Combine

Reasons you might decide to combine TMFs include:

• A need to have a separate TMF that addresses planning, design, and implementation and one that guides evaluation. A common example of this combination is to use a pure planning TMF such as the Diffusion of Innovations Theory along with the RE-AIM framework that will guide the evaluation of the proposed work.
• A need to expand on a quantitative measurement of outcomes with more contextual understanding. An example is the use of the Consolidated Framework for Implementation Research (CFIR) as the contextual model better understand the quantitative outcomes informed by the RE-AIM Framework.
• One TMF might provide a broad and multilevel description of an issue or phenomena and another help you hone in on one specific level of this issue (e.g., provider level factors), where one TMF may allow for expansion of constructs in another broader, less specialized TMF. A widely used example is the combined use of the Consolidated Framework for Implementation Research (CFIR) with the Theoretical Domains Framework (TDF).
• One TMF might help the operationalization and evaluation of another construct from a larger TMF. An example is the use of the Practical Robust Implementation and Sustainability Model (PRISM) with the FRAME Adaptation and Modification Model that supports systematic documentation of adaptations, or the Program Sustainability Assessment Tool (PSAT) by Luke et al for guiding planning for sustainment.
• TMFs may be used in a temporal fashion with some of the constructs playing key role in earlier and others at later phases.
• TMFs may be relevant at various levels of the socioecological framework.
• Some cases for which you need to combine a D&I TMF with a more specialized TMF from another discipline. One such example would be to combine the Kingdon Model of Policy Factors and Institutional Theory from the economics field that uses an interdisciplinary approach to understand how social, governmental, political, cultural, and commercial institutions influence decision-making.

The first step for combining TMFs is to identify multiple TMFs that may support various aspects of your planned work. In the Select section of this webtool you can run multiple searches and choose TMFs for these various purposes, using the key constructs you have identified in the Plan section. Another tool that can guide you with identifying and comparing of multiple TMFs for D&I is T-CaST: an implementation theory comparison and selection tool.

More details about this tool can be found:
Birken, S.A., Rohweder, C.L., Powell, B.J. et al. T-CaST: an implementation theory comparison and selection tool. Implementation Science 13, 143 (2018) doi:10.1186/s13012-018-0836-4. PMID: 30466450

1. Before assigning roles and operational definitions to each TMF, you need to address the potential need for adaptations to local context and specific purposes. The separate section on Adapt can help with these steps.
2. Combining TMFs can increase the complexity of your work. Usually you do not want to attempt to combine more than two TMFs in a single study.
3. You should clearly identify the role of the TMF you select – each might address different issues and fit different parts of your logic model. You will need to provide a rationale for use of each TMF and why you chose this particular combination.
4. If you include multiple TMFs for the same purpose, it may confuse readers/reviewers (unless, you are specifically testing one TMF versus another).
5. You should provide description on how and when the various constructs will be operationalized in the course of the project. The Use section can provide you with guidance on how to make sure that your TMFs are well integrated throughout the entire project.

A few publications describing common combinations of models are listed below:

1. A review of the combined use of the CFIR and TDF:
   Birken, S.A., Powell, B.J., Presseau, J. et al. Combined use of the Consolidated Framework for Implementation Research (CFIR) and the Theoretical Domains Framework (TDF): a systematic review. Implementation Sci 12, 2 (2017)
2. An example of how the PRISM and Stirman adaptation and modification framework have been combined:
   Rabin BA, McCreight M, Battaglia C, Ayele R, Burke RE, Hess PL, Frank JW and Glasgow RE (2018) Systematic, Multimethod Assessment of Adaptations Across Four Diverse Health Systems Interventions. Front. Public Health 6:102.
3. An example of the integration of CFIR and RE-AIM where CFIR is used to contextualize the quantitatively measured RE-AIM outcomes:
   Damschroder LJ, Reardon CM, AuYoung M, Moin T, Datta SK, et al. Implementation findings from a hybrid III implementation-effectiveness trial of the Diabetes Prevention Program (DPP) in the Veterans Health Administration (VHA) (2017) Implementation Sci 12(1):94.
4. An example of the combined use of EPIS and other models including an economic perspective:
   Bowser, D., Henry, B. F., & McCollister, K. E. (2019). An Overlapping Systems Conceptual Framework to Evaluate Implementation of a Behavioral Health Intervention for Justice–Involved Youth. Health Services Insights, 12, 1178632919855037.
5. An example of the combined use of EPIS and CFIR as complementary models to support conceptualization and evaluation:
   Hunter, S. B., Han, B., Slaughter, M. E., Godley, S. H., & Garner, B. R. (2017). Predicting evidence-based treatment sustainment: results from a longitudinal study of the Adolescent-Community Reinforcement Approach. Implementation Science, 12(1), 75.
6. An example of the combination of PRISM and the learning evaluation framework:
   Linke, S. E., Kallenberg, G., Kronick, R., Tai-Seale, M., De-Guzman, K., & Rabin, B. (2020). Integrating “Exercise Is Medicine” into primary care workflow: a study protocol. Translational Behavioral Medicine.