Development of BreeZe: a Self-management Support Intervention for Burn Survivors Informed by Evidence, Theory, and Stakeholder Co-Creation

Development of BreeZe: a Self-management Support Intervention for Burn Survivors Informed by Evidence, Theory, and Stakeholder Co-Creation | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Development of BreeZe: a Self-management Support Intervention for Burn Survivors Informed by Evidence, Theory, and Stakeholder Co-Creation Sven J.G. Geelen, Sharon L. Blok, Anuschka S. Niemeijer, Gerbrig Bijker, and 11 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7345137/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 26 Dec, 2025 Read the published version in BMC Health Services Research → Version 1 posted 9 You are reading this latest preprint version Abstract Background Following a severe burn injury, individuals embark on a lifelong process of managing and integrating the physical, psychological, and social consequences, including functional limitations, fatigue, altered body image, and psychological trauma. To aid in this process, healthcare professionals can provide self-management support. To date, however, no self-management support intervention has been developed to meet the unique needs and preferences of burn survivors within the context of burn aftercare. In this article, we describe the process of developing a self-management support intervention for burn aftercare and present the resulting intervention. Methods A structured, multi-stage process was followed from May 2021 to December 2023 to develop the intervention, guided by established frameworks for the development and adaptation of complex interventions. The process included evidence review, stakeholder consultation, and participatory observations to identify needs, inform design decisions, and ensure contextual fit. A hybrid approach to intervention development was adopted, combining adaptation of an existing intervention with augmentation through five co-creative workshops involving burn survivors, healthcare professionals, researchers, and burn care decision-makers. The final prototype was refined through expert reviews and real-world pilot-testing to assess its feasibility and acceptability. Results The structured, multistage process resulted in a self-management support intervention addressing the physical, psychological, and social needs of burn survivors. The intervention was named BreeZe (Brandwonden en Zelfmanagement/Burns and self-management). Intervention Core components of the intervention include a holistic care approach, goal setting and action planning, solution-focused brief therapy, motivational interviewing, case management, and the acknowledgment and involvement of informal caregivers. BreeZe is supported by materials like the Self-Management Web, a patient booklet, training for healthcare professonials, and a comprehensive manual. BreeZe is delivered by trained healthcare professionals and is structured into five phases, focusing on holistic needs assessment, goal setting, progress monitoring, and ongoing motivational support. Conclusions The structured, multi-stage development process was thorough and carefully considered, balancing diverse stakeholder perspectives with scientific evidence and theory. BreeZe offers an evidence-based model tailored to the Dutch context that can be integrated into routine practice that shows the potential to enhance the effectiveness of care and support a more collaborative, patient-centred approach. Trial registration: Not applicable. Intervention development Intervention adaptation Complex intervention Burns self-efficacy self-determination motivation case management goal setting holistic care Figures Figure 1 Background Over the past 30 years, rapid advancements in healthcare have significantly reduced burn-related mortality rates in high- and middle-income countries ( 1 ). As a result, the number of patients with major burns who survived increased, and these individuals face a lifelong process of managing and integrating the physical, psychological, and social consequences of their injuries ( 2 ). Examples of such consequences include functional limitations, itching, pain, aesthetic concerns, fatigue, and psychological trauma. Burn survivors, much like individuals with other chronic conditions, must learn to manage and integrate the consequences of their injuries as part of daily life ( 3 ). Self-management can be defined as “the ability of the individual in conjunction with family, community, and healthcare professionals to manage symptoms, treatments, lifestyle changes, and psychosocial, cultural, and spiritual consequences of health conditions” ( 4 , 5 ). For burn survivors, self-management encompasses activities such as wound and scar care, maintaining mobility through exercising, accepting changes in body image, and finding ways to reintegrate socially and professionally ( 3 ). However, due to the sudden onset of a burn injury and the overwhelming burden of its consequences, effective self-management may not be self-evident after discharge from a burn centre. To aid burn survivors, healthcare professionals can provide self-management support after discharge from a burn centre, which can be defined as “the systematic provision of education and supportive interventions to improve burn survivors’ skills and confidence in managing their health problems, including regular assessment of progress and problems, goal setting, and problem-solving support” ( 6 , 7 ). Self-management support represents a shift from merely managing a chronic condition – focused on symptom and disease control – to helping individuals manage well with their chronic condition , which encompasses broader goals of health, wellbeing, and overall quality of life ( 8 ). Previous research has demonstrated that self-management support interventions can lead to significant improvements in quality of life and reductions in healthcare service utilization, with the strongest evidence in diabetes, respiratory disorders, cardiovascular disorders, and mental health ( 9 , 10 ). In addition, growing pressure on healthcare systems – due to workforce shortages, an ageing population, and declining interest in care professions – makes empowering patients through self-management not just beneficial, but increasingly essential for sustainable care delivery ( 9 , 11 – 13 ). However, for burn survivors, self-management support interventions are lacking. To date, only Shahryari et al. ( 14 ) has described a self-management support intervention in burn survivors: a face-to-face, single-component educational session provided during hospitalization and around the time of a surgical procedure (skin grafting), aimed at reducing anxiety and increasing comfort levels. However, this intervention was limited in scope, timing, and methodological quality, underscoring the absence of a comprehensive, evidence-based self-management support approach tailored to the burn aftercare phase. In this paper, we report on the development of a new self-management support intervention specifically designed for burn survivors after discharge from a burn centre and present the resulting intervention. We do this by outlining each stage of the development, sharing lessons learned, and presenting the final version of the intervention. Methods Study Design A self-management support intervention should be considered a complex intervention ( 15 ), as it must be tailored to individual needs and address multiple life domains such as medical management, emotional well-being, and social roles ( 16 , 17 ). It involves interacting components, requires sensitivity to context, and often entails a transformative learning process for healthcare professionals, as well as flexibility across care settings ( 18 ). This complexity calls for a dynamic and iterative development process that includes stakeholder co-creation, integration of up-to-date research, use of relevant theoretical frameworks, articulation of a program theory, comprehensive data collection, and a deep contextual understanding ( 19 ). We developed a self-management support program addressing the physical, psychological, and social needs of burn survivors, named BreeZe (Brandwonden en Zelfmanagement/Burns and self-management) in line with such a process. It was informed by frameworks and guidance from Hawkins and colleagues ( 20 ), as well as by the more recent guidance for developing new complex interventions ( 19 ), the guidance for adapting existing interventions to new contexts ( 21 ), and the Co-creation Impact Compass ( 22 ). Based on these, the process was structured in five stages executed between May 2021 and December 2023 (Fig. 1 ): 1) Preparation; 2) Evidence review, stakeholder consultation, and participatory observations; 3) Choosing the pathway for intervention development and adaptation; 4) Adapt and augment an existing intervention to Dutch burn aftercare; 5) Prototyping. The objectives of the methods used, the topics explored, and the key lessons derived from each stage are summarized in Table 1 . Table 1 Key results from stage 1 to 5 Objective Activity Results Stage 1. Preparation Identify stakeholders Stakeholder mapping Identified stakeholders in Dutch burn care Discuss stakeholders’ roles Participation game Stakeholders’ involvement at different stages has been mapped (see Additional File 4 ) Establish consensus on the key steps of development Process mapping Key development steps are outlined (see Fig. 1 ) Stage 2. Evidence review, stakeholder consultation, and participatory observations Develop a comprehensive understanding of existing evidence on self-management and self-management support Evidence map Key findings from our literature: • Self-management support is shaped by interdependent factors ( 29 ) • Self-management support integration requires a mind-set shift, not just training ( 18 ) • Burn survivors self-manage similarly to individuals with chronic conditions ( 3 ) • Face-to-face, multicomponent, skill-enhancing interventions improve outcomes ( 30 ) • Key core functions of self-management support interventions are: adapt to readiness to change, include goal setting and action planning ( 30 ) • The intrinsic processes motivation and self-efficacy are crucial for success ( 31 ) • Patients expect healthcare professionals to play an active role in self-management ( 16 ) • Patients’ attitudes, needs, and preferences for self-management support vary ( 32 ) • No studies found on the perspectives of healthcare professionals working in burn aftercare Identify whether effective interventions exist for burn survivors, what their components are, and what impact they report. Systematic review • Only one eligible study identified ( 14 ); low methodological quality • This study suggested that a face-to-face educational intervention during hospitalization and surrounding surgical intervention may reduce anxiety and increase comfort • Intervention was single-component (only education) and took place during hospitalization Identify the needs and preferences for self-management support after burn centre discharge among burn survivors Interviews with burn survivors • The moment of discharge is a critical touchpoint with lasting impact on survivors’ ability to integrate the consequences of their burns into daily life • A strong, ongoing partnership with a trusted healthcare professional is essential for self-management. Gain a deeper understanding of their experiences and the challenges informal caregivers face in supporting burn survivors Interviews with informal caregivers • Informal caregivers need recognition and support from both their social and professional networks to sustain their role. • Informal caregivers often struggle to balance caregiving with their own wellbeing. Explore how healthcare professionals already provide self-management support to burn survivors Interviews with healthcare professionals ( 39 ) • Healthcare professionals vary in how they provide self-management support • These variations reflect differences in role interpretation • Support can be improved through training and tools to identify burn survivor needs • Healthcare professionals need guidance in managing role boundaries and responsibilities • Clear team roles, shared priorities, and time for providing support are also essential Explore how burn care decision-makers view the topics “self-management” and “self-management support” and gain insight into routine burn aftercare Unstructured consultations with burn care decision-makers and conducting participatory observations • Divergence in what constitutes aftercare, with continuous nursing support in two burn centres and start of care after wound closure in another. • Differences in how burn aftercare is structured across three Dutch burn centres. • Varying discipline roles and responsibilities after discharge – burn nurse practitioners, burn aftercare nurses, and burn nurses handling transmural care. • Significant variation in the time allocated for aftercare across the centres. Stage 3. Defining the pathway for intervention development and adaptation Identify candidate interventions Explore the (grey) literature • The ZENN (ZElfmanagement Na Niertransplantatie) intervention ( 44 ) emerged as the most suitable candidate for adaptation. Critical assessment of each candidate intervention’s suitability for adaptation Organize two workshops • A hybrid “adapt and augment” approach ( 21 ) to translating the ZENN intervention to burn aftercare was determined to be necessary. Stage 4. Adapt and augment the intervention to Dutch burn aftercare Adapt and augment the intervention, including its core functions and materials, for Dutch burn aftercare, while developing a corresponding program theory Organize multiple workshops; Regular meetings with healthcare professionals and burn care decision-makers • The results of stage 4 and 5 concern adjustments to the ZENN intervention as shown in Table 3 . Stage 5. Prototyping Identify issues around feasibility and acceptability Expert review by original developers • The results of stage 4 and 5 concern adjustments to the ZENN intervention as shown in Table 3 . Healthcare professional and stakeholder review • The results of stage 4 and 5 concern adjustments to the ZENN intervention as shown in Table 3 . Preliminary testing at a burn outpatient clinic • The results of stage 4 and 5 concern adjustments to the ZENN intervention as shown in Table 3 . Formal approval of the new self-management support intervention Presentation for the the steering committee of the Alliance of Dutch Burn Care. • The adapted and augmented intervention, including all core functions, materials, and theory of change, was formally approved at the three Dutch burn centres. The intervention is called BreeZe (Brandwonden en Zelfmanagement). The intervention development has been reported following the GUIDance for the rEporting of intervention Development checklist (GUIDED) ( 23 ) (see Additional File 1 ). Context and Setting The Netherlands has three dedicated burn centres located at the Maasstad Hospital in Rotterdam, the Martini Hospital in Groningen, and the Red Cross Hospital in Beverwijk. These facilities collaborate with specialized trauma centres and other hospitals to form an integrated burn care network. Each year, these centres treat approximately 1,000 burn survivors [Dutch Burn Rository (DBR R3), the Netherlands]. Upon admission to a burn centre, patients undergo an assessment to determine the severity of their injuries, followed by a tailored treatment plan. Of the admitted burn patients, 11.3% require intensive care during their stay [DBR R3, the Netherlands]. The average hospitalization lasts 9.9 days, with a median stay of 4 days (based on data from 2020–2023; DBR R3, the Netherlands]. After discharge, aftercare typically includes outpatient visits, home nursing, physical therapy, scar therapy, or, in cases requiring more intensive rehabilitation, a temporary admission to a rehabilitation centre. Each burn centre is staffed by a multidisciplinary team specializing in both burn emergency treatment and aftercare for both children and adults. These teams include surgeons (both general surgeons, plastic surgeons, and specialized burn physicians), intensivists, pediatricians, burn nurse practitioners, ICU and burn nurses, social workers, physiotherapists, occupational therapists, dietitians, and psychologists. Aftercare is coordinated by burn physicians, burn nurse practitioners, or dedicated burn aftercare nurses, who serve as key contacts for burn survivors throughout their recovery. Development Stage 1: Preparation The first stage of the development aimed to identify relevant stakeholders and define their roles in the development process. We began by identifying stakeholders using the co-creative tool stakeholder mapping ( 24 ). Through brainstorming and listing all relevant individuals, we identified key stakeholders, including professionals from the multidisciplinary burn aftercare teams of the three Dutch burn centres, burn survivors, burn centre team leaders, burn centre department heads, and the Dutch Burns Foundation. To better understand the relationships among these stakeholders and determine the appropriate level of involvement, we created a power versus interest grid ( 24 ) in combination with the participation game ( 25 ). The power versus interest grid is a two-by-two matrix that visually maps stakeholders based on their political interest in the new intervention (y-axis) and their organizational power or control over the burn care system (x-axis). This tool helped us prioritize the stakeholders because it was neither feasible nor necessary to engage all with the same level of intensity. We then engaged with the identified stakeholders to explore their desired roles throughout the process. To actively discuss and shape their involvement, we employed the participation game – a serious game designed as an interactive and safe platform for discussion. This game is grounded in the participation ladder model ( 26 ), which defines levels of participation ranging from passive information sharing to active decision-making. Stakeholders with a more central role in the process participated in group sessions using the game, while those with a more peripheral role were engaged in individual conversations guided by the same principles. Stakeholder roles and tasks developed iteratively over time and were continuously refined as the project progressed. An overview of the final roles and levels of engagement is provided in Additional File 2 . This first stage also involved process mapping ( 27 ) during three face-to-face workshops to build consensus on the development process. The research team (including a patient expert, two burn nurse practitioners, a burn physician, one junior researcher, and three senior researchers) reviewed relevant examples and guidance documents and engaged in structured discussions to define key principles, essential actions, and their intended sequence. At this point, the process could only be mapped up to Stage 3, as two potential pathways – developing a new complex intervention or adapting an existing one – remained under consideration. From Stage 1 onwards, the process map was continuously refined during bi-monthly team meetings to align with emerging insights and evolving needs. The final version is shown in Fig. 1 . Development Stage 2: Evidence Review, Stakeholder Consultation, and Participatory Observations The second stage aimed to review the literature on self-management support, gather multiple perspectives about self-management support in burn care, and get insight into current practices in routine burn aftercare. Literature review To develop a comprehensive understanding of existing evidence on self-management and self-management support, we conducted a pragmatic literature search to create an evidence map ( 28 ). This involved a search across a broad field to identify knowledge gaps and present the findings in a user-friendly, searchable database. The search focused on keywords such as “self-management” and “self-management support”, with a focus on publications from the past ten years (2012–2022) and was conducted at MEDLINE (through PubMed). Snowballing was used to track down additional relevant studies. We identified evidence on nurses’ perspectives, showing that providing self-management support in patients with chronic conditions is influenced by multiple interdependent factors ( 29 ). Importantly, integrating self-management support is not an automatic outcome of training but requires a transformative learning process to trigger the necessary shift in mindset ( 18 ). We found no studies on healthcare professionals’ views on self-management support in burn aftercare. Only one study examined self-management in burn survivors, showing that they self-manage similarly to individuals with other chronic conditions ( 3 ). We also identified evidence on effective self-management support interventions, demonstrating that face-to-face, multicomponent interventions tailored to enhance patients' self-management skills can improve outcomes in patients with chronic conditions ( 30 ). These interventions should be adapted to burn survivors’ readiness to change, incorporate action planning, and focus on goal setting. Another study emphasized that successful interventions in patients with chronic conditions should also target intrinsic processes, such as motivation and self-efficacy ( 31 ). Patient with chronic conditions’ perspectives on self-management highlighted that they do not manage on their own but expect healthcare professionals to play a comprehensive role ( 16 ). We also found evidence suggesting that patient with chronic conditions’ attitudes, needs, and preferences for self-management support vary ( 32 ). In addition, we conducted a systematic review to examine the effects of self-management support interventions on health-related patient-reported outcomes in burn survivors. The review aimed to identify whether effective interventions exist for this population, what their components are, and what impact they report. We searched five major databases (MEDLINE, CINAHL, Cochrane, EMBASE, and PsycINFO) for studies published between 2010 and 2024, using search terms including “self-management support”, “burns”, and “intervention”. The review yielded only one eligible study ( 14 ), which was of low methodological quality. This study ( 14 ) suggested that a face-to-face single-component educational intervention, provided during hospitalization and around the time of a surgical procedure (skin grafting), may help reduce anxiety and increase comfort levels. Interviews with burn survivors Given the limited evidence on burn survivors’ specific needs and preferences for self-management support in burn aftercare – beyond indications that they seem to self-manage in ways comparable to individuals with chronic conditions ( 3 ) – we conducted semi-structured interviews with 17 burn survivors who had been admitted to one of the three Dutch burn centres within the past five years and had been discharged at least four weeks previously (topic guide: Additional File 3 ). Using maximum variation sampling strategy ( 33 ), we ensured diversity in age, sex, burn severity, time since discharge, and treatment location. Interviews were analysed using a Directed Content Analysis approach ( 34 ), supported by the Self-Management Support Needs model ( 16 ). In light of the aim of the development process, the interviews highlighted two particularly important insights. First, the moment of discharge emerged as a critical touchpoint with lasting impact on burn survivors’ ability to integrate the consequences of their burns into daily life. This period was described as one in which additional, targeted support is often needed. Second, a strong, ongoing partnership with a trusted healthcare professional was seen as essential. Burn survivors valued being truly seen and understood, and emphasized the importance of having a consistent point of contact who could provide both emotional and practical support. A full account of the interview study is provided in a separate manuscript, currently under review. Interviews with informal caregivers During the interviews with burn survivors, it became apparent that most relied on informal caregivers – individuals from their immediate environment who played a key role in helping them manage and integrate the consequences of their burns after discharge, for example partners. This aligns with the view that condition management is often a shared, family-based process ( 35 ). To gain deeper insight into their experience, we conducted semi-structured interviews with 12 informal caregivers, recruited via the interviewed survivors and the Dutch Association of Burn Survivors (topic guide: Additional File 3 ). Interviews were analysed using Interpretative Phenomenological Analysis ( 36 ), a qualitative method suited to exploring complex, ambiguous, emotionally charged experiences that have not been described before. Several themes emerged, some of which are particularly relevant to the development of self-management support interventions. Informal caregivers emphasized that the sustainability of their caregiving role largely depended on being acknowledged – not only by their social network, but also by hospital staff and home care services. Another key finding was the tension caregivers experienced between continuing their caregiving responsibilities and maintaining their own wellbeing. Many reported a tendency to prioritize the burn survivor’s needs at the expense of their own, often neglecting their own physical and emotional health. A full account of the interview study is provided in a separate manuscript, currently under review. Interviews with healthcare professionals Given the absence of studies on healthcare professionals’ views on self-management support in burn aftercare, we conducted semi-structured interviews to explore their perspectives. We defined self-management support as enabling individuals to manage and integrate the consequences of their burns in order to “live well”, and we posited that all burn care professionals are, consciously or not, already engaged in supporting self-management to some degree in aftercare. Using an inductive, interpretative qualitative approach, we interviewed a theoretical sample ( 37 ) of six burn physicians, three burn nurse practitioners, three burn aftercare nurses, two occupational therapists, and two medical psychologists working in the three participating Dutch burn centres (topic guide: Additional File 3 ). Data were analysed using a constant comparative approach described by Charmaz ( 38 ). The interviews showed considerable variation in the self-management support strategies – such as providing information, instilling confidence in burn survivors, and shifting the focus to patient-centred needs – reflecting how professionals interpret their own role, that of the patient, and other disciplines within the team. This variation was rooted in three core tensions: [1] difficulty recognizing burn survivors’ support needs after discharge, [2] navigating the boundaries of one’s own professional responsibility, and [3] unclear team roles, conflicting priorities, and time constraints. The findings suggest the need for targeted training in communication skills and a holistic needs assessment tools. Additionally, clarifying roles within each team may enhance collaboration and effectiveness. Finally, prioritizing burn survivors' values and needs, and allocating more time for personalized self-management support, may need to be considered. A full account of the interview study is provided in a separate manuscript, currently under review, and a preprint is available ( 39 ). Consultations with burn care decision-makers and participatory observations In addition to the interviews and literature reviews, we conducted unstructured consultations with burn care decision-makers (i.e., burn centre team leaders, burn centre department heads, members of the steering committee of the Alliance of Dutch Burn Care) to gather broader contextual insights. We also carried out eight participatory observations during outpatient aftercare consultations at the three Dutch burn centres, using qualitative shadowing techniques ( 40 ). Shadowing allowed us to observe real-time care practices and organizational dynamics. Data from both activities were recorded as field notes and thematically analysed ( 41 ). Findings showed considerable variation between centres in how burn aftercare is organized – particularly regarding who (which discipline) takes on responsibilities in burn aftercare. In addition to the role of the burn physician, one centre relies on burn nurse practitioners (Nursing Practitioner, NP), another employs burn aftercare nurses (Registered Nurse, RN), and a third includes burn aftercare nurses (Registered Nurse, RN) with dedicated tasks for transmural care. As a result, roles, responsibilities, and available time for nurses differed considerably across the centres. The concept of what constitutes "aftercare" also varied: two centres providing continuous nursing support throughout the entire continuum post-discharge, while one began aftercare only after wound closure. In addition, there were also nuanced variations in how and when allied healthcare professionals became involved throughout the patient journey, influencing the type and timing of support burn survivors received. Development Stage 3: Defining the Pathway for Intervention Development and Adaptation Stage 3 focused on deciding whether to develop a new self-management support intervention or adapt an existing one for burn aftercare. Based on the findings of stage 1 and 2, we formed an Intervention Development Group (IDG) comprising four researchers, two patient experts, a burn physician, and two burn nurse practitioners. A systematic consensus-building process was facilitated by the lead researcher, following the tentative roadmap on consensus-building processes described by Leising and colleagues ( 42 ), with a strong emphasis on partnership-based collaboration ( 26 ). The IDG set out to identify self-management support interventions that could potentially be adapted for burn aftercare. Therefore, the IDG expanded the search scope both within the scientific literature – beyond the burn survivor population – and grey literature ( 43 ), thereby including unpublished interventions currently being studied or implemented in other patient populations. The IDG critically assessed identified interventions for adaptation suitability using six criteria ( 19 , 21 ): [1] the intervention-context fit; [2] the availability of detailed information about the intervention; [3] similarities between the original and the new context; [4] the robustness of the effectiveness claims; [5] usability in terms of intellectual property; and [6] required costs and resources for usage. To operationalize the first criterion – intervention-context fit – the IDG developed specific fit indicators grounded in the findings from stage 2 (see Table 2 ). Table 2 The criteria a self-management support intervention in burn aftercare should adhere to. Source: Fit indicators. A self-management intervention in Dutch burn aftercare should: Literature review 1. Emphasize a structured yet flexible approach tailored to the individual needs of burn survivors; Literature review 2. Include face-to-face guidance; Literature review 3. Be multicomponent; Literature review 4. Allow adaptations based on the burn survivor’s readiness to change; Literature review 5. Incorporate action planning and goal-setting as intervention strategies; Interviews with burn survivors 6. Create opportunities to initiate self-management support around the time of discharge; Interviews with burn survivors 7. Encourage a continuous, trusting relationship between burn survivors and a consistent healthcare professional; Interviews with informal caregivers 8. Acknowledge informal caregivers as partners in care; Interviews with informal caregivers 9. Create space to involve informal caregivers in self-management support; Interviews with professionals 10. Clarify which healthcare professional is responsible for delivering self-management support and at what stages; Interviews with professionals 11. Provide training and tools to help healthcare professionals identify burn survivors' self-management needs and align with their intrinsic self-management processes; Interviews with professionals 12. Avoid adding extra workload for healthcare professionals; Consultations with burn care decision-makers and participatory observations 13. Accommodate the differences across the three Dutch burn centres; Consultations with burn care decision-makers and participatory observations 14. Accommodate the differences across the three Dutch burn centres in what constitutes “aftercare”. In total, 22 self-management interventions were reviewed across two workshops. Twenty-one were deemed unsuitable due to poor documentation (including a lack of available materials), an overly biomedical focus, or complex and costly implementation requirements (e.g., requiring an app). The ZENN (ZElfmanagement Na Niertransplantatie, self-management after kidney transplantation) intervention ( 44 ) was the only intervention deemed suitable for adaptation to burn care. The ZENN intervention aims to enhance patients’ self-management skills in order to integrate their treatment- and life goals, thereby improving quality of life and health-related outcomes ( 44 ). It includes four key elements: [1] a general structure with room for individual tailoring, [2] a holistic approach, [3] shared-decision making between nurse practitioner (NP) and patient, and [4] patient empowerment. Grounded in Self-regulation Theory ( 45 ), the intervention incorporates techniques from Motivational Interviewing ( 46 ) and Solution-Focused Brief Therapy (SFBT) ( 47 ). The ZENN intervention is structured over four sessions. In the first session, a Self-Management Web ( 44 ) is used to holistically assess self-management challenges across 14 life areas, such as emotional well-being, mobility, and work. Based on this assessment, the nurse practitioner and patient use solution-focused techniques to set SMART goals and create action plans. Subsequent sessions focus on tracking progress, addressing new challenges, and reinforcing goal attainment. Follow-up sessions include a combination of in-person and telephone consultations, and double appointments with NPs ensure sufficient time to address patient concerns. The intervention emphasizes relapse prevention and the generalization of skills to other areas of life. The ZENN intervention was considered well-suited for adaptation, sufficiently meeting all six eligibility criteria. First, it showed a strong intervention-context fit, aligning sufficiently with the established fit criteria for burn care (Table 2 ). Second, comprehensive documentation from the original developer (EKM) – including matrices of change objectives, delivery strategies, and materials such as e-learning modules, patient workbooks, and resources for healthcare professionals – provided the IDG with a clear understanding of its structure and working mechanisms. Third, despite being developed for kidney transplant patients, the IDG noted that both contexts share similar challenges in self-management, with certain differences that were deemed manageable. Importantly, the IDG determined that the underlying change objectives did not need to be adjusted when applied in burn aftercare. Fourth, evidence of effectiveness was promising: a pilot study ( 48 ) reported improvements in patient-centred care and quality of life, particularly in the physical role domain. Furthermore, psychosocial topics were addressed more comprehensively in the intervention group, demonstrating effectiveness in meeting patients' needs. At the time, a multicentre, stepped-wedge randomized controlled trial ( 49 ) was ongoing to evaluate its broader impact. Fifth, intellectual property rights posed no barriers, as the original developer (EKM) had made the intervention available for adaptation. Finally, the costs associated with adaptation for and implementation in burn aftercare were considered low, supporting its feasibility for burn aftercare. Despite its strengths, a direct adaptation of ZENN was deemed unsuitable, as the intervention’s procedures, activities, sequence, delivery, and materials as they were, were incompatible with the context of Dutch burn care. This was due to several key differences across the three Dutch burn centres, including variations in how aftercare is organized, the acute and traumatic nature of burn injuries from the patient’s perspective, and the diverse roles and responsibilities of healthcare professionals following discharge from the burn centre. In light of these differences, the IDG opted for a hybrid approach – an “adapt and augment” strategy ( 21 ) – in which ZENN would be tailored to the burn aftercare context. Development Stage 4: Adapting and Augmenting the Intervention for the Context of Dutch Burn Aftercare In stage 4, the IDG held five workshops to iteratively adapt and augment the selected intervention to the context of Dutch burn aftercare. These workshops involved discussing the content, providing feedback, refining ideas, and incorporating further feedback as the process progressed. During these workshops, the IDG engaged in several key activities ( 19 , 21 ): [1] articulating the program theory; [2] identifying and responding to barriers and facilitators that may influence effectiveness and implementation; [3] adapting and augmenting the intervention, including its core functions and materials; [4] considering potential unintended consequences that could arise from implementation in the new context; and [5] evaluating the costs and resources required for implementation in Dutch burn aftercare. Healthcare professionals, burn care decision-makers and one of the developers of the original ZENN intervention (EKM) provided feedback on draft versions of the intervention, including its core functions, delivery strategies, and materials. To support the articulation of the program theory, the IDG drew on the matrices of change objectives established by the original development team of the ZENN intervention and remained aligned with the principles of the Intervention Mapping (IM) approach ( 50 ). To guide decision-making about whether and how to adapt and augment the intervention, the IDG applied the Model for Adaptation Design and Impact (MADI) ( 51 ) prospectively during the workshops. In line with this model, potential adaptations were assessed against core functions, goals, and expected impacts to minimize risks of negative outcomes, supported by the comprehensive documentation provided by the original developer (EKM). This structured approach helped the IDG weigh trade-offs, anticipate unintended consequences, and refine the intervention to enhance contextual fit. The iterative process continued until the IDG reached sufficient consensus for prototyping. Development Stage 5: Prototyping To gain preliminary feedback on the acceptability and feasibility of the intervention, the draft version underwent real-world testing, review by the original developer (EKM), and stakeholder review. Feedback from these sources was systematically processed by the IDG over three workshops. First, five burn survivors currently receiving care, along with two burn nurse practitioners and a burn physician, tested various intervention materials at the burn outpatient clinic. They provided feedback, particularly focusing on improving the readability, design, and language of patient materials, such as the burn survivors’ workbook, to make it more accessible and engaging. Simultaneously, the core intervention functions, delivery strategies, manual, and supporting materials were sent to the original ZENN developer (EKM) for expert review, focusing on conceptual alignment, appropriateness, and suggested refinements. In parallel, all healthcare professionals and decision-makers from the three Dutch burn centres were invited to review the draft manual which covered all aspects of the intervention, assessing its acceptability and feasibility in routine practice, and considering how it could be integrated into existing workflows. To guide how input from these sources was incorporated, the IDG continued to apply the MADI ( 51 ). All changes made during stages 4 and 5 were also documented using the MADI ( 51 ) (Table 3 ). The final intervention, including its core components, delivery strategies, materials, and theory of change, was approved by the steering committee of the Alliance of Dutch Burn Care at the end of stage 5. Table 3 Summary of adaptations and augmentations – Based on the Model for Adaptation Design and Impact (MADI) a ( 51 ) What is modified? Nature of A/A? Who participated in A/A decision-making? For whom/what is the A/A made? Is the adaptation consistent with core functions, or does it constitute an augmentation that introduces a new core function? Goal and rationale for A/A Was the A/A made with consideration of its impact on outcomes and processes? Was the A/A prompted by an anticipated barrier? Which outcomes are expected to be affected by this A/A? b,c Intervention title Changed the name of the “ZENN” intervention to the “BreeZe” intervention Contextual tailoring IDG All stakeholders in burn care Consistent with core functions To align the intervention framing with the perspectives of all stakeholders in burn care Yes Yes, overcoming the “not-invented-here syndrome” and clarifying that the intervention is an adapted version Adoption (+) Acceptability (+) Appropriateness (+) Feasibility Fidelity Cost Penetration Sustainability (+) Patient outcomes Service outcomes Intervention goal N/A Intervention core functions Added case management as an intervention core function Adding an element IDG Burn survivors and healthcare professionals Augmentation introducing a new core function To accommodate the differences across the three Dutch burn centres in professionals working in burn aftercare, to encourage a continuous, trusting relationship between burn survivors and a consistent healthcare professional, and to clarify which healthcare professional is responsible for delivering self-management support and at what stages Yes Yes, ambiguity in roles and responsibilities in multidisciplinary burn aftercare teams and potential lack of effectiveness Adoption (+) Acceptability (+) Appropriateness (+) Feasibility (-) Fidelity Costs Penetration Sustainability Patient outcomes (+) Service outcomes (+) Structurally integrated the acknowledgement and involvement of informal caregivers across all phases of the intervention Adding an element IDG Informal caregivers, burn survivors, and healthcare professionals Augmentation introducing a new core function To acknowledge informal caregivers as partners in care and to create space for informal caregiver’s involvement Yes Yes, informal caregivers’ limited capacity to support burn survivors Adoption Acceptability Appropriateness (+) Feasibility (-) Fidelity Costs Penetration Sustainability Patient outcomes (+) Service outcomes (+) Intervention materials Translated the Self-Management Web to English, German, Polish and Arabic Linguistic tailoring IDG, healthcare professionals; professional language agency Burn survivors and healthcare professionals Consistent with core functions In response to healthcare professionals’ experiences of frequent contact with patients from diverse cultural backgrounds; languages were selected based on the most prevalent non-Dutch language groups in burn care. Yes Yes, linguistic inaccessibility for burn survivors whose primary language is neither Dutch nor English. Adoption Acceptability Appropriateness (+) Feasibility Fidelity Costs Penetration (+) Sustainability Patient outcomes Service outcomes Adapted the comprehensive manual for healthcare professionals to the context of Dutch burn aftercare Format and usability redesign IDG, healthcare professionals; burn care decision-makers; original intervention developers Burn survivors, healthcare professionals, and burn care decision-makers Consistent with core functions To align the content and format of the manual with Dutch burn aftercare practices and needs, to facilitate consensus-building during its development, and to clarify who does what, and when in burn aftercare Yes Yes, limited applicability of the original manual’s content to the specific workflows and terminology in burn aftercare Adoption (+) Acceptability (+) Appropriateness (+) Feasibility Fidelity (+) Costs Penetration Sustainability Patient outcomes (+) Service outcomes (+) Developed a visual communication tool “praatplaat” to supplement the manual Addition of a visual communication tool IDG, healthcare professionals, burn care decision-makers, original intervention developers, professional designers Healthcare professionals, and burn care decision-makers Consistent with core functions To enhance clarity, accessibility, and usability of the manual by visually summarizing key information, and to support healthcare professionals in understanding who does what, and when in burn aftercare Yes Yes, healthcare professionals expressed a need for more accessible and actionable guidance on roles and responsibilities Adoption (+) Acceptability (+) Appropriateness (+) Feasibility Fidelity (+) Costs Penetration Sustainability Patient outcomes (+) Service outcomes (+) Reformatted the patient diary into a structured, paper patient booklet Reformatting and expansion Patient experts; IDG; healthcare professionals; a professional designer Burn survivors and healthcare professionals Consistent with core functions In response to healthcare professionals’ request to make the intervention more tangible and aligned with their perspectives on self-management roles and responsibilities. Patient experts also emphasized the importance of developing an accessible tool to track progress and document experiences. Yes Yes, perceived over-emphasis on the role of healthcare professionals in burn survivor’s self-management behaviour and the inability of burn survivors to keep track of the BreeZe process Adoption (+) Acceptability (+) Appropriateness (+) Feasibility Fidelity Costs (-) Penetration (+) Sustainability Patient outcomes (+) Service outcomes (+) Adapted the integrated training program (e-learning + in-person session) to the context of Dutch burn care professionals. Contextual tailoring IDG; original intervention developers; the company behind the e-learning; professional actor Healthcare professionals Consistent with core functions To align the integrated training program with the perspectives of healthcare professionals working in Dutch burn aftercare Yes Yes, a potential perceived misfit between the training and the clinical practice healthcare professionals have to apply the knowledge Adoption (+) Acceptability (+) Appropriateness (+) Feasibility Fidelity Costs Penetration Sustainability Patient outcomes Service outcomes Reformatted the Visual Analogue Scales into a stand-alone, visually accessible tools Reformatting IDG; healthcare professionals Healthcare professionals Consistent with core functions To enhance usability and integration into routine burn aftercare Yes Yes, to address the potential barrier that the Visual Analogue Scales embedded in the patient booklet alone may not be used Adoption (+) Acceptability Appropriateness Feasibility Fidelity (+) Costs Penetration Sustainability Patient outcomes Service outcomes Developed a documentation guide for healthcare professionals to help healthcare professionals Adding an element IDG; healthcare professionals Healthcare professionals Consistent with core functions To encourage a continuous, trusting relationship between burn survivors and a consistent healthcare professional, and to provide tools that support intrinsic self-management process alignment Yes Yes, to address the potential lack of continuity in goal setting and action planning Adoption (+) Acceptability Appropriateness Feasibility Fidelity (+) Costs Penetration Sustainability Patient outcomes Service outcomes Intervention procedures, activities, sequence, and/or processes Reframed the intervention structure from discrete sessions ( 48 ) to overarching phases ( 49 ), and embedded it within routine outpatient consultations without extending appointment times Reframing of procedural structure in line with recent changes made by the original developers IDG; healthcare professionals; burn care decision-makers Burn survivors; healthcare professionals Consistent with core functions To align with updated ZENN intervention conceptualization, avoid adding extra workload for healthcare professionals in the BreeZe intervention, and accommodate the differences across the three Dutch burn centres in what constitutes “aftercare” Yes Yes, lack of sustained funding and impracticality of scheduling separate or prolonged sessions in routine outpatient care Adoption (-) Acceptability (-) Appropriateness Feasibility (-) Fidelity (-) Costs Penetration Sustainability (+) Patient outcomes Service outcomes (+) Adapted the patient selection criteria and timing of intervention initiation to fit diverse patient trajectories in burn care (with or without admission) Adjustment of eligibility criteria and timing of delivery IDG; healthcare professionals Burn survivors; healthcare professionals Consistent with core functions To allow adaptations based on the burn survivor’s readiness to change, emphasize a structured yet flexible approach tailored to individual needs of burn survivors, and accommodate the differences across the three Dutch burn centres in what constitutes “aftercare” Yes Yes, the variability in patient trajectories within burn care made the original timing and selection criteria impractical Adoption (+) Acceptability (+) Appropriateness (+) Feasibility Fidelity (+) Costs Penetration (+) Sustainability (+) Patient outcomes Service outcomes (+) Introduction of Phase 0 for burn survivors who have been admitted, focusing on initial engagement and transition from inpatient care to home Adding an element IDG; healthcare professionals; patient experts Burn survivors who have been admitted to a burn centre Augmentation in line with the new core function (case-management) To create opportunities to initiate self-management support around the time of discharge Yes Yes, the barrier was that without this early phase, there may be insufficient foundation for a strong collaborative relationship. Adoption Acceptability Appropriateness (+) Feasibility (-) Fidelity Costs Penetration (+) Sustainability Patient outcomes (+) Service outcomes Intervention delivery The intervention delivery, which was originally designed to be provided by nurse practitioners, was adapted to include burn aftercare nurses, burn nurse practitioners, and burn physicians. Contextual tailoring IDG; healthcare professionals Healthcare professionals Augmentation broadening the scope of healthcare professionals To ensure the intervention can be implemented consistently across different burn centres, where healthcare roles and responsibilities vary. By widening the scope, the intervention is able to accommodate the differences across the three Dutch burn centres in professionals working in burn aftercare Yes Yes, the barrier was that some burn centres do not have nurse practitioners. Adoption (+) Acceptability (+) Appropriateness (+) Feasibility (+) Fidelity (+) Costs Penetration Sustainability (+) Patient outcomes Service outcomes (+) A/A = adaptation/augmentation; IDG = intervention development group consisting of four members from the burn care research team with diverse expertise, two patient experts, a burn physician, and two burn nurse practitioners; a = the MADI also includes the construct “When did the adaptation occur?” which was left out of the table as all adaptations and augmentations described here have occurred during phase 4 and 5; b = the outcomes described here are described in detail by Proctor et al. Adm Policy Ment Health. 2011 Mar;38( 2 ):65–76. doi: 10.1007/s10488-010-0319-7 .; c = for each outcome the expected intended and unintended impact has been considered in terms of (+) positive, and (-) negative; Results The result of our structured, multistage development process is a self-management support program for burn survivors, named BreeZe (Brandwonden en Zelfmanagement/Burns and self-management). The reporting of the intervention below is structured according to the Template for Intervention Description and Replication (TIDieR) checklist ( 52 ). Additionally, the program theory underlying the BreeZe intervention is presented in Additional File 4 . Intervention goal The BreeZe self-management support intervention takes a holistic, patient-centred approach, addressing the medical, emotional, and social aspects of self-management. It aims to strengthen burn survivors’ self-efficacy and intrinsic motivation by helping them identify challenges after discharge from the burn centre, explore solutions, and develop personalized action plans. The intervention aligns with the full range of fit indicators presented in Table 2 . BreeZe is a comprehensive, multicomponent intervention that offers a structured yet flexible approach, includes face-to-face guidance, and can be adapted according to the burn survivor’s readiness to change. It incorporates goal-setting and action planning, emphasizes fostering continuous, trusting relationships between burn survivors and healthcare professionals, and actively promotes motivation and self-efficacy as well as the involvement of informal caregivers. Intervention core functions The following core functions are drawn directly from the BreeZe intervention outlined above: Holistic Care Approach ( 53 ), Goal Setting and Action Planning ( 54 ), Solution-Focused Brief Therapy ( 47 ), Motivational Interviewing ( 46 ), Case Management ( 55 ), and acknowledging and involving informal caregivers. Intervention delivery (who, how, where, when, and how much) The BreeZe intervention is designed primarily for burn survivors whose wound healing time exceeds at least 14 days, as the IDG assumed these burn survivors experience more significant long-term consequences of the burn injury. BreeZe is delivered by trained healthcare professionals, including dedicated burn aftercare nurses, burn nurse practitioners, and burn physicians when no nurse or nurse practitioners are available. To ensure effective delivery, healthcare professionals offering BreeZe must complete an integrated training program. For each burn survivor, one of these healthcare professionals will act as a “case manager”. A case manager coordinates the post-discharge aftercare process and serves as the primary point of contact, guiding the burn survivor and his/her caregiver(s) through the various phases of recovery. The BreeZe intervention is implemented within the (outpatient) clinical treatment trajectory, either starting during the burn survivor’s hospitalization (Phase 0) or shortly after discharge (Phase 1). For burn survivors starting in an outpatient trajectory, Phase 1 starts 7 to 14 days after their injury or discharge. Intervention materials Various intervention materials have been developed to support the goals of the BreeZe self-management support intervention. For burn survivors, these include: Self-Management Web ( 44 ) – A visual communication tool designed to help burn survivors and healthcare professionals assess and discuss various life domains in a structured way. It provides a standardized overview of 14 key areas, supporting a holistic approach to self-management while promoting intrinsic motivation by allowing burn survivors to prioritize their focus. This tool facilitates shared decision-making and ensures that support aligns with individual needs. This tool is available in Dutch, English, German, Polish, and Arabic. Patient booklet – A structured booklet that guides burn survivors through the different phases of self-management: identifying challenges and needs, exploring solutions, and developing personalized action plans. Designed by burn survivors, it serves as a reflective tool to track progress, document experiences, and support ongoing self-management efforts. Visual analogue scales (VAS) scales – These VAS scales are tools used to assess key aspects of self-management, including intrinsic motivation and goal progression. The scales allow burn survivors to visually track their progress over time, providing both the healthcare professionals and the burn survivors with a clear representation of changes in key areas. This makes it easier to identify challenges and facilitates motivational interviewing and positive reinforcement. For healthcare professionals these include Integrated Training Program – This training, originally developed for the ZENN Intervention ( 49 ) and later adapted to the burn care context, consists of two complementary components. Burn care professionals first complete an e-learning module covering the theoretical background, key concepts, and intervention steps. This is followed by an in-person session, led by one of the original developers (EKM) together with a professional training actor (MvB), where participants practice communication skills in realistic scenarios. Additionally, a booster session is organized approximately 4–8 weeks after the in-person training to address questions from clinical experience and to further practice skills. The training follows the CRe-DEPTH criteria ( 56 ) and is detailed in Additional File 5 . Comprehensive manual for healthcare professionals – A manual that covers all aspects of the BreeZe intervention, including the intervention goal, underlying rationale, intervention core functions, and its alignment with other developments in burn care. It also provides practical suggestions for engaging in everyday conversations with burn survivors, offering guidance on how to effectively support them throughout their self-management journey. Visual communication tool (“praatplaat”/”poster that elicits talking”) – A visually designed summary that complements the comprehensive manual by presenting key information and intervention phases in an accessible and engaging format. The tool clarifies the roles and responsibilities of healthcare professionals within the BreeZe intervention, supporting implementation in practice by helping teams quickly grasp what needs to happen, when, and by whom. See Additional File 6 . Documentation Guide for Healthcare Professionals – A structured framework for documenting patients’ self-management support progression throughout the outpatient journey in the Electronic Health Record system. Intervention procedures, activities, sequence, and/or processes The BreeZe intervention consists of five flexible phases that support burn survivors in building self-management skills after discharge. Each phase is adapted to individual needs and progress (for a visual presentation, see Additional File 6 ): Intervention phase 0: Introduction and Transition to Home (for hospitalized burn survivors only) Prepares burn survivors for discharge by building rapport, addressing immediate concerns, and introduces the concept of goal pursuit and setting. Intervention phase 1: Assessment (7–14 days post-discharge or post-injury) Focuses on understanding the burn survivor’s priorities, challenges, and goals. Key tools like the Self-Management Web and VAS scales are used to gauge desired outcome and current status, intrinsic motivation, and self-efficacy. Intervention phase 2: Solidify (around 3 months post-discharge) Revisits and refines goals, develops action plans or adjusts if needed, assesses progress, and focuses on reinforcing intrinsic motivation. The healthcare professional ensures that the burn survivor is on track and offers additional guidance to overcome barriers. Intervention phase 3: Continuation (around 6 months post-discharge) Ongoing review of progress and implementation of action plans. Motivation and self-efficacy are reassessed using VAS scales to support long-term engagement. Intervention phase 4: Monitor (around 12 months post-discharge) Focuses on maintaining and expanding self-management skills, addressing relapse prevention, planning for long-term independence, and generalising self-management skills to other situations. Each phase of the intervention is integrated into routine care and takes approximately 15 to 30 minutes, depending on the type of routine care consultation. Phases may be spread over multiple sessions, depending on the burn survivor’s recovery and coping process. A minimum of two weeks between phases is recommended to allow time for implementing action plans. During each phase, professionals are also prompted to ask about the presence of an informal caregiver, and whether they should be involved in the BreeZe process. Discussion This report outlines the development of a self-management support intervention for burn survivors following discharge from burn centres. The primary aim was to develop a self-management support intervention for burn survivors while ensuring transparency in the developmental process to facilitate future replication, scaling, learning, and broader implementation. The developmental process incorporated a collaborative, multi-stakeholder approach, integrating scientific evidence, theory, and expert feedback. This process resulted in BreeZe – a comprehensive, evidence-based, and theoretically grounded intervention designed to meet the unique needs of burn survivors and tailored to the context of Dutch burn aftercare. BreeZe includes key core functions such as a Holistic Care Approach ( 53 ), Goal Setting and Action Planning ( 54 ), Solution-Focused Brief Therapy ( 47 ), Motivational Interviewing ( 46 ), and Case Management ( 55 ), supported by materials like the Self-Management Web ( 44 ), a patient booklet, an integrated training program, and a comprehensive manual for healthcare professionals. The developmental process, spanning 32 months, was thorough and carefully considered, requiring us to balance the diverse perspectives of stakeholders with scientific evidence and theory, ultimately resulting in an intervention that holds promise for improving burn care and increasing the likelihood of successful adoption and implementation. Use of theories, models and frameworks The development of the BreeZe intervention was informed by several complementary frameworks ( 19 – 22 ) that can be categorized as “process models” – a term used by Nilsen ( 57 ) to describe theoretical approaches that support the translation of research into practice through clearly defined, phased steps. These helped structure and guide our process, offering clarity and flexibility – essential in balancing scientific evidence, theory, and diverse stakeholder perspectives throughout a complex and lengthy development process requiring iteration, participation, and responsiveness to contextual factors. However, while these models were valuable in guiding how to develop and adapt the intervention, they paid less attention to why it might work — the mechanisms of change. To address this, we drew on a wide range of behavioural theories ( 45 , 58 – 63 ) inherited from the original ZENN intervention ( 49 ). These theories informed both the original and adapted matrices of change objectives and helped articulate a preliminary program theory for BreeZe ( Additional File 4 ) that provides a plausible explanation about how BreeZe is supposed to function and achieve its objectives. Looking back, our layered approach – combining structured process guidance with theoretical depth – proved both valuable and demanding. While the use of multiple theories, models and frameworks contributed to methodological rigour, it also required continuous reflection on when and how each of them was applicable, and how they related to one another. This appeared to be particularly complex in a participatory context. Working collaboratively using participatory methodologies meant investing in the capacity and capability of co-creators to engage meaningfully with theoretical concepts, which requires upskilling efforts. Moreover, translating abstract theories into practical, actionable steps demanded sustained effort from the project lead, who had to mediate between academic expectations and real-world constraints. A clear example of these dynamics was our consideration of more closely adhering to the Intervention Mapping (IM) approach ( 50 ), which had underpinned the development of the original ZENN intervention. While IM is a well-established, systematic approach to planning and developing health promotion interventions, its focus on new intervention development overlapped with other process models already guiding our approach ( 19 – 22 ), offering limited added value to the adaptation-focused BreeZe process. Importantly, the decision not to shift to an IM-based approach was made collectively. To assess whether IM was relevant and valuable in our specific phase, context, and goals, all co-creators had to engage with the underlying methodological assumptions and compare them to the demands of the adaptation process. This required grappling with complex concepts such as intervention logic models, and the distinction between adaptation and de novo development. The process underscored the importance of upskilling, as highlighted in previous research, to enable meaningful and informed participation ( 64 ). Use of co-creation The co-creative approach played a central role in the development of the BreeZe intervention and brought several key benefits. By actively involving burn survivors, their informal caregivers, burn care professionals, and burn care decision-makers, we were able to develop an intervention that we expect to be closely aligned with their perspectives and well-fitted to the context in which it will be implemented. We expect that, as suggested by Hawkins and colleagues ( 20 ), this inclusive approach has fostered a sense of ownership and buy-in across the three burn centres. Involving a broad range of stakeholders also facilitated the integration of experiential and scientific knowledge – an important function of co-creation highlighted by Leask and colleagues ( 64 ). For example, input from patient experts and burn care professionals was essential in determining the optimal timing of key elements of the BreeZe intervention, such as when to introduce goal setting and when to move to action planning within the patient journey. Moreover, our co-creative process enabled stakeholders to influence the changes the intervention aims to bring about, to prepare for those changes, and to ensure that the intervention aligned with what they themselves found valuable – three conditions identified by Nilsen and colleagues ( 65 ) as critical for successful organizational change. Despite its many benefits, the co-creative development process also posed several challenges. One key difficulty was balancing the diverse priorities, routines, and cultural values of the three burn centres and their staff, which sometimes led to tension between local practices. Another challenge lay in managing the breadth of participation. While stage 1 tools such as stakeholder mapping and the power-interest grid helped identify relevant stakeholders, ensuring the right level of involvement throughout the development process proved complex. Roles and tasks evolved iteratively and required continuous alignment as the project progressed. To manage this, we adopted a layered engagement strategy: a core group of stakeholders (the IDG) participated intensively in consensus-building workshops, while others were regularly informed, consulted, or asked for advice – reflecting the three levels of participation (Information, Consultation, and Advice). However, navigating competing agendas, time constraints, and occasional ambiguity around decision-making authority, required ongoing effort. In hindsight, integrating a tool like the Value Proposition Canvas might have further streamlined this process ( 22 ). By clarifying the distinct value that each stakeholder group places on the new intervention early on, we could have facilitated more focused and efficient collaboration. These challenges resonate with those found in other studies ( 20 , 66 ), and underline the reality that while co-creation enhances contextual fit and alignment with stakeholder perspectives, it also demands sustained coordination, reflexivity, and flexibility throughout the process. Future activities As noted by Skivingston and colleagues ( 15 ), developing a complex intervention does not end once the content has been agreed upon. Instead, refinement continues as insights accumulate, based on early implementation experiences and how the intervention interacts with different real-world contexts. We expect this to also be true for the BreeZe intervention. While its core components have now been defined, we anticipate that further tailoring together with our stakeholders, may be needed as we move into the evaluation phase, especially given the diversity in how burn aftercare is organized and delivered across centres and in burn survivors’ patient journeys. This may include, for example, implementation strategies to better support local adoption in practice. As we move forward, the program theory of BreeZe will require further elaboration ( 15 ). While we have established the change objectives, determinants, and performance objectives that underpin the intervention, the precise outcome measures remain under development. This includes determining how self-management support and behavior will be defined and measured, establishing appropriate timeframes for measurement, and identifying the patient and service outcomes that should be linked to these processes. Additionally, it is crucial to define the implementation outcomes that underlie the adaptations highlighted in Table 3 . Unlike the approach of Maindal and colleagues ( 66 ), who developed a detailed core outcome set early in their intervention development, we have opted to defer this step to the next phase wherein we will conduct a systematic evaluation of its effectiveness after implementation. In addition to continuous refinement of the intervention and program theory, economic considerations will also be essential in the next phase ( 15 ). As outlined in our program theory ( Additional File 4 ) and introduction paragraph, assessing the intervention’s effect on burn care service utilization and sustainability will be critical to determine its value from a broader point of view ( 67 , 68 ). Engagement with economic experts will ensure that these considerations are integrated, allowing us to evaluate the intervention’s cost-effectiveness after implementation. Conclusion The development of the BreeZe intervention has been a rigorous, multi-faceted process, integrating scientific evidence, theoretical frameworks, and input from a diverse group of stakeholders, including burn survivors, healthcare professionals, and burn care decision-makers. By addressing the complex physical, psychological, and social needs of individuals recovering from burns, BreeZe offers a holistic, person-centred approach to self-management support after discharge from burn centres. Its core components – such as goal setting, action planning, and case management – are designed to foster sustainable self-management behaviours and contribute to more effective, collaborative burn care. As the intervention moves into the implementation and evaluation phase, continued refinement will be crucial to ensure it remains responsive to evolving needs and changing real-world contexts. This systematic development process not only lays the groundwork for successful adoption, scaling, and replication of this particular intervention, but also contributes to the broader evidence base on developing and adapting complex interventions beyond the field of burn care. Abbreviations BreeZe – Brandwonden en Zelfmanagement (burns and self-management) CRe-DEPTH criteria – Criteria for Reporting Education, Development, and Provider Evaluation DBR R3 – Dutch Burn Registry GUIDED – GUIDance for the rEporting of intervention IDG – Intervention Development Group IM – Intervention Mapping MADI – Model for Adaptation Design and Impact MRC – Medical Research Council SFBT – Solution-Focused Brief Therapy TIDieR – Template for Intervention Development and Replication VAS – Visual Analogue Scales ZENN – ZElfmanagement Na Niertransplantatie (self-management after kidney transplantation) Declarations Ethics approval and consent to participate All study procedures were conducted in accordance with relevant guidelines and regulations, including the Declaration of Helsinki. Ethical approval was obtained where required (e.g., interview studies), with approval granted by the Ethics Committee of the Martini Hospital [2022-092; 2022-093; 2023-008] and re-approved locally at the Maasstad Hospital and Red Cross Hospital. Participants involved in relevant stages of the study provided written informed consent prior to participation. Consent for publication Not applicable. Availability of data and materials The data generated and analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Funding This work was supported by the Netherlands Organization for Health Research and Development (ZonMW; reference number 10070022010003). ZonMW did not play a role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review or approval of the manuscript; and decision to submit the manuscript for publication. Acknowledgements The authors wish to thank the following Dutch burn centers for their support: Maasstad Hospital in Rotterdam, Martini Hospital in Groningen, and the Red Cross Hospital in Beverwijk. Moreover, we would like to thank the burn survivors, families, and healthcare professionals who contributed to the development of the BreeZe intervention, and we would like to thank Marijke van Bemmel (MvB) who contributed as a professional training actor. Authors’ contributions MKN and SMHJSJ conceived the overall study concept. SJGG led the coordination of the project and maintained oversight, supported by SLB. The design of the various stages of the development process was a collaborative effort by SJGG, SLB, ASN, IV, SMHJSJ, and MKN. 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The Quintuple Aim for Health Care Improvement: A New Imperative to Advance Health Equity. Jama. 2022;327(6):521-2. Additional Declarations No competing interests reported. Supplementary Files AdditionalFile4GeelenetalDevelopmentBreeZe.pdf AdditionalFile6GeelenetalDevelopmentBreeZe.pdf AdditionalFiles.docx Cite Share Download PDF Status: Published Journal Publication published 26 Dec, 2025 Read the published version in BMC Health Services Research → Version 1 posted Editorial decision: Revision requested 02 Nov, 2025 Reviews received at journal 02 Nov, 2025 Reviews received at journal 14 Oct, 2025 Reviewers agreed at journal 11 Sep, 2025 Reviewers agreed at journal 11 Sep, 2025 Reviewers invited by journal 11 Sep, 2025 Editor assigned by journal 18 Aug, 2025 Submission checks completed at journal 18 Aug, 2025 First submitted to journal 18 Aug, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Co-Creation","fulltext":[{"header":"Background","content":"\u003cp\u003eOver the past 30 years, rapid advancements in healthcare have significantly reduced burn-related mortality rates in high- and middle-income countries (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). As a result, the number of patients with major burns who survived increased, and these individuals face a lifelong process of managing and integrating the physical, psychological, and social consequences of their injuries (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Examples of such consequences include functional limitations, itching, pain, aesthetic concerns, fatigue, and psychological trauma.\u003c/p\u003e\u003cp\u003eBurn survivors, much like individuals with other chronic conditions, must learn to manage and integrate the consequences of their injuries as part of daily life (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Self-management can be defined as \u0026ldquo;the ability of the individual in conjunction with family, community, and healthcare professionals to manage symptoms, treatments, lifestyle changes, and psychosocial, cultural, and spiritual consequences of health conditions\u0026rdquo; (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). For burn survivors, self-management encompasses activities such as wound and scar care, maintaining mobility through exercising, accepting changes in body image, and finding ways to reintegrate socially and professionally (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). However, due to the sudden onset of a burn injury and the overwhelming burden of its consequences, effective self-management may not be self-evident after discharge from a burn centre.\u003c/p\u003e\u003cp\u003eTo aid burn survivors, healthcare professionals can provide self-management support after discharge from a burn centre, which can be defined as \u0026ldquo;the systematic provision of education and supportive interventions to improve burn survivors\u0026rsquo; skills and confidence in managing their health problems, including regular assessment of progress and problems, goal setting, and problem-solving support\u0026rdquo; (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Self-management support represents a shift from merely \u003cem\u003emanaging a chronic condition\u003c/em\u003e \u0026ndash; focused on symptom and disease control \u0026ndash; to helping individuals \u003cem\u003emanage well with their chronic condition\u003c/em\u003e, which encompasses broader goals of health, wellbeing, and overall quality of life (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Previous research has demonstrated that self-management support interventions can lead to significant improvements in quality of life and reductions in healthcare service utilization, with the strongest evidence in diabetes, respiratory disorders, cardiovascular disorders, and mental health (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). In addition, growing pressure on healthcare systems \u0026ndash; due to workforce shortages, an ageing population, and declining interest in care professions \u0026ndash; makes empowering patients through self-management not just beneficial, but increasingly essential for sustainable care delivery (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). However, for burn survivors, self-management support interventions are lacking. To date, only Shahryari et al. (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e) has described a self-management support intervention in burn survivors: a face-to-face, single-component educational session provided during hospitalization and around the time of a surgical procedure (skin grafting), aimed at reducing anxiety and increasing comfort levels. However, this intervention was limited in scope, timing, and methodological quality, underscoring the absence of a comprehensive, evidence-based self-management support approach tailored to the burn aftercare phase.\u003c/p\u003e\u003cp\u003eIn this paper, we report on the development of a new self-management support intervention specifically designed for burn survivors after discharge from a burn centre and present the resulting intervention. We do this by outlining each stage of the development, sharing lessons learned, and presenting the final version of the intervention.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy Design\u003c/h2\u003e\u003cp\u003eA self-management support intervention should be considered a \u003cem\u003ecomplex intervention\u003c/em\u003e (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e), as it must be tailored to individual needs and address multiple life domains such as medical management, emotional well-being, and social roles (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). It involves interacting components, requires sensitivity to context, and often entails a transformative learning process for healthcare professionals, as well as flexibility across care settings (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). This complexity calls for a dynamic and iterative development process that includes stakeholder co-creation, integration of up-to-date research, use of relevant theoretical frameworks, articulation of a program theory, comprehensive data collection, and a deep contextual understanding (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). We developed a self-management support program addressing the physical, psychological, and social needs of burn survivors, named BreeZe (Brandwonden en Zelfmanagement/Burns and self-management) in line with such a process. It was informed by frameworks and guidance from Hawkins and colleagues (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e), as well as by the more recent guidance for developing new complex interventions (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e), the guidance for adapting existing interventions to new contexts (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e), and the Co-creation Impact Compass (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Based on these, the process was structured in five stages executed between May 2021 and December 2023 (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e): 1) Preparation; 2) Evidence review, stakeholder consultation, and participatory observations; 3) Choosing the pathway for intervention development and adaptation; 4) Adapt and augment an existing intervention to Dutch burn aftercare; 5) Prototyping. The objectives of the methods used, the topics explored, and the key lessons derived from each stage are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eKey results from stage 1 to 5\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eObjective\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eActivity\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eResults\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eStage 1. Preparation\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIdentify stakeholders\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eStakeholder mapping\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eIdentified stakeholders in Dutch burn care\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDiscuss stakeholders\u0026rsquo; roles\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eParticipation game\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eStakeholders\u0026rsquo; involvement at different stages has been mapped (see \u003cb\u003eAdditional File 4\u003c/b\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEstablish consensus on the key steps of development\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eProcess mapping\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eKey development steps are outlined (see Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eStage 2. Evidence review, stakeholder consultation, and participatory observations\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDevelop a comprehensive understanding of existing evidence on self-management and self-management support\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEvidence map\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eKey findings from our literature:\u003c/p\u003e\u003cp\u003e\u0026bull; Self-management support is shaped by interdependent factors (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e)\u003c/p\u003e\u003cp\u003e\u0026bull; Self-management support integration requires a mind-set shift, not just training (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)\u003c/p\u003e\u003cp\u003e\u0026bull; Burn survivors self-manage similarly to individuals with chronic conditions (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e\u003cp\u003e\u0026bull; Face-to-face, multicomponent, skill-enhancing interventions improve outcomes (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e)\u003c/p\u003e\u003cp\u003e\u0026bull; Key core functions of self-management support interventions are: adapt to readiness to change, include goal setting and action planning (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e)\u003c/p\u003e\u003cp\u003e\u0026bull; The intrinsic processes motivation and self-efficacy are crucial for success (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e)\u003c/p\u003e\u003cp\u003e\u0026bull; Patients expect healthcare professionals to play an active role in self-management (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e)\u003c/p\u003e\u003cp\u003e\u0026bull; Patients\u0026rsquo; attitudes, needs, and preferences for self-management support vary (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e)\u003c/p\u003e\u003cp\u003e\u0026bull; No studies found on the perspectives of healthcare professionals working in burn aftercare\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIdentify whether effective interventions exist for burn survivors, what their components are, and what impact they report.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSystematic review\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026bull; Only one eligible study identified (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e); low methodological quality\u003c/p\u003e\u003cp\u003e\u0026bull; This study suggested that a face-to-face educational intervention during hospitalization and surrounding surgical intervention may reduce anxiety and increase comfort\u003c/p\u003e\u003cp\u003e\u0026bull; Intervention was single-component (only education) and took place during hospitalization\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIdentify the needs and preferences for self-management support after burn centre discharge among burn survivors\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eInterviews with burn survivors\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026bull; The moment of discharge is a critical touchpoint with lasting impact on survivors\u0026rsquo; ability to integrate the consequences of their burns into daily life\u003c/p\u003e\u003cp\u003e\u0026bull; A strong, ongoing partnership with a trusted healthcare professional is essential for self-management.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGain a deeper understanding of their experiences and the challenges informal caregivers face in supporting burn survivors\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eInterviews with informal caregivers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026bull; Informal caregivers need recognition and support from both their social and professional networks to sustain their role.\u003c/p\u003e\u003cp\u003e\u0026bull; Informal caregivers often struggle to balance caregiving with their own wellbeing.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eExplore how healthcare professionals already provide self-management support to burn survivors\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eInterviews with healthcare professionals (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026bull; Healthcare professionals vary in how they provide self-management support\u003c/p\u003e\u003cp\u003e\u0026bull; These variations reflect differences in role interpretation\u003c/p\u003e\u003cp\u003e\u0026bull; Support can be improved through training and tools to identify burn survivor needs\u003c/p\u003e\u003cp\u003e\u0026bull; Healthcare professionals need guidance in managing role boundaries and responsibilities\u003c/p\u003e\u003cp\u003e\u0026bull; Clear team roles, shared priorities, and time for providing support are also essential\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eExplore how burn care decision-makers view the topics \u0026ldquo;self-management\u0026rdquo; and \u0026ldquo;self-management support\u0026rdquo; and gain insight into routine burn aftercare\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUnstructured consultations with burn care decision-makers and conducting participatory observations\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026bull; Divergence in what constitutes aftercare, with continuous nursing support in two burn centres and start of care after wound closure in another.\u003c/p\u003e\u003cp\u003e\u0026bull; Differences in how burn aftercare is structured across three Dutch burn centres.\u003c/p\u003e\u003cp\u003e\u0026bull; Varying discipline roles and responsibilities after discharge \u0026ndash; burn nurse practitioners, burn aftercare nurses, and burn nurses handling transmural care.\u003c/p\u003e\u003cp\u003e\u0026bull; Significant variation in the time allocated for aftercare across the centres.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eStage 3. Defining the pathway for intervention development and adaptation\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIdentify candidate interventions\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eExplore the (grey) literature\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026bull; The ZENN (ZElfmanagement Na Niertransplantatie) intervention (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e) emerged as the most suitable candidate for adaptation.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCritical assessment of each candidate intervention\u0026rsquo;s suitability for adaptation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOrganize two workshops\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026bull; A hybrid \u0026ldquo;adapt and augment\u0026rdquo; approach (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e) to translating the ZENN intervention to burn aftercare was determined to be necessary.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eStage 4. Adapt and augment the intervention to Dutch burn aftercare\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAdapt and augment the intervention, including its core functions and materials, for Dutch burn aftercare, while developing a corresponding program theory\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOrganize multiple workshops;\u003c/p\u003e\u003cp\u003eRegular meetings with healthcare professionals and burn care decision-makers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026bull; The results of stage 4 and 5 concern adjustments to the ZENN intervention as shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eStage 5. Prototyping\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIdentify issues around feasibility and acceptability\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eExpert review by original developers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026bull; The results of stage 4 and 5 concern adjustments to the ZENN intervention as shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHealthcare professional and stakeholder review\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026bull; The results of stage 4 and 5 concern adjustments to the ZENN intervention as shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePreliminary testing at a burn outpatient clinic\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026bull; The results of stage 4 and 5 concern adjustments to the ZENN intervention as shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFormal approval of the new self-management support intervention\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePresentation for the the steering committee of the Alliance of Dutch Burn Care.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026bull; The adapted and augmented intervention, including all core functions, materials, and theory of change, was formally approved at the three Dutch burn centres. The intervention is called BreeZe (Brandwonden en Zelfmanagement).\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe intervention development has been reported following the GUIDance for the rEporting of intervention Development checklist (GUIDED) (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e) (see \u003cb\u003eAdditional File 1\u003c/b\u003e).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eContext and Setting\u003c/h3\u003e\n\u003cp\u003eThe Netherlands has three dedicated burn centres located at the Maasstad Hospital in Rotterdam, the Martini Hospital in Groningen, and the Red Cross Hospital in Beverwijk. These facilities collaborate with specialized trauma centres and other hospitals to form an integrated burn care network.\u003c/p\u003e\u003cp\u003eEach year, these centres treat approximately 1,000 burn survivors [Dutch Burn Rository (DBR R3), the Netherlands]. Upon admission to a burn centre, patients undergo an assessment to determine the severity of their injuries, followed by a tailored treatment plan. Of the admitted burn patients, 11.3% require intensive care during their stay [DBR R3, the Netherlands]. The average hospitalization lasts 9.9 days, with a median stay of 4 days (based on data from 2020\u0026ndash;2023; DBR R3, the Netherlands]. After discharge, aftercare typically includes outpatient visits, home nursing, physical therapy, scar therapy, or, in cases requiring more intensive rehabilitation, a temporary admission to a rehabilitation centre.\u003c/p\u003e\u003cp\u003eEach burn centre is staffed by a multidisciplinary team specializing in both burn emergency treatment and aftercare for both children and adults. These teams include surgeons (both general surgeons, plastic surgeons, and specialized burn physicians), intensivists, pediatricians, burn nurse practitioners, ICU and burn nurses, social workers, physiotherapists, occupational therapists, dietitians, and psychologists. Aftercare is coordinated by burn physicians, burn nurse practitioners, or dedicated burn aftercare nurses, who serve as key contacts for burn survivors throughout their recovery.\u003c/p\u003e\n\u003ch3\u003eDevelopment Stage 1: Preparation\u003c/h3\u003e\n\u003cp\u003eThe first stage of the development aimed to identify relevant stakeholders and define their roles in the development process. We began by identifying stakeholders using the co-creative tool \u003cem\u003estakeholder mapping\u003c/em\u003e (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Through brainstorming and listing all relevant individuals, we identified key stakeholders, including professionals from the multidisciplinary burn aftercare teams of the three Dutch burn centres, burn survivors, burn centre team leaders, burn centre department heads, and the Dutch Burns Foundation. To better understand the relationships among these stakeholders and determine the appropriate level of involvement, we created a \u003cem\u003epower versus interest grid\u003c/em\u003e (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e) in combination with the \u003cem\u003eparticipation game\u003c/em\u003e (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). The \u003cem\u003epower versus interest grid\u003c/em\u003e is a two-by-two matrix that visually maps stakeholders based on their political interest in the new intervention (y-axis) and their organizational power or control over the burn care system (x-axis). This tool helped us prioritize the stakeholders because it was neither feasible nor necessary to engage all with the same level of intensity. We then engaged with the identified stakeholders to explore their desired roles throughout the process. To actively discuss and shape their involvement, we employed the \u003cem\u003eparticipation game\u003c/em\u003e \u0026ndash; a serious game designed as an interactive and safe platform for discussion. This game is grounded in the participation ladder model (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e), which defines levels of participation ranging from passive information sharing to active decision-making. Stakeholders with a more central role in the process participated in group sessions using the game, while those with a more peripheral role were engaged in individual conversations guided by the same principles. Stakeholder roles and tasks developed iteratively over time and were continuously refined as the project progressed. An overview of the final roles and levels of engagement is provided in \u003cb\u003eAdditional File 2\u003c/b\u003e.\u003c/p\u003e\u003cp\u003eThis first stage also involved \u003cem\u003eprocess mapping\u003c/em\u003e (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e) during three face-to-face workshops to build consensus on the development process. The research team (including a patient expert, two burn nurse practitioners, a burn physician, one junior researcher, and three senior researchers) reviewed relevant examples and guidance documents and engaged in structured discussions to define key principles, essential actions, and their intended sequence. At this point, the process could only be mapped up to Stage 3, as two potential pathways \u0026ndash; developing a new complex intervention or adapting an existing one \u0026ndash; remained under consideration. From Stage 1 onwards, the process map was continuously refined during bi-monthly team meetings to align with emerging insights and evolving needs. The final version is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\n\u003ch3\u003eDevelopment Stage 2: Evidence Review, Stakeholder Consultation, and Participatory Observations\u003c/h3\u003e\n\u003cp\u003eThe second stage aimed to review the literature on self-management support, gather multiple perspectives about self-management support in burn care, and get insight into current practices in routine burn aftercare.\u003c/p\u003e\n\u003ch3\u003eLiterature review\u003c/h3\u003e\n\u003cp\u003eTo develop a comprehensive understanding of existing evidence on self-management and self-management support, we conducted a pragmatic literature search to create an evidence map (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). This involved a search across a broad field to identify knowledge gaps and present the findings in a user-friendly, searchable database. The search focused on keywords such as \u0026ldquo;self-management\u0026rdquo; and \u0026ldquo;self-management support\u0026rdquo;, with a focus on publications from the past ten years (2012\u0026ndash;2022) and was conducted at MEDLINE (through PubMed). Snowballing was used to track down additional relevant studies. We identified evidence on nurses\u0026rsquo; perspectives, showing that providing self-management support in patients with chronic conditions is influenced by multiple interdependent factors (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Importantly, integrating self-management support is not an automatic outcome of training but requires a transformative learning process to trigger the necessary shift in mindset (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). We found no studies on healthcare professionals\u0026rsquo; views on self-management support in burn aftercare. Only one study examined self-management in burn survivors, showing that they self-manage similarly to individuals with other chronic conditions (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). We also identified evidence on effective self-management support interventions, demonstrating that face-to-face, multicomponent interventions tailored to enhance patients' self-management skills can improve outcomes in patients with chronic conditions (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). These interventions should be adapted to burn survivors\u0026rsquo; readiness to change, incorporate action planning, and focus on goal setting. Another study emphasized that successful interventions in patients with chronic conditions should also target intrinsic processes, such as motivation and self-efficacy (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). Patient with chronic conditions\u0026rsquo; perspectives on self-management highlighted that they do not manage on their own but expect healthcare professionals to play a comprehensive role (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). We also found evidence suggesting that patient with chronic conditions\u0026rsquo; attitudes, needs, and preferences for self-management support vary (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn addition, we conducted a systematic review to examine the effects of self-management support interventions on health-related patient-reported outcomes in burn survivors. The review aimed to identify whether effective interventions exist for this population, what their components are, and what impact they report. We searched five major databases (MEDLINE, CINAHL, Cochrane, EMBASE, and PsycINFO) for studies published between 2010 and 2024, using search terms including \u0026ldquo;self-management support\u0026rdquo;, \u0026ldquo;burns\u0026rdquo;, and \u0026ldquo;intervention\u0026rdquo;. The review yielded only one eligible study (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e), which was of low methodological quality. This study (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e) suggested that a face-to-face single-component educational intervention, provided during hospitalization and around the time of a surgical procedure (skin grafting), may help reduce anxiety and increase comfort levels.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eInterviews with burn survivors\u003c/h2\u003e\u003cp\u003eGiven the limited evidence on burn survivors\u0026rsquo; specific needs and preferences for self-management support in burn aftercare \u0026ndash; beyond indications that they seem to self-manage in ways comparable to individuals with chronic conditions (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) \u0026ndash; we conducted semi-structured interviews with 17 burn survivors who had been admitted to one of the three Dutch burn centres within the past five years and had been discharged at least four weeks previously (topic guide: \u003cb\u003eAdditional File 3\u003c/b\u003e). Using maximum variation sampling strategy (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e), we ensured diversity in age, sex, burn severity, time since discharge, and treatment location. Interviews were analysed using a Directed Content Analysis approach (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e), supported by the Self-Management Support Needs model (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). In light of the aim of the development process, the interviews highlighted two particularly important insights. First, the moment of discharge emerged as a critical touchpoint with lasting impact on burn survivors\u0026rsquo; ability to integrate the consequences of their burns into daily life. This period was described as one in which additional, targeted support is often needed. Second, a strong, ongoing partnership with a trusted healthcare professional was seen as essential. Burn survivors valued being truly seen and understood, and emphasized the importance of having a consistent point of contact who could provide both emotional and practical support. A full account of the interview study is provided in a separate manuscript, currently under review.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eInterviews with informal caregivers\u003c/h3\u003e\n\u003cp\u003e During the interviews with burn survivors, it became apparent that most relied on informal caregivers \u0026ndash; individuals from their immediate environment who played a key role in helping them manage and integrate the consequences of their burns after discharge, for example partners. This aligns with the view that condition management is often a shared, family-based process (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). To gain deeper insight into their experience, we conducted semi-structured interviews with 12 informal caregivers, recruited via the interviewed survivors and the Dutch Association of Burn Survivors (topic guide: \u003cb\u003eAdditional File 3\u003c/b\u003e). Interviews were analysed using Interpretative Phenomenological Analysis (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e), a qualitative method suited to exploring complex, ambiguous, emotionally charged experiences that have not been described before. Several themes emerged, some of which are particularly relevant to the development of self-management support interventions. Informal caregivers emphasized that the sustainability of their caregiving role largely depended on being acknowledged \u0026ndash; not only by their social network, but also by hospital staff and home care services. Another key finding was the tension caregivers experienced between continuing their caregiving responsibilities and maintaining their own wellbeing. Many reported a tendency to prioritize the burn survivor\u0026rsquo;s needs at the expense of their own, often neglecting their own physical and emotional health. A full account of the interview study is provided in a separate manuscript, currently under review.\u003c/p\u003e\n\u003ch3\u003eInterviews with healthcare professionals\u003c/h3\u003e\n\u003cp\u003eGiven the absence of studies on healthcare professionals\u0026rsquo; views on self-management support in burn aftercare, we conducted semi-structured interviews to explore their perspectives. We defined self-management support as enabling individuals to manage and integrate the consequences of their burns in order to \u0026ldquo;live well\u0026rdquo;, and we posited that all burn care professionals are, consciously or not, already engaged in supporting self-management to some degree in aftercare. Using an inductive, interpretative qualitative approach, we interviewed a theoretical sample (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e) of six burn physicians, three burn nurse practitioners, three burn aftercare nurses, two occupational therapists, and two medical psychologists working in the three participating Dutch burn centres (topic guide: \u003cb\u003eAdditional File 3\u003c/b\u003e). Data were analysed using a constant comparative approach described by Charmaz (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). The interviews showed considerable variation in the self-management support strategies \u0026ndash; such as providing information, instilling confidence in burn survivors, and shifting the focus to patient-centred needs \u0026ndash; reflecting how professionals interpret their own role, that of the patient, and other disciplines within the team. This variation was rooted in three core tensions: [1] difficulty recognizing burn survivors\u0026rsquo; support needs after discharge, [2] navigating the boundaries of one\u0026rsquo;s own professional responsibility, and [3] unclear team roles, conflicting priorities, and time constraints. The findings suggest the need for targeted training in communication skills and a holistic needs assessment tools. Additionally, clarifying roles within each team may enhance collaboration and effectiveness. Finally, prioritizing burn survivors' values and needs, and allocating more time for personalized self-management support, may need to be considered. A full account of the interview study is provided in a separate manuscript, currently under review, and a preprint is available (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e).\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eConsultations with burn care decision-makers and participatory observations\u003c/h2\u003e\u003cp\u003eIn addition to the interviews and literature reviews, we conducted unstructured consultations with burn care decision-makers (i.e., burn centre team leaders, burn centre department heads, members of the steering committee of the Alliance of Dutch Burn Care) to gather broader contextual insights. We also carried out eight participatory observations during outpatient aftercare consultations at the three Dutch burn centres, using qualitative \u003cem\u003eshadowing techniques\u003c/em\u003e (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). Shadowing allowed us to observe real-time care practices and organizational dynamics. Data from both activities were recorded as field notes and thematically analysed (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). Findings showed considerable variation between centres in how burn aftercare is organized \u0026ndash; particularly regarding who (which discipline) takes on responsibilities in burn aftercare. In addition to the role of the burn physician, one centre relies on burn nurse practitioners (Nursing Practitioner, NP), another employs burn aftercare nurses (Registered Nurse, RN), and a third includes burn aftercare nurses (Registered Nurse, RN) with dedicated tasks for transmural care. As a result, roles, responsibilities, and available time for nurses differed considerably across the centres. The concept of what constitutes \"aftercare\" also varied: two centres providing continuous nursing support throughout the entire continuum post-discharge, while one began aftercare only after wound closure. In addition, there were also nuanced variations in how and when allied healthcare professionals became involved throughout the patient journey, influencing the type and timing of support burn survivors received.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eDevelopment Stage 3: Defining the Pathway for Intervention Development and Adaptation\u003c/h2\u003e\u003cp\u003eStage 3 focused on deciding whether to develop a new self-management support intervention or adapt an existing one for burn aftercare. Based on the findings of stage 1 and 2, we formed an Intervention Development Group (IDG) comprising four researchers, two patient experts, a burn physician, and two burn nurse practitioners. A systematic consensus-building process was facilitated by the lead researcher, following the tentative roadmap on consensus-building processes described by Leising and colleagues (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e), with a strong emphasis on partnership-based collaboration (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe IDG set out to identify self-management support interventions that could potentially be adapted for burn aftercare. Therefore, the IDG expanded the search scope both within the scientific literature \u0026ndash; beyond the burn survivor population \u0026ndash; and grey literature (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e), thereby including unpublished interventions currently being studied or implemented in other patient populations. The IDG critically assessed identified interventions for adaptation suitability using six criteria (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e): [1] the intervention-context fit; [2] the availability of detailed information about the intervention; [3] similarities between the original and the new context; [4] the robustness of the effectiveness claims; [5] usability in terms of intellectual property; and [6] required costs and resources for usage. To operationalize the first criterion \u0026ndash; intervention-context fit \u0026ndash; the IDG developed specific fit indicators grounded in the findings from stage 2 (see Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eThe criteria a self-management support intervention in burn aftercare should adhere to.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSource:\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFit indicators. A self-management intervention in Dutch burn aftercare should:\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLiterature review\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1. Emphasize a structured yet flexible approach tailored to the individual needs of burn survivors;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLiterature review\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2. Include face-to-face guidance;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLiterature review\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3. Be multicomponent;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLiterature review\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4. Allow adaptations based on the burn survivor\u0026rsquo;s readiness to change;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLiterature review\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5. Incorporate action planning and goal-setting as intervention strategies;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInterviews with burn survivors\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6. Create opportunities to initiate self-management support around the time of discharge;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInterviews with burn survivors\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7. Encourage a continuous, trusting relationship between burn survivors and a consistent healthcare professional;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInterviews with informal caregivers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8. Acknowledge informal caregivers as partners in care;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInterviews with informal caregivers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9. Create space to involve informal caregivers in self-management support;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInterviews with professionals\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10. Clarify which healthcare professional is responsible for delivering self-management support and at what stages;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInterviews with professionals\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11. Provide training and tools to help healthcare professionals identify burn survivors' self-management needs and align with their intrinsic self-management processes;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInterviews with professionals\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12. Avoid adding extra workload for healthcare professionals;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eConsultations with burn care decision-makers and participatory observations\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e13. Accommodate the differences across the three Dutch burn centres;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eConsultations with burn care decision-makers and participatory observations\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e14. Accommodate the differences across the three Dutch burn centres in what constitutes \u0026ldquo;aftercare\u0026rdquo;.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eIn total, 22 self-management interventions were reviewed across two workshops. Twenty-one were deemed unsuitable due to poor documentation (including a lack of available materials), an overly biomedical focus, or complex and costly implementation requirements (e.g., requiring an app). The ZENN (ZElfmanagement Na Niertransplantatie, self-management after kidney transplantation) intervention (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e) was the only intervention deemed suitable for adaptation to burn care. The ZENN intervention aims to enhance patients\u0026rsquo; self-management skills in order to integrate their treatment- and life goals, thereby improving quality of life and health-related outcomes (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e). It includes four key elements: [1] a general structure with room for individual tailoring, [2] a holistic approach, [3] shared-decision making between nurse practitioner (NP) and patient, and [4] patient empowerment. Grounded in Self-regulation Theory (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e), the intervention incorporates techniques from Motivational Interviewing (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e) and Solution-Focused Brief Therapy (SFBT) (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e). The ZENN intervention is structured over four sessions. In the first session, a Self-Management Web (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e) is used to holistically assess self-management challenges across 14 life areas, such as emotional well-being, mobility, and work. Based on this assessment, the nurse practitioner and patient use solution-focused techniques to set SMART goals and create action plans. Subsequent sessions focus on tracking progress, addressing new challenges, and reinforcing goal attainment. Follow-up sessions include a combination of in-person and telephone consultations, and double appointments with NPs ensure sufficient time to address patient concerns. The intervention emphasizes relapse prevention and the generalization of skills to other areas of life.\u003c/p\u003e\u003cp\u003eThe ZENN intervention was considered well-suited for adaptation, sufficiently meeting all six eligibility criteria. First, it showed a strong intervention-context fit, aligning sufficiently with the established fit criteria for burn care (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Second, comprehensive documentation from the original developer (EKM) \u0026ndash; including matrices of change objectives, delivery strategies, and materials such as e-learning modules, patient workbooks, and resources for healthcare professionals \u0026ndash; provided the IDG with a clear understanding of its structure and working mechanisms. Third, despite being developed for kidney transplant patients, the IDG noted that both contexts share similar challenges in self-management, with certain differences that were deemed manageable. Importantly, the IDG determined that the underlying change objectives did not need to be adjusted when applied in burn aftercare. Fourth, evidence of effectiveness was promising: a pilot study (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e) reported improvements in patient-centred care and quality of life, particularly in the physical role domain. Furthermore, psychosocial topics were addressed more comprehensively in the intervention group, demonstrating effectiveness in meeting patients' needs. At the time, a multicentre, stepped-wedge randomized controlled trial (\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e) was ongoing to evaluate its broader impact. Fifth, intellectual property rights posed no barriers, as the original developer (EKM) had made the intervention available for adaptation. Finally, the costs associated with adaptation for and implementation in burn aftercare were considered low, supporting its feasibility for burn aftercare.\u003c/p\u003e\u003cp\u003eDespite its strengths, a direct adaptation of ZENN was deemed unsuitable, as the intervention\u0026rsquo;s procedures, activities, sequence, delivery, and materials as they were, were incompatible with the context of Dutch burn care. This was due to several key differences across the three Dutch burn centres, including variations in how aftercare is organized, the acute and traumatic nature of burn injuries from the patient\u0026rsquo;s perspective, and the diverse roles and responsibilities of healthcare professionals following discharge from the burn centre. In light of these differences, the IDG opted for a hybrid approach \u0026ndash; an \u0026ldquo;adapt and augment\u0026rdquo; strategy (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e) \u0026ndash; in which ZENN would be tailored to the burn aftercare context.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eDevelopment Stage 4: Adapting and Augmenting the Intervention for the Context of Dutch Burn Aftercare\u003c/h2\u003e\u003cp\u003eIn stage 4, the IDG held five workshops to iteratively adapt and augment the selected intervention to the context of Dutch burn aftercare. These workshops involved discussing the content, providing feedback, refining ideas, and incorporating further feedback as the process progressed.\u003c/p\u003e\u003cp\u003eDuring these workshops, the IDG engaged in several key activities (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e): [1] articulating the program theory; [2] identifying and responding to barriers and facilitators that may influence effectiveness and implementation; [3] adapting and augmenting the intervention, including its core functions and materials; [4] considering potential unintended consequences that could arise from implementation in the new context; and [5] evaluating the costs and resources required for implementation in Dutch burn aftercare. Healthcare professionals, burn care decision-makers and one of the developers of the original ZENN intervention (EKM) provided feedback on draft versions of the intervention, including its core functions, delivery strategies, and materials.\u003c/p\u003e\u003cp\u003eTo support the articulation of the program theory, the IDG drew on the matrices of change objectives established by the original development team of the ZENN intervention and remained aligned with the principles of the Intervention Mapping (IM) approach (\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e). To guide decision-making about whether and how to adapt and augment the intervention, the IDG applied the Model for Adaptation Design and Impact (MADI) (\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e) prospectively during the workshops. In line with this model, potential adaptations were assessed against core functions, goals, and expected impacts to minimize risks of negative outcomes, supported by the comprehensive documentation provided by the original developer (EKM). This structured approach helped the IDG weigh trade-offs, anticipate unintended consequences, and refine the intervention to enhance contextual fit.\u003c/p\u003e\u003cp\u003eThe iterative process continued until the IDG reached sufficient consensus for prototyping.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eDevelopment Stage 5: Prototyping\u003c/h2\u003e\u003cp\u003eTo gain preliminary feedback on the acceptability and feasibility of the intervention, the draft version underwent real-world testing, review by the original developer (EKM), and stakeholder review. Feedback from these sources was systematically processed by the IDG over three workshops.\u003c/p\u003e\u003cp\u003eFirst, five burn survivors currently receiving care, along with two burn nurse practitioners and a burn physician, tested various intervention materials at the burn outpatient clinic. They provided feedback, particularly focusing on improving the readability, design, and language of patient materials, such as the burn survivors\u0026rsquo; workbook, to make it more accessible and engaging. Simultaneously, the core intervention functions, delivery strategies, manual, and supporting materials were sent to the original ZENN developer (EKM) for expert review, focusing on conceptual alignment, appropriateness, and suggested refinements. In parallel, all healthcare professionals and decision-makers from the three Dutch burn centres were invited to review the draft manual which covered all aspects of the intervention, assessing its acceptability and feasibility in routine practice, and considering how it could be integrated into existing workflows.\u003c/p\u003e\u003cp\u003eTo guide how input from these sources was incorporated, the IDG continued to apply the MADI (\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e). All changes made during stages 4 and 5 were also documented using the MADI (\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The final intervention, including its core components, delivery strategies, materials, and theory of change, was approved by the steering committee of the Alliance of Dutch Burn Care at the end of stage 5.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSummary of adaptations and augmentations \u0026ndash; Based on the Model for Adaptation Design and Impact (MADI)\u003csup\u003ea\u003c/sup\u003e (\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"9\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWhat is modified?\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNature of A/A?\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eWho participated in A/A decision-making?\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eFor whom/what is the A/A made?\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eIs the adaptation consistent with core functions, or does it constitute an augmentation that introduces a new core function?\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eGoal and rationale for A/A\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eWas the A/A made with consideration of its impact on outcomes and processes?\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eWas the A/A prompted by an anticipated barrier?\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003eWhich outcomes are expected to be affected by this A/A? \u003csup\u003eb,c\u003c/sup\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"9\" nameend=\"c9\" namest=\"c1\"\u003e\u003cp\u003eIntervention title\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eChanged the name of the \u0026ldquo;ZENN\u0026rdquo; intervention to the \u0026ldquo;BreeZe\u0026rdquo; intervention\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eContextual tailoring\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eIDG\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eAll stakeholders in burn care\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eConsistent with core functions\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eTo align the intervention framing with the perspectives of all stakeholders in burn care\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eYes, overcoming the \u0026ldquo;not-invented-here syndrome\u0026rdquo; and clarifying that the intervention is an adapted version\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u003cb\u003eAdoption (+)\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eAcceptability (+)\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eAppropriateness (+)\u003c/b\u003e\u003c/p\u003e\u003cp\u003eFeasibility\u003c/p\u003e\u003cp\u003eFidelity\u003c/p\u003e\u003cp\u003eCost\u003c/p\u003e\u003cp\u003ePenetration\u003c/p\u003e\u003cp\u003e\u003cb\u003eSustainability (+)\u003c/b\u003e\u003c/p\u003e\u003cp\u003ePatient outcomes\u003c/p\u003e\u003cp\u003eService outcomes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"9\" nameend=\"c9\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eIntervention goal\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eN/A\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"9\" nameend=\"c9\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eIntervention core functions\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAdded case management as an intervention core function\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAdding an element\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eIDG\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eBurn survivors and healthcare professionals\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eAugmentation introducing a new core function\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eTo accommodate the differences across the three Dutch burn centres in professionals working in burn aftercare, to encourage a continuous, trusting relationship between burn survivors and a consistent healthcare professional, and to clarify which healthcare professional is responsible for delivering self-management support and at what stages\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eYes, ambiguity in roles and responsibilities in multidisciplinary burn aftercare teams and potential lack of effectiveness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u003cb\u003eAdoption (+)\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eAcceptability (+)\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eAppropriateness (+)\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eFeasibility (-)\u003c/b\u003e\u003c/p\u003e\u003cp\u003eFidelity\u003c/p\u003e\u003cp\u003eCosts\u003c/p\u003e\u003cp\u003ePenetration\u003c/p\u003e\u003cp\u003eSustainability\u003c/p\u003e\u003cp\u003e\u003cb\u003ePatient outcomes (+)\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eService outcomes (+)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStructurally integrated the acknowledgement and involvement of informal caregivers across all phases of the intervention\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAdding an element\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eIDG\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eInformal caregivers, burn survivors, and healthcare professionals\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eAugmentation introducing a new core function\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eTo acknowledge informal caregivers as partners in care and to create space for informal caregiver\u0026rsquo;s involvement\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eYes, informal caregivers\u0026rsquo; limited capacity to support burn survivors\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eAdoption\u003c/p\u003e\u003cp\u003eAcceptability\u003c/p\u003e\u003cp\u003e\u003cb\u003eAppropriateness (+)\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eFeasibility (-)\u003c/b\u003e\u003c/p\u003e\u003cp\u003eFidelity\u003c/p\u003e\u003cp\u003eCosts\u003c/p\u003e\u003cp\u003ePenetration\u003c/p\u003e\u003cp\u003eSustainability\u003c/p\u003e\u003cp\u003e\u003cb\u003ePatient outcomes (+)\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eService outcomes (+)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"9\" nameend=\"c9\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eIntervention materials\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTranslated the Self-Management Web to English, German, Polish and Arabic\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLinguistic tailoring\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eIDG, healthcare professionals; professional language agency\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eBurn survivors and healthcare professionals\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eConsistent with core functions\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eIn response to healthcare professionals\u0026rsquo; experiences of frequent contact with patients from diverse cultural backgrounds; languages were selected based on the most prevalent non-Dutch language groups in burn care.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eYes, linguistic inaccessibility for burn survivors whose primary language is neither Dutch nor English.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eAdoption\u003c/p\u003e\u003cp\u003eAcceptability\u003c/p\u003e\u003cp\u003e\u003cb\u003eAppropriateness (+)\u003c/b\u003e\u003c/p\u003e\u003cp\u003eFeasibility\u003c/p\u003e\u003cp\u003eFidelity\u003c/p\u003e\u003cp\u003eCosts\u003c/p\u003e\u003cp\u003e\u003cb\u003ePenetration (+)\u003c/b\u003e\u003c/p\u003e\u003cp\u003eSustainability\u003c/p\u003e\u003cp\u003ePatient outcomes\u003c/p\u003e\u003cp\u003eService outcomes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAdapted the comprehensive manual for healthcare professionals to the context of Dutch burn aftercare\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFormat and usability redesign\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eIDG, healthcare professionals; burn care decision-makers; original intervention developers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eBurn survivors, healthcare professionals, and burn care decision-makers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eConsistent with core functions\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eTo align the content and format of the manual with Dutch burn aftercare practices and needs, to facilitate consensus-building during its development, and to clarify who does what, and when in burn aftercare\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eYes, limited applicability of the original manual\u0026rsquo;s content to the specific workflows and terminology in burn aftercare\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u003cb\u003eAdoption (+) Acceptability (+)\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eAppropriateness (+)\u003c/b\u003e\u003c/p\u003e\u003cp\u003eFeasibility\u003c/p\u003e\u003cp\u003e\u003cb\u003eFidelity (+)\u003c/b\u003e\u003c/p\u003e\u003cp\u003eCosts\u003c/p\u003e\u003cp\u003ePenetration\u003c/p\u003e\u003cp\u003eSustainability\u003c/p\u003e\u003cp\u003e\u003cb\u003ePatient outcomes (+)\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eService outcomes (+)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDeveloped a visual communication tool \u0026ldquo;praatplaat\u0026rdquo; to supplement the manual\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAddition of a visual communication tool\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eIDG, healthcare professionals, burn care decision-makers, original intervention developers, professional designers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eHealthcare professionals, and burn care decision-makers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eConsistent with core functions\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eTo enhance clarity, accessibility, and usability of the manual by visually summarizing key information, and to support healthcare professionals in understanding who does what, and when in burn aftercare\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eYes, healthcare professionals expressed a need for more accessible and actionable guidance on roles and responsibilities\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u003cb\u003eAdoption (+) Acceptability (+)\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eAppropriateness (+)\u003c/b\u003e\u003c/p\u003e\u003cp\u003eFeasibility\u003c/p\u003e\u003cp\u003e\u003cb\u003eFidelity (+)\u003c/b\u003e\u003c/p\u003e\u003cp\u003eCosts\u003c/p\u003e\u003cp\u003ePenetration\u003c/p\u003e\u003cp\u003eSustainability\u003c/p\u003e\u003cp\u003e\u003cb\u003ePatient outcomes (+)\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eService outcomes (+)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eReformatted the patient diary into a structured, paper patient booklet\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eReformatting and expansion\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePatient experts; IDG; healthcare professionals; a professional designer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eBurn survivors and healthcare professionals\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eConsistent with core functions\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eIn response to healthcare professionals\u0026rsquo; request to make the intervention more tangible and aligned with their perspectives on self-management roles and responsibilities. Patient experts also emphasized the importance of developing an accessible tool to track progress and document experiences.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eYes, perceived over-emphasis on the role of healthcare professionals in burn survivor\u0026rsquo;s self-management behaviour and the inability of burn survivors to keep track of the BreeZe process\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u003cb\u003eAdoption (+)\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eAcceptability (+)\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eAppropriateness (+)\u003c/b\u003e\u003c/p\u003e\u003cp\u003eFeasibility\u003c/p\u003e\u003cp\u003eFidelity\u003c/p\u003e\u003cp\u003e\u003cb\u003eCosts (-)\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003ePenetration (+)\u003c/b\u003e\u003c/p\u003e\u003cp\u003eSustainability\u003c/p\u003e\u003cp\u003e\u003cb\u003ePatient outcomes (+)\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eService outcomes (+)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAdapted the integrated training program (e-learning\u0026thinsp;+\u0026thinsp;in-person session) to the context of Dutch burn care professionals.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eContextual tailoring\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eIDG; original intervention developers; the company behind the e-learning; professional actor\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eHealthcare professionals\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eConsistent with core functions\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eTo align the integrated training program with the perspectives of healthcare professionals working in Dutch burn aftercare\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eYes, a potential perceived misfit between the training and the clinical practice healthcare professionals have to apply the knowledge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u003cb\u003eAdoption (+)\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eAcceptability (+)\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eAppropriateness (+)\u003c/b\u003e\u003c/p\u003e\u003cp\u003eFeasibility\u003c/p\u003e\u003cp\u003eFidelity\u003c/p\u003e\u003cp\u003eCosts\u003c/p\u003e\u003cp\u003ePenetration\u003c/p\u003e\u003cp\u003eSustainability\u003c/p\u003e\u003cp\u003ePatient outcomes\u003c/p\u003e\u003cp\u003eService outcomes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eReformatted the Visual Analogue Scales into a stand-alone, visually accessible tools\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eReformatting\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eIDG; healthcare professionals\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eHealthcare professionals\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eConsistent with core functions\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eTo enhance usability and integration into routine burn aftercare\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eYes, to address the potential barrier that the Visual Analogue Scales embedded in the patient booklet alone may not be used\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u003cb\u003eAdoption (+)\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAcceptability\u003c/p\u003e\u003cp\u003eAppropriateness\u003c/p\u003e\u003cp\u003eFeasibility\u003c/p\u003e\u003cp\u003e\u003cb\u003eFidelity (+)\u003c/b\u003e\u003c/p\u003e\u003cp\u003eCosts\u003c/p\u003e\u003cp\u003ePenetration\u003c/p\u003e\u003cp\u003eSustainability\u003c/p\u003e\u003cp\u003ePatient outcomes\u003c/p\u003e\u003cp\u003eService outcomes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDeveloped a documentation guide for healthcare professionals to help healthcare professionals\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAdding an element\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eIDG; healthcare professionals\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eHealthcare professionals\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eConsistent with core functions\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eTo encourage a continuous, trusting relationship between burn survivors and a consistent healthcare professional, and to provide tools that support intrinsic self-management process alignment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eYes, to address the potential lack of continuity in goal setting and action planning\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u003cb\u003eAdoption (+)\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAcceptability\u003c/p\u003e\u003cp\u003eAppropriateness\u003c/p\u003e\u003cp\u003eFeasibility\u003c/p\u003e\u003cp\u003e\u003cb\u003eFidelity (+)\u003c/b\u003e\u003c/p\u003e\u003cp\u003eCosts\u003c/p\u003e\u003cp\u003ePenetration\u003c/p\u003e\u003cp\u003eSustainability\u003c/p\u003e\u003cp\u003ePatient outcomes\u003c/p\u003e\u003cp\u003eService outcomes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"9\" nameend=\"c9\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eIntervention procedures, activities, sequence, and/or processes\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eReframed the intervention structure from discrete sessions (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e) to overarching phases (\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e), and embedded it within routine outpatient consultations without extending appointment times\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eReframing of procedural structure in line with recent changes made by the original developers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eIDG; healthcare professionals; burn care decision-makers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eBurn survivors; healthcare professionals\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eConsistent with core functions\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eTo align with updated ZENN intervention conceptualization, avoid adding extra workload for healthcare professionals in the BreeZe intervention, and accommodate the differences across the three Dutch burn centres in what constitutes \u0026ldquo;aftercare\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eYes, lack of sustained funding and impracticality of scheduling separate or prolonged sessions in routine outpatient care\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u003cb\u003eAdoption (-)\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eAcceptability (-)\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAppropriateness\u003c/p\u003e\u003cp\u003e\u003cb\u003eFeasibility (-)\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eFidelity (-)\u003c/b\u003e\u003c/p\u003e\u003cp\u003eCosts\u003c/p\u003e\u003cp\u003ePenetration\u003c/p\u003e\u003cp\u003e\u003cb\u003eSustainability (+)\u003c/b\u003e\u003c/p\u003e\u003cp\u003ePatient outcomes\u003c/p\u003e\u003cp\u003e\u003cb\u003eService outcomes (+)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAdapted the patient selection criteria and timing of intervention initiation to fit diverse patient trajectories in burn care (with or without admission)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAdjustment of eligibility criteria and timing of delivery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eIDG; healthcare professionals\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eBurn survivors; healthcare professionals\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eConsistent with core functions\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eTo allow adaptations based on the burn survivor\u0026rsquo;s readiness to change, emphasize a structured yet flexible approach tailored to individual needs of burn survivors, and accommodate the differences across the three Dutch burn centres in what constitutes \u0026ldquo;aftercare\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eYes, the variability in patient trajectories within burn care made the original timing and selection criteria impractical\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u003cb\u003eAdoption (+)\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eAcceptability (+)\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eAppropriateness (+)\u003c/b\u003e\u003c/p\u003e\u003cp\u003eFeasibility\u003c/p\u003e\u003cp\u003e\u003cb\u003eFidelity (+)\u003c/b\u003e\u003c/p\u003e\u003cp\u003eCosts\u003c/p\u003e\u003cp\u003e\u003cb\u003ePenetration (+)\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eSustainability (+)\u003c/b\u003e\u003c/p\u003e\u003cp\u003ePatient outcomes\u003c/p\u003e\u003cp\u003e\u003cb\u003eService outcomes (+)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIntroduction of Phase 0 for burn survivors who have been admitted, focusing on initial engagement and transition from inpatient care to home\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAdding an element\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eIDG; healthcare professionals; patient experts\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eBurn survivors who have been admitted to a burn centre\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eAugmentation in line with the new core function (case-management)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eTo create opportunities to initiate self-management support around the time of discharge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eYes, the barrier was that without this early phase, there may be insufficient foundation for a strong collaborative relationship.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eAdoption\u003c/p\u003e\u003cp\u003eAcceptability\u003c/p\u003e\u003cp\u003e\u003cb\u003eAppropriateness (+)\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eFeasibility (-)\u003c/b\u003e\u003c/p\u003e\u003cp\u003eFidelity\u003c/p\u003e\u003cp\u003eCosts\u003c/p\u003e\u003cp\u003e\u003cb\u003ePenetration (+)\u003c/b\u003e\u003c/p\u003e\u003cp\u003eSustainability\u003c/p\u003e\u003cp\u003e\u003cb\u003ePatient outcomes (+)\u003c/b\u003e\u003c/p\u003e\u003cp\u003eService outcomes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"9\" nameend=\"c9\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eIntervention delivery\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eThe intervention delivery, which was originally designed to be provided by nurse practitioners, was adapted to include burn aftercare nurses, burn nurse practitioners, and burn physicians.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eContextual tailoring\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eIDG; healthcare professionals\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eHealthcare professionals\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eAugmentation broadening the scope of healthcare professionals\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eTo ensure the intervention can be implemented consistently across different burn centres, where healthcare roles and responsibilities vary. By widening the scope, the intervention is able to accommodate the differences across the three Dutch burn centres in professionals working in burn aftercare\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eYes, the barrier was that some burn centres do not have nurse practitioners.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u003cb\u003eAdoption (+)\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eAcceptability (+)\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eAppropriateness (+)\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eFeasibility (+)\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eFidelity (+)\u003c/b\u003e\u003c/p\u003e\u003cp\u003eCosts\u003c/p\u003e\u003cp\u003ePenetration\u003c/p\u003e\u003cp\u003e\u003cb\u003eSustainability (+)\u003c/b\u003e\u003c/p\u003e\u003cp\u003ePatient outcomes\u003c/p\u003e\u003cp\u003e\u003cb\u003eService outcomes (+)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"9\"\u003eA/A\u0026thinsp;=\u0026thinsp;adaptation/augmentation; IDG\u0026thinsp;=\u0026thinsp;intervention development group consisting of four members from the burn care research team with diverse expertise, two patient experts, a burn physician, and two burn nurse practitioners; \u003csup\u003ea\u003c/sup\u003e = the MADI also includes the construct \u0026ldquo;When did the adaptation occur?\u0026rdquo; which was left out of the table as all adaptations and augmentations described here have occurred during phase 4 and 5; \u003csup\u003eb\u003c/sup\u003e = the outcomes described here are described in detail by Proctor et al. Adm Policy Ment Health. 2011 Mar;38(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e):65\u0026ndash;76. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s10488-010-0319-7\u003c/span\u003e\u003cspan address=\"10.1007/s10488-010-0319-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.; \u003csup\u003ec\u003c/sup\u003e = for each outcome the expected intended and unintended impact has been considered in terms of (+) positive, and (-) negative;\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe result of our structured, multistage development process is a self-management support program for burn survivors, named BreeZe (Brandwonden en Zelfmanagement/Burns and self-management). The reporting of the intervention below is structured according to the Template for Intervention Description and Replication (TIDieR) checklist (\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e). Additionally, the program theory underlying the BreeZe intervention is presented in \u003cb\u003eAdditional File 4\u003c/b\u003e.\u003c/p\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eIntervention goal\u003c/h2\u003e\u003cp\u003eThe BreeZe self-management support intervention takes a holistic, patient-centred approach, addressing the medical, emotional, and social aspects of self-management. It aims to strengthen burn survivors\u0026rsquo; self-efficacy and intrinsic motivation by helping them identify challenges after discharge from the burn centre, explore solutions, and develop personalized action plans. The intervention aligns with the full range of fit indicators presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. BreeZe is a comprehensive, multicomponent intervention that offers a structured yet flexible approach, includes face-to-face guidance, and can be adapted according to the burn survivor\u0026rsquo;s readiness to change. It incorporates goal-setting and action planning, emphasizes fostering continuous, trusting relationships between burn survivors and healthcare professionals, and actively promotes motivation and self-efficacy as well as the involvement of informal caregivers.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eIntervention core functions\u003c/h2\u003e\u003cp\u003eThe following core functions are drawn directly from the BreeZe intervention outlined above: Holistic Care Approach (\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e), Goal Setting and Action Planning (\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e), Solution-Focused Brief Therapy (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e), Motivational Interviewing (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e), Case Management (\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e), and acknowledging and involving informal caregivers.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003eIntervention delivery (who, how, where, when, and how much)\u003c/h2\u003e\u003cp\u003eThe BreeZe intervention is designed primarily for burn survivors whose wound healing time exceeds at least 14 days, as the IDG assumed these burn survivors experience more significant long-term consequences of the burn injury. BreeZe is delivered by trained healthcare professionals, including dedicated burn aftercare nurses, burn nurse practitioners, and burn physicians when no nurse or nurse practitioners are available. To ensure effective delivery, healthcare professionals offering BreeZe must complete an integrated training program. For each burn survivor, one of these healthcare professionals will act as a \u0026ldquo;case manager\u0026rdquo;. A case manager coordinates the post-discharge aftercare process and serves as the primary point of contact, guiding the burn survivor and his/her caregiver(s) through the various phases of recovery. The BreeZe intervention is implemented within the (outpatient) clinical treatment trajectory, either starting during the burn survivor\u0026rsquo;s hospitalization (Phase 0) or shortly after discharge (Phase 1). For burn survivors starting in an outpatient trajectory, Phase 1 starts 7 to 14 days after their injury or discharge.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003eIntervention materials\u003c/h2\u003e\u003cp\u003eVarious intervention materials have been developed to support the goals of the BreeZe self-management support intervention. For burn survivors, these include:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e\u003cem\u003eSelf-Management Web\u003c/em\u003e (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e) \u0026ndash; A visual communication tool designed to help burn survivors and healthcare professionals assess and discuss various life domains in a structured way. It provides a standardized overview of 14 key areas, supporting a holistic approach to self-management while promoting intrinsic motivation by allowing burn survivors to prioritize their focus. This tool facilitates shared decision-making and ensures that support aligns with individual needs. This tool is available in Dutch, English, German, Polish, and Arabic.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cem\u003ePatient booklet\u003c/em\u003e \u0026ndash; A structured booklet that guides burn survivors through the different phases of self-management: identifying challenges and needs, exploring solutions, and developing personalized action plans. Designed by burn survivors, it serves as a reflective tool to track progress, document experiences, and support ongoing self-management efforts.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cem\u003eVisual analogue scales (VAS) scales\u003c/em\u003e \u0026ndash; These VAS scales are tools used to assess key aspects of self-management, including intrinsic motivation and goal progression. The scales allow burn survivors to visually track their progress over time, providing both the healthcare professionals and the burn survivors with a clear representation of changes in key areas. This makes it easier to identify challenges and facilitates motivational interviewing and positive reinforcement.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eFor healthcare professionals these include\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e\u003cem\u003eIntegrated Training Program\u003c/em\u003e \u0026ndash; This training, originally developed for the ZENN Intervention (\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e) and later adapted to the burn care context, consists of two complementary components. Burn care professionals first complete an e-learning module covering the theoretical background, key concepts, and intervention steps. This is followed by an in-person session, led by one of the original developers (EKM) together with a professional training actor (MvB), where participants practice communication skills in realistic scenarios. Additionally, a booster session is organized approximately 4\u0026ndash;8 weeks after the in-person training to address questions from clinical experience and to further practice skills. The training follows the CRe-DEPTH criteria (\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e) and is detailed in \u003cb\u003eAdditional File 5\u003c/b\u003e.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cem\u003eComprehensive manual for healthcare professionals\u003c/em\u003e \u0026ndash; A manual that covers all aspects of the BreeZe intervention, including the intervention goal, underlying rationale, intervention core functions, and its alignment with other developments in burn care. It also provides practical suggestions for engaging in everyday conversations with burn survivors, offering guidance on how to effectively support them throughout their self-management journey.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cem\u003eVisual communication tool (\u0026ldquo;praatplaat\u0026rdquo;/\u0026rdquo;poster that elicits talking\u0026rdquo;)\u003c/em\u003e \u0026ndash; A visually designed summary that complements the comprehensive manual by presenting key information and intervention phases in an accessible and engaging format. The tool clarifies the roles and responsibilities of healthcare professionals within the BreeZe intervention, supporting implementation in practice by helping teams quickly grasp what needs to happen, when, and by whom. See \u003cb\u003eAdditional File 6\u003c/b\u003e.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cem\u003eDocumentation Guide for Healthcare Professionals\u003c/em\u003e \u0026ndash; A structured framework for documenting patients\u0026rsquo; self-management support progression throughout the outpatient journey in the Electronic Health Record system.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003eIntervention procedures, activities, sequence, and/or processes\u003c/h2\u003e\u003cp\u003eThe BreeZe intervention consists of five flexible phases that support burn survivors in building self-management skills after discharge. Each phase is adapted to individual needs and progress (for a visual presentation, see \u003cb\u003eAdditional File 6\u003c/b\u003e):\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\u003ch2\u003e Intervention phase 0: Introduction and Transition to Home (for hospitalized burn survivors only)\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003ePrepares burn survivors for discharge by building rapport, addressing immediate concerns, and introduces the concept of goal pursuit and setting.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e\u003ch2\u003e Intervention phase 1: Assessment (7\u0026ndash;14 days post-discharge or post-injury)\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eFocuses on understanding the burn survivor\u0026rsquo;s priorities, challenges, and goals. Key tools like the Self-Management Web and VAS scales are used to gauge desired outcome and current status, intrinsic motivation, and self-efficacy.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec23\" class=\"Section3\"\u003e\u003ch2\u003e Intervention phase 2: Solidify (around 3 months post-discharge)\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eRevisits and refines goals, develops action plans or adjusts if needed, assesses progress, and focuses on reinforcing intrinsic motivation. The healthcare professional ensures that the burn survivor is on track and offers additional guidance to overcome barriers.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec24\" class=\"Section2\"\u003e\u003ch2\u003eIntervention phase 3: Continuation (around 6 months post-discharge)\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eOngoing review of progress and implementation of action plans. Motivation and self-efficacy are reassessed using VAS scales to support long-term engagement.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec25\" class=\"Section3\"\u003e\u003ch2\u003e Intervention phase 4: Monitor (around 12 months post-discharge)\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eFocuses on maintaining and expanding self-management skills, addressing relapse prevention, planning for long-term independence, and generalising self-management skills to other situations.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eEach phase of the intervention is integrated into routine care and takes approximately 15 to 30 minutes, depending on the type of routine care consultation. Phases may be spread over multiple sessions, depending on the burn survivor\u0026rsquo;s recovery and coping process. A minimum of two weeks between phases is recommended to allow time for implementing action plans. During each phase, professionals are also prompted to ask about the presence of an informal caregiver, and whether they should be involved in the BreeZe process.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis report outlines the development of a self-management support intervention for burn survivors following discharge from burn centres. The primary aim was to develop a self-management support intervention for burn survivors while ensuring transparency in the developmental process to facilitate future replication, scaling, learning, and broader implementation. The developmental process incorporated a collaborative, multi-stakeholder approach, integrating scientific evidence, theory, and expert feedback. This process resulted in BreeZe \u0026ndash; a comprehensive, evidence-based, and theoretically grounded intervention designed to meet the unique needs of burn survivors and tailored to the context of Dutch burn aftercare. BreeZe includes key core functions such as a Holistic Care Approach (\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e), Goal Setting and Action Planning (\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e), Solution-Focused Brief Therapy (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e), Motivational Interviewing (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e), and Case Management (\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e), supported by materials like the Self-Management Web (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e), a patient booklet, an integrated training program, and a comprehensive manual for healthcare professionals. The developmental process, spanning 32 months, was thorough and carefully considered, requiring us to balance the diverse perspectives of stakeholders with scientific evidence and theory, ultimately resulting in an intervention that holds promise for improving burn care and increasing the likelihood of successful adoption and implementation.\u003c/p\u003e\u003cdiv id=\"Sec27\" class=\"Section2\"\u003e\u003ch2\u003eUse of theories, models and frameworks\u003c/h2\u003e\u003cp\u003eThe development of the BreeZe intervention was informed by several complementary frameworks (\u003cspan additionalcitationids=\"CR20 CR21\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e) that can be categorized as \u0026ldquo;process models\u0026rdquo; \u0026ndash; a term used by Nilsen (\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e) to describe theoretical approaches that support the translation of research into practice through clearly defined, phased steps. These helped structure and guide our process, offering clarity and flexibility \u0026ndash; essential in balancing scientific evidence, theory, and diverse stakeholder perspectives throughout a complex and lengthy development process requiring iteration, participation, and responsiveness to contextual factors. However, while these models were valuable in guiding \u003cem\u003ehow\u003c/em\u003e to develop and adapt the intervention, they paid less attention to \u003cem\u003ewhy\u003c/em\u003e it might work \u0026mdash; the mechanisms of change. To address this, we drew on a wide range of behavioural theories (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan additionalcitationids=\"CR59 CR60 CR61 CR62\" citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e) inherited from the original ZENN intervention (\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e). These theories informed both the original and adapted matrices of change objectives and helped articulate a preliminary program theory for BreeZe (\u003cb\u003eAdditional File 4\u003c/b\u003e) that provides a plausible explanation about how BreeZe is supposed to function and achieve its objectives.\u003c/p\u003e\u003cp\u003eLooking back, our layered approach \u0026ndash; combining structured process guidance with theoretical depth \u0026ndash; proved both valuable and demanding. While the use of multiple theories, models and frameworks contributed to methodological rigour, it also required continuous reflection on when and how each of them was applicable, and how they related to one another. This appeared to be particularly complex in a participatory context. Working collaboratively using participatory methodologies meant investing in the capacity and capability of co-creators to engage meaningfully with theoretical concepts, which requires upskilling efforts. Moreover, translating abstract theories into practical, actionable steps demanded sustained effort from the project lead, who had to mediate between academic expectations and real-world constraints. A clear example of these dynamics was our consideration of more closely adhering to the Intervention Mapping (IM) approach (\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e), which had underpinned the development of the original ZENN intervention. While IM is a well-established, systematic approach to planning and developing health promotion interventions, its focus on new intervention development overlapped with other process models already guiding our approach (\u003cspan additionalcitationids=\"CR20 CR21\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e), offering limited added value to the adaptation-focused BreeZe process. Importantly, the decision not to shift to an IM-based approach was made collectively. To assess whether IM was relevant and valuable in our specific phase, context, and goals, all co-creators had to engage with the underlying methodological assumptions and compare them to the demands of the adaptation process. This required grappling with complex concepts such as intervention logic models, and the distinction between adaptation and de novo development. The process underscored the importance of upskilling, as highlighted in previous research, to enable meaningful and informed participation (\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec28\" class=\"Section2\"\u003e\u003ch2\u003eUse of co-creation\u003c/h2\u003e\u003cp\u003eThe co-creative approach played a central role in the development of the BreeZe intervention and brought several key benefits. By actively involving burn survivors, their informal caregivers, burn care professionals, and burn care decision-makers, we were able to develop an intervention that we expect to be closely aligned with their perspectives and well-fitted to the context in which it will be implemented. We expect that, as suggested by Hawkins and colleagues (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e), this inclusive approach has fostered a sense of ownership and buy-in across the three burn centres. Involving a broad range of stakeholders also facilitated the integration of experiential and scientific knowledge \u0026ndash; an important function of co-creation highlighted by Leask and colleagues (\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e). For example, input from patient experts and burn care professionals was essential in determining the optimal timing of key elements of the BreeZe intervention, such as when to introduce goal setting and when to move to action planning within the patient journey. Moreover, our co-creative process enabled stakeholders to influence the changes the intervention aims to bring about, to prepare for those changes, and to ensure that the intervention aligned with what they themselves found valuable \u0026ndash; three conditions identified by Nilsen and colleagues (\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e) as critical for successful organizational change.\u003c/p\u003e\u003cp\u003eDespite its many benefits, the co-creative development process also posed several challenges. One key difficulty was balancing the diverse priorities, routines, and cultural values of the three burn centres and their staff, which sometimes led to tension between local practices. Another challenge lay in managing the breadth of participation. While stage 1 tools such as stakeholder mapping and the power-interest grid helped identify relevant stakeholders, ensuring the right level of involvement throughout the development process proved complex. Roles and tasks evolved iteratively and required continuous alignment as the project progressed. To manage this, we adopted a layered engagement strategy: a core group of stakeholders (the IDG) participated intensively in consensus-building workshops, while others were regularly informed, consulted, or asked for advice \u0026ndash; reflecting the three levels of participation (Information, Consultation, and Advice). However, navigating competing agendas, time constraints, and occasional ambiguity around decision-making authority, required ongoing effort. In hindsight, integrating a tool like the Value Proposition Canvas might have further streamlined this process (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). By clarifying the distinct value that each stakeholder group places on the new intervention early on, we could have facilitated more focused and efficient collaboration. These challenges resonate with those found in other studies (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e), and underline the reality that while co-creation enhances contextual fit and alignment with stakeholder perspectives, it also demands sustained coordination, reflexivity, and flexibility throughout the process.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec29\" class=\"Section2\"\u003e\u003ch2\u003eFuture activities\u003c/h2\u003e\u003cp\u003eAs noted by Skivingston and colleagues (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e), developing a complex intervention does not end once the content has been agreed upon. Instead, refinement continues as insights accumulate, based on early implementation experiences and how the intervention interacts with different real-world contexts. We expect this to also be true for the BreeZe intervention. While its core components have now been defined, we anticipate that further tailoring together with our stakeholders, may be needed as we move into the evaluation phase, especially given the diversity in how burn aftercare is organized and delivered across centres and in burn survivors\u0026rsquo; patient journeys. This may include, for example, implementation strategies to better support local adoption in practice.\u003c/p\u003e\u003cp\u003eAs we move forward, the program theory of BreeZe will require further elaboration (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). While we have established the change objectives, determinants, and performance objectives that underpin the intervention, the precise outcome measures remain under development. This includes determining how self-management support and behavior will be defined and measured, establishing appropriate timeframes for measurement, and identifying the patient and service outcomes that should be linked to these processes. Additionally, it is crucial to define the implementation outcomes that underlie the adaptations highlighted in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. Unlike the approach of Maindal and colleagues (\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e), who developed a detailed core outcome set early in their intervention development, we have opted to defer this step to the next phase wherein we will conduct a systematic evaluation of its effectiveness after implementation.\u003c/p\u003e\u003cp\u003eIn addition to continuous refinement of the intervention and program theory, economic considerations will also be essential in the next phase (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). As outlined in our program theory (\u003cb\u003eAdditional File 4\u003c/b\u003e) and introduction paragraph, assessing the intervention\u0026rsquo;s effect on burn care service utilization and sustainability will be critical to determine its value from a broader point of view (\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e, \u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e). Engagement with economic experts will ensure that these considerations are integrated, allowing us to evaluate the intervention\u0026rsquo;s cost-effectiveness after implementation.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe development of the BreeZe intervention has been a rigorous, multi-faceted process, integrating scientific evidence, theoretical frameworks, and input from a diverse group of stakeholders, including burn survivors, healthcare professionals, and burn care decision-makers. By addressing the complex physical, psychological, and social needs of individuals recovering from burns, BreeZe offers a holistic, person-centred approach to self-management support after discharge from burn centres. Its core components \u0026ndash; such as goal setting, action planning, and case management \u0026ndash; are designed to foster sustainable self-management behaviours and contribute to more effective, collaborative burn care. As the intervention moves into the implementation and evaluation phase, continued refinement will be crucial to ensure it remains responsive to evolving needs and changing real-world contexts. This systematic development process not only lays the groundwork for successful adoption, scaling, and replication of this particular intervention, but also contributes to the broader evidence base on developing and adapting complex interventions beyond the field of burn care.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eBreeZe \u0026ndash; Brandwonden en Zelfmanagement (burns and self-management)\u003c/p\u003e\n\u003cp\u003eCRe-DEPTH criteria \u0026ndash; Criteria for Reporting Education, Development, and Provider Evaluation\u003c/p\u003e\n\u003cp\u003eDBR R3 \u0026ndash; Dutch Burn Registry\u003c/p\u003e\n\u003cp\u003eGUIDED \u0026ndash;\u0026nbsp;GUIDance for the rEporting of intervention\u003c/p\u003e\n\u003cp\u003eIDG \u0026ndash; Intervention Development Group\u003c/p\u003e\n\u003cp\u003eIM \u0026ndash; Intervention Mapping\u003c/p\u003e\n\u003cp\u003eMADI \u0026ndash; Model for Adaptation Design and Impact\u003c/p\u003e\n\u003cp\u003eMRC \u0026ndash; Medical Research Council\u003c/p\u003e\n\u003cp\u003eSFBT \u0026ndash; Solution-Focused Brief Therapy\u003c/p\u003e\n\u003cp\u003eTIDieR \u0026ndash; Template for Intervention Development and Replication\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eVAS \u0026ndash; Visual Analogue Scales\u003c/p\u003e\n\u003cp\u003eZENN \u0026ndash; ZElfmanagement Na Niertransplantatie (self-management after kidney transplantation)\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll study procedures were conducted in accordance with relevant guidelines and regulations, including the Declaration of Helsinki. Ethical approval was obtained where required (e.g., interview studies), with approval granted by the Ethics Committee of the Martini Hospital\u0026nbsp;[2022-092; 2022-093; 2023-008] and re-approved locally at the Maasstad Hospital and Red Cross Hospital. Participants involved in relevant stages of the study provided written informed consent prior to participation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data generated and analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by the Netherlands Organization for Health Research and Development (ZonMW; reference number 10070022010003). ZonMW did not play a role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review or approval of the manuscript; and decision to submit the manuscript for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors wish to thank the following Dutch burn centers for their support: Maasstad Hospital in Rotterdam, Martini Hospital in Groningen, and the Red Cross Hospital in Beverwijk. Moreover, we would like to thank the burn survivors, families, and healthcare professionals who contributed to the development of the BreeZe intervention, and we would like to thank Marijke van Bemmel (MvB) who contributed as a professional training actor.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMKN and SMHJSJ conceived the overall study concept. SJGG led the coordination of the project and maintained oversight, supported by SLB. The design of the various stages of the development process was a collaborative effort by SJGG, SLB, ASN, IV, SMHJSJ, and MKN. Contributions to the creation of the BreeZe intervention – were made by SJGG, SLB, ASN, GB, IV, RB, CKvdS, DvU, RV, ABvdB, SMHJSJ, and MKN. EKM contributed to the project as the original developer of the ZENN intervention. SJGG drafted the initial version of the manuscript, with substantial input from SLB, ASN, CKvdS, EB, SMHJSJ, and MKN. All authors reviewed the manuscript, provided critical feedback, and approved the final version for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFootnotes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003ePereira C, Murphy K, Herndon D. Outcome measures in burn care. Is mortality dead? 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Res Involv Engagem. 2019;5:2.\u003c/li\u003e\n\u003cli\u003eNilsen P, Seing I, Ericsson C, Birken SA, Schildmeijer K. Characteristics of successful changes in health care organizations: an interview study with physicians, registered nurses and assistant nurses. BMC Health Serv Res. 2020;20(1):147.\u003c/li\u003e\n\u003cli\u003eMaindal HT, Timm A, Dahl-Petersen IK, Davidsen E, Hillersdal L, Jensen NH, et al. Systematically developing a family-based health promotion intervention for women with prior gestational diabetes based on evidence, theory and co-production: the Face-it study. BMC Public Health. 2021;21(1):1616.\u003c/li\u003e\n\u003cli\u003eBodenheimer T, Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med. 2014;12(6):573-6.\u003c/li\u003e\n\u003cli\u003eNundy S, Cooper LA, Mate KS. The Quintuple Aim for Health Care Improvement: A New Imperative to Advance Health Equity. Jama. 2022;327(6):521-2.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Intervention development, Intervention adaptation, Complex intervention, Burns, self-efficacy, self-determination, motivation, case management, goal setting, holistic care","lastPublishedDoi":"10.21203/rs.3.rs-7345137/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7345137/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eFollowing a severe burn injury, individuals embark on a lifelong process of managing and integrating the physical, psychological, and social consequences, including functional limitations, fatigue, altered body image, and psychological trauma. To aid in this process, healthcare professionals can provide self-management support. To date, however, no self-management support intervention has been developed to meet the unique needs and preferences of burn survivors within the context of burn aftercare. In this article, we describe the process of developing a self-management support intervention for burn aftercare and present the resulting intervention.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA structured, multi-stage process was followed from May 2021 to December 2023 to develop the intervention, guided by established frameworks for the development and adaptation of complex interventions. The process included evidence review, stakeholder consultation, and participatory observations to identify needs, inform design decisions, and ensure contextual fit. A hybrid approach to intervention development was adopted, combining \u003cem\u003eadaptation\u003c/em\u003e of an existing intervention with \u003cem\u003eaugmentation\u003c/em\u003e through five co-creative workshops involving burn survivors, healthcare professionals, researchers, and burn care decision-makers. The final prototype was refined through expert reviews and real-world pilot-testing to assess its feasibility and acceptability.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThe structured, multistage process resulted in a self-management support intervention addressing the physical, psychological, and social needs of burn survivors. The intervention was named BreeZe (Brandwonden en Zelfmanagement/Burns and self-management). Intervention Core components of the intervention include a holistic care approach, goal setting and action planning, solution-focused brief therapy, motivational interviewing, case management, and the acknowledgment and involvement of informal caregivers. BreeZe is supported by materials like the Self-Management Web, a patient booklet, training for healthcare professonials, and a comprehensive manual. BreeZe is delivered by trained healthcare professionals and is structured into five phases, focusing on holistic needs assessment, goal setting, progress monitoring, and ongoing motivational support.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003e The structured, multi-stage development process was thorough and carefully considered, balancing diverse stakeholder perspectives with scientific evidence and theory. BreeZe offers an evidence-based model tailored to the Dutch context that can be integrated into routine practice that shows the potential to enhance the effectiveness of care and support a more collaborative, patient-centred approach.\u003c/p\u003e\u003ch2\u003eTrial registration:\u003c/h2\u003e\u003cp\u003eNot applicable.\u003c/p\u003e","manuscriptTitle":"Development of BreeZe: a Self-management Support Intervention for Burn Survivors Informed by Evidence, Theory, and Stakeholder Co-Creation","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-22 09:25:23","doi":"10.21203/rs.3.rs-7345137/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-11-03T03:30:40+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-02T07:51:49+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-14T14:42:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"340006333420831636824877646179704358790","date":"2025-09-11T09:16:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"166043483622850743619639093216313733820","date":"2025-09-11T08:27:56+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-11T05:24:40+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-19T03:09:08+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-18T08:44:13+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2025-08-18T08:38:44+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"99d5b9c5-3330-4e7b-a808-c89a7ccff882","owner":[],"postedDate":"September 22nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-29T16:00:49+00:00","versionOfRecord":{"articleIdentity":"rs-7345137","link":"https://doi.org/10.1186/s12913-025-13849-5","journal":{"identity":"bmc-health-services-research","isVorOnly":false,"title":"BMC Health Services Research"},"publishedOn":"2025-12-26 15:57:42","publishedOnDateReadable":"December 26th, 2025"},"versionCreatedAt":"2025-09-22 09:25:23","video":"","vorDoi":"10.1186/s12913-025-13849-5","vorDoiUrl":"https://doi.org/10.1186/s12913-025-13849-5","workflowStages":[]},"version":"v1","identity":"rs-7345137","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7345137","identity":"rs-7345137","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}