Stakeholder Engagement Process Research Articles

Strategic use of resources to enhance colorectal cancer screening for patients with diabetes (SURE: CRC4D) in federally qualified health centers: a protocol for hybrid type ii effectiveness-implementation trial

BackgroundPersons with diabetes have 27% elevated risk of developing colorectal cancer (CRC) and are disproportionately from priority health disparities populations. Federally qualified health centers (FQHCs) struggle to implement CRC screening programs for average risk patients. Strategies to effectively prioritize and optimize CRC screening for patients with diabetes in the primary care safety-net are needed.MethodsGuided by the Exploration, Preparation, Implementation and Sustainment Framework, we conducted a stakeholder-engaged process to identify multi-level change objectives for implementing optimized CRC screening for patients with diabetes in FQHCs. To identify change objectives, an implementation planning group of stakeholders from FQHCs, safety-net screening programs, and policy implementers were assembled and met over a 7-month period. Depth interviews (n = 18–20) with key implementation actors were conducted to identify and refine the materials, methods and strategies needed to support an implementation plan across different FQHC contexts. The planning group endorsed the following multi-component implementation strategies: identifying clinic champions, development/distribution of patient educational materials, developing and implementing quality monitoring systems, and convening clinical meetings. To support clinic champions during the initial implementation phase, two learning collaboratives and bi-weekly virtual facilitation will be provided. In single group, hybrid type 2 effectiveness-implementation trial, we will implement and evaluate these strategies in a in six safety net clinics (n = 30 patients with diabetes per site). The primary clinical outcomes are: (1) clinic-level colonoscopy uptake and (2) overall CRC screening rates for patients with diabetes assessed at baseline and 12-months post-implementation. Implementation outcomes include provider and staff fidelity to the implementation plan, patient acceptability, and feasibility will be assessed at baseline and 12-months post-implementation.DiscussionStudy findings are poised to inform development of evidence-based implementation strategies to be tested for scalability and sustainability in a future hybrid 2 effectiveness-implementation clinical trial. The research protocol can be adapted as a model to investigate the development of targeted cancer prevention strategies in additional chronically ill priority populations.Trial registrationThis study was registered in ClinicalTrials.gov (NCT05785780) on March 27, 2023 (last updated October 21, 2023).

Stakeholder Engagement in Instagram-Based Complaint Handling Indihome Service PT Telkom Yogyakarta Region

This research aims to analyze Telkom Indonesia's engagement strategies with its stakeholders in Yogyakarta during a surge of complaints regarding their Indihome product on Instagram (@indihome.yogya). As a dominant internet service provider, Telkom Indonesia, through its Indihome product, faces a high volume of customer complaints, further amplified by the prevalence of social media platforms like Instagram, which provide a direct channel for customers to air their grievances. The study employs the Stakeholder Circle Model to examine the steps undertaken by Telkom Witel Yogyakarta in addressing customer complaints. A qualitative descriptive approach is adopted to gain a comprehensive understanding of the phenomenon under investigation. Data is gathered through interviews with key informants and a thorough examination of relevant documentation. The findings reveal that Telkom Witel Yogyakarta implements a five-stage stakeholder engagement process: (1) Identification: Creating a list of stakeholders; (2) Prioritization: Developing a stakeholder assessment scale; (3) Visualization: Conducting stakeholder mapping and dividing stakeholders into four quadrants; (4) Engagement: Implementing appropriate communication strategies tailored to each stakeholder category; (5) Monitoring: Evaluating the effectiveness of engagement efforts and ensuring alignment with expectations. This research contributes to the understanding of stakeholder engagement in complain handling from customers on social media platforms. The five-stage stakeholder engagement process offers a valuable framework for organizations seeking to improve their stakeholder relationships and effectively address customer concerns through social media channels.

Stakeholder engagement to introduce a standardised register for improved inpatient care of newborns and sick children in Bangladesh.

Despite a global decrease of 59% in under-five mortality rates from 1990 to 2021, child survival remains a pressing issue. This holds true for Bangladesh, as well. In response, the Government of Bangladesh introduced a standardised register for strengthening the inpatient management of newborns and sick children in 2021. We employed a comprehensive four-phase stakeholder engagement process to implement an inpatient register for newborns and sick children. The first stage included identifying and prioritising potential stakeholders at the national and district levels. We identified eight organisations involved in newborn and child health and selected 24 participants from various other sectors for workshops aimed at raising awareness about the register's introduction. These stakeholders also participated in the register's design, development strategies planning, and implementation phases. These phases were led by the 'National Newborn Health and IMCI programme' with support from various partners. A technical working group reviewed existing registers and helped prepare training materials. Feedback from each workshop was crucial in finalising the register. The Government of Bangladesh has recognised the need for an indoor register for newborns and sick children, which was to be established in collaboration with development partners. This initiative can enhance the quality of care for sick children and increase service provider accountability. Due to its successful implementation, it will continue to be used in the Kushtia and Dinajpur districts, with plans for a nationwide scale-up. The Government has allocated funds in the next health sector programme for orientation and register printing. A strengths, weaknesses, opportunities, and threats (SWOT) analysis of the stakeholder engagement process highlighted strengths such as a context-specific approach and collaborative engagement, as well as challenges such as time resource requirements. Implementing an inpatient register for newborns and sick children through stakeholder engagement can effectively improve child health care services. Aside from challenges such as resource intensiveness and stakeholder commitments, success depended on the organising authority's expertise in relationship building, budget allocation, time management, and workforce dedication. Therefore, strategic planning, staff recruitment, networking, and budgeting are crucial for successful stakeholder engagement and health care initiatives.

Stakeholder engagement processes for the made in Italy small‐ and medium‐sized enterprises: Value co‐creation in the stakeholder network

AbstractThis article aims to explore the role of stakeholder engagement in partnerships and the effects that it has on small‐ and medium‐sized enterprises' (SMEs) competitiveness and their ability to expand into foreign markets. This study employs a qualitative approach to research by gathering empirical data from nine SMEs that have engaged in a partnership fostered by a digital platform that operates as an online sales channel. Our study reveals that SMEs engaging in cooperative activities are able to leverage external stakeholders to improve their competitive advantage and increase their capabilities to permeate into foreign markets and better their structural costs and product variety. The insights derived from this study prove useful to both theory and practice. First, the obtained findings underline the significance of cooperative activities in enhancing SMEs' likelihood of growth and thriving amidst the ever‐changing global market. Second, the present article underlines the impact partnerships have on all three dimensions of stakeholder engagement, namely strategic, pragmatic and moral. Third, the present manuscript corroborates the influence of digital platforms in fostering collaborative initiatives. Finally, the findings carry insights supporting the significance of shared values, norms and objectives amongst businesses as crucial elements of the stakeholder engagement process.

A context-driven approach through stakeholder engagement to introduce a digital emergency obstetric and newborn care register into routine obstetric health care services in Bangladesh.

Emergency obstetric and newborn care (EmONC) in Bangladesh focusses on maternal health, whereby it addresses childbirth and postpartum complications to ensure women's health and well-being. It was transitioned to a digital platform to overcome challenges with the paper-based EmONC register and we conducted implementation research to assess the outcome. Here we outline the stakeholder engagement process integral to the implementation research process. We adopted a four-step stakeholder engagement model based on the identification, sensitisation, involvement, and engagement of stakeholders. The approach was informed by previous experience, desk reviews, and expert consultations to ensure comprehensive engagement with stakeholders at multiple levels. Led by the Maternal Health Programme of the Government of Bangladesh, we involved high-power and high-interest stakeholders in developing a joint action plan for digitisation of the paper-based EmONC register. Finally, we demonstrated this digital EmONC register in real-life settings to stakeholders at different levels. The successful demonstration process fostered government ownership and collaboration with multiple stakeholders, while laying the foundation for scalability and sustainability. Nevertheless, our experience highlighted that the stakeholder engagement process is context-driven, time-consuming, resource-intensive, iterative, and dynamic, and it requires involving stakeholders with varied expertise. Effective strategic planning, facilitation, and the allocation of sufficient time and resources are essential components for successful stakeholder engagement. Our experience demonstrates the potential of adopting the 'identification, sensitisation, involvement, and engagement' stakeholder engagement model. Success in implementing this model in diverse settings depends on leveraging knowledge gained during implementation, maintaining robust communication with stakeholders, and harnessing the patience and determination of the facilitating organisation.

How the COVID-19 pandemic changed stakeholder engagement processes in sustainability research in the long-term

Background The COVID-19 pandemic affected stakeholder engagement in sustainability research projects in many ways. But which effects appear permanent today, after the pandemic ended? Methods To address this, we interviewed researchers and stakeholders and carried out a survey among European sustainability research projects in 2022. Results We find that the pandemic years disrupted stakeholder-based research, also with lasting effects. The forced shift to online modes showed how digital engagement can bring benefits in terms of easier and more efficient stakeholder engagement, but also that important aspects are lost, particularly regarding intensity of collaboration and depth of insights. Whether to go online or stay offline depends largely on the research objective, which stakeholders to involve, and how well researchers and stakeholders already know each other. Most researchers and stakeholders want to continue online collaboration in the long term, especially those with positive online collaboration experiences from the pandemic years. Conclusions The pandemic has a long-term impact on stakeholder engagement in research; online engagement cannot replace all benefit of previous in-person interactions with stakeholders, but it has led to digital innovations and expanded the engagement portfolio. Our research has provided qualitative insights into the impact of the pandemic on stakeholder engagement in various sustainability research projects and the implications for the long-term future that are relevant to researchers and funding agencies.

Double Materiality Disclosure as an Emerging Practice: The Assessment Process, Impacts, Risks, and Opportunities

The Corporate Sustainability Reporting Directive 2022/2464 (CSRD) introduces the concept of double materiality in the preparation of sustainability reports in the European Union (EU) starting in 2024. Our research aim is to provide ex-ante empirical evidence on how large Romanian enterprises perform materiality assessment and disclose impacts, risks, and opportunities. Data are collected from 20 listed Romanian companies, using an inductive approach. Most companies report information on their materiality assessment process; direct, inside out, and positive impacts (and less financial materiality), environmental risks and opportunities, and social impacts. Companies engage mainly with stakeholders in the social realm and less with financial capital providers. The stakeholder engagement process is not continuous, relying predominantly on isolated events. Internal processes are implemented and overseen by dedicated governance structures. Further clarifications and stricter requirements on the implementation of the double materiality concept are needed for the effective application of the CSRD.

Scenarios for offshore wind co-existence opportunities and trade-offs

This paper introduces the MARCO (MARine CO-existence scenario building) concept for using scenario exploration in stakeholder engagement processes in offshore wind. MARCO builds on spatial analyses using geographic information systems (GIS), and projections over time using system dynamics simulation models. We position the concept within the existing literature on tools for decision support and stakeholder participation, and provide a preliminary status on the spatial baselines, as well as example scenarios for area usage in offshore wind and implications, including risks and co-existence opportunities, on other sectors and nature.

Promoting sustainable urban freight through stakeholder engagement to co-create decarbonisation pathways in the UK

The contribution of greenhouse gas emissions from UK urban freight is growing in absolute terms, but the existence of alternative technology options means the urban part of the freight system has potential for relatively early decarbonisation. However, barriers are limiting the speed and extent of uptake. Indeed, freight decarbonisation is a sociotechnical challenge. Behaviour change is usually required to facilitate technological change. For this reason, stakeholders are central to processes of identifying pathways to decarbonisation. The paper reports findings from two projects undertaken in the UK in 2020–21 which examined how stakeholder engagement on freight decarbonisation could be enhanced to promote the process of identifying pathways through co-creation. The projects involved the conduct of literature reviews, stakeholder mapping exercises, and stakeholder engagement in coproduction workshops. The stakeholder mapping and engagement process led to the identification of groups of actors which were relatively easy and hard to include. Engagement and interaction were found to be promoted in some respects by the need to conduct the data collection remotely rather than in presence, and by building on established networks. In terms of the identification of pathways, stakeholders showed mixed levels of knowledge. Uncertainty about the future was generally high, with perceived risks being important. Nonetheless, short, medium and long-term pathway features were identified, with electrification playing a key role in the long term. However, the need for strong multilevel governance providing a clear regulatory framework and incentives for change was perceived by stakeholders overall to be more significant than a particular technology. The paper concludes with an agenda for further research.

Land use planning and climate change adaptation in river-dependent communities in Nigeria

Land use planning and climate change adaptation are critical for ensuring sustainable development and resilience in river-dependent communities in Nigeria. This study examines land use planning and climate adaptation in river-dependent communities in the Lower Niger River region of Nigeria. The research utilizes a mixed-methods approach. Data for the study were gathered from 198 households through surveys, complemented by 17 qualitative interviews and remote sensing techniques to assess land use changes and community perceptions. Findings reveal a notable trend where poor farmers face heightened vulnerability to climate change due to financial constraints, hindering their adoption of adaptive land use strategies. Specifically, more than half of the sampled households possess individual land for agricultural purposes yet lack the resources to effectively mitigate climate-related risks. Among the studied communities, Odekpe emerged as particularly vulnerable, with a prevalence of vulnerability at 32.3% and higher exposure to flood-prone zones.The quantitative analysis delineates community engagement in land management practices, showcasing proactive resource allocation and conflict resolution efforts among over 60% of participants. However, a significant portion (57.6%) lacked awareness of hydrological changes, potentially impeding effective land use planning and adaptation measures.Further analysis through remote sensing and mapping techniques revealed shifts in land use land cover, highlighting a transition from predominantly vegetated areas to built-up regions over the past three decades. The flood vulnerability assessment maps underscored substantial vulnerability across the Lower Niger basin, especially in downstream regions, indicating heightened risks due to proximity to the Niger River and heavy rainfall.Qualitative insights from stakeholder interviews identified challenges impeding effective land use planning, including uncertain climate projections, insufficient data, institutional capacity constraints, and conflicting priorities. Additionally, participants emphasized the need for resilient land use decisions to address urbanization impacts, altered drainage patterns, and diminishing green spaces. The study recommends several key actions to enhance the effectiveness of land use planning and climate adaptation in the Lower Niger River region. These include the imperative to strengthen institutional capacities, improve stakeholder engagement processes, integrate traditional knowledge and practices into planning efforts, fortify legal frameworks governing land use, and prioritize the promotion of sustainable livelihoods among local communities.

Extrajudicial Dispute Resolution in Handling Environmental Cases in Indonesia (Case Study: River Water Pollution by PT Sugar Labinta in South Lampung)

This paper examines extrajudicial dispute resolution mechanisms utilized in addressing environmental cases in Indonesia, with a focus on a specific case involving the alleged pollution of river water by PT Sugar Labinta in South Lampung. It delves into the legal frameworks, stakeholder engagement processes, and outcomes of extrajudicial dispute resolution efforts in environmental matters. Drawing on a case study approach, the paper analyzes the effectiveness and challenges of extrajudicial mechanisms in resolving environmental disputes, particularly in cases of alleged pollution by industrial entities. It explores the roles of various stakeholders, including government agencies, industry representatives, affected communities, and non-governmental organizations, in the resolution process. Furthermore, the paper evaluates the implications of extrajudicial dispute resolution on environmental protection, legal accountability, and community rights. It examines the extent to which such mechanisms contribute to the realization of environmental justice, sustainable development, and corporate responsibility in Indonesia. In conclusion, the paper offers insights into the strengths and limitations of extrajudicial dispute resolution in handling environmental cases, using the PT Sugar Labinta case as a lens. It suggests recommendations for improving the effectiveness and fairness of extrajudicial mechanisms, enhancing transparency, accountability, and community participation in environmental decision-making processes.

Participatory Process Anchored in Systems Thinking for Implementing Ethics in Medical AI: A Qualitative Study.

Implementing ethics is a complex issue and should engage stakeholders. Yet, ensuring a fair, transparent, and meaningful participatory process contributes to the complexity. This qualitative study explores how to engage with stakeholders about a COVID-19 AI app following principles of Critical Systems Thinking. The study is set to explore both process and outcomes of stakeholder engagement and draw recommendations for both.

Stakeholder engagement: the role of facilitators and gender in ‘opening up’ conversations and enabling participation

ABSTRACT A successful global transition to net-zero emissions requires complex transformational change involving stakeholders from across society. Traditionally, stakeholder engagement has been debated predominantly from a pragmatic, functionalist and instrumental perspective. Recent approaches in business communication, sustainability, energy and environmental management show that meaningful and ‘sustainable’ stakeholder engagement is helpful in maintaining an organisation’s social licence to operate. We problematise the notion of participation in deliberative processes and analyse whether the outcomes of an online Australian citizens’ panel are truly representative of all participants or whether specific cultural and demographic factors, particularly gender, influence participation, potentially shaping the outcome. The study shows how gender need to be considered and managed as part of a legitimate deliberation process. Applying Gastil’s input-process-outcome model as a framework, we examine the engagement achieved through deliberations conducted on Zoom. We focus on gender as a variable and the role of the facilitator in managing participation. The results suggest that participants’ contributions to discussions vary based on gender of both participants and facilitators. Based on findings, the challenges of achieving equality in participatory processes are identified. The facilitator’s role is re-defined as a curator of the stakeholder engagement processes, complementing existing theory on stakeholder participation and engagement.

Risk mapping for better governance in biobanking: the case of biobank.cy.

Introduction: Risk governance is central for the successful and ethical operation of biobanks and the continued social license for being custodians of samples and data. Risks in biobanking are often framed as risks for participants, whereas the biobank's risks are often considered as technical ones. Risk governance relies on identifying, assessing, mitigating and communicating all risks based on technical and standardized procedures. However, within such processes, biobank staff are often involved tangentially. In this study, the aim has been to conduct a risk mapping exercise bringing biobank staff as key actors into the process, making better sense of emerging structure of biobanks. Methods: Based on the qualitative research method of situational analysis as well as the card-based discussion and stakeholder engagement processes, risk mapping was conducted at the biobank setting as an interactive engagement exercise. The analyzed material comprises mainly of moderated group discussions. Results: The findings from the risk mapping activity are framed through an organismic metaphor: the biobank as a growing, living organism in a changing environment, where trust and sustainability are cross-cutting elements in making sense of the risks. Focusing on the situatedness of the dynamics within biobanking activity highlights the importance of prioritizing relations at the core of risk governance and promoting ethicality in the biobanking process by expanding the repertoire of considered risks. Conclusion: With the organismic metaphor, the research brings the diverse group of biobank staff to the central stage for risk governance, highlighting how accounting for such diversity and interdependencies at the biobank setting is a prerequisite for an adaptive risk governance.

Developing a digital mind body medicine supportive care intervention for people with amyotrophic lateral sclerosis using stakeholder engagement and design thinking

Background Amyotrophic lateral sclerosis disease (ALS) is also called the disease of a thousand farewells. Consequently, it is important to offer supportive care interventions that can be applied continuously during the whole course of the disease. People with ALS are interested in complementary and integrative medicine. Due to ALS’ progressive nature, digital solutions might be most feasible and accessible for people with ALS in the long-term. Objectives In our study, we explored with stakeholders which digital complementary and integrative medicine interventions and formats are considered as supportive for people with ALS, and which settings are needed by the people with ALS to incorporate the interventions in everyday life. Methods We used a participatory research approach and conducted a stakeholder engagement process, applying a design thinking process with qualitative research methods (interviews, workshops). Results Due to the unpredictable course of the disease on their loss of abilities, people with ALS welcome online settings because they are accessible and easy to implement in their daily life. Stakeholders considered the following implementation factors for a complementary and integrative medicine intervention as essential: short-term realization of planned interventions, short duration of interventions, and user-friendliness in terms of accessibility and applicability. Concerning the complementary and integrative medicine interventions, the people with ALS preferred mind body medicine interventions, such as breathing, mindfulness and relaxation exercises. Conclusions Short-term treatment intervals and short online mind body medicine interventions align with the needs of people with ALS. The complementary and integrative medicine interventions as well as the digital infrastructure must meet the special accessibility and applicability needs of people with ALS.

Stakeholder engagement in natural resources management: Where go from here?

Stakeholder engagement (SE) has become a core practice for natural resources management. However, little is known about how interactive relationships between SE components have been considered during a dynamic SE process, compromising our capacity for SE configuration. This study proposes a comprehensive 5 P–10 R framework encompassing five components (P1-problems, P2-purpose, P3-participants, P4-processes, and P5-products) and ten relationships between any two components delineating interactions between them. The framework is applied to examine all SE case studies (n = 1119) on natural resources management published in Web of Sciences until 2021. Findings suggested that among 561 pairs of combinations of these components, only 13% of relationships were significant. The existing knowledge of SE on natural resources management showed a polarized pattern of either knowledge homogenization or knowledge dearth, calling for more theoretical and interdisciplinary research on SE.

Navigating the Medical Disability Assessment and Personal Injury Claims Landscape in Malaysia

Introduction Individuals who have sustained permanent residual disabilities due to injuries or illnesses and relevant stakeholders engaged in the adjudication process persistently encounter obstacles in accessing equitable and just systems for assessment, support, and facilitation. These systems enable such individuals to secure appropriate compensation and lead fulfilling lives within their communities. Objective This stakeholder engagement process explores the lived experiences of individuals with disabilities and their journey through the claims processes, understanding their concerns and expectations. Results A total of 152 participants participated in the seminar. Thirty-nine participants with extensive experience in medical disability assessment and the claims process were purposefully surveyed, and in-depth interviews were conducted. Several themes emerged from the interview: awareness and education, the legal and judicial system and processes, expert opinion, and reports. Conclusion The findings concluded that expert opinion and report emerged as a critical theme, with participants stressing the need for guidelines, professionalism, and accreditation for expert witnesses. Establishing a multidisciplinary regulatory body to design and develop an educational program for court experts is suggested, as is creating and maintaining a public register of court experts. Such measures will promote transparency, accountability, and quality in expert testimony and reporting

CO-DESIGNING A STAGE 1B FEASIBILITY STUDY OF INPATIENT PALLIATIVE COMMUNITY HEALTH WORKER SUPPORT

Abstract Persons living with dementia (PLWD) are 2-3 times more likely than their non-dementia peers to be hospitalized annually and experience burdensome care transitions and treatments at the late stage of dementia. Minoritized PLWDs are significantly more likely to be hospitalized and experience frequent transitions between care settings, and also less likely to access palliative care. There is a pressing need to develop better models of care transition support for PLWDs and their family caregivers. Proactive palliative care can reduce unnecessary hospitalization and improve outcomes for PLWDs and family caregivers. Community health workers (CHW) can effectively bridge cultural gaps between vulnerable patients/families and formal care systems, and provide care navigation and coaching support. We are currently conducting a single-site randomized controlled pilot trial study to co-design with key stakeholders (Stage 1a), implement and assess (Stage 1b) the acceptability and feasibility of a palliative CHW support for hospitalized PLWDs and caregivers. To date, we have conducted a needs assessment with 34 PLWD/caregiver dyads, key informant interviews with 4 palliative care providers and 2 CHW and social care experts, and multiple stakeholder meetings with hospital frontline providers and CHW groups to develop intervention components and research implementation plans that address language and cultural barriers and healthcare provider and system level barriers experienced by PLWD and caregivers from minoritized and financially vulnerable backgrounds. In this presentation, we will describe stakeholder engagement and co-design process outcomes and preliminary findings on intervention fidelity, participant recruitment and retention, and PLWD/caregiver outcomes.

Agenda-setting for education reform: the case of the Vision Statement for the Future of Scottish Education

ABSTRACT Policy cycles are initiated via a variety of context-bound causal drivers. In situations where systemic reform is desired, agenda-setting is vital to this process. This paper examines ‘The National Discussion on Scottish Education’, which was a sequence of stakeholder engagements promoted as a listening exercise to enable policy agenda-setting for a period of education reform. By considering key elements of the context of education reform in Scotland, the design of the stakeholder engagement process, the published outcome of the process, and by reflecting on the purposes underpinning these, this paper examines the conceptual bases upon which the National Discussion and the Vision Statement that arose from it were founded. The intention to create a vision that was both consensual and compelling was challenging to realise in practice. However, the focus on communitarian values evinced through the Vision Statement offers a helpful orientation for future policymaking and professional practice in education, suggesting the important interrelationship between vision and values for agenda-setting in policy.

Engaging stakeholders to retrospectively discern implementation strategies to support program evaluation: Proposed method and case study

BackgroundAvailability of evidence-based practices (EBPs) is critical for improving health care outcomes, but diffusion can be challenging. Implementation activities increase the adoption of EBPs and support sustainability. However, when implementation activities are a part of quality improvement processes, evaluation of the time and cost associated with these activities is challenged by the need for a correct classification of these activities to a known taxonomy of implementation strategies by implementation actors. DesignObservational study of a four-stage, stakeholder-engaged process for identifying implementation activities and estimating the associated costs. ResultsA national initiative in the Veterans Health Administration (VHA) to improve Advance Care Planning (ACP) via Group Visits (ACP-GV) for rural veterans identified 49 potential implementation activities. Evaluators translated and reduced these to 14 strategies used across three groups with the aid of implementation actors. Data were collected to determine the total implementation effort and applied cost estimates to estimate the budget impact of implementation for VHA. LimitationsRecall bias may influence the identification of potential implementation activities. ConclusionsThis process improved understanding of the implementation effort and allowed estimation of ACP-GV 's budget impact. ImplicationsA four-stage, stakeholder-engaged methodology can be applied to other initiatives when a pragmatic evaluation of implementation efforts is needed.