Obiezu-Umeh Chisom, Subramaniam Divya S, Nwaozuru Ucheoma, Gbaja-Biamila Titilola, Blessing Lateef Akeem, Shato Thembekile, Oladele David, Hirschhorn Lisa R, Shacham Enbal, Xian Hong, Ezechi Oliver Chukwujekwu, Iwelunmor Juliet
Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, United States.
Department of Health and Clinical Outcomes Research, Saint Louis University School of Medicine, Saint Louis, MO, United States.
Front Health Serv. 2025 Jul 24;5:1618400. doi: 10.3389/frhs.2025.1618400. eCollection 2025.
Despite substantial research and growing evidence on effectiveness, the longer-term benefits of proven healthcare interventions and programs have not been fully explored due to challenges sustaining such efforts. Existing sustainability measures developed in high-income countries may not reflect determinants unique to the sustainability of interventions in low- and middle-income countries (LMICs), including African countries. To address this gap, our study developed a Sustainability Tool to Assess Evidence-Based Interventions and Programs (STEPS), which provides a theory-based measure that can be used to assess multilevel determinants of sustainability from the perspective of frontline health workers, service providers, or implementation practitioners.
STEPS domains and the initial scale item pool were generated based on a review of existing literature on sustainability in the African region. Two rounds of expert reviews were conducted with 12 experts from nine African countries, providing ratings and feedback on the relevancy of each item. Then, face validity was conducted among ten healthcare workers involved in implementing interventions and programs in Nigeria. Content validity metrics and consensus methods were used to remove redundancy, reducing the final scale to 31 items. Subsequently, we piloted STEPS among 256 healthcare workers in Nigeria directly involved in implementing evidence-based programs and/or interventions. Data were analyzed using exploratory factor analysis (EFA) to identify the underlying factor structure, followed by reliability analysis.
The EFA indicated that a four-factor 31-item structure best fits the data (Kaiser Criterion of eigenvalues >1, confirmed by scree plot, and interpretability). The four subscales are: (1) intervention characteristics (2) organizational capacity, (3) implementation context and values, and 4) socio-cultural and community context. The Cronbach's alpha for the subscales ranged from 0.83 to 0.95. Overall, STEPS demonstrated adequate content validity and excellent internal consistency for the overall scale with a Cronbach's alpha of 0.97.
Our research findings contribute to the implementation science literature by providing future researchers or programmers a means to assess factors associated with the long-term delivery and subsequent benefits of evidence-based interventions and programs in African settings. STEPS provides a context-relevant tool for assessing sustainability in the African context and other LMICs.
尽管已有大量研究且越来越多的证据表明医疗保健干预措施和项目具有有效性，但由于维持此类努力面临挑战，已证实的医疗保健干预措施和项目的长期效益尚未得到充分探索。高收入国家制定的现有可持续性措施可能无法反映低收入和中等收入国家（包括非洲国家）干预措施可持续性所特有的决定因素。为了填补这一空白，我们的研究开发了一种评估循证干预措施和项目的可持续性工具（STEPS），它提供了一种基于理论的衡量方法，可用于从一线卫生工作者、服务提供者或实施从业者的角度评估可持续性的多层次决定因素。
STEPS的领域和初始量表项目池是基于对非洲地区现有可持续性文献的回顾而生成的。对来自九个非洲国家的12名专家进行了两轮专家评审，他们对每个项目的相关性给出评分并提供反馈。然后，在尼日利亚参与实施干预措施和项目的十名医护人员中进行了表面效度评估。使用内容效度指标和共识方法消除冗余，将最终量表缩减至31个项目。随后，我们在尼日利亚直接参与实施循证项目和/或干预措施的256名医护人员中对STEPS进行了试点。使用探索性因素分析（EFA）来识别潜在因素结构，随后进行可靠性分析。
探索性因素分析表明，一个包含31个项目的四因素结构最适合数据（特征值>1的凯泽准则，通过碎石图和可解释性得到证实）。这四个子量表分别是：（1）干预特征；（2）组织能力；（3）实施背景和价值观；以及（4）社会文化和社区背景。子量表的克朗巴哈系数在0.83至0.95之间。总体而言，STEPS量表显示出足够的内容效度和出色的内部一致性，克朗巴哈系数为0.97。
我们的研究结果为实施科学文献做出了贡献，为未来的研究人员或项目人员提供了一种手段，以评估与非洲背景下循证干预措施和项目的长期实施及后续效益相关的因素。STEPS为评估非洲及其他低收入和中等收入国家背景下的可持续性提供了一个与背景相关的工具。
