The tool was developed in Canada, has been psychometrically tested also in other countries and is presently used in several large studies in high-income settings [20, 25–27].The ACT contains eight dimensions measuring (1) leadership, (2) culture, (3) feedback, (4) connection amongst people, (5) formal interactions, (6) informal interactions, (7) structural and electronic resources and (8) organizational slack (sub-divided into staffing, space and time) .The rationale for forming this multi-country team was our common interest in context as an explanatory factor influencing the implementation of health interventions.The COACH tool development has gone through six different phases resulting in five different versions of the COACH tool (see Fig. Findings from one phase fed into the development of the next version of the tool including deletion of items, revisions of items and development of new items.The three available tools were developed for, and validated in, high-income settings [17–19, 25, 26].There has been no tool readily available for use in low- and middle-income countries (LMICs), where contextual issues influencing efforts to implement EBPs might include other aspects than those in high-income settings [28, 29].
The Promoting Action on Research Implementation in Health Services (PARIHS) framework was developed to provide a framework to understand implementation as a multifaceted process .
The importance of understanding context prior to and during the evaluation of the implementation of EBPs has led to the development of three quantitative tools aimed at assessing healthcare context, all of which have been developed based on the PARIHS framework [17–19].
Out of the three tools, the Alberta Context Tool (ACT) is the one that has been most widely used and has been subjected to the most rigorous evaluation of validity and reliability [13, 20–24].
Hence, there is a need to go beyond measuring the ‘hardware’ of the health system to capturing the ‘software’, i.e.
contextual issues, including the ideas, values, norms and power relations that determine health system performance .
Thus, the network formed a core group to carry out the COACH project including health services researchers from Bangladesh, Vietnam, Uganda, South Africa, Nicaragua and Sweden having extensive experience from working in LMICs and implementing EBPs in these settings.