Complex Health Interventions Research Articles

11.D. Scientific session: Participatory approaches and co-creation in complex interventions to reduce inequity in health

Abstract Health disparities are linked to social inequalities, necessitating health researchers to address the health gaps that exist between different social groups, particularly in the realm of health interventions. This workshop delves into the significance of co-creation processes and participatory approaches in complex health interventions to reduce social inequities in health outcomes. Through empirical cases illustrating co-creation processes in intervention research, the workshop aims to enlighten the audience on the continuum of participatory approaches. The MRC/NIH framework of complex interventions highlights the importance of engagement with relevant stakeholders throughout the research phases to enhance the likelihood of developing or identifying interventions that can positively impact health outcomes. However, the extent and nature of stakeholder involvement may vary depending on the specific context and stage of the research. While stakeholder involvement has been a longstanding focus, the concept of co-creation, where stakeholders actively participate in the entire process of intervention development, implementation, and evaluation, has emerged more recently. This shift from creating interventions for the target population to collaborating with them in the intervention’s creation has led to the emergence of more inclusive health interventions that are contextually relevant and tailored to the local settings where they are intended to create change. Yet, introducing participatory approaches in intervention research may raise new questions about decision-making and power dynamics. While interventions led solely by experts and researchers may overlook the empowerment and capacity-building potential among stakeholders and intervention sites, co-creation processes have the capacity to empower stakeholders and address health inequities effectively. However, challenges persist in ensuring equal collaboration between researchers and participants, especially in disadvantaged groups. This workshop aims to prompt reflection on ethical issues arising from traditional health intervention approaches and approaches to ensure participants’ ownership of interventions when they are adapted in new contexts. Moreover, this workshop will discuss the design of participatory interventions: What methods can we use to co-create? What stakeholders to involve? At what stages of the intervention should co-creation occur? The workshop program begins with an introductory presentation of participatory approaches and co-creation in health intervention research, with examples from a school-based intervention. Next, three empirical cases of co-creation processes introduced in interventions in different contexts are presented. Finally, the audience is invited to a take part in a discussion focusing on how participatory approaches among disadvantaged populations can potentially contribute to reduced social inequity in health. Key messages • The involvement of stakeholders in the development, implementation and evaluation of health interventions can take many forms, and what is meaningful for the specific context needs to be considered. • Co-creation approaches in health interventions empower participants and address unequal power dynamics between those who deliver and those who receive health interventions.

Exploring Implementation Processes of a Multicomponent Family Support Intervention in Intensive Care Units (FICUS) Study: A Mixed-Methods Process Evaluation.

To investigate the experience with and progress of the implementation of a Family Support Intervention (FSI) into adult intensive care units (ICUs) as part of the cluster-randomised FICUS trial. A mixed-methods process evaluation using a multiple case study approach guided by the normalisation process theory. This study took place between June 2022 and July 2023 in eight Swiss ICUs randomised to the intervention arm. A tailored implementation strategy was used to introduce the multicomponent FSI, consisting of a new family nursing role and a family care pathway, into interprofessional ICU teams. Participants were 40 ICU key clinical partners. Qualitative data were collected twice, early (3-6 months) and mid-implementation (9-12 months), using small group interviews. A questionnaire with psychometric measures (Acceptability of Intervention Measure, Feasibility of Intervention Measure, Intervention Appropriateness Measure, Normalisation Measure Development Questionnaire) was administered at mid-implementation. RITA pragmatic rapid thematic analysis and descriptive statistics were used to analyse the data. Qualitative and quantitative results were then compared across ICUs (cases). Findings indicated the desired progress of the FSI integration overall and across cases, with high acceptability and appropriateness ratings but only moderate to high feasibility scores. Study-related barriers were noted in all ICUs (i.e., FSI delivery as part of a clinical trial). Implementation barriers included family nurses' limited capacity and clinician's attitudes towards the FSI. Leadership support and interprofessional collaboration were identified as facilitators. Case-based, integrated findings yielded two implementation pathways, namely early and protracted adopters. Implementation barriers were related to the feasibility of FSI delivery within the study context that required a high degree of standardisation and protocol adherence. Implementation progress was shaped by an interprofessional culture of family care, sufficient staff and time resources, and leadership support. The study's findings will inform future implementation of complex health interventions in ICUs. Good reporting of a Mixed-Methods Study (GRAMMS). Within the FICUS trial, a patient and family advisory board with a patient expert, three family members and a patient with own lived experience of critical care collaborate with the research team.

Development of a complex intervention to strengthen municipality-based breastfeeding support to reduced social inequity in breastfeeding

BackgroundBreastfeeding is the ideal nutrition for infants and protects infants and mothers from a range of adverse health outcomes during their lifespan. In Denmark, while the breastfeeding initiation rate is high, only 14% of mothers meet the World Health Organization’s recommendation of exclusive breastfeeding at six months. Furthermore, a notable social inequity exists among those who achieve this recommendation. Knowledge of effective interventions to reduce breastfeeding inequity is limited. A previous hospital-based intervention succeeded in increasing breastfeeding duration. However, most breastfeeding support is provided in Danish municipalities by health visitors. This called for adapting the intervention to the health visiting program and developing an intensified intervention addressing the social inequity in breastfeeding. This article describes the adaptation and development process of a municipality-based intervention.MethodsDuring a 15-month period in 2020–21, the municipal intervention was iteratively developed using a three-stage framework for developing complex health interventions described by Hawkins et al. The three stages were 1) need assessment and stakeholder consultation, 2) co-production and 3) prototyping. The process was inspired by O’Cathain et al.’s principles for a user-centred, co-created and theory- and evidence-based approach, involving parents and health visitors.ResultsIn stage 1, we identified the needs and priorities of the target groups of the intervention. In stage 2, the intervention was developed through action research design and inspired by Duus’ ‘learning cycles’ as the method to enhance motivation and ownership and to strengthen the implementation process by creating a joint room for learning and reflection with health visitors and developers. In stage 3, the intervention was tested for feasibility and usefulness during a 2.5-month period accompanied by monthly dialogue meetings with health visitors and developers. In this period, the intervention was refined based on the gathered experiences and was subsequently prepared for evaluation.ConclusionThe description of the development of this complex intervention, aimed at increasing breastfeeding duration and reducing inequity, offers breastfeeding practitioners and researchers a transparent foundation for continuously improving breastfeeding support and a methodology for complex intervention development.Trial registrationRegistered at Clinical Trials NCT05311631.

Patient engagement in the development and implementation of navigation services: a scoping review protocol

IntroductionPatient navigation, a complex health intervention meant to address widespread fragmentation across the healthcare landscape, has been widely adopted internationally. This rapid uptake in patient navigation has led to a...

From PERFORM to PERFORM2Scale: lessons from scaling-up a health management strengthening intervention to support Universal Health Coverage in three African countries.

Strengthening management and leadership competencies among district and local health managers has emerged as a common approach for health systems strengthening and to achieve Universal Health Coverage (UHC). While the literature is rich with localized examples of initiatives that aim to strengthen the capacity of district or local health managers, particularly in sub-Saharan Africa, considerably less attention is paid to the science of 'how' to scale-up these initiatives. The aim of this paper is thus to examine the 'process' of scaling-up a management strengthening intervention (MSI) and identify new knowledge and key lessons learned that can be used to inform the scale-up process of other complex health interventions, in support of UHC. Qualitative methods were used to identify lessons learned from scaling-up the MSI in Ghana, Malawi and Uganda. We conducted 14 interviews with district health management team (DHMT) members, three scale-up assessments with 20 scale-up stakeholders, and three reflection discussions with 11 research team members. We also kept records of activities throughout MSI and scale-up implementation. Data were recorded, transcribed and analysed against the Theory of Change to identify both scale-up outcomes and the factors affecting these outcomes. The MSI was ultimately scaled-up across 27 districts. Repeated MSI cycles over time were found to foster greater feelings of autonomy among DHMTs to address longstanding local problems, a more innovative use of existing resources without relying on additional funding and improved teamwork. The use of 'resource teams' and the emergence of MSI 'champions' were instrumental in supporting scale-up efforts. Challenges to the sustainability of the MSI include limited government buy-in and lack of sustained financial investment.

An evaluation of the national testing response during the COVID-19 pandemic in England: a multistage mixed-methods study protocol

IntroductionIn 2020, the UK government established a large-scale testing programme to rapidly identify individuals in England who were infected with SARS-CoV-2 and had COVID-19. This comprised part of the UK...

Statistical analysis plan for a cluster randomised trial in Madhya Pradesh, India: community health promotion and medical provision and impact on neonates (CHAMPION2)

BackgroundNeonatal mortality in India has fallen steadily and was estimated to be 24 per 1000 live births in the year 2017. However, neonatal mortality remains high in rural parts of the country. The Community Health Promotion and Medical Provision and Impact On Neonates (CHAMPION2) trial investigates the effect of a complex health intervention on neonatal mortality in the Satna District of Madhya Pradesh.Methods/designThe CHAMPION2 trial forms one part of a cluster-randomised controlled trial with villages (clusters) randomised to receive either a health (CHAMPION2) or education (STRIPES2) intervention. Villages receiving the health intervention are controls for the education intervention and vice versa. The primary outcome is neonatal mortality. The effect of the active intervention on the primary outcome (compared to usual care) will be expressed as a risk ratio, estimated using a generalised estimating equation approach with robust standard errors that take account of clustering at village level. Secondary outcomes include maternal mortality, stillbirths, perinatal deaths, causes of death, health care and knowledge, hospital admissions of enrolled women during pregnancy or in the immediate post-natal care period or of their babies (during the neonatal period), maternal blood transfusions, and the cost effectiveness of the intervention. A total of 196 villages have been randomised and over 34,000 women have been recruited in CHAMPION2.DiscussionThis update to the published trial protocol gives a detailed plan for the statistical analysis of the CHAMPION2 trial.Trial registrationRegistry of India: CTRI/2019/05/019296. Registered on 23 May 2019. https://ctri.nic.in/Clinicaltrials/pmaindet2.php?EncHid=MzExOTg=&Enc=&userName=champion2

Systematic review of applications and properties of the NoMAD instrument for assessing implementation outcomes: Study protocol.

Implementation outcomes measures can be used to assess the implementation of complex health and social care interventions, but evidence for the use of these measures, and their psychometric properties, remains limited. The NoMAD ( Normalisation Me asure Development) survey, based on Normalisation Process Theory, was developed to assess, monitor, or measure factors likely to affect normalisation of a new practice from the perspective of participants who are engaged in an implementation process. Since publication in 2015, NoMAD has been translated into several languages and is increasingly being used in health and care research. This systematic review will identify, appraise, and synthesise the existing literature on the use of NoMAD as an implementation outcome measure, focusing on use and application across different studies and settings, and on its properties as a measurement tool. We will systematically search the bibliographic databases Web of Science, Scopus and PubMed for articles reporting empirical data in peer-reviewed journals. A citation search will also be undertaken in Google Scholar for primary NoMAD publications. Studies will be eligible for inclusion if they: (a) specify using NoMAD as a method and report results from using it, and/or (b) report a translation and/or validation study of NoMAD's measurement properties. Screening of abstracts and full text articles will be done independently by two researchers. Data extraction will be structured to allow collection and descriptive synthesis of data on study characteristics, use of NoMAD, psychometric results, and authors' reflections and recommendations. This review will provide the first synthesis of how NoMAD has been applied in health and care research, and evidence on its properties as an outcome measure since its publication. This will be used to update existing freely accessible guidance for researchers and other users, and disseminated through peer-reviewed publications, and engagement activities with researchers and practitioners.

Protocol for a trial-based economic evaluation analysis of a complex digital health intervention including a computerised decision support tool: the iFraP intervention

Background Digital health interventions (DHI) are associated with significant promise. In recent years, the need to assess the value of these healthcare technologies has motivated a debate regarding the suitability of existing economic evaluation methods in the context of DHI evaluation. Some have argued that robust economic evaluation methods may not be capable of capturing relevant DHI’s characteristics. Others consider that assessing the value of DHI might not be feasible. This protocol paper challenges that view. More specifically, it describes early Health Technology Assessments (HTA) methods to rigorously assess the value for money of a complex intervention including a digital decision support tool i.e., Improving uptake of Fracture Prevention drug treatments (iFraP) as a tracer intervention. iFraP is a complex intervention consisting of a computerised decision support tool, a clinician training package, and information resources to facilitate shared decision-making, increase informed medicine initiation and reduce levels of medicine discontinuation. iFraP’s development was motivated by a view that good quality shared decision-making conversations have the potential to improve levels of osteoporosis medicine uptake. Methods An early economic evaluation of the iFraP intervention was designed to identify, measure, and evaluate the costs and health benefits of iFraP compared to usual practice in Fracture Liaison Services (FLSs). A within-trial cost-effectiveness from the perspective of the National Health Service and Personal Social Service in England will be conducted using patient’s self-reported health related quality of life (HRQoL) and resource use from the iFraP randomised controlled trial. Microanalysis will be used to estimate iFraP’s intervention cost. Finally, Bayesian Value of Information analysis will allow us to estimate an upper bound for the potential health benefits gained from reducing uncertainty on the impact of the iFraP intervention to support uptake and adherence with osteoporosis medicines. Trial registration ISRCTN10606407 - https://doi.org/10.1186/ISRCTN10606407

Development and validation of a hip hop intervention programme for pre-school children: Crescer+ (Grow+)

Physical inactivity and obesity in children are public health problems that can be fought through the practice of rhythmic activities such as hip hop. The aim of this study was to develop and validate the Crescer+ hip hop physical exercise programme, designed to promote increased physical activity and improved physical-motor skills in children aged 3 to 5 years old. The exercise programme was designed and validated by physical fitness and motor development specialists, following the Revised Guidelines for Reporting Criteria on the Development and Evaluation of Complex Health Interventions (CReDECI2), and the Consensus Guidelines on Physical Exercise Programme Reporting Model (CERT), and went through three phases: development, piloting and evaluation. This study presents an intervention proposal based on children's motor development, emphasizing foundational motor skills and drawn on hip hop's identity motor skills, as well as its exploration of various coordinative abilities. The Crescer+ programme proposal presents suggestions for adapting to the target population and choreographies that can be replicated by physical fitness professionals. Keywords: motor development, second childhood, foundational motor skills, complex intervention, fitness

Promoting equitable and patient-centred care: an analysis of patient satisfaction in urban, rural and remote primary care sites in the Philippines

ObjectivesThis study measured changes in patient satisfaction levels before and after the introduction of primary care system strengthening interventions in urban, rural, and remote sites in the Philippines.MethodsA previously validated...

Abstract WP54: Design and Preliminary Results on an Educational Intervention to Foster Stroke Coordinator Engagement, Knowledge, and Job Satisfaction

Background: Stroke Coordinators (SC) are instrumental in overseeing the development, evaluation, and sustainability of processes that drive the Stroke Care System. However, there are many practice barriers that impact the SC role including time management, mentorship, education, and training. The aim of this study s to train SC throughout Alabama’s six EMS regions and evaluate whether training in certification in Stroke Nursing increases overall job satisfaction. Methods: This part of StrokeSTAT, a larger observational trial designed to evaluate the implementation of severity-based stroke triage across Alabama’s six EMS regions. Key elements of the intervention include partnerships with the Alabama Department of Public Health and the State’s professional multi-disciplinary association of health care professionals involved in the care of stroke patients (Alabama Stroke Alliance of Professionals, ASAP), bringing stroke symposia to each EMS region; providing SCs with a Stroke Certified Registered Nurse (SCRN) review course to encourage and inspire nurses caring for patients with acute stroke to sit for the exam; and reimbursement for successful certification. Results: At present, two regional courses have been offered with 27 Registered Nurses in attendance from 33 Stroke Centers. Evaluations (n=20) indicated that before the course, SCs were “slightly comfortable” (5%), “somewhat comfortable” (20%), “for the most part comfortable” (75%) with exam content. In the post-course evaluation, 100% of attendees responded, “the information in this activity will help me do my job.” Conclusions: Stroke care continues to rapidly evolve, and SC are often untrained for the role. The partnership with key stakeholder organizations, bringing the symposia to each region, and focusing on improving knowledge and preparation to sit for the SCRN exam were highly effective in engaging the Alabama SCs in the two EMS regions thus far. The symposia provided specialized knowledge for the practice of Stroke Nursing, and uniformly increased participant’s perception of their ability to perform their duties. Evaluation of impact of the different elements of this complex health intervention on stroke coordinator perception is ongoing.

Mis-implementation of evidence-based behavioural health practices in primary care: lessons from randomised trials in Federally Qualified Health Centers.

Implementing evidence-based practices (EBPs) within service systems is critical to population-level health improvements - but also challenging, especially for complex behavioral health interventions in low-resource settings. "Mis-implementation" refers to poor outcomes from an EBP implementation effort; mis-implementation outcomes are an important, but largely untapped, source of information about how to improve knowledge exchange. We present mis-implementation cases from three pragmatic trials of behavioral health EBPs in U.S. Federally Qualified Health Centers (FQHCs). We adapted the Consolidated Framework for Implementation Research and its Outcomes Addendum into a framework for mis-implementation and used it to structure the case summaries with information about the EBP and trial, mis-implementation outcomes, and associated determinants (barriers and facilitators). We compared the three cases to identify shared and unique mis-implementation factors. Across cases, there was limited adoption and fidelity to the interventions, which led to eventual discontinuation. Barriers contributing to mis-implementation included intervention complexity, low buy-in from overburdened providers, lack of alignment between providers and leadership, and COVID-19-related stressors. Mis-implementation occurred earlier in cases that experienced both patient- and provider-level barriers, and that were conducted during the COVID-19 pandemic. Multi-level determinants contributed to EBP mis-implementation in FQHCs, limiting the ability of these health systems to benefit from knowledge exchange. To minimize mis-implementation, knowledge exchange strategies should be designed around common, core barriers but also flexible enough to address a variety of site-specific contextual factors and should be tailored to relevant audiences such as providers, patients, and/or leadership.

Process evaluations for the scale-up of complex interventions – A scoping review

Background: Process evaluation (PE) is an essential part of testing and adapting complex health interventions (CHIs) and involves evaluating what is implemented (and how), mechanisms of change, and how context affects implementation and health outcomes. To address complex health needs, the focus is on developing new CHIs, rather than on adapting and scaling up existing interventions to promote stronger integration, increased population coverage, or comprehensiveness. Therefore, more attention is needed to process evaluations conducted during the scale-up process as they may have distinctive features, stakeholders, or objectives. We aim to describe the current practice of process evaluations conducted during the scale-up of CHIs.
 Who is it for? The results of this review are relevant to all stakeholders involved in the scale-up of CHI.
 Who did you involve and engage with? All authors of this review have been involved in the scale-up of integrated care across multiple contexts.
 What did you do? Eight primary data sources (PubMed, Embase, CENTRAL, Web of Science, CINAHL, Global Health, Scielo and African Index Medicus) and grey literature were searched. Studies were screened following gold standard review procedures. Study demographics, scale-up dimensions (i.e., integration, coverage, comprehensiveness), features of the complex intervention and PE were charted. Process evaluation was further assessed in terms of stakeholders involved and proposed objectives of the PE. For this review, the United Kingdom Medical Research Council’s (MRC) definition of PE was adjusted in terms of “scale-up” instead of “delivery and functioning.”
 What results did you get? We identified 10303 unique records of which 34 were included after abstract (n=223) and full-text (n=91) screening. Twenty of the 34 studies were conducted in one or more low-middle income countries (LMICs). Most CHIs studied looked at scale-up of interventions for patient empowerment through digital health, strengthening primary care, or person-centered care models. In the absence of a guiding framework for PEs in the context of scale-up, a variety of other frameworks were often used including the RE-AIM framework (n=5), Consolidated Framework for Implementation Research (n=3), or MRC framework for the PE of CHIs (n=1). Some of these frameworks were subsequently adapted to facilitate unexpected pathways to impact or interactions with contextual factors to emerge as well. Interestingly, in 12 out of 34 studies, beneficiaries (e.g., patients) were not stakeholders in the PE.
 What is the learning for the international audience? Process evaluations specific to the process of scaling up is advertently different from implementing a CHI. In the absence of a gold standard framework to guide PE during scale-up, the development of such guidance could be considered.
 What are the next steps? We plan to seek further engagement, including with those funded under the “Global Alliance of Chronic Disease” scale-up program, to determine the value and content of a process evaluation framework for scale-up.

Engaging healthcare professionals in refining the target group of a new care type: The Acute Geriatric Community Hospital (AGCH) referral decision study

Background: The acute geriatric community hospital (AGCH) is an alternative to conventional hospitalisation of older adults. At the AGCH, patients receive acute medical specialist treatment in combination with early rehabilitation in an fitting environment by an interdisciplinary team of professionals. Ambiguity exists on the exact definition of the target group for the AGCH and the difference with the target groups for bed-based intermediate care and geriatric hospital care models.
 Objective: Limited guidelines and methods exist to refine the target group of new care model or (complex) health interventions. The aim of this study was to provide refined assessment criteria for the AGCH by using a target-group refinement procedure with case vignettes.
 Design: A design based research using qualitative research techniques. 
 Setting: Two pioneer sites who have an AGCH in their region and seven pioneer sites who have the ambition to implement an AGCH in their region.
 Subjects: A total of 20 healthcare professionals (elderly care physicians, clinical geriatricians and other medical specialists, physician assistants, nurse specialists) participated in the AGCH target group refinement project, either active in hospitals (n=10) or intermediate care facilities (n=7) or skilled nursing facilities (n=3), and all involved in the implementation of an AGCH in their region.
 Methods: The developed target-group refinement procedure consisted of three phases. 1) Healthcare professionals from the pioneer sites were asked to submit case vignettes for a specific care type or an ambiguous boundary between the AGCH and other care models. These case vignettes were reviewed during 2) web-based vignette questionnaires and 3) two online working sessions. Both during phase 2 and 3, participants were asked to make a referral decision for the case vignettes they were presented with and to report their considerations during this process.
 
 Results: In total, 23 case vignettes were collected and reviewed by 18 healthcare professionals. Triage dilemmas were identified and discussed during online working sessions, following from which the AGCH assessment criteria were refined. We found that the final referral outcome is the result of an interplay of clinical and organisational triage factors.
 Conclusions: This target group refinement procedure enabled involving of a variety of healthcare professionals and was suitable to refine the AGCH assessment criteria. In a short time period, it provided us further insight into (1) the required changes to the AGCH assessment criteria; (2) the (ambiguous) boundaries between the AGCH and other care models, and (3) the considerations made by healthcare professionals during referral decision-making for older adults with an acute care need. We recommend to use this novel procedure as a tool for specifying the target group of (new) care models or healthcare interventions.

Cross-country lessons from the SCUBY project on country-specific roadmaps for scaling up integrated care in Belgium, Slovenia, and Cambodia

Background: The aim of the SCUBY project was to provide evidence on the scaling up of an Integrated Care Package (ICP) for type II Diabetes (T2D) and hypertension (HT) across three distinct health systems (Cambodia, Slovenia, and Belgium) through the development and implementation of country-specific roadmaps for a national scale-up strategy. Harnessing mixed-methods research and stakeholder engagement informed the development of country-specific “living” roadmaps. Here, we aim to extract the different elements that make each country-specific roadmap, identify cross-country similarities and differences, and identify lessons learned. 
 Who is it for? The make-up of the different roadmaps, and the shared learnings in developing these roadmaps will be of interest to academic and non-academic stakeholders involved in the scale-up of complex health interventions, including integrated care. 
 Who did you involve and engage with? Stakeholder mapping and engagement included beneficiaries of integrated care, implementers, healthcare workers, academics, and policy makers. Extensive reflection took place between the consortium members driving the SCUBY roadmap work package, which included the various country-specific leads, to identify cross-country learnings. 
 What did you do? Qualitative content analysis was used to derive key roadmap elements from key SCUBY documents (n=20) including policy briefs, consortium meeting notes, interim reports, amongst others. Subsequently, the roadmap components were mapped against the ten core roadmap components as proposed by Weber et al. (2022).
 
 What results did you get? The content of the three roadmaps differed according to priority needs and position of the change team in the country. The Cambodian team recognised the need of wider coverage of the proposed ICP, and the need to improve quality of the current implementation. The roadmap comprised quality improvement measures, referral pathways, and strengthening monitoring systems. The Belgium roadmap comprises three themes: primary care change management coaching, development of chronic care dashboards, and monitoring change in financing structures. The Slovenian roadmap included pilot studies to generate evidence for new e-health and peer-patient components to support expanding the ICP. Common cross-country elements were: (i) task-shifting to decentralise and involve patients, carers, and their environment, (ii) strengthening monitoring and evaluation, and (iii) creating an enabling environment for ICP implementation. The implementation of many included system-wide strategies extends beyond the project scope, which make it difficult to measure impact. 
 What is the learning for the international audience? Scale-up is a complex intervention that requires engagement with multiple stakeholders and adaptation of plans to the context and new development. The roadmaps are thus living documents that require continuous engagement and reflection amongst stakeholders to identify key elements and priorities. The linkage of research teams with key implementation stakeholders and policy makers leads to change-teams that allow moving from formative phase to implementation of roadmap strategies and full scale-up in due time.
 What are the next steps? Through the SCUBY project, members of the consortium have spanned boundaries and entered dialogues that can further assist the scale-up of integrated care across the various countries. The roadmaps and their development process have provided essential learnings that can help shape these dialogues moving forward.

The impact of breast surgeon information on women’s breast outcome: evidence from breast conserving therapy

Introduction: With the increase in life expectancy and the development of medical knowledge, the expectation that individuals will live a quality life till the very last days is becoming the norm. Palliative care is an approach that improves the quality of life of patients and their families facing the issues associated with life-threatening illness, through the prevention and relief of suffering by means of early identification, comprehensive assessment and a management plan that considers, physical, psychosocial and spiritual needs. Despite this wholesome definition, the majority of palliative care interventions remain localized and siloed.
 Context: In 2019, the Ministry of Health in Ontario, Canada, announced the Ontario Health Teams (OHTs) as an innovative integrated care network model to deliver integrated person-centred care to Ontarians across their life trajectory (currently there are 54 teams covering 95% of the population). These teams utilize a population health management philosophy to integrate care in a person-centered manner. Integrating palliative care across care sectors and along the trajectory of the palliative care journey is a priority to many of these teams.
 Approach: In the Spring of 2022, Burlington OHT formed a working group to co-design an integrated palliative care model. This working group included patients, caregivers, palliative care physicians and nurses, primary care physicians and nurses, home and community care providers, hospice care providers, policy makers, researchers and evaluators. A participatory experience-based co-design approach was taken to identify the gaps, determine best practices, design a new care model, create an implementation plan, implement, evaluate and improve.
 The participatory experience-based co-design approach was guided by the 11-step methodology described by O'Cathain A, et al in 2019 when co-designing complex health interventions. We added some additional steps. The modified methodology included 1) planning the co-design process, 2) involving all stakeholders (including those who will implement, deliver, use and benefit from the intervention), 3) bring together a team and establish decision-making processes, 4) needs assessment via multiple engagement tools (surveys and virtual and in-person engagement sessions), 5) review published research evidence, 6) draw on existing theories/frameworks, 7) identify relevant change ideas, 8) articulate programme theory, 9) undertake primary data collection, 10) understand the local context, 11) pay attention to future implementation of the intervention in the real world, 12) design and refine the intervention and finally 13) implement and evaluate.
 The project is in its concluding stages and the final findings including the detailed integrated palliative care model description and the implementation plan will be available for the conference in May
 Implications for applicability/transferability: Designing integrated palliative care programs is a novice area of integrated care across the world. Describing the participatory experience-based co-design approach that we followed to plan our intervention has a great potential of guiding policymakers, planners, funders and implementers on how to plan and implement such interventions by facilitating a work together-plan together approach.

Working Together-Planning together. A participatory experience-based co-design approach to build an integrated palliative care model in Ontario, Canada.

Introduction: With the increase in life expectancy and the development of medical knowledge, the expectation that individuals will live a quality life till the very last days is becoming the norm. Palliative care is an approach that improves the quality of life of patients and their families facing the issues associated with life-threatening illness, through the prevention and relief of suffering by means of early identification, comprehensive assessment and a management plan that considers, physical, psychosocial and spiritual needs. Despite this wholesome definition, the majority of palliative care interventions remain localized and siloed.
 Context: In 2019, the Ministry of Health in Ontario, Canada, announced the Ontario Health Teams (OHTs) as an innovative integrated care network model to deliver integrated person-centred care to Ontarians across their life trajectory (currently there are 54 teams covering 95% of the population). These teams utilize a population health management philosophy to integrate care in a person-centered manner. Integrating palliative care across care sectors and along the trajectory of the palliative care journey is a priority to many of these teams.
 Approach: In the Spring of 2022, Burlington OHT formed a working group to co-design an integrated palliative care model. This working group included patients, caregivers, palliative care physicians and nurses, primary care physicians and nurses, home and community care providers, hospice care providers, policy makers, researchers and evaluators. A participatory experience-based co-design approach was taken to identify the gaps, determine best practices, design a new care model, create an implementation plan, implement, evaluate and improve.
 The participatory experience-based co-design approach was guided by the 11-step methodology described by O'Cathain A, et al in 2019 when co-designing complex health interventions. We added some additional steps. The modified methodology included 1) planning the co-design process, 2) involving all stakeholders (including those who will implement, deliver, use and benefit from the intervention), 3) bring together a team and establish decision-making processes, 4) needs assessment via multiple engagement tools (surveys and virtual and in-person engagement sessions), 5) review published research evidence, 6) draw on existing theories/frameworks, 7) identify relevant change ideas, 8) articulate programme theory, 9) undertake primary data collection, 10) understand the local context, 11) pay attention to future implementation of the intervention in the real world, 12) design and refine the intervention and finally 13) implement and evaluate.
 The project is in its concluding stages and the final findings including the detailed integrated palliative care model description and the implementation plan will be available for the conference in May
 Implications for applicability/transferability: Designing integrated palliative care programs is a novice area of integrated care across the world. Describing the participatory experience-based co-design approach that we followed to plan our intervention has a great potential of guiding policymakers, planners, funders and implementers on how to plan and implement such interventions by facilitating a work together-plan together approach.

Mobilising context as complex and dynamic in evaluations of complex health interventions

BackgroundThe relationship between healthcare interventions and context is widely conceived as involving complex and dynamic interactions over time. However, evaluations of complex health interventions frequently fail to mobilise such complexity, reporting context and interventions as reified and demarcated categories. This raises questions about practices shaping knowledge about context, with implications for who and what we make visible in our research. Viewed through the lens of case study research, we draw on data collected for the Triple C study (focused on Case study, Context and Complex interventions), to critique these practices, and call for system-wide changes in how notions of context are operationalised in evaluations of complex health interventions.MethodsThe Triple C study was funded by the Medical Research Council to develop case study guidance and reporting principles taking account of context and complexity. As part of this study, a one-day workshop with 58 participants and nine interviews were conducted with those involved in researching, evaluating, publishing, funding and developing policy and practice from case study research. Discussions focused on how to conceptualise and operationalise context within case study evaluations of complex health interventions. Analysis focused on different constructions and connections of context in relation to complex interventions and the wider social forces structuring participant’s accounts.ResultsWe found knowledge-making practices about context shaped by epistemic and political forces, manifesting as: tensions between articulating complexity and clarity of description; ontological (in)coherence between conceptualisations of context and methods used; and reified versions of context being privileged when communicating with funders, journals, policymakers and publics.ConclusionWe argue that evaluations of complex health interventions urgently requires wide-scale critical reflection on how context is mobilised - by funders, health services researchers, journal editors and policymakers. Connecting with how scholars approach complexity and context across disciplines provides opportunities for creatively expanding the field in which health evaluations are conducted, enabling a critical standpoint to long-established traditions and opening up possibilities for innovating the design of evaluations of complex health interventions.

Building Spaces for Dialogues to Rethink Evaluator Competencies: Lessons from the Webinars Organized by the Evaluation Centre for Complex Health Interventions

Background: There is a need to rethink evaluator competencies given the harsh and paralyzing realities of COVID. The pandemic was a time where there was a need to balance diverse perspectives given the limited scientific evidence that existed when faced with a genuinely unprecedented time. In the Fall of 2021 (September to October), the Evaluation Centre for Complex Health Interventions in partnership with the Asia Pacific Evaluation Association organized a three-part webinar series in response to the multiple issues that surfaced during COVID-19, and specifically, the implications of the pandemic for rethinking evaluator competencies and evaluator training. The presenters were from multiple countries including India, Canada, USA, UK, and South Africa.
 Purpose: The presenters pushed for more responsive evaluation approaches to address inequities and sustainability and for a decolonized approach to knowledge building. The webinar raised a number of themes that have potential implications for future discussions on evaluator competencies including: enhancing evaluation contributions to the Sustainable Development Goals (SDGs), the need to rethink evaluation criteria, the need to embrace and address varieties of uncertainties, focus on diversity and heterogeneity; understanding the role of contexts in complex programs and policies; the need to reconceptualize sustainability; being more explicit about inequities and vulnerabilities; and the need to pay attention to systems and system dynamics.
 Setting: The webinars were organized by the Evaluation Centre and the Asia Pacific Evaluation Association on a Zoom platform.
 Intervention: Not applicable.
 Research Design: Not applicable.
 Data Collection and Analysis: Not applicable.
 Findings: Not applicable.