the causes, effects, and factors that determine its success (or failure) Grol, et al. (2007). Planning and studying improvement in patient care: The use of theoretical perspectives. Milbank Quarterly, 85(1), 93–138. Insufficient reporting of contextual factors
- 54. Assess targeted EBP change and context French SD, Green SE, O'Connor DA, et al. Developing theory-informed behaviour change interventions to implement evidence into practice: a systematic approach using the Theoretical Domains Framework. Implement Sci. Apr 24 2012;7(1):38. Develop tailored implementation strategy Who needs to do what differently? Which barriers & facilitators need to be addressed? What strategies could be used to address barriers & facilitators? Applying Theory
- 55. Implementation Strategy Construct Issue/Barrier Change Strategies Goals & Feedback 55 Powell, Byron J., Thomas J. Waltz, Matthew J. Chinman, Laura J. Damschroder, Jeffrey L. Smith, Monica M. Matthieu, Enola K. Proctor, and JoAnn E. Kirchner. "A refined compilation of implementation strategies: results from the Expert Recommendations for Implementing Change (ERIC) project." Implementation Science 10, no. 1 (2015): 21. •It is challenging to track patients’ weight and other measures over time. Often staff lack time and ability to analyze these data and develop cogent business cases needed to support the program. • Clearly align program data with org goals & communicate CFIR • Develop tools for quality monitoring1 • Audit and provide feedback1 • Anecdotal success stories help to bring data “alive” for leaders and other stakeholders. Strategies
- 56. Expert Recommendations for Implementing Change (ERIC) • A mixed methods approach to establish expert consensus on a common nomenclature for implementation strategy terms and definitions Strategies
- 57. Engage consumers Train and educate stakeholders Change infrastructure Develop stakeholder interrelationships Provide interactive assistance Utilize financial strategies Use evaluative and iterative strategies Adapt & tailor to context Support clinicians 73 strategies clustered into 9 groups 1 2 3 28 3442 49 66&70 9 10 11 12 13 22 44 4 5 14 18 23 61 26 27 46 56 37 39 41 50 62 69 6 7 17 40 47 52 64 48 51 63 67 68 24 25 36 38 45 65 72 35 57 8 33 53 54 58 21 30 32 59 15 1629 60 19 20 31 43 55 71 73 SLIDE CREDIT: Dr. Byron Powell, University North Carolina, USA. 2015 Strategies
- 58. E.g., Provide Interactive Assistance 1 2 3 28 3442 49 66&70 9 10 11 12 13 22 44 4 5 14 18 23 61 26 27 46 56 37 39 41 50 62 69 6 7 17 40 47 52 64 48 51 63 67 68 24 25 36 38 45 65 72 35 57 8 33 53 54 58 21 30 32 59 15 1629 60 19 20 31 43 55 71 73 8 Centralize technical assistance 53 Provide local clinical supervision 33 Facilitation 54 Provide local technical assistance SLIDE CREDIT: Dr. Byron Powell, University North Carolina, USA. 2015 Strategies
- 59. Tailoring to Context • Which strategies best address specific barriers as aligned with constructs from the CFIR? ERIC Strategies • Build a coalition • Identify and prepare champions • Involve patients and family members • Inform local opinion leaders • Conduct educational meetings • Use mass media • Visit other sites • Conduct educational meetings • Conduct local consensus discussions • Conduct educational outreach visits • Capture and share local knowledge • Tailor strategies • Conduct local needs assessment • Alter incentive/allowance structures • Conduct cyclical small tests of change • Develop a formal implementation blueprint • Identify early adopters • Promote adaptability CFIR Constructs I. INTERVENTION CHARACTERISTICS A Intervention Source B Evidence Strength & Quality C Relative advantage D Adaptability E Trialability F Complexity G Design Quality and Packaging H Cost II. OUTER SETTING A Patient Needs & Resources B Cosmopolitanism C Peer Pressure D External Policy & Incentives III. INNER SETTING A Structural Characteristics B Networks & Communications Strategies
- 60. Survey of Implementation Experts Audit and provide feedback Select and rank up to 7 strategies that best address barriers related to Goals and Feedback: ♦ Goals are not clearly communicated or acted upon, nor do stakeholders receive feedback that is aligned with goals. ♦ Strategies
- 62. Tailor an Intervention Strategy Select a domain
- 63. Tailor an Intervention Strategy Techniques Select a construct Learn more about the construct in the wiki, or click Techniques
- 64. Tailor an Intervention Strategy Audit and provide feedback Obtain and use patient/consumer and family feedback Facilitate relay of clinical data to providers Process: Reflecting & Evaluating Select techniques you want to include for each construct…
- 65. Tailor an Intervention Strategy Repeat steps until all relevant constructs have been addressed, then click “Create Tailored Implementation Strategy” Create Tailored Implementation Strategy 0
- 66. Tailor an Intervention Strategy Reflecting & Evaluating • Facilitate relay of clinical data to providers Structural Characteristics • Create new clinical teams • Make billing easier • Change service sites Leadership Engagement • Provide clinical supervision Evidence Strength & Quality • Provide on-going consultation Process Inner Setting The tool will generate a document that lists the techniques you chose which can then be used as a basis for a documented tailored Implementation Strategy Innovation Characteristics
- 67. Assess targeted EBP change and context French SD, Green SE, O'Connor DA, et al. Developing theory-informed behaviour change interventions to implement evidence into practice: a systematic approach using the Theoretical Domains Framework. Implement Sci. Apr 24 2012;7(1):38. Develop tailored implementation strategy Who needs to do what differently? Which barriers & facilitators need to be addressed? What techniques could be used to address barriers & facilitators? How can change (progress) be measured and understood? Applying Theory
- 68. Applying Theory 68 Execute tailored implementation strategy Assess targeted EBP change and context Develop tailored implementation strategy Concurrent monitoring and refinement Theory-informed
- 69. Applying Theory 69 Execute tailored implementation strategy Assess targeted EBP change and context Develop tailored implementation strategy Evaluate effectiveness of implementation strategy Proctor E., et al. Outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda. Adm. Policy Ment Health 2011;38:65-76
- 70. Achieving Optimal Outcomes 70 Clinical Innovation Adapted from: Proctor, E. K., Landsverk, J., Aarons, G., Chambers, D., Glisson, C., & Mittman, B. (2009). Implementation research in mental health services: An emerging science with conceptual, methodological, and training challenges. Administration and Policy in Mental Health and Mental Health Services Research, 36(1), 24-34. Roadmap
- 71. Applying Theory 7171 Assess fit of findings with initial theory Execute tailored implementation strategy Evaluate effectiveness of implementation strategy Assess targeted EBP change and context Develop tailored implementation strategy
- 72. Applying Theory 72 Assess fit of findings with initial theory Execute tailored implementation strategy Evaluate effectiveness of implementation strategy Assess targeted EBP change and context Develop tailored implementation strategy Add to the knowledge-base
- 73. Example Critique of CFIR
- 74. Roadmap for Implementation Science • Foundation: Common Terminology & Constructs • Assess Context – Quantitative & Qualitative • Targeted innovations – Intervention mapping (http://www.interventionmapping.com) – Adaptations (http://www.biomedcentral.com/content/pdf/1748-5908-8-65.pdf ) • Implementation Strategies – Strategy Taxonomy (e.g., http://www.implementationscience.com/content/10/1/21/abstract) – Tailored to context (forthcoming) • Generate Testable Theories Roadmap
- 75. Packaging for the (real) world • Guidance for planning successful implementations – Context assessment tools • Implementation Strategies – “How to” execute strategies – Tailored to context • “Learning” repositories – Collective learning Roadmap
- 76. 76 What works where and why? Contact: Laura.Damschroder@va.gov
- 77. Poll Question #5 What are your next steps? I plan to … A. access the CFIR Tool. B. read the NCCMT summary of the CFIR Tool. C. consider using the CFIR Tool. D. tell a colleague about the CFIR Tool. 77
- 78. Follow us @nccmt Suivez-nous @ccnmo • Use Q&A to post comments and/or questions • ‘Send’ questions to All (not privately to ‘Host’) Q&A Participant Side Panel in WebExYour Comments/Questions 78
- 79. Your Feedback is Important Please take a few minutes to share your thoughts on today’s webinar. Your comments and suggestions help to improve the resources we offer and plan future webinars. The short survey is available at: https://nccmt.co1.qualtrics.com/SE/?SID=SV_8H AZ4HrWTZsPszP 79
- 80. After Today The PowerPoint presentation (in English and French) and English audio recording will be made available. These resources are available at: PowerPoint: http://www.slideshare.net/NCCMT/ Audio Recording: https://www.youtube.com/user/nccmt/videos 80
- 81. Join us for our next webinar NCCMT’s Applicability & Transferability Tool December 9, 2015 from 1:00 – 2:30pm EST The Applicability and Transferability of Evidence Tool (A&T Tool) is designed to help public health managers and planners decide whether the evidence you find can be used in your local setting. Register at: https://health-evidence.webex.com 81
- 82. Follow us @nccmt Suivez-nous @ccnmo Funded by the Public Health Agency of Canada | Affiliated with McMaster University The views expressed here do not necessarily reflect the views of the Public Health Agency of Canada. For more information about the National Collaborating Centre for Methods and Tools: NCCMT website www.nccmt.ca Contact: nccmt@mcmaster.ca