Transitioning from the Consolidated Framework for Implementation Research (CFIR) to the updated CFIR for quantitative measurement of influences on implementation outcomes in a faith-based walking intervention

Abstract

Background

Our research team has used the highly cited Consolidated Framework for Implementation Research (CFIR) a priori throughout the research process to better understand influences on implementation outcomes of an organizational change innovation to promote physical activity and healthy eating in faith-based settings. CFIR has recently been updated to include substantial changes in some domains and constructs, and our research team is preparing to carry out a new implementation study of an evidence-based innovation in churches. The purpose of this paper is to describe the process we undertook to map CFIR domains, constructs, and quantitative measures from our earlier studies onto updated CFIR domains, constructs, and quantitative measures for the new project, providing a model for other researchers.

Methods

The measurement team engaged in a systematic, structured, and iterative planning process that included the key actions of clarifying the goal for the transition process from CFIR to updated CFIR, reviewing/comparing CFIR and updated CFIR domains and constructs and how they changed, segmenting the five CFIR/updated CFIR domains for discussion and structuring each discussion with handouts in an iterative process, compiling the items from each domain, obtaining and incorporating feedback on the items from community partners, and compiling the final table of items that incorporates community input.

Results

The culmination of our process was a table that included updated CFIR domains and subdomains, constructs, survey respondents, and the data collection timeframe (baseline, post-training, and 32 weeks).

Conclusions

We offer our experience as a model for other implementation science research teams who wish to transition from CFIR to updated CFIR domains, subdomains, constructs, subconstructs, and associated quantitative measures to better understand implementation outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-026-00903-4.

Contributions to the literature.

This paper: 

• Describes the process our team used for mapping CFIR domains, constructs, and associated survey items from an earlier project onto updated CFIR domains, constructs, and corresponding quantitative items in a new project

• Provides other researchers an operationalized model of the transition process from the original to updated CFIR

Background

The Consolidated Framework for Implementation Research (CFIR) is a meta-theoretical framework that unified implementation theory by consolidating key published implementation theory constructs [1]. It emphasized the need to evaluate context-specific influences on implementation outcomes to increase the uptake of evidence-based policies and practices and has been among the most highly cited implementation frameworks [2]. The CFIR was designed to evolve as the field of implementation science progressed [1]. Accordingly, Damschroder and colleagues [3] recently updated the framework to updated CFIR based on feedback from a literature review and a survey of authors with published studies applying CFIR. The updated CFIR includes revisions to existing CFIR domains and constructs with the addition, removal, renaming, or relocation of some constructs to address critiques of CFIR.

Kirk et al. [4] reported in a systematic review that the CFIR has been applied largely using mixed or qualitative methodology in the post-implementation phase and that use of the framework has not been integrated throughout the research process. In our research team’s prior dissemination and implementation (D&I) work, we successfully applied the CFIR, along with the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework [5], a priori throughout the research process to better understand implementation outcomes in faith-based settings. Specifically, we applied the CFIR to guide the quantitative assessment of influences on adoption [6–8], implementation [9, 10], and maintenance [11] of an organizational change innovation to promote healthy eating and physical activity in churches (Faith, Activity, and Nutrition or FAN).

As described in depth elsewhere, during our recent FAN project, a church coordinator, several church members, and the pastor (optional) formed a committee and participated in eight lessons of online training delivered once per week to enable them to plan and carry out the innovation [10, 12]. These organizational change agents implemented four core components in their churches to promote physical activity and healthy eating: (1) increase opportunities, (2) set policies, (3) share messages, and (4) enlist pastor support. The FAN innovation, developed and evaluated in partnership with the AME Church [13, 14], is guided by Cohen et al.’s [15] structural model of health behavior, and mobilizes the church’s social, policy, and practice environments to increase physical activity and healthy eating opportunities for all church members.

We are expanding upon our work with FAN related to promoting physical activity and healthy eating in churches via a new project that will adapt and study the implementation of an innovation (Walk Your Heart to Health or WYHH) [16], also in church settings. Both FAN and WYHH are listed as National Cancer Institute Evidence-Based Cancer Control Programs [17, 18], and both met seven criteria for dissemination to African American faith-based organizations (only 6 of 66 evidence-based programs identified in a systematic review met these criteria) [19].

Our current innovation, WYHH, is a 32-week walking group program facilitated by trained lay leaders [16] and is designed to leverage the local community physical environment (i.e., via identification of safe walking paths) and to provide a cohesive, socially supportive walking group for adults. In our new project, the focus is on older members (≥ 55 years) in the church. The core elements of WYHH [20] are to: (1) identify and train walking group facilitators, (2) host a walking group session three times per week, building to 50 min of walking per session, (3) provide a suitable space for indoor (for inclement weather) and outdoor walking year-round, and (4) facilitate group cohesion through strategies such as selecting a group name, developing team goals, taking a group photo, and other tactics. The walking group leader and several church members will receive integrated online training that incorporates material from both FAN and WYHH to enable them to carry out the walking groups for older adults (WYHH) within a church environment that supports physical activity (FAN). To reduce complexity and burden on the churches, and because FAN has been shown to be effective in several previous studies in church settings [8–10, 14], implementation evaluation in the new project will focus on WYHH.

With the introduction of updated CFIR in 2022, our research team faced the challenge of converting our previous application of the CFIR Framework and associated quantitative items used in the evaluation of FAN implementation to apply the updated CFIR framework for our new implementation study with WYHH. Because CFIR is so widely used, many research teams are likely in a situation similar to ours and may learn from our transition experience. Consistent with guidance from Damschroder et al. [3], our goal was to create a comprehensive set of items to assess updated CFIR-guided influences on adoption, implementation, and maintenance in WYHH via data collection with individuals in churches with power and/or influence over implementation outcomes, fully operationalizing updated CFIR prior to its use in our new implementation study. Accordingly, the purposes of this paper are to: (1) describe the process our team used for mapping CFIR domains, constructs, and associated survey items from FAN onto updated CFIR domains, constructs, and corresponding quantitative items for WYHH, and 2) provide other researchers an operationalized model of the transition process from CFIR to updated CFIR.

Methods

Preparation

To prepare for the transition process, we reviewed the CFIR domains, constructs, and associated quantitative survey items used in our FAN implementation studies [9, 10], as shown in Table 1. We noted 30 CFIR constructs that were associated with adoption, implementation, or maintenance outcomes in our FAN studies; these were prioritized for further examination of influences on WYHH implementation outcomes. In addition, to inform our discussion of relevant constructs beyond those identified in FAN, we updated the nearly current literature database from the funded proposal (based on decades of work in faith-based settings) with a Google Scholar search on CFIR-based influences on implementation outcomes in faith-based studies. We used the search terms “faith-based,” “implementation outcomes,” and “CFIR” and selected articles not published by our research team, not already in our literature database, and that reported CFIR-based qualitative or quantitative influences on implementation outcomes. This targeted update identified seven recent studies in faith-based settings. Studies included colorectal cancer screening in faith-based settings [22], hypertension control in community sites including faith-based settings [23], a faith-based lay health advisor model (COVID-19 Health Ambassador Program) for underserved, older African American adults [24], a cardiovascular disease risk-reduction intervention in rural churches [25], the CRUZA trial designed to increase capacity among Catholic parishes to implement evidence-based programs for cancer [26], a diabetes self-management program in a diverse range of faith‑based organizations [27], and a physical activity program in Catholic and Protestant churches with large Latina populations [28]. All studies except one [26] used qualitative methodology, and all seven studies used the CFIR. There was congruency between CFIR-based influences identified in these studies and those in our earlier studies of FAN. However, four variables from these studies were not previously assessed in FAN and were added to our tables of constructs that guided our discussions for relevance to WYHH: presence/absence of sufficient space and personnel [28], scheduling complexity for classes that need to find space and to fit into the church schedule [27], health promotion activities being supported by religious beliefs [25], and partners’ perceived need for the innovation [22, 25].

Table 1.

The original Damschroder et al. [1] CFIR domains, constructs, and associated physical activity survey items as used in FAN

Construct	Sample items
Domain 1: Intervention/Program Characteristics
Adaptability	The physical activity parts of FAN can be adapted to fit my church.*
Complexity	The physical activity parts of FAN are easy to use.* The physical activity parts of FAN are clear and understandable.* [21]
Cost	The physical activity parts of FAN are expensive to implement The physical activity parts of FAN take a great deal of time to implement.*
Relative advantage	FAN is more effective than other health programs your church has used. *
Domain 2: Outer Setting
External policy & incentives	Conference or district leaders of your denomination expect your church to participate in FAN
Peer pressure	FAN helps your church keep up with what other churches are doing
Domain 3: Inner Setting
Structural characteristics	Does your church have a health ministry? (yes/no)*
	Have you led or co-led any health promotion efforts at your church elsewhere in the past year? (yes/no)*
	On average, about how many people attend worship service(s) each week at your church? (1–19, 20–99, 100–499, 500 or more)*
	Please estimate what percentage (%) of worshipers in your church are of Hispanic, Latino, or Spanish origin Please estimate what percentage (%) of worshipers in your church belong to each of the following race groups: White, Black or African American, American Indian or Alaska Native, Asian, Native Hawaiian or Other Pacific Islander, Some other race).*
	How long has your pastor/church leader been the leader at your church? (< 1 year, 1–5 years, 6–10 years, 11–20 years, > 20 years)*
Culture	Mean composite of two items:* – Your pastor has a sense of personal responsibility for improving congregant health – Your pastor is open to changes in church practices
Networks & communications	There is very little tension and conflict between members in your church
	Mean composite of three items:* – Your pastor and church leaders actively share information and knowledge with each other – Leaders in your church involve members when decisions are made – Your pastor has good working relationships with other church leaders There is very little tension and conflict between members in your church
Implementation climate  • Tension for change	Tension for change New ideas are readily accepted in your church.* Leaders in your church like to keep to established, traditional ways of doing things
• Compatibility	Compatibility Using FAN fits well with the way I like to work.* FAN matches the priorities of our church.*
• Relative priority	Relative priority The health ministry is as important as the spiritual ministry in your church.*
• Organizational incentives & rewards	Organizational incentives & rewards You are recognized in your church for carrying out the physical activity parts of FAN.*
Readiness for implementation  • Leadership engagement  • Available resources	Leader engagement: Your pastor encouraged congregants to embrace the physical activity parts of FAN.* Available resources: You received enough training to carry out the physical activity parts of FAN in your church.*
Congregant needs and preferences	The physical activity parts of FAN have been well-received by most of the congregants.*
Domain 4: Characteristics of Individuals Involved with Implementation (i.e., implementers)
Beliefs about the intervention	The physical activity parts of FAN are valuable for our church.*
Self-efficacy	You have the skills that are needed to make the physical activity changes for FAN work.* I am confident that I can make the physical activity changes for FAN.*
Perceived benefits	I think my church will benefit from the physical activity changes for FAN.* In the long run, it will be worthwhile for me if my church makes physical activity changes.*
Individual identification with organization	You want to perform to the best of your ability for your church.* You feel a strong sense of commitment to your church.*
Other personal attributes	How long have you been a member of your church?* (< 1 year, 1–5 years, 6–10 years, 11–20 years, > 20 years) Gender (male, female, other) Age (What is your age in years?) Education (Never attended school or only attended kindergarten, Grades 1 through 8 (Elementary), Grades 9 through 11 (Some high school), Grade 12 or GED (High school graduate), College 1 to 3 years (Some college or technical school), College 4 years or more (College graduate)) Meeting guidelines for physical activity (3 moderate-intensity items from the 2009 BRFSS) https://www.cdc.gov/brfss/questionnaires/pdf-ques/2009brfss.pdf Self-rated health (5 = excellent, very good, good, fair, 1 = poor) Body mass index: (kg/m2: About how much do you weigh without shoes? About how tall are you without shoes?)
Domain 5: Implementation Process
Engaging  • Opinion leaders  • Champions	Opinion leaders: Leaders in your church are actively involved in the physical activity parts of FAN.* Champions: There is at least one person in your church who is a champion for the physical activity parts of FAN.*
Executing	Fidelity & completeness of implementation as assessed by implementation measures

This table was adapted from Wilcox et al. [9] Supplemental Table 2

^*Item associated with adoption, implementation, or sustainability in FAN [6, 7, 9–11]

Facilitating conditions

Several elements contributed to the success of the transition process, starting with the support and active engagement of the project Principal Investigator (SW), who had devoted time within the project timeline for the planning process and who also participated in the measurement team. The active engagement of the discussion facilitator (RPS), who was a member of the team, and measurement team members (SW, JPB, ACR, ATK), were crucial. Team members collectively reflected decades of experience in faith-based settings with diverse populations, participated on the previous project, and have a diverse set of skills and backgrounds including community based participatory research (SW, JPB), exercise science (SW, JPB, AK), nutrition (SW), health promotion in community and organizational settings (RPS, ACR, ATK), quantitative and qualitative measurement of implementation outcomes and influences on implementation outcomes (SW, RPS, ACR, ATK, JPB), policy and environmental influences on health (ATK), and health economics (ACR). All members read materials prior to meetings and were comfortable with an iterative process that included review, reflection, discussion, revision, and revisiting prior decisions with new information or learning. Other key elements included the construction of detailed handouts (by the facilitator) that guided discussion and evolved over time to incorporate notes and group decisions, and engaging in facilitated discussions every other week to maintain momentum in the process.

Procedure and consensus-building

Overview of the process

The transition from CFIR to updated CFIR was facilitated by structuring a series of targeted discussions based on resource materials adapted from Damschroder et al. [3] as well as WYHH materials. The process required iterative and continuous action broken into manageable sub-parts. The measurement team met for one hour approximately every two weeks from November 2024 to April 2025. The discussion at each meeting was facilitated by a team member who prepared and distributed the handouts to guide discussion, along with an agenda via email, ahead of time. Measurement team members reviewed the documents prior to the meeting. Team members achieved consensus by sharing perspectives and disciplinary expertise with examples and frequently referring to the work of Damschroder and colleagues for guidance [1, 3]. Consensus was achieved via discussion until complete agreement was reached. Some handouts provided background information and informed discussion, whereas others were working documents that evolved as the team moved through the changes from CFIR to updated CFIR. Updates to evolving handouts, which documented notes and group decisions, were distributed within one day of each meeting.

The key actions in the series of iterative discussion are outlined in Fig. 1 and involved the following six steps: (1) clarify the goal for the transition process, (2) review/compare CFIR and updated CFIR domains and constructs throughout the process, (3) hold segmented discussions of the five CFIR/updated CFIR domains and use handouts to guide discussions, (4) compile survey items, (5) obtain and incorporate feedback on survey items from community members, and (6) finalize survey items and specify respondents and time frame for data collection. These process steps are described in more detail in the section below on “Process for Changing from CFIR to updated CFIR.” In preparing this paper, the measurement team edited the handouts/tables that guided our discussions to improve their clarity.

Fig. 1.

Process for transitioning from CFIR to updated CFIR (simplified version of an iterative process)

Step 1: clarify the goal for the transition process

As described, our primary goal was to map CFIR domains, constructs, and associated survey items from FAN onto updated CFIR domains, constructs, and corresponding quantitative items for use in WYHH. The Principal Investigator (SW) tasked the measurement team with mapping CFIR-informed items from FAN onto updated CFIR informed items for WYHH early in the project. Nonetheless, it was essential for the group to discuss the importance of the change to keep current with advances in implementation science and create optimal measures for the new implementation project. The agreed-upon product to emerge from this process was a table of updated CFIR domains/constructs, associated quantitative survey items, optimal survey respondents, and timeframes for administering surveys to guide data collection over the life of the five-year WYHH project.

Step 2: review/compare CCIR and updated CFIR throughout the process

The purposes of our CFIR/updated CFIR review were to relate CFIR as applied in FAN to updated CFIR for WYHH. Damschroder and colleagues [3] provided a detailed description of CFIR to updated CFIR changes in domains, subdomains, constructs, and subconstructs that was used to inform how the changes in CFIR related to the FAN and WYHH projects. We encourage other users to review the full document produced in Damschroder et al. [3], including their additional online files, to identify the changes of most importance to them. See Additional File 1 for an example applicable to WYHH. The measurement team used this reference document throughout the discussion process.

Notable changes from CFIR to updated CFIR included altered terminology for many terms, especially the use of “innovation” rather than “intervention” to distinguish between what is to be implemented versus the process used for implementation. Overall, as described further below, we found that the changes in the Innovation domain (previously the Intervention Characteristics domain) content were minimal. In contrast, there were numerous changes in the Outer and Inner Setting domains, which included renaming, adding, relocating, or eliminating constructs and subconstructs. The most substantial changes were in the Individual and Implementation Process domains. This information informed our approach to discussion, as outlined in more detail below.

Step 3: hold a segmented discussion of each of the five CFIR/updated CFIR domains and use handouts to guide discussions

This series of actions is where the core work for transitioning from CFIR to updated CFIR took place. The measurement team developed working documents that segmented the five domains of updated CFIR into manageable sub-parts for a series of topic-specific discussions. Our process entailed three sets of discussions, each with a specific handout:

• Innovation, Outer Setting, and Inner Setting domains

• Individual domain

• Implementation Process domain

Unlike the Innovation, Outer Setting, Inner Setting, and Individual domains, which focus on the influence of contextual factors on implementation outcomes, the Implementation Process domain focuses on the approach to implementation and implementation strategies and how these influence implementation outcomes [3]. For the Implementation Process domain discussion, we documented that our comprehensive set of WYHH implementation strategies, organized by the taxonomy created by the Expert Recommendations for Implementing Change (ERIC) [29, 30], were fully congruent with the updated CFIR Implementation Process domain constructs [3]. Because this discussion did not contribute to developing quantitative survey items for assessing contextual influences on implementation outcomes (and due to space limitations), we do not discuss this important domain further in this paper. In the future, we plan to address the influence of specific implementation strategies and implementation fidelity on implementation outcomes in the new project. Therefore, the current paper presents our discussion of contextual influences on implementation outcomes guided by the Innovation, Outer Setting, Inner Setting, and Individual domains.

Innovation, outer setting, and inner setting domains

We use the example of the Inner Setting domain to illustrate the measurement team’s process for transitioning the Innovation, Outer Setting, and Inner Setting domains. There were numerous changes when moving from CFIR to updated CFIR for the Inner Setting domain. Discussions were guided by an evolving table that included updated CFIR constructs and subconstructs and their definitions, adapted from Damschroder et al. [3] (See [3], including their additional online file), along with an indication of whether the construct was used in CFIR, updated CFIR, and/or FAN, and the associated CFIR-informed survey item. Table 2 provides a snapshot of a point in the discussion for the Inner Setting domain (see Additional File 2 for a snapshot of the Innovation, Outer Setting, and Inner Setting domains). This document summarizes information needed for the complex change process involved in transitioning from the CFIR to updated CFIR framework, from FAN to WYHH, and for developing updated CFIR-based quantitative items from CFIR-based quantitative items.

Table 2.

Discussion guide for the inner setting domain

Updated CFIR Construct Name	CFIR	Updated CFIR	FAN	Original CFIR-Informed Items Used in Previous FAN Project	Updated CFIR Definition (from Damschroder et al. [3])
				Old constructs & definitions that were removed or moved in CFIR 2.0 are italicized Team discussions/decisions are indented and in smaller font
A. Structural Characteristics	✓	✓	✓	Presence of health ministry: Does your church have a health ministry? (yes/no) Health promotion experience: Have you led or co-led any health promotion efforts at your church elsewhere in the past year? (yes/no) Number of worshipers: On average, about how many people attend worship service(s) each week at your church? (1–19, 20–99, 100–499, 500 or more) Predominant race/ethnicity of congregation: Please estimate what percentage (%) of worshipers in your church are of Hispanic, Latino, or Spanish origin. Please estimate what percentage (%) of worshipers in your church belong to each of the following race groups: White, Black or African American, American Indian or Alaska Native, Asian, Native Hawaiian or Other Pacific Islander, Some other race. [reported by pastor] Agreed to retain above demographic items Pastor duration, % ≥ 6 years: How long has your pastor/church leader been the leader at your church? (< 1 year, 1–5 years, 6–10 years, 11–20 years, > 20 years) Agreed to move pastor duration to Individual domain as it is not infrastructure per se	Infrastructure components support functional performance of the Inner Setting Use this construct to capture themes related to Structural Characteristics that are not included in the subconstructs below
1. Physical Infrastructure		✓			Layout and configuration of space and other tangible material features support functional performance of the Inner Setting
2. Information Technology Infrastructure		✓			Technological systems for tele-communication, electronic documentation, and data storage, management, reporting, and analysis support functional performance of the Inner Setting
3. Work Infrastructure		✓			Organization of tasks and responsibilities within and between individuals and teams, and general staffing levels, support functional performance of the Inner Setting
B. Relational Connections (Networks & Communication in CFIR were split into B-Relational Connections and C-Communications)	✓	✓	✓	Mean composite of 3 items: – You have good working relationships with lay leaders in your church – You actively share information and knowledge with your church – You involve members when decisions are made that affect them There is very little tension and conflict between members in your church Agreed to retain first, third, and fourth items and to move second item to Communications below	There are high quality formal and informal relationships, networks, and teams within and across Inner Setting boundaries (e.g., structural, professional)
C. Communications	✓	✓	✓	You actively share information and knowledge with your church Construct retained, but item requires rewording	There are high quality formal and informal information sharing practices within and across Inner Setting boundaries (e.g., structural, professional)
D. Culture	✓	✓	✓	Mean composite of 2 items: – Your pastor has a sense of personal responsibility for improving congregant health – Your pastor is open to changes in church practices Agreed to retain construct. First item will be reworded and moved to Recipient Centeredness. Agreed to retain construct for second item but to use a different, existing item from below (Tension for Change) here instead: New ideas are readily accepted in your church	There are shared values, beliefs, and norms across the Inner Setting. Use this construct to capture themes related to Culture that are not included in the subconstructs below
1. Human Equality-Centeredness		✓			There are shared values, beliefs, and norms about the inherent equal worth and value of all human beings
2. Recipient-Centeredness		✓		Agreed to retain construct but reword item, originally in Culture, “Your pastor as a sense of personal responsibility for congregant health,” e.g., “This church has a sense of responsibility for improving the health of its congregants.” Will also use the pastor-specific item, which goes in the Individual domain	There are shared values, beliefs, and norms around caring, supporting, and addressing the needs and welfare of recipients
3. Deliverer-Centeredness		✓			There are shared values, beliefs, and norms around caring, supporting, and addressing the needs and welfare of deliverers
4. Learning-Centeredness		✓			There are shared values, beliefs, and norms around psychological safety, continual improvement, and using data to inform practice. Constructs E – K are specific to the implementation and/or delivery of the innovation
				Old construct and definition: Implementation Climate- The absorptive capacity for change, shared receptivity of involved individuals to an intervention and the extent to which use of that intervention will be rewarded, supported, and expected within their organization	Construct removed from the updated CFIR; reclassified as an antecedent assessment in the CFIR Outcomes Addendum
E. Tension for Change	✓	✓	✓	Leaders in your church like to keep to established, traditional ways of doing things New ideas are readily accepted in your church Agreed to reword and move first item to Individual Characteristics and to move second item to Culture above	The current situation is intolerable and needs to change
F. Compatibility	✓	✓	✓	Using FAN fits well with the way I like to work FAN matches the priorities of our church Construct and first item retained but may need rewording. Second item moved to Mission Alignment for a better conceptual fit	The innovation fits with workflows, systems, and processes
G. Relative Priority	✓	✓	✓	The health ministry is as important as the spiritual ministry in my church Construct and item retained but moved to Mission Alignment below	Implementing and delivering the innovation is important compared to other initiatives
H. Incentive Systems (Organizational Rewards & Incentives in CFIR)	✓	✓	✓	You are recognized in your church for carrying out the physical activity parts of FAN Construct retained, but item requires rewording	Tangible and/or intangible incentives and rewards and/or disincentives and punishments support implementation and delivery of the innovation
I. Mission Alignment (Goals & Feedback in CFIR)	✓	✓		FAN matches the priorities of our church Item moved from Compatibility above	Implementing and delivering the innovation is in line with the overarching commitment, purpose, or goals in Inner Setting
	✓			Old construct & definition: Learning Climate-A climate in which: a) leaders express their own fallibility and need for team members’ assistance and input; b) team members feel they are essential, valued, and knowledgeable partners in the change process; c) individuals feel psychologically safe to try new methods; and d) there is sufficient time and space for reflective thinking and evaluation	Construct renamed and relocated; see Inner Setting: Culture: Learning-Centeredness
	✓			Old construct & definition: Readiness for Implementation- Tangible and immediate indicators of organizational commitment to its decision to implement an intervention	Construct removed from the updated CFIR; reclassified as an antecedent assessment in the CFIR Outcomes Addendum [1]
	✓		✓	Old construct & definition: Leadership Engagement- Commitment, involvement, and accountability of leaders and managers with the implementation One item for Leadership Engagement was included in FAN, “Your pastor encouraged congregants to embrace the physical activity parts of FAN.” Agreed to reword and move to Individual domain	Construct separated, renamed, and relocated; and see Individuals Domain: Roles Subdomain: High-Level & Mid-Level Leaders; Characteristics Subdomain: Motivation
J. Available Resources	✓	✓	✓	You received enough training to carry out the physical activity parts of FAN in your church Agreed to move this item to K-Access to Knowledge & Information	Resources are available to implement and deliver the innovation. Use this construct to capture themes related to Available Resources that are not included in the subconstructs below
1. Funding		✓			Funding is available to implement and deliver the innovation
2. Space		✓		Agreed to select items with content such as: “The program has access to outdoor space needed for walking. The program has access to indoor space needed for walking when the weather is bad. The group members have good access to drinking water and restroom facilities.”	Physical space is available to implement and deliver the innovation
3. Materials & Equipment		✓			Supplies are available to implement and deliver the innovation
K. Access to Knowledge & Information		✓		You received enough training to carry out the physical activity part of FAN in your church Agreed to add new item to fully assess construct, e.g., “You received enough technical assistance after online training that helped you carry out the program.”	Guidance and/or training is accessible to implement and deliver the innovation

This information was adapted from Damschroder et al. [3], including their additional online file (4)

See Additional File 2 for a snapshot of the discussion guides for the Innovation, Outer Setting, and Inner Setting domains

Item wording is not finalized in this table

As reflected in Table 2, some Inner Setting items from our previous FAN project required no edits for adaptation to updated CIFR and WYHH (e.g., Relative Priority; “The health ministry is as important as the spiritual ministry in my church”), whereas others needed revision to better reflect updated CFIR construct definitions (e.g., for Culture, instead of “Your pastor is open to changes in church practice” use “New ideas are readily accepted in your church”). A few previously developed items were moved to a different domain/subdomain to be consistent with updated CFIR (e.g., “Leaders in your church like to keep to established, traditional ways of doing things” was moved from the Tension for Change construct to the Individuals domain). Several new items were added to address new updated CFIR constructs or subconstructs if they were applicable to the faith-based setting or the WYHH program (e.g., for Space, “The WYHH program has access to outdoor space needed for walking”). If a subconstruct that was new in updated CFIR did not apply to the church setting, we did not create a new item for it (e.g., Information Technology Structure).

Individual domain

There were extensive changes from CFIR to updated CFIR in the Individual domain, described here due to the challenges of learning this domain that was new to us. Specifically, all five original CFIR constructs were removed, and the two subdomains of Roles and Characteristics were added. The Roles subdomain includes nine roles of people involved in implementing, delivering, and/or receiving the innovation, including High- and Mid-Level and Opinion Leaders; Implementation Facilitators, Leads, Team Members, and Other Support; and Innovation Deliverers and Recipients [3]. The Characteristics subdomain posits four categories of influential characteristics of individuals involved in implementing, delivering, and/or receiving the innovation: Need, Capability, Opportunity, and Motivation [3]. Capability, Opportunity, and Motivation are from the COM-B system [31, 32], which is based on and summarizes the Theoretical Domains Framework (TDF) [31, 33]. These additional resource articles were used extensively to inform our understanding of the Characteristics subdomain. Finally, our discussion was guided by an adapted version of the matrix of Roles and Characteristics provided in Damschroder et al. [3] (See [3], including their additional online file), which considers the characteristics of individuals involved in implementation specific to their role.

We use the example of the Implementation Lead Role (WYHH group leader) subdomain to illustrate the measurement team’s process for transitioning to the Individual domain (Additional File 3 presents Characteristic constructs and items for the roles of High-Level Leaders, Mid-Level Leaders, Implementation Leads, and Implementation Team Members). Table 3 provides a snapshot of our discussion process. Table 3 is organized with the two left-most columns presenting the four Characteristics constructs, informed by COM-B, and nine associated Characteristics subconstructs, informed by TDF, for the Implementation Lead role. The central column presents proposed items for each subconstruct, which were identified by matching and adapting existing FAN items to the subconstructs or, if necessary, creating new items. The right-most column indicates whether the item was newly created or adapted from FAN. For example, the Need construct has no subconstructs and is assessed by one new item (“The WYHH program will address/addresses the health needs of walking group members”). The Capability construct has two subconstructs, Knowledge and Skills, each with a single new item (“I have the knowledge needed to make WYHH work in my church” and “I have the skills that are needed to make WYHH work in my church,” respectively). The Opportunity construct has two subconstructs, Social Environment (with one new item and one item adapted from FAN) and Environmental Context and Resources (with three new items and one item documented by research staff). The Motivation construct has four subconstructs of Social/Professional Role and Identity (with two items adapted from FAN), Beliefs about Capabilities (with one item adapted from FAN), Beliefs about Consequences (with three items adapted from FAN), and Intention (with one item adapted from FAN).

Table 3.

Discussion guide for the individuals domain and subdomain role of implementation lead (WYHH group leader)

Characteristics		Proposed Items	Item source
Constructs*	Subconstructs**
Need	N/A	The WYHH program will address/addresses the health needs of walking group members	New item
Capability	Knowledge	I have the knowledge needed to make WYHH work in my church	New Item
	Skills	I have the skills needed to make WYHH work in my church	FAN Item adapted for WYHH
Opportunity	Social Environment (Norms)	The support for physical activity in this church makes your job as WYHH leader easy	New item
		There is at least one person in your church who is a champion for WYHH	FAN item adapted for WYHH
	Environmental Context and Resources	Getting the WYHH program on the regular church schedule was challenging	New item
		I have experienced personal challenges that made it difficult to lead WYHH	New item
		The church has experienced challenges that made it difficult to lead WYHH	New item
		Turnover in the pastor and/or the WYHH Leader during this project	RESEARCH STAFF WILL DOCUMENT
Motivation	Social/Professional Role and Identity	I want to perform to the best of my ability as WYHH leader	FAN item adapted for WYHH
		How long have you been a member of your church? (< 1 year, 1–5 years, 6–10 years, 11–20 years, > 20 years)	FAN item adapted for WYHH
	Beliefs about Capabilities	I am confident that I can carry out WYHH in my church	FAN item adapted for WYHH
	Beliefs about Consequences	My church will benefit from the WYHH program	FAN item adapted for WYHH
		WYHH group members will benefit from being in the program	FAN item adapted for WYHH
		WYHH has been well-received by most WYHH group members	FAN item adapted for WYHH
	Intention	I intend to fully carry out WYHH	FAN item adapted for WYHH

This table was adapted from the matrix provided in Damschroder et al. [3], from their additional online file (6)

See Additional File 3 for the Characteristics subdomains for High-level Leader, Mid-Level Leaders, Implementation Lead, and Implementation Team Member Roles

Item wording is not finalized in this table

^*Informed by COM-B + Need [31, 32]

^**Informed by Theoretical Domains Framework [31, 33]

Step 4: compile survey items

We collected survey items from the innovation, outer setting, inner setting, and individual domains and formatted them for presentation to the Community Advisory Board (CAB). The CAB is comprised of organizational partners from faith-based and other settings and has grown from over two decades of our team’s work with community-engaged partners in faith-based settings [9, 12, 13, 34].

Step 5: obtain and incorporate feedback from community partners

The survey items were distributed to our CAB in advance of a monthly meeting for discussion. During the meeting, the Principal Investigator (SW) presented a lay-friendly version of the updated CFIR to help CAB members understand how the measurement team conceptualized influences on implementation outcomes. She then presented all sections of the surveys, covering the items and their purpose, and invited the CAB to comment along the way with questions, concerns, or suggestions. CAB members did not have concerns about the items in either survey. She also asked if there were factors that CAB members thought could influence the success of putting WYHH into place that the survey did not ask about. A CAB member suggested that we assess consistent involvement in WYHH, since engagement in programs often starts high but subsides over time. This suggestion was addressed by adding a construct, Commitment & Perceived Commitment, and two items to the survey for the WYHH group leader and two items for the pastor, including “I am committed to leading walking groups in WYHH for at least 32 weeks” and “Walking group members will be committed to participating in the walking group for at least 32 weeks.”

Step 6: finalize survey items, respondents, and the data collection time frame

As with our previous CFIR discussion for FAN [9], we considered the optimal timing for administering each item. Updated CFIR items that required no understanding of WYHH (e.g., church culture) were to be assessed at baseline, whereas items that required some understanding of WYHH (e.g., compatibility) were to be assessed post-training, and items that required experience with implementing WYHH (e.g., group members’ receptivity to WYHH) were to be administered at 32 weeks. Item wording was further adjusted as needed to accommodate variations in the administration timeframe. Based on our extensive prior work in churches [9, 10], we selected the optimal survey respondents, based on their influence on the implementation process: high-level church leaders (pastors) and church personnel involved in WYHH implementation (WYHH group leaders). Finally, we formatted the items into surveys with appropriate response options. For most updated CFIR items, the response options for rating agreement are on a 4-point scale (1 = strongly disagree, 2 = disagree, 3 = agree, 4 = strongly agree), such that 4 indicates the most favorable response (with reverse coding as needed).

Results

In Step 6, items from the Innovation, Outer Setting, Inner Setting, and Individual domains, along with subdomains, constructs, survey respondents, and the timeframe for data collection (baseline, post-training, and 32 weeks) were compiled into a final table (see Table 4). This table, which was the primary goal for our transition from CFIR to updated CFIR, included items taken or adapted from FAN, new items from updated CFIR and WYHH, and new constructs and items from the CAB.

Table 4.

Respondents (Pastor and WYHH Leader), time frame of data collection, and compiled updated CFIR survey items from the innovation, outer setting, inner setting, and individual domains

Domain Construct	Pastor		WYHH Leader			Survey Item
	Base	32 wks	Base	Post-train	32 wks
Innovation
Relative advantage		✓		✓	✓	WYHH is more effective than other health programs your church has used
Adaptability				✓	✓	WYHH can be adapted to fit your church
Complexity				✓	✓	WYHH is easy to use
Design				✓	✓	WYHH is a well-designed program.*
Cost			✓	✓	✓	Base: If your church chose to provide a walking program, it would be expensive to do so Post-train: WYHH will be expensive to put in place 32 wks: WYHH has been expensive to put in place. (reverse scored)
			✓	✓	✓	Base: If your church chose to provide a walking program, it would take a great deal of time to do so Post-train: WYHH will take a great deal of time to put into place 32 wks: WYHH has taken a great deal of time to put in place. (reverse scored)
Outer setting
Local Conditions			✓			Walk score for area around church: https://www.walkscore.com/*
			✓			Base (composite score of four items with 4-point rating):* There are many places to go within easy walking distance of my church There are sidewalks on most of the streets near my church There are many interesting things to look at while walking near my church The crime rate near my church makes it unsafe to go on walks during the day
External Pressure	✓					Conference or district leaders of your denomination expect your church to participate in WYHH
Market Pressure	✓	✓				Base: Offering a walking program will help your church attract new members and keep existing members.* 32 wks: WYHH has helped your church attract new members and keep existing members.*
Inner setting
Structural Characteristics	✓		✓			Does your church have a health ministry? A health ministry is a recognized team of people who sponsor regular educational events and experiences that promote well-being. (yes/no)
			✓			Have you led or co-led any health promotion efforts at your church in the past year?
	✓					Has your church held any health promotion efforts in the past year? (yes/no)
	✓					On average, about how many people attend worship service(s) each week at your church? (1–19, 20–99, 100–499, 500 or more)
	✓					Predominant race/ethnicity of congregation: Please estimate what percentage (%) of worshipers in your church are of Hispanic, Latino, or Spanish origin Please estimate what percentage (%) of worshipers in your church belong to each of the following race groups: White, Black or African American, American Indian or Alaska Native, Asian, Native Hawaiian or Other Pacific Islander, Some other race
Work Infrastructure	✓		✓			Staffing levels at this church are adequate to run the church.*
Relational Connections	✓					You have good working relationships with lay leaders in your church
			✓			Your pastor has good working relationships with lay leaders in your church
	✓					You involve members of your church when decisions are made that affect them
			✓			Leaders in your church involve members when decisions are made that affect the members
	✓		✓			There is very little tension and conflict between members in your church
Communications	✓		✓			Information and knowledge are actively shared between leaders and members of your church
Culture	✓		✓			New ideas are readily accepted in your church
Recipient Centeredness	✓		✓			This church has a sense of responsibility for improving the health of its congregants
Compatibility	✓		✓	✓	✓	Base: Using a walking program fits well with the way you like to work Post-train: Using WYHH fits well with the way you like to work 32 wks: Using WYHH fits well with the way you like to work
Relative Priority	✓	✓	✓		✓	The health ministry is as important as the spiritual ministry in your church
Incentive Systems					✓	You have been recognized in your church for carrying out WYHH
Misson Alignment	✓	✓	✓	✓	✓	Base: A walking program matches the priorities of your church Post-train: WYHH matches the priorities of your church 32 wks: WYHH matches the priorities of your church
	✓	✓	✓	✓	✓	Base: A walking program fits with the teachings from the Bible.* Post-train: WYHH fits with teachings from the Bible.* 32 wks: WYHH fits with teachings from the Bible.*
Resources: Space			✓		✓	Base: Your church has access to outdoor space needed for a walking program.* 32 wks: The WYHH program had access to outdoor space needed for walking.*
			✓		✓	Base: Your church has access to indoor space needed for a walking program when the weather is bad.* 32 wks: The WYHH program had access to indoor space needed for walking when the weather is bad.*
			✓		✓	Base: Members of a walking group would have access to drinking water and restroom facilities.* 32 wks: WYHH group members had access to drinking water and restroom facilities.*
Access to Knowledge & Information				✓	✓	You received enough training to carry out WYHH in your church
					✓	You received enough technical assistance after the online training to carry out the WYHH program.*
Individuals
High level leader role
COMB-OPPORT-Social Influences		✓				You encouraged congregants to embrace WYHH
					✓	Your pastor encouraged congregants to embrace WYHH
COMB-OPPORT-Environmental Context & Resources		✓				You experienced challenges in your personal life during the past 8 months.* (reverse coded)
		✓				Your church experienced major challenges during the past 8 months.* (reverse coded)
COMB-MOT-Beliefs About Consequences	✓	✓				Base: Your church will benefit from a walking program 32 wks: Your church has benefited from the WYHH program
	✓	✓				Base: Most people who take part in a walking program will benefit 32 wks: Most WYHH group members have benefited from being in the program
	✓	✓				Base: A walking program will be well-received by most people who take part in it 32 wks: WYHH has been well-received by most group members
MOT-Engagement						Pastor completed at least one lesson of WYHH training (The learning management system that houses the training will automatically record lesson completions)
COMB-MOT-Social/Prof. Role & Identity	✓					You have a sense of personal responsibility for improving congregant health
			✓			Your pastor has a sense of personal responsibility for improving congregant health
Leadership Duration	✓					How long have you been the leader at your church? (< 1 year, 1–5 years, 6–10 years, 11–20 years, > 20 years)
CFIR 2.0-NEEDS	✓	✓				Base: A walking program will address the health needs of most people who take part in it.* Post-train: The WYHH program will address the health needs of most group members.* 32 wks: The WYHH program addressed the health needs of most walking group members.*
Mid-level leader role
COMB-OPPORT-Social Influences		✓			✓	Church leaders encouraged congregants to embrace WYHH
	✓		✓			Leaders in your church like to keep to established, traditional ways of doing things. (reverse coded)
MOT-Engagement		✓			✓	Leaders in your church have been actively involved in WYHH
Implementation leads role
COMB-CAP-Skills			✓	✓	✓	Base: You have the skills that are needed to lead a walking program in your church Post-train: You have the skills that are needed to lead WYHH in your church 32 wks: You have the skills that were needed to lead WYHH in your church
COMB-CAP-Knowledge			✓	✓	✓	Base: You have the knowledge that is needed to make a walking program work in your church.* Post-train: You have the knowledge that is needed to make WYHH work in your church.* 32 wks: You have the knowledge that was needed to make WYHH work in your church.*
COMB-OPPORT-Social Environment			✓		✓	Base: Support for being physically active in this church will make it easy for you to put a walking program in place.* 32 wks: Support for being physically active in this church made your job as WYHH leader easy.*
				✓	✓	Post-train: There is at least one person in your church who will be a champion for WYHH 32 wks: There was at least one person in your church who was a champion for WYHH
COMB-OPPORT Environmental Context & Resources			✓	✓	✓	Base: Getting a walking program on the regular church schedule will be challenging.* Post-train: Base: Getting WYHH on the regular church schedule will be challenging.* 32 wks: Getting WYHH on the regular church schedule was challenging.*
					✓	You experienced challenges in your personal life during the past 8 months.* (reverse coded)
					✓	Your church experienced major challenges during the past 8 months.* (reverse coded)
COMB-MOT-Beliefs about Capabilities			✓	✓	✓	Base: You are confident that you can carry out a walking program in your church Post-train: You are confident that you can carry out WYHH in your church 32 wks: You are confident that you can continue to carry out WYHH in your church
COMB-MOT-Social/Pprof Role & Identity				✓		You want to perform to the best of your ability as a WYHH leader
Membership Duration			✓			How long have you been a member of your church? (< 1 year, 1–5 years, 6–10 years, 11–20 years, > 20 years)
COMB-MOT-Beliefs about Consequences			✓	✓	✓	Base: Your church will benefit from a walking program Post-train: Your church will benefit from the WYHH program 32 wks: Your church has benefited from the WYHH program
			✓	✓	✓	Base: Most people who take part in a walking program will benefit Post-train: Most WYHH group members will benefit from being in the program 32 wks: Most WYHH group members have benefited from being in the program
			✓	✓	✓	Base: A walking program will be well-received by most people who take part in it Post-train: WYHH will be well-received by most WYHH group members 32 wks: WYHH has been well-received by most WYHH group members
COMB-MOT-Intention				✓	✓	Post-train: You intend to fully carry out WYHH.* 32 wks: You intend to continue carrying out WYHH.*
CFIR 2.0-NEEDS			✓	✓	✓	Base: A walking program will address the health needs of most people who take part in it.* Post-train: The WYHH program will address the health needs of most group members.* 32 wks: The WYHH program addressed the health needs of most walking group members.*
WYHH CFIR 2.0- Commitment & Perceived Commitment**			✓			I am committed to leading walking groups in WYHH for at least 32 weeks.**
			✓	✓		Walking group members will be committed to participating in the walking group for at least 32 weeks.**
Implementation team members role
COMB-CAP-Skills				✓	✓	Post-train: The WYHH Committee has the skills needed to help make WYHH work in your church 32 wks: The WYHH Committee had the skills needed to help make WYHH work in your church
COMB-CAP-Knowledge				✓	✓	Post-train: The WYHH Committee has the knowledge needed to help make WYHH work in your church.* 32 wks: The WYHH Committee had the knowledge needed to help make WYHH work in your church.*
COMB-OPPORT-Environmental Context & Resources					✓	There has been turnover in the WYHH Committee members.* (reverse coded)
					✓	Some WYHH committee members experienced challenges in their personal lives during the past 8 months.* (reverse coded)
MOT-Engagement					✓	Most WYHH Committee members were actively involved in putting WYHH in place.*

Item wording in this table has been reviewed and approved by the Community Advisory Board

^*New item for updated CFIR and WYHH

^**New construct and items created based on suggestions from the Community Advisory Board

Discussion

The process described in this manuscript is not a “shortcut” to applying updated CFIR. Rather, engaging in this process required a “deep dive” into understanding all elements of updated CFIR as applied to WYHH. Specifically, our measurement team engaged in context-specific learning about updated CFIR [3], COM-B [31, 32], TDF [31, 33], and the WYHH innovation [16]. Our application of this process was rooted in faith-based settings and the team’s substantial collective experiences in partnership with churches for over two decades. However, this process is applicable to other research settings, and our experience and description of the team’s process in this manuscript provides a model for other research teams that wish to transition from CFIR to updated CFIR and to create quantitative survey items to assess contextual influences on implementation outcomes. Specifically, the discussion tables presented in the manuscript and the Additional Files that guided our transition process may be used or adapted as templates by other research teams.

We started from “where we were” in our understanding of CFIR applied to our previous study (FAN) and used that as a springboard to apply updated CFIR to a new project and innovation in the same setting (WYHH). Converting from the quantitative assessment of influences on implementation in our previous study FAN, guided by CFIR [1], to the quantitative assessment of influences on implementation in the new study WYHH, guided by updated CFIR [3], was involved, “messy” at times, and took nearly six months. Nonetheless, it resulted in a beneficial transformation and creation of key work products that will not only inform the WYHH project but also other studies undergoing a similar process. The ultimate work product emerging from this process is a table of updated CFIR domains/constructs, associated quantitative survey items, optimal survey respondents, and timeframes for administering surveys that will guide data collection over the life of the WYHH project. Having this concrete product as the goal for the process provided the team with a focus that enabled us to deal with the complexity of simultaneously changing from CFIR to updated CFIR and from FAN to WYHH.

The lessons learned through this process differed for each set of updated CFIR domains. For the Innovation, Outer Setting, and Inner Setting domains, we were challenged with learning new terminology, framework structure, and concepts, which required some degree of “unlearning” CFIR as used in our previous research project, FAN. The updated CFIR Individual domain was new to the team and required extensive background work in theory (COM-B and TDF) beyond the material presented by Damschroder et al. [3]. We found it helpful to consider Characteristics specific to the Roles played by individuals involved in and/or with influence on implementation by organizing them together in a table (e.g., Table 3 and Additional File 3). Our understanding of the role and scope of Inner Setting change agents and influences on their roles in implementation expanded and resulted in identifying additional corresponding items.

For research teams completely new to CFIR, Reardon and colleagues [35] provided a comprehensive guide for using CFIR. Our process for converting from CFIR to updated CFIR focused on elements from steps 1B (define implementation determinant domains), 2A (determine data collection approach), 2B (construct selection), and 2C (sampling strategy) of the process described by Reardon and colleagues [35]. For example, research teams new to CFIR could engage in a process analogous to the one presented here by selecting domains and constructs from updated CFIR that are appropriate to the innovation, setting, and population of interest to create a context-specific updated CFIR-based framework and then specifying the survey respondents and timeframe(s) for assessment (and any necessary rewording). Instead of adapting existing CFIR-based survey items, the team would identify appropriate new survey items from the appendix included with Reardon et al. [35] and the literature. Our team’s initial process for developing a CFIR framework and associated quantitative items is described in Wilcox et al. [9]. The CFIR website [36], now in the process of being updated to reflect updated CFIR, serves as a valuable resource for instrument development.

Strengths and limitations

Throughout the process of changing to updated CFIR, we followed the guidance of Damschroder et al. [3] to collect data from individuals who have power and/or influence over WYHH implementation (i.e., pastors and WYHH leaders) and fully operationalized updated CFIR prior to use. Furthermore, we used project-specific language as needed and added salient constructs associated with implementation outcomes in our prior work and in other studies conducted in faith-based settings. The transition process was systematic and comprehensive, though we did not report our process for the Implementation Process domain in this paper, as our focus here was on quantitative contextual influences on implementation outcomes and not implementation approaches and strategies on implementation outcomes. Excluding the Implementation Process domain may limit the ability to assess mediation. The product, a set of updated CFIR-informed survey items for pastors and WYHH leaders, will help our team understand adoption, implementation, and sustainability specific to the faith-based setting and our research project on implementing WYHH. Our approach applied the updated CFIR to health promotion in community (versus healthcare) settings. The change process described in this manuscript was necessarily guided by the faith-based setting and the healthy eating and physical activity foci of FAN and WYHH. However, our process and work products are not exclusively applicable in those contexts and are generalizable to the transition from CFIR to updated CFIR in other settings and for other innovation types. The survey items developed in this work also require pilot testing and may further evolve based on item performance and respondent feedback.

Conclusions

With the appropriate project facilitating conditions, including an engaged measurement team, we systematically transitioned from a CFIR framework with associated CFIR-based quantitative survey items to an updated CFIR framework with associated quantitative survey items. The description of this process and the examples of documents used to facilitate discussion for this process provide a model and template for other research teams that wish to change from CFIR to updated CFIR.

Abbreviations

NCI

National Cancer Institute

CFIR

Consolidated Framework for Implementation Research

FAN

Faith, Activity, and Nutrition

WYHH

Walk Your Heart to Health

CAB

Community Advisory Board

COM-B

Capability, Opportunity, Motivation and Behavior

TDF

Theoretical Domains Framework

Authors’ contributions

SW enabled the discussion process to transition from CFIR to updated CFIR. RPS created the initial discussion handouts and facilitated the discussion process. RS, SW, ACR, AK, and JPB all participated in the discussion process to transition from CFIR to updated CFIR. RPS, SW, and ACR drafted the manuscript. RS, SW, ACR, AK, and JPB read and approved the final manuscript.

Funding

This project, U48DP006780, is supported by the Centers for Disease Control and Prevention (CDC) of the U.S. Department of Health and Human Services (HHS). The contents are those of the authors and do not necessarily represent the official views of, nor an endorsement, by CDC/HHS, or the U.S. Government.

Data availability

Not applicable.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors have no relevant financial or non-financial interests to disclose.