Does better than expected life expectancy in areas of disadvantage indicate health resilience? Stakeholder perspectives and possible explanations.

Some places have better than expected health trends despite being disadvantaged in other ways. Thematic analysis of qualitative data from stakeholders (N = 25) in two case studies of disadvantaged local authorities the North West and South East of England assessed explanations for the localities' apparent health resilience. Participants identified ways of working that might contribute to improved life expectancy, such as partnering with third sector, targeting and outcome driven action. Stakeholders were reluctant to assume credit for better-than-expected health outcomes. External factors such as population change, national politics and finances were considered crucial. Local public health stakeholders regard their work as important but unlikely to cause place-centred health resilience.

Investigating health and social outcomes of the Big Local community empowerment initiative in England: a mixed method evaluation.

Background: Most research on community empowerment provides evidence on engaging communities for health promotion purposes rather than attempts to create empowering conditions. This study addresses this gap. Intervention: Big Local started in 2010 with £271M from the National Lottery. Ending in 2026, it gives 150 relatively disadvantaged communities in England control over £1M to improve their neighbourhoods. Objective: To investigate health and social outcomes, at the population level and among engaged residents, of the community engagement approach adopted in a place-based empowerment initiative. Study design, data sources and outcome variables: This study reports on the third wave of a longitudinal mixed-methods evaluation. Work package 1 used a difference-in-differences design to investigate the impact of Big Local on population outcomes in all 150 Big Local areas compared to matched comparator areas using secondary data. The primary outcome was anxiety; secondary outcomes included a population mental health measure and crime in the neighbourhood. Work package 2 assessed active engagement in Big Local using cross-sectional data and nested cohort data from a biannual survey of Big Local partnership members. The primary outcome was mental well-being and the secondary outcome was self-rated health. Work package 3 conducted qualitative research in 14 Big Local neighbourhoods and nationally to understand pathways to impact. Work package 4 undertook a cost-benefit analysis using the life satisfaction approach to value the benefits of Big Local, which used the work package 1 estimate of Big Local impact on life satisfaction. Results: At a population level, the impacts on 'reporting high anxiety' (-0.8 percentage points, 95% confidence interval -2.4 to 0.7) and secondary outcomes were not statistically significant, except burglary (-0.054 change in z-score, 95% confidence interval -0.100 to -0.009). There was some effect on reduced anxiety after 2017. Areas progressing fastest had a statistically significant reduction in population mental health measure (-0.053 change in z-score, 95% confidence interval -0.103 to -0.002). Mixed results were found among engaged residents, including a significant increase in mental well-being in Big Local residents in the nested cohort in 2018, but not by 2020; this is likely to be COVID-19. More highly educated residents, and males, were more likely to report a significant improvement in mental well-being. Qualitative accounts of positive impacts on mental well-being are often related to improved social connectivity and physical/material environments. Qualitative data revealed increasing capabilities for residents' collective control. Some negative impacts were reported, with local factors sometimes undermining residents' ability to exercise collective control. Finally, on the most conservative estimate, the cost-benefit calculations generate a net benefit estimate of £64M. Main limitations: COVID-19 impacted fieldwork and interpretation of survey data. There was a short 4-year follow-up (2016/20), no comparators in work package 2 and a lack of power to look at variations across areas. Conclusions: Our findings suggest the need for investment to support community organisations to emerge from and work with communities. Residents should lead the prioritisation of issues and design of solutions but not necessarily lead action; rather, agencies should work as equal partners with communities to deliver change. Funding: This project was funded by the National Institute for Health and Care Research (NIHR) Public Health Research Programme (16/09/13) and will be published in full in Public Health Research; Vol. 11, No. 9. See the NIHR Journals Library website for further project information.

The Communities in Control study is looking at the health impacts of the Big Local community empowerment programme, funded by the National Lottery Community Fund and managed by Local Trust (a national charitable organisation). Residents of 150 English areas have at least £1M and other support to improve the neighbourhoods. There have been three phases of the research. This report shares findings from their third phase, which began in 2018. First, we used data from a national survey and data from national health and welfare services to compare changes in mental health between people living in Big Local areas and those in similar areas that did not have a Big Local partnership. Furthermore, we also used publicly available data on crime in the neighbourhoods. We found weak evidence that Big Local was linked with improved mental health and a reduction in burglaries. Second, we used data from a survey conducted by Local Trust to look at health and social impacts on the most active residents. We found an increase in mental well-being in 2018 but this was not maintained in 2020, probably due to the COVID-19 pandemic. Third, we did interviews and observations in 14 Big Local areas to understand what helps and what does not help residents to improve their neighbourhoods. We found that partnerships need to have legitimacy, the right balance of support, and learning opportunities. Residents suggested that creating social connections and welcoming social spaces, improving how people view the area and tackling poverty contributed to health improvements. Direct involvement in Big Local was both stressful and rewarding. Finally, we did a cost­benefit analysis by putting a monetary value on residents' increase in life satisfaction due to Big Local and comparing it with the costs of Big Local. We found that the benefits exceed the costs by at least £60M, suggesting that Big Local provides good value for money.

Illustrating the impact of commercial determinants of health on the global COVID-19 pandemic: Thematic analysis of 16 country case studies.

Previous research on commercial determinants of health has primarily focused on their impact on non-communicable diseases. However, they also impact on infectious diseases and on the broader preconditions for health. We describe, through case studies in 16 countries, how commercial determinants of health were visible during the COVID-19 pandemic, and how they may have influenced national responses and health outcomes. We use a comparative qualitative case study design in selected low- middle- and high-income countries that performed differently in COVID-19 health outcomes, and for which we had country experts to lead local analysis. We created a data collection framework and developed detailed case studies, including extensive grey and peer-reviewed literature. Themes were identified and explored using iterative rapid literature reviews. We found evidence of the influence of commercial determinants of health in the spread of COVID-19. This occurred through working conditions that exacerbated spread, including precarious, low-paid employment, use of migrant workers, procurement practices that limited the availability of protective goods and services such as personal protective equipment, and commercial actors lobbying against public health measures. Commercial determinants also influenced health outcomes by influencing vaccine availability and the health system response to COVID-19. Our findings contribute to determining the appropriate role of governments in governing for health, wellbeing, and equity, and regulating and addressing negative commercial determinants of health.

Knowledge exchange in crisis settings: A scoping review.

BACKGROUND: Public health practice and efforts to improve the social determinants of health operate within a climate characterised by multiple and intersecting crises. This includes the Covid-19 pandemic as well as more protracted crises such as climate change and persistent social inequalities that impact health. We sought to understand and compare how knowledge exchange (KE) processes occur across different crises, and how knowledge on improving social determinants of health can be utilised at times of crisis to reduce health inequalities and strengthen public systems. METHODS: We conducted a scoping review to understand how KE on improving social determinants of health can occur across different types of crises (e.g. environmental, pandemics, humanitarian). Relevant studies were identified through electronic searching of Medline, EMBASE, Global Health, Scopus and Web of Science databases. RESULTS: We identified 86 studies for inclusion in the review. Most studies concerned pandemic or environmental crises. Fewer studies explored KE during technical (e.g. nuclear), terror-related or humanitarian crises. This may reflect a limitation of the searches. Few studies assessed KE as part of longer-term responses to social and economic impacts of crises, with studies more likely to focus on immediate response or early recovery stages. Exchange of research evidence or data with policy or practice contextual knowledge was common but there was variation in the extent that lay (public) knowledge was included as part of KE processes. CONCLUSION: As ongoing crises continue with significant public health implications, KE processes should appropriately reflect the complexity inherent in crises and foreground health inequalities. Doing so could include the utilisation of systems or complexity-informed methods to support planning and evaluation of KE, a greater focus on KE to support action to address social determinants of health, and the inclusion of a plurality of knowledge-including lived experience-in planning and responding to crises.

Policies for Social and Health Equity: The Case for Equity Sensitive Universalism Comment on "Implementing Universal and Targeted Policies for Health Equity: Lessons From Australia".

This commentary reflects on an important article by Fisher and colleagues who draw on four Australian policy case studies to examine how universal and targeted approaches or a combination can be deployed to improve health equity. They conclude that universal approaches are central to action to increase health equity, but that targeting can improve equity of access in some situations including in the context of proportionate universalism. However, we argue that although target services may provide benefits for some populations, they are often stigmatizing and fail to reach may people they aim to support. Instead of accepting the dominant discourse about the key role for targeted approaches, we argue that those committed to reduce social and health inequities should consider the potential of Equity Sensitive Universalism (ESU). This approach focuses on achieving proportionate outcomes with equally provided resources rather than proportionate inputs and provides a 'cohesion dividend,' increasing social solidarity.

Gender Equality and the Global Gender Gap in Life Expectancy: An Exploratory Analysis of 152 Countries.

When looking at life expectancy (LE) by sex, women live longer than men in all countries. Biological factors alone do not explain gender differences in LE, and examining structural differences may help illuminate other explanatory factors. The aim of this research is to analyse the influence of gender inequality on the gender gap in LE globally. We have carried out a regression analysis between the gender gap in relativised LE and the UN Gender Inequality Index (GII), with a sensitivity analysis conducted for its three dimensions, stratified by the six World Health Organization (WHO) regions. We adjusted the model by taking into consideration gross national income (GNI), democratic status and rural population. The results indicated a positive association for the European region (ß=0.184) and the Americas (ß=0.136) in our adjusted model. Conversely, for the African region, the relations between gender equality and the LE gender gap were found to be negative (ß=-0.125). The findings suggest that in the WHO European region and the Americas, greater gender equality leads to a narrowing of the gender LE gap, while it has a contrary relationship in Africa. We suggest that this could be because only higher scores in the GII between men and women show health benefits.

From fringe to centre-stage: experiences of mainstreaming health equity in a health research collaboration.

BACKGROUND: Action to address the structural determinants of health inequalities is prioritized in high-level initiatives such as the United Nations Sustainable Development Goals and many national health strategies. Yet, the focus of much local policy and practice is on behaviour change. Research shows that whilst lifestyle approaches can improve population health, at best they fail to reduce health inequalities because they fail to address upstream structural determinants of behaviour and health outcomes. In health research, most efforts have been directed at three streams of work: understanding causal pathways; evaluating the equity impact of national policy; and developing and evaluating lifestyle/behavioural approaches to health improvement. As a result, there is a dearth of research on effective interventions to reduce health inequalities that can be developed and implemented at a local level. OBJECTIVE: To describe an initiative that aimed to mainstream a focus on health equity in a large-scale research collaboration in the United Kingdom and to assess the impact on organizational culture, research processes and individual research practice. METHODS: The study used multiple qualitative methods including semi-structured interviews, focus groups and workshops (n = 131 respondents including Public Advisers, university, National Health Service (NHS), and local and document review. RESULTS: utilizing Extended Normalization Process Theory (ENPT) and gender mainstreaming theory, the evaluation illuminated (i) the processes developed by Collaboration for Leadership in Applied Health Research and Care North West Coast to integrate ways of thinking and acting to tackle the upstream social determinants of health inequities (i.e. to mainstream a health equity focus) and (ii) the factors that promoted or frustrated these efforts. CONCLUSIONS: Findings highlight the role of contextual factors and processes aimed at developing and implementing a robust strategy for mainstreaming health equity as building blocks for transformative change in applied health research.

'It is surprising how much nonsense you hear': How residents experience and react to living in a stigmatised place. A narrative synthesis of the qualitative evidence.

There are significant geographical inequalities in health. Spatial stigma - negative representations of particular localities - could be an important mechanism through which place influences population health. To explore this, we undertook a narrative synthesis of studies reporting residents' perspectives of living in stigmatised localities. Qualitative research (38 studies) was reviewed to identify how spatial stigma manifested in residents' lives, their strategies to cope with stigma and the health consequences. The review found residents internalised stigma, but also resisted it differently. Although relatively few studies purposefully investigated health, living somewhere stigmatised had psychological effects and constrained life opportunities that have implications for health.

Evaluation of public health interventions from a complex systems perspective: A research methods review.

INTRODUCTION: Applying a complex systems perspective to public health evaluation may increase the relevance and strength of evidence to improve health and reduce health inequalities. In this review of methods, we aimed to: (i) classify and describe different complex systems methods in evaluation applied to public health; and (ii) examine the kinds of evaluative evidence generated by these different methods. METHODS: We adapted critical review methods to identify evaluations of public health interventions that used systems methods. We conducted expert consultation, searched electronic databases (Scopus, MEDLINE, Web of Science), and followed citations of relevant systematic reviews. Evaluations were included if they self-identified as using systems- or complexity-informed methods and if they evaluated existing or hypothetical public health interventions. Case studies were selected to illustrate different types of complex systems evaluation. FINDINGS: Seventy-four unique studies met our inclusion criteria. A framework was developed to map the included studies onto different stages of the evaluation process, which parallels the planning, delivery, assessment, and further delivery phases of the interventions they seek to inform; these stages include: 1) theorising; 2) prediction (simulation); 3) process evaluation; 4) impact evaluation; and 5) further prediction (simulation). Within this framework, we broadly categorised methodological approaches as mapping, modelling, network analysis and 'system framing' (the application of a complex systems perspective to a range of study designs). Studies frequently applied more than one type of systems method. CONCLUSIONS: A range of complex systems methods can be utilised, adapted, or combined to produce different types of evaluative evidence. Further methodological innovation in systems evaluation may generate stronger evidence to improve health and reduce health inequalities in our complex world.

New Perspective on Why Women Live Longer Than Men: An Exploration of Power, Gender, Social Determinants, and Capitals.

BACKGROUND: Women live longer than men, even though many of the recognised social determinants of health are worse for women than men. No existing explanations account fully for these differences in life expectancy, although they do highlight the complexity and interaction of biological, social and health service factors. METHODS: this paper is an exploratory explanation of gendered life expectancy difference (GLED) using a novel combination of epidemiological and sociological methods. We present the global picture of GLED. We then utilise a secondary data comparative case analysis offering explanations for GLED in Australia and Ethiopia. We combine a social determinant of health lens with Bourdieu's concepts of capitals (economic, cultural, symbolic and social). RESULTS: we confirmed continuing GLED in all countries ranging from less than a year to over 11 years. The Australian and Ethiopian cases demonstrated the complex factors underpinning this difference, highlighting similarities and differences in socioeconomic and cultural factors and how they are gendered within and between the countries. Bourdieu's capitals enabled us to partially explain GLED and to develop a conceptual model of causal pathways. CONCLUSION: we demonstrate the value of combing a SDH and Bourdieu's capital lens to investigate GLED. We proposed a theoretical framework to guide future research.

Power, control, communities and health inequalities. Part II: measuring shifts in power.

In the health field, there is great interest in the role empowerment might play in reducing social inequalities in health. Empowerment is understood here as the processes of developing capabilities that individuals and/or communities need to exercise control over decisions and actions impacting on their lives and health. There is a fundamental problem, however, in identifying and measuring capabilities for collective control that emerge at the level of the collective, with much of the existing literature focusing on individual measures even where community-level processes are concerned. Collective measures need to capture the dynamics of interactions within and between groups, not simply aggregate individual-level measures. This article, Part 2 in a three-part series, takes up the challenge of identifying qualitative markers of capabilities for collective control. We applied the emancipatory power framework (EPF) reported in Part 1 of the series, to qualitative data generated during a longitudinal evaluation of a major English area-based empowerment initiative, the Big Local (BL). We identified empirical 'markers' of shifts towards greater collective control pertaining to each of the 'power' dimensions in the EPF-'power within', 'power with' and 'power to'-and markers of communities exercising 'power over' other institutions/community members. These markers can usefully be applied in the evaluation planning and evaluation of empowerment initiatives. Part 3 in the series uses these markers and a second analytical framework developed during our evaluation of BL to explore how power dynamics unfold in participatory spaces in BL neighbourhoods.

Power, control, communities and health inequalities III: participatory spaces-an English case.

This article-third in a series of three-uses theoretical frameworks described in Part 1, and empirical markers reported in Part 2, to present evidence on how power dynamics shifted during the early years of a major English community empowerment initiative. We demonstrate how the capabilities disadvantaged communities require to exercise collective control over decisions/actions impacting on their lives and health (conceptualized as emancipatory power) and the exercise of power over these communities (conceptualized as limiting power) were shaped by the characteristics of participatory spaces created by and/or associated with this initiative. Two main types of participatory spaces were identified: governance and sense-making. Though all forms of emancipatory power emerged in all spaces, some were more evident in particular spaces. In governance spaces, the development and enactment of 'power to' emerged as residents made formal decisions on action, allocated resources and managed accountability. Capabilities for alliance building-power with-were more likely to emerge in these spaces, as was residents' resistance to the exercise of institutional power over them. In contrast, in sense-making spaces residents met informally and 'made sense' of local issues and their ability to influence these. These processes led to the development of power within capabilities and power to resist stigmatizing forms of productive power. The findings highlight the importance of designing community initiatives that: nurture diverse participatory spaces; attend to connectivity between spaces; and identify and act on existing power dynamics undermining capabilities for collective control in disadvantaged communities.

Power, control, communities and health inequalities I: theories, concepts and analytical frameworks.

This is Part I of a three-part series on community empowerment as a route to greater health equity. We argue that community 'empowerment' approaches in the health field are increasingly restricted to an inward gaze on community psycho-social capacities and proximal neighbourhood conditions, neglecting the outward gaze on political and social transformation for greater equity embedded in foundational statements on health promotion. We suggest there are three imperatives if these approaches are to contribute to increased equity. First, to understand pathways from empowerment to health equity and drivers of the depoliticisation of contemporary empowerment practices. Second, to return to the original concept of empowerment processes that support communities of place/interest to develop capabilities needed to exercise collective control over decisions and actions in the pursuit of social justice. Third, to understand, and engage with, power dynamics in community settings. Based on our longitudinal evaluation of a major English community empowerment initiative and research on neighbourhood resilience, we propose two complementary frameworks to support these shifts. The Emancipatory Power Framework presents collective control capabilities as forms of positive power. The Limiting Power Framework elaborates negative forms of power that restrict the development and exercise of a community's capabilities for collective control. Parts II and III of this series present empirical findings on the operationalization of these frameworks. Part II focuses on qualitative markers of shifts in emancipatory power in BL communities and Part III explores how power dynamics unfolded in these neighbourhoods.

The Health Inequalities Assessment Toolkit: supporting integration of equity into applied health research.

BACKGROUND: Despite insistent calls for more and better evidence to inform action to reduce health inequities, applied health research sensitive to these inequalities is rare. Recognising this problem, the Collaboration for Leadership in Applied Research and Care in the North West Coast (England) developed the Health Inequalities Assessment Toolkit (HIAT) to support those involved in health research to integrate equity into their work. OBJECTIVE: This paper reports on an evaluation of the extent to which HIAT enhances the equity focus of the work of users. METHODS: The evaluation used semi-structured interviews, focus groups and workshops (n = 131 respondents including Public Advisers, university, NHS and local government partners). Routine data included HIAT feedback forms. FINDINGS: HIAT can help to strengthen the equity focus of applied health research by: increasing understanding of how socioeconomic inequities impact on health; building capacity for integrating equity into all aspects of research, implementation and capacity building; stimulating thinking on action to address local structural drivers of health inequalities; and increasing understanding of the positive contribution public involvement can make to research. CONCLUSION: If we are to advance health equity goals delivering research and training needs to be combined with political commitment to create more equal societies.

Why do some countries do better or worse in life expectancy relative to income? An analysis of Brazil, Ethiopia, and the United States of America.

BACKGROUND: While in general a country's life expectancy increases with national income, some countries "punch above their weight", while some "punch below their weight" - achieving higher or lower life expectancy than would be predicted by their per capita income. Discovering which conditions or policies contribute to this outcome is critical to improving population health globally. METHODS: We conducted a mixed-method study which included: analysis of life expectancy relative to income for all countries; an expert opinion study; and scoping reviews of literature and data to examine factors that may impact on life expectancy relative to income in three countries: Ethiopia, Brazil, and the United States. Punching above or below weight status was calculated using life expectancy at birth and gross domestic product per capita for 2014-2018. The scoping reviews covered the political context and history, social determinants of health, civil society, and political participation in each country. RESULTS: Possible drivers identified for Ethiopia's extra 3 years life expectancy included community-based health strategies, improving access to safe water, female education and gender empowerment, and the rise of civil society organisations. Brazil punched above its weight by 2 years. Possible drivers identified included socio-political and economic improvements, reduced inequality, female education, health care coverage, civil society, and political participation. The United States' neoliberal economics and limited social security, market-based healthcare, limited public health regulation, weak social safety net, significant increases in income inequality and lower levels of political participation may have contributed to the country punching 2.9 years below weight. CONCLUSIONS: The review highlighted potential structural determinants driving differential performance in population health outcomes cross-nationally. These included greater equity, a more inclusive welfare system, high political participation, strong civil society and access to employment, housing, safe water, a clean environment, and education. We recommend research comparing more countries, and also to examine the processes driving within-country inequities.

The longitudinal NIHR ARC North West Coast Household Health Survey: exploring health inequalities in disadvantaged communities.

BACKGROUND: The Household Health Survey (HHS) was developed to understand the socioeconomic determinants of mental and physical health, and health inequalities in health and social care. This paper aims to provide a detailed rationale of the development and implementation of the survey and explore socio-economic variations in physical and mental health and health care. METHODS: This comprehensive longitudinal public health survey was designed and piloted in a disadvantaged area of England, comprising questions on housing, physical health, mental health, lifestyle, social issues, environment, work, and finances. After piloting, the HHS was implemented across 28 neighbourhoods - 10 disadvantaged neighbourhoods for learning (NfLs), 10 disadvantaged comparator sites, and eight relatively advantaged areas, in 2015 and 2018. Participants were recruited via random sampling of households in pre-selected neighbourhoods based on their areas of deprivation. RESULTS: 7731 residents participated in Wave 1 (N = 4319) and 2 (n = 3412) of the survey, with 871 residents having participated in both. Mental health, physical health, employment, and housing quality were poorer in disadvantaged neighbourhoods than in relatively advantaged areas. CONCLUSIONS: This survey provides important insights into socio-economic variations in physical and mental health, with findings having implications for improved care provision to enable residents from any geographical or socio-economic background to access suitable care.

'The opportunity to have their say'? Identifying mechanisms of community engagement in local alcohol decision-making.

BACKGROUND: Engaging the community in decisions-making is recognised as important for improving public health, and is recommended in global alcohol strategies, and in national policies on controlling alcohol availability. Yet there is little understanding of how to engage communities to influence decision-making to help reduce alcohol-related harms. We sought to identify and understand mechanisms of community engagement in decision-making concerning the local alcohol environment in England. METHODS: We conducted case studies in three local government areas in England in 2018, purposively selected for examples of community engagement in decisions affecting the local alcohol environment. We conducted 20 semi-structured interviews with residents, workers, local politicians and local government practitioners, and analysed documents linked to engagement and alcohol decision-making. RESULTS: Four rationales for engaging the community in decision-making affecting the alcohol environment were identified: i) as part of statutory decision-making processes; ii) to develop new policies; iii) as representation on committees; and iv) occurring through relationship building. Many of the examples related to alcohol licensing processes, but also local economy and community safety decision-making. The impact of community inputs on decisions was often not clear, but there were a few instances of engagement influencing the process and outcome of decision-making relating to the alcohol environment. CONCLUSIONS: While influencing statutory licensing decision-making is challenging, community experiences of alcohol-related harms can be valuable 'evidence' to support new licensing policies. Informal relationship-building between communities and local government is also beneficial for sharing information about alcohol-related harms and to facilitate future engagement. However, care must be taken to balance the different interests among diverse community actors relating to the local alcohol environment, and extra support is needed for those with least capacity to engage but who face more burden of alcohol-related harms, to avoid compounding existing inequalities.

A 'strategy of resistance'? How can a place-based empowerment programme influence local media portrayals of neighbourhoods and what are the implications for tackling health inequalities?

Place-based stigma is linked with health and social harms, but few studies have assessed what actions may reduce these. Area-based programmes are one potential strategy but may exacerbate stigma by targeting disadvantaged neighbourhoods. We reviewed newspaper coverage in two stigmatised neighbourhoods to identify whether a programme funded in these localities influenced reporting. While both areas were dominated by negative coverage, the progamme provided an impetus for some positive stories over time and enabled community activists to articulate alternative narratives about where they lived, countering negative external portrayals. The involvement of residents should be central to strategies to tackle place-based stigma.

Mainstreaming public involvement in a complex research collaboration: A theory-informed evaluation.

INTRODUCTION: There is an extensive literature on public involvement (PI) in research, but this has focused primarily on experiences for researchers and public contributors and factors enabling or restricting successful involvement in specific projects. There has been less consideration of a 'whole system' approach to embedding PI across an organization from governance structures through to research projects. OBJECTIVE: To investigate how a combination of two theoretical frameworks, one focused on mainstreaming and the other conceptualizing quality, can illuminate the embedding of positive and influential PI throughout a research organization. METHODS: The study used data from the evaluation of a large UK research collaboration. Primary data were collected from 131 respondents (including Public Advisers, university, NHS and local government staff) via individual and group interviews/workshops. Secondary sources included monitoring data and internal documents. FINDINGS: CLAHRC-NWC made real progress in mainstreaming PI. An organizational vision and infrastructure to embed PI at all levels were created, and the number and range of opportunities increased; PI roles became more clearly defined and increasingly public contributors felt able to influence decisions. However, the aspiration to mainstream PI throughout the collaboration was not fully achieved: a lack of staff 'buy-in' meant that in some areas, it was not experienced as positively or was absent. CONCLUSION: The two theoretical frameworks brought a novel perspective, facilitating the investigation of the quality of PI in structures and processes across the whole organization. We propose that combining these frameworks can assist the evaluation of PI research.