Skip to main content
  • Poster presentation
  • Open access
  • Published:

The Context Assessment for Community Health tool - investigating why what works where in low- and middle-income settings


The gap between what is known and what is practiced results in patients not benefitting from advances in healthcare and unnecessary costs for clients and health systems. The Promoting Action on Research Implementation in Health Services (PARIHS) framework posits (1) strong evidence, (2) context in terms of coping with change, and (3) facilitation as elements influencing successful implementation of new knowledge [1]. A strong context is considered key to warrant an environment receptive to change. Tools for systematic mapping of aspects of context influencing implementation have been developed for, and are being used in, high-income settings whereas there are no tools available for this purpose for low- and middle-income countries (LMICs).

Materials and methods

The development of the Context Assessment for Community Health (COACH) tool departed from the PARIHS framework and was undertaken in Bangladesh, Vietnam, Uganda, South Africa and Nicaragua in six phases; (1) defining dimensions and draft tool development, (2) quantitative and qualitative content validity amongst in-country experts, (3) content validity amongst international experts, (4) response process, (5) translation and (6) evaluation of psychometric properties. The tool has been validated for use amongst physicians, nurse/midwives and community health workers in these five settings.


This study indicates that dimensions of context identified to influence implementation in high-income healthcare settings are also relevant in LMICs. Having said this, there are additional aspects of context of relevance in LMICs. The final version of the tool includes 49 items measuring the following eight aspects of context: leadership, work culture, monitoring services for action, sources of information, resources, community engagement, commitment to work and informal payment.


Application of the COACH tool will allow for systematic characterization of local healthcare context prior to or as part of the evaluation of implementing new interventions and allow for deepened insights into the black-box of implementation in LMICs.


  1. Rycroft-Malone J: The PARIHS framework - a framework for guiding the implementation of evidence-based practice. J Nurs Care Qual. 2004, 19: 297-304. 10.1097/00001786-200410000-00002.

    Article  PubMed  Google Scholar 

Download references


We wish to thank the Swedish International Development Cooperation Agency for funding this project. Additional members of the COACH research team include: Professor Lars-Åke Persson, Associate Professor Carina Källestål, Associate Professor Mats Målqvist, Professor Stefan Peterson, Dr Katarina Selling and Dr Nguyen Nga (all from Uppsala University), Professor Petter Gustavsson (Karolinska Institutet), Professor Carole Estabrooks (University of Alberta) and Associate Professor Janet Squires (University of Ottawa).

Author information

Authors and Affiliations


Rights and permissions

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Bergström, A., Dinh, H., Duong, D. et al. The Context Assessment for Community Health tool - investigating why what works where in low- and middle-income settings. BMC Health Serv Res 14 (Suppl 2), P8 (2014).

Download citation

  • Published:

  • DOI: