"They don't have the luxury of time": interviews exploring the determinants of public health research activity that contextualise embedded researcher roles in local government.

BACKGROUND: Embedded researchers are a novel intervention to improve the translation of research evidence into policy and practice settings, including public health. These roles are being implemented with increasing popularity, but they often lack clear evaluative frameworks. Understanding initial levels of research activity, including associated barriers and opportunities, is essential to developing theories of change and thus shaping the roles and defining expectations. We aimed to identify the principal determinants of research activity in public health that contextualise embedded researcher roles, including attributes of the embedded researcher themselves. METHODS: We undertook seventeen semi-structured interviews with embedded researchers in diverse public health settings in English local government. Interviews were analysed using thematic analysis. RESULTS: We identified thirteen interlinked determinants of research activity within local government public health settings. Research and interpersonal skills, as well as pre-existing connections and knowledge within local government, were highly valued individual attributes for embedded researchers. Resource deficiencies (funding, time, and infrastructure) were primary barriers to research activity, whereas a strong local appetite for evidence informed decision making presented a valuable opportunity. However, there was inconsistencies across public health teams relating to perceptions of what constituted "research" and the resources that would be required. CONCLUSIONS: Our results suggest that successful embedded researchers will have equally strong research and communication skills and should be offered mentorship and clear career progression pathways. Perceptions of research within local government are closely linked to resource deficiencies and senior endorsement. Embedded researchers could benefit from taking the time to develop locally contextualised knowledge of this research culture. Theories of change for embedded researchers should conceptualise the interconnections across individual, interpersonal, and organisational barriers and opportunities underlying local government research activity. Further research is needed to identify methods for exploring the influence of embedded researchers as well as to unpack the stages of research activity within local government and the associated behaviours.

Community-based participatory-research through co-design: supporting collaboration from all sides of disability.

BACKGROUND: As co-design and community-based participatory research gain traction in health and disability, the challenges and benefits of collaboratively conducting research need to be considered. Current literature supports using co-design to improve service quality and create more satisfactory services. However, while the 'why' of using co-design is well understood, there is limited literature on 'how' to co-design. We aimed to describe the application of co-design from start to finish within a specific case study and to reflect on the challenges and benefits created by specific process design choices. METHODS: A telepractice re-design project has been a case study example of co-design. The co-design was co-facilitated by an embedded researcher and a peer researcher with lived experience of disability. Embedded in a Western Australian disability organisation, the co-design process included five workshops and a reflection session with a team of 10 lived experience and staff participants (referred to as co-designers) to produce a prototype telepractice model for testing. RESULTS: The findings are divided into two components. The first describes the process design choices made throughout the co-design implementation case study. This is followed by a reflection on the benefits and challenges resulting from specific process design choices. The reflective process describes the co-designers' perspective and the researcher's and organisational experiences. Reflections of the co-designers include balancing idealism and realism, the value of small groups, ensuring accessibility and choice, and learning new skills and gaining new insights. The organisational and research-focused reflections included challenges between time for building relationships and the schedules of academic and organisational decision-making, the messiness of co-design juxtaposed with the processes of ethics applications, and the need for inclusive dissemination of findings. CONCLUSIONS: The authors advocate that co-design is a useful and outcome-generating methodology that proactively enables the inclusion of people with disability and service providers through community-based participatory research and action. Through our experiences, we recommend community-based participatory research, specifically co-design, to generate creative thinking and service design.

Changing the culture: a qualitative study exploring research capacity in local government.

BACKGROUND: Local government has become a key constituent for addressing health inequalities and influencing the health of individuals and communities in England. Lauded as an effective approach to tackle the multiple determinants of health, there are concerns that generating and utilising research evidence to inform decision-making and action is a challenge. This research was conducted in a local authority situated in the north of England and addressed the research question - 'What is the capacity to collaborate and deliver research?'. The study explored the assets that exist to foster a stronger research culture, identified barriers and opportunities for developing research capacity, and how a sustainable research system could be developed to impact on local residents' health and reduce health inequalities. METHODS: This was a qualitative study utilising semi-structured interviews and focus groups. The study used an embedded researcher (ER) who was digitally embedded within the local authority for four months to conduct the data collection. Senior Managers were purposively sampled from across the local authority to take part in interviews. Three focus groups included representation from across the local authority. Framework analysis was conducted to develop the themes which were informed by the Research Capacity Development framework. RESULTS: Tensions between research led decision making and the political and cultural context of local government were identified as a barrier to developing research which addressed health inequalities. Research was not prioritised through an organisational strategy and was led sporadically by research active employees. A recognition across leaders that a culture shift to an organisation which used research evidence to develop policy and commission services was needed. Building relationships and infrastructure across local government, place-based collaborators and academic institutions was required. The embedded researcher approach is one method of developing these relationships. The study identifies the strengths and assets that are embedded in the organisational make-up and the potential areas for development. CONCLUSION: Research leadership is required in local government to create a culture of evidence-based principles and policy. The embedded research model has high utility in gaining depth of information and recognising contextual and local factors which would support research capacity development.

Relational aspects of building capacity in economic evaluation in an Australian Primary Health Network using an embedded researcher approach.

BACKGROUND: Health organisations are increasingly implementing 'embedded researcher' models to translate research into practice. This paper examines the impact of an embedded researcher model known as the embedded Economist (eE) Program that was implemented in an Australian Primary Health Network (PHN) located in regional New South Wales, Australia. The site, participants, program aims and design are described. Insights into the facilitators, challenges and barriers to the integration of economic evaluation perspectives into the work of the PHN are provided. METHODS: The eE Program consisted of embedding a lead health economist on site, supported by offsite economists, part-time, for fifteen weeks to collaborate with PHN staff. Evaluation of the eE at the PHN included qualitative data collection via semi-structured interviews (N= 34), observations (N=8) and a field diary kept by the embedded economists. A thematic analysis was undertaken through the triangulation of this data. RESULTS: The eE Program successfully met its aims of increasing PHN staff awareness of the value of economic evaluation principles in decision-making and their capacity to access and apply these principles. There was also evidence that the program resulted in PHN staff applying economic evaluations when commissioning service providers. Evaluation of the eE identified two key facilitators for achieving these results. First, a highly receptive organisational context characterised by a work ethic, and site processes and procedures that were dedicated to improvement. Second was the development of trusted relationships between the embedded economist and PHN staff that was enabled through: the commitment of the economist to bi-directional learning; facilitating access to economic tools and techniques; personality traits (likeable and enthusiastic); and because the eE provided ongoing support for PHN projects beyond the fifteen-week embedding period. CONCLUSIONS: This study provides the first detailed case description of an embedded health economics program. The results demonstrate how the process, context and relational factors of engaging and embedding the support of a health economist works and why. The findings reinforce international evidence in this area and are of practical utility to the future deployment of such programs.

Embedding an economist in regional and rural health services to add value and reduce waste by improving local-level decision-making: protocol for the 'embedded Economist' program and evaluation.

BACKGROUND: Systematic approaches to the inclusion of economic evaluation in national healthcare decision-making are usual. It is less common for economic evaluation to be routinely undertaken at the 'local-level' (e.g. in a health service or hospital) despite the largest proportion of health care expenditure being determined at this service level and recognition by local health service decision makers of the need for capacity building in economic evaluation skills. This paper describes a novel program - the embedded Economist (eE) Program. The eE Program aims to increase local health service staff awareness of, and develop their capacity to access and apply, economic evaluation principles in decision making. The eE program evaluation is also described. The aim of the evaluation is to capture the contextual, procedural and relational aspects that assist and detract from the eE program aims; as well as the outcomes and impact from the specific eE projects. METHODS: The eE Program consists of a embedding a health economist in six health services and the provision of supported education in applied economic evaluation, provided via a community of practice and a university course. The embedded approach is grounded in co-production, embedded researchers and 'slow science'. The sites, participants, and program design are described. The program evaluation includes qualitative data collection via surveys, semi-structured interviews, observations and field diaries. In order to share interim findings, data are collected and analysed prior, during and after implementation of the eE program, at each of the six health service sites. The surveys will be analysed by calculating frequencies and descriptive statistics. A thematic analysis will be conducted on interview, observation and filed diary data. The Framework to Assess the Impact from Translational health research (FAIT) is utilised to assess the overall impact of the eE Program. DISCUSSION: This program and evaluation will contribute to knowledge about how best to build capacity and skills in economic evaluation amongst decision-makers working in local-level health services. It will examine the extent to which participants are able to improve their ability to utilise evidence to inform decisions, avoid waste and improve the value of care delivery.

Re-Framing the Knowledge to Action Challenge Through NIHR Knowledge Mobilisation Research Fellows Comment on "CIHR Health System Impact Fellows: Reflections on 'Driving Change' Within the Health System".

The ambition of the Canadian Institutes for Health Research Health System Impact (HSI) Fellowship initiative to modernise the health system is impressive. Embedded researchers who work between academia and non-academic settings offer an opportunity to reframe the problem of evidence uptake as a product of a gap between those who produce knowledge and those who use it. As such, there has been an increasing interest in the potential of people in embedded research roles to work with stakeholders in the co-production of knowledge to address service challenges. In this commentary, we draw on research and experiential evidence of an embedded researcher initiative, which has similar intentions to the HSI Fellowships programme: the National Institute for Health Research (NIHR) Knowledge Mobilisation Research Fellowship (KMRF) scheme. We outline the similarities and differences between the two schemes, and then consider the work, characteristics and skills, and organisational arrangements evident in operationalising these types of roles.

Empirical research in clinical ethics: The 'committed researcher' approach.

After the 'empirical turn' in bioethics, few specific approaches have been developed for doing clinical ethics research in close connection with clinical decision-making on a daily basis. In this paper we describe the 'committed researcher' approach to research in clinical ethics that we have developed over the years. After comparing it to two similar research methodological approaches, the 'embedded researcher' and 'deliberative engagement', we highlight its main features: it is patient-oriented, it is implemented by collegial and multidisciplinary teams, it uses an ethical grid to build the interview guide, and it is geared towards bringing the results to bear on the public debate surrounding the issue at stake. Finally, we position our methodological approach with respect to the 'is vs. ought' distinction. We argue that our 'commitment researcher' approach to clinical ethics research takes concerned people's life-building values as the main data, and compares them to the larger normative framework underlying the medical practice at stake.

The Health System Impact Fellowship: Perspectives From the Program Leads Comment on "CIHR Health System Impact Fellows: Reflections on 'Driving Change' Within the Health System".

As the Canadian Institutes of Health Research (CIHR) leads in designing and implementing the new Health System Impact (HSI) Fellowship program, we congratulate Sim et al for their thoughtful contribution to the nascent literature on embedded research, and for advancing our own learning about the HSI Fellowship experience. In our commentary, we describe the HSI Fellowship and its key components, discuss the factors that motivated and inspired the creation of the program, and highlight successes thus far.

It's All About the IKT Approach: Three Perspectives on an Embedded Research Fellowship Comment on "CIHR Health System Impact Fellows: Reflections on 'Driving Change' Within the Health System".

As a group of Health System Impact (HSI) postdoctoral fellows, Sim and colleagues offer their reflections on 'driving change' within the health system and present a framework for understanding the HSI fellow as an embedded researcher. Our commentary offers a different perspective of the fellow's role by highlighting the integrated knowledge translation (IKT) approach we consider to be foundational to the fellowship experience. Further, we provide several recommendations to enhance Sim and colleagues' framework to ensure we capture the full value of the fellowship program to the HSI fellow, health system organization, and academic institution.

CIHR Health System Impact Fellows: Reflections on "Driving Change" Within the Health System.

Learning health systems necessitate interdependence between health and academic sectors and are critical to address the present and future needs of our health systems. This concept is being supported through the new Canadian Institutes of Health Research (CIHR) Health System Impact (HSI) Fellowship, through which postdoctoral fellows are situated within a health system-related organization to help propel evidence-informed organizational transformation and change. A voluntary working group of fellows from the inaugural cohort representing diversity in geography, host setting and personal background, collectively organized a panel at the 2018 Canadian Association for Health Services and Policy Research Conference with the purpose of describing this shared scholarship experience. Here, we present a summary of this panel reflecting on our experiential learning in a practice environment and its ability for impact.