Outcomes of an integrated knowledge translation approach in five African countries: A mixed methods comparative case study

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The Collaboration for Evidence-based Healthcare and Public Health in Africa (CEBHA+) undertook research on non-communicable diseases in Ethiopia, Malawi, Rwanda, South Africa, and Uganda. Alongside the research activities, we implemented an IKT approach, which entailed training and the development and implementation of site-specific IKT strategies. We evaluated these strategies according to a pre-defined programme theory. Methods : Drawing on our published protocol (https://rdcu.be/dyfBP), we interviewed and surveyed CEBHA+ researchers and their decision-making counterparts during two project stages (3/2020-2/2021; 9/2022-5/2023) and collected IKT-related documents. Transcripts and documents were analysed using qualitative content analysis and surveys were analysed descriptively, with subsequent integration, cross-case analysis, and revision of the programme theory. Results : A total of 36 researchers and 19 decision-makers participated in surveys, focus groups and/or interviews, and we collected 92 documents. Relationship-building, capacity-building, and collaborative research were the most proximal intervention outcomes: CEBHA+ researchers and their counterparts built mutual appreciation and partnerships, accessed contacts and networks, and expanded skills in conducting and using research and in IKT. The level of trust between partners varied. Intermediate outcomes were changes in attitudes and knowledge; beyond the conceptualisation in our initial programme theory, researchers substantially increased their understanding of the decision-making context and developed a vision for ‘research impact’. While it was challenging to evaluate distal outcomes, the IKT approach was linked to the production of research perceived as addressing local priorities and being highly applicable and contextualised; and some consideration of evidence among decision-makers. Unintended effects included high opportunity costs associated with undertaking IKT. An unanticipated outcome was the heightened interest of the research funder in policy engagement. Our updated programme theory constitutes a low-level theory for IKT. Conclusion : Whilst this study faced many challenges common to the evaluation of knowledge translation interventions, it presents rich, theory-informed insights into IKT outcomes. These are based on documented IKT activities and participants’ views, particularly in-depth insights of researchers’ experiences with implementing the CEBHA+ IKT approach. Public health integrated knowledge translation evaluation implementation non-communicable diseases Uganda Rwanda Malawi South Africa Ethiopia Figures Figure 1 Figure 2 Figure 3 Figure 4 Background Integrated knowledge translation (IKT) describes an ongoing relationship between researchers and knowledge users and constitutes one approach to enhancing evidence-informed decision-making (EIDM) in healthcare and public health (1,2). IKT goes beyond ‘simple’ knowledge translation (KT), originally defined as the ‘synthesis, exchange, and application of knowledge by relevant stakeholders to accelerate the benefits of global and local innovation in strengthening health systems and improving people’s health’ (3). KT encompasses the production and utilisation of knowledge in a cyclical knowledge-to-action process (4) whilst IKT underpins this and emphasises the building of continuous relationships between researchers and knowledge users, which are considered key to fostering (i) evidence uptake, (ii) the production of relevant research, and (iii) conditions that facilitate EIDM (5). IKT is distinct from other collaborative research approaches by focussing on knowledge users with the authority to implement policy or practice changes (6). This emphasis on involving decision-makers, including policy-makers, sets IKT apart from, for example, community-based participatory research (7) and engaged scholarship (8). Nevertheless, all these approaches are similar in their intent to democratise knowledge creation and use, and in that they require substantial time and resources (8). Interest in IKT has increased, including among research funders who view the involvement of knowledge users and KT activities as critical for achieving research impact (9,10), which serves as a justification for public funding of research (11). Whilst the promises of IKT are widely acknowledged, until recently, IKT outcomes have rarely been evaluated (1). Reasons include political and logistical challenges (12), and lack of conceptual clarity, evaluation tools and guidance (13). Since our research was conceptualised, more frameworks for KT and IKT (14–16) and tools to evaluate research partnerships including IKT have become available (17–19) and several evidence syntheses of available (I)KT evaluations and descriptions have been undertaken (1,20), including in African settings (2,21–23). Edwards et al. (2019) emphasise the potential of IKT for African health research settings; they identified the sustained engagement of knowledge users as a key facilitator to KT efforts and found that KT strategies drawing on integrated efforts or longer-term exchange featured prominently among existing strategies (23). However, they noted that (I)KT strategies were still under-described, as also noted internationally (1). They also concluded that there remains a ‘persistently unclear change pathway between research, KT strategies and policy formulation’ (23). This underpins that, paradoxically, EIDM lacks a rigorous evidence base for effective strategies (12). Despite emerging evidence that IKT is associated with improved capacity to use evidence among knowledge users and production of more relevant research, empirical research on IKT outcomes is still limited (1,5). No study to date has examined IKT outcomes across multiple African countries and research employing theoretical frameworks addressing this gap has been strongly recommended (23). Objectives We describe proximal, intermediate, and distal outcomes of the CEBHA+ IKT approach. As secondary objectives, we explore variation across the five African sites and revisit the CEBHA+ IKT programme theory. Methods Research approach and paradigm We undertook a mixed methods comparative case study employing semi-structured interviews and an online survey at two evaluation stages (subsequently ‘waves’; 3/2020-2/2021 for the first wave and 9/2022-5/2023 for the second wave). Documents were collected until June 2023. Our methods largely followed the protocol (24) but we had to make some adaptations linked to the COVID-19 pandemic and staff turnover. These included a change from face-to-face to online interviews during the first wave; during the second wave, they entailed a switch from interviews to online focus group discussions (FGDs) and foregoing interviews with decision-makers. Our work was informed by a critical realist research paradigm. This is rooted in an understanding an objective reality exists and that this can be studied using scientific methods – whilst such knowledge is subjective and socially constructed reflecting ‘epistemological relativism and ontological realism’ (25). Evaluations rooted in critical realism are intended to generate understanding about causal mechanisms and context and incorporate programme theories (26) to delineate ‘what works, for whom, why and in what circumstances’ (27). Intervention description and implementation This study was undertaken in the context of the Collaboration for Evidence-Based Healthcare and Public Health in Africa (CEBHA +). The consortium comprised nine academic institutions in Ethiopia, Germany, Malawi, Rwanda, South Africa, and Uganda, and was funded by the German Federal Ministry of Education and Research from 2017 to 2023. It aimed to conduct policy-relevant and practice-relevant research on the prevention and integrated care of non-communicable diseases (NCDs), notably diabetes and hypertension, and road traffic injuries. The German project partner LMU Munich was tasked with leading on the development and evaluation of the CEBHA+ IKT approach. The CEBHA+ IKT approach entailed training and guidance on IKT and the implementation of IKT strategies at the five African sites. A detailed description (28) and reflections about the IKT experiences in CEBHA+ were previously published (29–32). Systematic approaches for mapping and analysing stakeholders[1] and for developing and implementing an ‘IKT strategy’ were key tools (33,34). Both tools enabled researchers to strategically collaborate with partners from policy and practice from the start of the project. Initially, they were utilised widely but less so at later stages in the project (28). Ongoing IKT activities were coordinated by one or two ‘IKT focal points’ per CEBHA+ institution. IKT focal points and IKT evaluators (the ‘IKT team’) met quarterly online to discuss IKT experiences, forming a community of practice. Programme theory We were not able to identify an existing programme theory for IKT that fit our scope. Programme theories guide evaluation by making assumptions about underlying mechanisms explicit (35). We therefore developed a programme theory, informed by a scoping review of IKT evaluations (1) and further purposively selected literature: hypothesised proximal outcomes were relationship-building, capacity-building, and collaborative research, as suggested by realist IKT theory (36). Intermediate outcomes included changes in attitudes and evidence use behaviour of decision-makers (5,36). Ultimately, we hypothesised that IKT would lead to increased use of contextualised research evidence in decision-making (conceptualised as the final outcome ) (Figure 1). Intervention context KT structures and culture pre-existed at all sites but varied considerably (28). This included a strong focus on EIDM among academic institutions in South Africa, government policy mandating community engagement in research in Rwanda, a KT platform in Malawi (37), and long-time practice of engaging stakeholders in Uganda. The research environment was shaped by resource constraints, with research depending on foreign funders, whose research agenda is often misaligned with local priorities (22). Sampling strategy All CEBHA+ researchers involved in IKT were eligible for inclusion. Policy and practice partners were eligible when they collaborated actively, were over 18 years old, and English-speaking. We did not undertake a sample size calculation, nor did we define a cut-off for inclusion of participants when data saturation would be reached due to the generally limited number of eligible individuals. Data collection methods Data collection for the first wave depended on the timing of the respective approval from local institutional review boards, resulting in a long data collection phase (3/2020–2/2021). The first wave therefore does not constitute a baseline assessment. Interviews were conducted in-person in Malawi. Following the onset of the COVID-19 pandemic, interviews were almost exclusively conducted online, except for interviews with Ugandan stakeholders, some of which were conducted in person by trained local staff. Researchers were contacted via email and invited to the interview and survey. Stakeholders were invited by their respective CEBHA+ contact who forwarded a formal invitation letter. Data collection for the second wave took place during project finalisation (9/2022–5/2023). Data collection instruments Instrument development As we were not able to identify suitable instruments we developed CEBHA+ surveys and interview guides based on relevant survey constructs from existing instruments, identified in a purposive search and drawing on our programme theory, as reported elsewhere (24). Surveys consisted of a demographic survey, followed by 69 questions for stakeholders and 62 for researchers in 8 dimensions, corresponding with the programme theory constructs. Semi-structured interview guides consisted of 9 topic areas, each including multiple probing questions on the constructs. We developed and pilot-tested stakeholder and researcher versions. All instruments are available elsewhere (24). Documents We included internal and external IKT-related documents. IKT updates, the main source of internal documents, were submitted by the IKT implementers every three months and replaced monitoring with a bespoke tool, which proved infeasible (28). External documents mentioned by CEBHA+ researchers (e.g. guidelines, policy documents) were included and supplemented with documents identified in a purposive google search. Data processing Interviews were recorded using the online conference tools’ recording function or a handheld recorder (OLYMPUS LS-P1). The interviewer wrote a memo after every interview. Recordings were securely stored on an encrypted device and transcribed verbatim by Audiotranskription, a transcription service complying with required levels of data protection (38). Transcripts were provided to the interviewees for review. Original audio files were deleted after transcription. Transcripts and documents were pseudonymised and analysed in ATLAS.ti (39). We conducted surveys in the online tool Limesurvey (40). Anonymous survey data were exported and analysed in Microsoft Excel. Data analysis We considered the five African sites as ‘cases’, analysing data separately per case (where possible) and subsequently comparing results across cases (41). We initially analysed data from surveys, interviews, documents, and focus groups separately, integrating these over time (42). Quantitative survey data was analysed descriptively, by sub-group (researchers, stakeholders). For qualitative content analysis, domains and constructs of the programme theory served as the initial coding frame (24,43). One researcher (KS) coded interviews and documents, applying codes deductively and inductively developing new codes and categories. Co-authors (JO, EB) reviewed the codebook and applied the coding frame to one interview each, which led to further refinement. One researcher (KS) applied the final coding frame to the entirety of included material, and double-coded the material. A subset of the coding was reviewed by a second researcher. One researcher (KS) then reviewed categories, associated codes and quantitative data by site and across sites and drafted the initial results section through ‘theoretical integration’ (42) and ‘abstraction and retroduction’ (25), which was reviewed by co-authors, discussed, and iteratively revised. Throughout this process, we adapted and expanded programme theory sub-constructs. Scientific rigour was enhanced by following the Standards for Reporting Qualitative Research (44) and using the ASSESS reporting tool, intended to harmonise reporting of implementation-focused studies employing mixed methodologies (45) (Supplement 1). Researcher characteristics and reflexivity KS, ER and LMP are based at a well-resourced university in Germany. They are from non-migrant, academic backgrounds and have some to moderate research experience in African settings. JO, EB and BG are from Uganda and Ethiopia, respectively, with substantial research experience in their countries and some research experience in Europe (JO) and the United States (BG). Whilst we aimed to address the issues around power, ‘foreign gaze and pose’ (46) in this collaborative work we were unable to achieve this to the extent we would have aspired to as the write-up of this publication occurred after project funding had expired. Thus, our results are likely to reflect the social positions and experience of the German authors more strongly than those of the other authors. Three authors were part of a small group of ‘IKT experts’ that developed and launched the IKT approach (LMP, ER) and provided continuous support for IKT implementers (KS). Whilst this level of involvement in IKT implementation was critical for enabling a deeper understanding of the implementation process, it blurs the lines between evaluators and implementers. Results Characteristics of study participants A total of 36 researchers and nineteen decision-makers participated in one or both waves (Table 1). In the first wave, 25 researchers and ten decision-makers participated. In this wave, no decision-makers from Rwanda and Ethiopia were involved as we deemed it unethical to approach them at the height of the COVID-19 pandemic. In 2022, no decision-makers from South Africa were approached for logistical reasons. In the second wave, 27 researchers were surveyed of which seven participated in a focus group discussion. TABLE 1 STUDY PARTICIPANTS Table 1 Overview of study participants CEBHA+ researchers Decision-makers 1 st wave 2 nd wave 1 st wave 2 nd wave Total N participants 25 27 10 11 Survey n responses a 24 27 7 11 Survey response rate 24/26 (92 %) 27/32 (84 %) 7/14 (50 %) 11/16 (69 %) Interview 25 - 8 - FGD - 8 - - Both (survey and interview or FGD) 23 7 5 - Country Ethiopia 2 5 0 2 Malawi 5 6 4 3 Rwanda 6 6 0 4 South Africa 7 7 1 0 Uganda 4 3 5 2 Gender 3 Female 16 13 1 4 Male 7 13 6 7 Prefer not to say 1 0 0 0 Highest educational background b Doctorate 11 10 1 1 Master’s degree 10 12 4 9 Professional degree 3 4 1 1 Bachelor’s degree 0 1 1 0 Professional background b Public Health 11 13 1 6 Medicine 10 7 3 1 Epidemiology 2 0 0 0 Other 1 5 3 4 Institution b University 19 18 0 0 Research Institute (not within a university) 5 7 0 1 Government department 0 1 5 8 Regional or local health authority 0 0 1 0 Non-governmental organisation 0 0 0 2 Time at this institution b One year or less 1 0 0 0 2 or 3 years 8 4 1 0 4 or 5 years 3 7 1 3 6 – 10 years 6 6 1 5 11 – 15 years 1 7 1 2 More than 15 years 4 3 3 1 Overall work experience in the field b 5 years or less 2 5 1 1 6 – 10 years 9 3 2 4 11 – 15 years 7 8 1 4 More than 15 years 5 11 3 2 Legend : FGD: focus group discussion; a participant numbers include incomplete forms (n =1; except in the DM 2020 wave); b based on sociodemographic information in survey responses; Included documents We included 92 IKT-related internal and external documents (Table 2). Table 2 : Included documents Ethiopia Malawi Rwanda South Africa Uganda Other Total IKT strategies (including revised versions) 1 3 1 3 2 10 IKT ‘updates’ 9 11 9 7 8 44 Documentation of IKT activities (e.g. meeting minutes) 1 5 0 1 7 14 IKT team call minutes 17 17 External documents (e.g. National Strategic Plans for NCDs or Road Safety, funder-initiated evaluation, WHO guideline, transport policy) 1 2 2 2 7 All documents 92 Proximal outcomes We identified proximal outcomes related to capacity-building, relationship-building , and collaborative research . Capacity-building Capacity-building is a multi-level concept (47). In our initial programme theory, hypothesised outcomes included only individual-level outcomes, notably ‘access to information and contacts’, ‘broadened perspective and skills’, and ‘capacity for collaboration’. Below, we expand these to capacity-building at the (i) individual and (ii) organisational level as well as capacity-building contributing to an (iii) enabling environment (47). Individual-level capacity-building Research and research use skills Researchers reported mostly positive results with respect to research skills gained (Figure 2). Approximately 80% of researchers indicated that the collaboration had increased their receptiveness to new ideas or evidence ((n=21 (2020), n=25 (2022)); and provided them with an opportunity for personal or professional development (n=19 (2020), n=21 (2022)). Fewer respondents indicated that they had improved their capacity to develop research questions, conduct research, and improve their ability to access relevant research information. In qualitative data, there was little reference to research skills gained. The majority of decision-makers indicated that the collaboration had helped them increase their research use skills , that is to locate, evaluate, interpret, and apply research evidence (Figure 2). In qualitative data, there was no reference to evidence use skills, except for researchers in Uganda and Rwanda reporting that decision-makers were interested in learning research methods. FIGURE 2 Figure 2 : Research skills and research use skills, in 2020 and 2022, respectively IKT skills IKT skills relate to the identification of stakeholders, development and implementation of an IKT strategy and general stakeholder engagement (Table 3). Most researchers already had substantial experience in stakeholder engagement as part of their work routine. They reported high levels of comfort and skills to engage in the research collaboration but few had received prior KT training. At the second wave, 88% of surveyed researchers indicated that the IKT approach helped them to make deliberate decisions about stakeholder engagement, 92% felt comfortable advising colleagues on this, and 77% would recommend an IKT approach in future projects. IKT skills were not investigated in our survey but featured strongly in qualitative data. In general, researchers from all countries had developed substantial skills in developing and implementing an IKT strategy and honed general stakeholder engagement skills (Table 3). However, skills related to de-prioritisation of stakeholders were only mentioned as important by three interviewees from South Africa. Knowledge of IKT as a theoretical concept and an area of research remained more ambiguous with researchers frequently describing that they were on a ‘learning curve’. Table 3 IKT skills IKT skills sub-category Skills Detail and exemplifying quotes Stakeholder identification skills Skills to identify, map, prioritise, and analyse stakeholders ‘Yes, so, when we did the stakeholder mapping, we specifically said what we needed each stakeholder for because they have different strengths and […] areas of expertise.’ (MW RS 4) ‘But also, which stakeholders can also negatively influence how your research/ […] how well it's received.’ (MW RS 2) IKT strategy development and implementation skills Skills to choose the appropriate timing for IKT Includes consideration of current stakeholder priorities and timeliness of responses: ‘You can't ignore […] what issues are priorities at that time. So, like a month before the election, people are very, very busy in every Ministry […]/ So, you can't go there and then say, “I want to talk about salt reduction, and, you know.” You have to sense the time.’ (MW RS 4) ‘[…] within CEBHA and also within other projects, the one thing that I’ve learned is around timeliness of responses and engagements and knowing when is the right time to contact and ask for information and also the right time for putting things forward […]. And so I think key to keeping that relationship going is timeliness of information […]/ people at the policy level are inundated with a lot of requests and lots of different researchers coming to them from all different fronts. So you must find ways of not also adding to that burden.’ (SA RS 7) Includes consideration of when not to engage stakeholders: ‘And there’s been moments where we’ve had to make decisions that actually maybe now is not a good time to actually engage that stakeholder about this particular issue because, in a month’s time, we want to engage them about something else.’ (SA RS 4) Skills to choose the appropriate messenger for IKT Included various strategies: identifying a team member who was ‘exceptionally good at forming personal relationships’ (Ethiopia) assigning messengers based on geographical proximity (Malawi) using researchers’ long-standing contacts (all teams) enlisting stakeholders as messengers, e.g. lower rank staff within the same organisation to follow-up with senior staff (Uganda) accessing new contacts through existing stakeholder contacts (Rwanda, South Africa, Malawi) ‘[… our messenger] varies from our communication to another one. […] For example, [… researcher] who has been working with a specific stakeholder like RBC, the Department of NCDs, [it is therefore] easier to let him continue in that way and keep enforcing the ties that are existing between the two institutions.’ (RW RS 2) Skills to choose the appropriate forum and medium for IKT Included skills in developing issue briefs. Included gauging whether stakeholders preferred further in-person meetings after initial face-to-face meetings and using conferences and trainings strategically as for a for engagement. General stakeholder engagement skills Understanding stakeholder needs and interests Closely linked to skills in stakeholder mapping and IKT strategy development: Understanding of stakeholders’ motivation helped researchers to choose an appropriate engagement strategy. Strategies included: highligting of the ‘mutual benefit’ of the collaboration showing appreciation for stakeholders’ input, e.g. by involving them as guest speakers monetary or in-kind incentives: ‘So for a lot of governmental departments, they will meet you if there's an allowance involved. So if you have a Skype meeting, for example, they don't really benefit anything. We can't get their transport reimbursed.’ (MW RS 2) Dealing with staff turnover Ugandan and South African teams strategically established multiple connections to address this challenge: ‘[…] if we are contacting Ministry of Health, […] we should not focus on one person. […] This has been a lesson to us. Never have just one person involved as a stakeholder from one organisation.’ (UG RS 1) ‘And to have multiple members of our staff know about those and be introduced to those relationships, so that we never are in a situation where we have a fractured relationship, […] that's been really important in terms of our strategy, irrespective of who's maintaining the relationships that were not overly reliant on individuals.’ (SA RS 3) Dealing with stakeholder power This was actively considered at the stakeholder mapping phase but was otherwise rarely addressed explicitly. Skills in navigating power imbalances in the research collaboration are still evident implicitly through the variety of strategies employed by researchers to deal with this challenge: making concessions to high-level decision-makers to accommodate their schedule considering hierarchies to choose an appropriate messenger balancing of researchers’ support of the decision-maker’s agenda managing of expectations regarding such tasks and available resources: ‘[Decision-makers] will be very excited about the project. But then they will have ideas on what it is they want to add. And you're like, "No. […] it would be wonderful to do that. But that's not part of my plan. And I actually don't have the resources for that". So it's something that one has to do. I think be wise. How do you say it without saying only interested in your own activity, which you can fund.“ (UG RS 2) TABLE 3 IKT SKILLS Organisational-level capacity-building Organisational capacity-building occurred to a variable extent. IKT staff time was under-budgeted for in four countries, which meant that IKT focal points undertook IKT in addition to other work (Ethiopia, Rwanda, Uganda). In Malawi, an intern coordinated IKT activities. The resulting limited staff time for IKT, in combination with insufficient IKT training and staff turnover, led to persisting uncertainty about the roles of IKT focal points and lack of team buy-in, hampering organisational capacity-building: ‘[…] we got trained [in IKT]. We came back to train others. I mean we were not experts, okay. So […] in the way we transferred the information […] we did not/ were not able to convince people, our colleagues to really take it very serious.’ (MW RS 3) Efforts to build structures for organisational capacity for EIDM included the development of an evidence-based public health course which was run in all CEBHA+ countries (48). In South Africa, this complemented one institution’s existing KT and issue brief courses (33,34,49,50), which were attended by some CEBHA+ researchers. The Ethiopian team’s collaboration with the new knowledge management unit at AHRI and the KT unit at the Ethiopian Public Health Institute contributed to cross-institutional capacity-building. Capacity-building for an enabling environment The Malawi team partially revived an existing KT platform. In South Africa, the NCD symposium (2020) presented an opportunity for a variety of actors to network and access local NCD research. The Ugandan team’s effort to improve road traffic data involved data collection training for police officers. The Ethiopian team initiated a longitudinal training and mentorship for junior researchers who undertook systematic reviews on topics prioritised by the Ministry of Health (MOH). Of note, none of these efforts were CEBHA+ deliverables. Instead, capacity-building for an enabling environment addressed local needs. Relationship-building Relationship-building is a process of establishing, strengthening and maintaining relationships. In our initial programme theory, outcomes linked to relationship-building were mutual understanding, trust, and attitudes. These were revised to include (i) appreciation, (ii) trust, (iii) partnership formation, and (iv) access to contacts and networks. Appreciation In quantitative and qualitative data, appreciation for the collaboration, the respective partner, and for early engagement featured prominently. Most survey respondents agreed that contributions of partners were valued, that the collaboration incorporated broad perspectives and added value to the research. Agreement was lower for statements about acknowledgement in project reports and of partners’ views (Table 4). Decision-makers strongly valued being involved by researchers early on in the research process and were content to provide input, which facilitated later work: ‘[Partners were] part of our planning meetings. They were the ones who told us you haven't thought about this, you haven't thought about that, you haven't included this person. So, it was very easy to go back to them once we started collecting data, and say, “[…] we're having a problem in this area. Can you help?” They were very keen to help because they already knew about us.’ (MW RS 4) Stakeholders appreciated the collaborative approach as it contrasted with usual practice: ‘We hear from [community stakeholders] that the CEBHA project is a good research because it has involved them, it is not the same as other research projects which come and collect data without involving them. They said if other studies are conducted like CEBHA it would be fine. So for them they are appreciating it.’ (RW RS 5) In Uganda, stakeholders appreciated the CEBHA+ meetings for providing a forum for conversation between various road transport stakeholders who would not normally talk to each. Table 4: Relationship-building outcomes: appreciation, trust Researchers Decision-makers 2020 2022 2020 2022 N (%) Agree N (%) Agree N/total Agree N/total Agree Appreciation The individuals involved represent a broad range of perspectives. a 21 (91) 24 (89) 6/7 7/8 CEBHA+ partners value my contributions. a 19 (83) 22 (81) 6/7 7/8 All partners are acknowledged in CEBHA+ project documents (e.g. reports, publications). a 15 (65) 20 (74) 4/7 6/8 The collaboration between stakeholders and researchers in CEBHA+ added value to the ongoing research. a 21 (91) 26 (96) 6/7 7/8 ...I feel that my views are heard . b 13 (54) 13 (48) 7/7 6/10 Trust ...the collaborating partners trust each other . b 13 (54) 13 (48) 3/7 7/10 ...I am able to express my views freely . b 20 (83) 19 (70) 6/7 6/10 Legend : Question format: a yes/no/don’t know; b check all that apply; Trust Survey participants mostly agreed that they were able to express their views freely in the collaboration but substantially fewer participants thought that collaborating partners trusted each other (Table 4). Qualitative data provided a more nuanced picture. Without prompting, decision-makers often referred to trust, along with professionalism and respect, as a key relationship characteristic: ‘I think it’s a trusted relationship. It’s a trusted one. It’s both professional and friendship.’ (MW SH 4) A substantial level of trust is evident from one Ugandan decision-maker’s statement: ‘[I]n most cases I tell [Researcher] what I think, irrespective of what the government position might be. Or the governmental shortcomings might be. So of course I tell her the challenges we are having, and some of them we discuss. Political relationship of this country. […] how road safety doesn’t get an investment.’ (UG SH 2) Instances of decision-maker initiated engagement, for example, to discuss evidence gaps during the COVID-19 pandemic, reflect that CEBHA+ researchers were seen as trusted sources of information. In Uganda and South Africa, decision-makers built trust with members of the broader research team over time, beyond the initial senior researcher contact. However, despite individual examples of trust between partners, other relationships were characterised by low levels of trust: survey questions about honest communication about needs, constraints or organisational realities received low endorsement rates. Fear of a ‘hidden agenda’ was frequently referred to by interviewees. Ugandan decision-makers mentioned ‘fear of losing face’ as a reason of why partners may not trust each other enough to communicate transparently. Partnership formation CEBHA+ teams formed partnerships with varying levels of partnership strength. The understanding of ‘partnership’ was ambiguous. Ugandan decision-makers appeared to understand ‘partnership’ mainly as a source of financial support. This may explain why, in 2022, three decision-makers (from Ethiopia and Rwanda) reported that they didn’t think they had established a partnership with CEBHA+ researchers. Others used the term ‘partnership’ or referred to partners as a ‘team’, being ‘part of the project’, or ‘on board’. Some particularly strong partnerships were rooted in longstanding connections: ‘I'm always available for [Researcher] to call me. I'm always available when [Researcher] calls the workshop. And I don't think I've ever, ever not responded to [their] call.’ (UG SH 2) Interviewees in South Africa described one decision-maker as their ‘champion’, a term introduced in IKT training: ‘[…] I would say the person who had made CEBHA more […] acceptable and implementable in South Africa, yeah, she was the champion. […] unfortunately, because of COVID, she was also very, very busy, and she really gave more than what a stakeholder of her calibre would, but it's because she had an interest of the kind of work that we're doing, the knowledge, the science.’ (SA RS 2) In IKT documents partnership formation was evident from the continuous presence of certain decision-makers in project meetings. Access to contacts and networks Researchers and decision-makers gained access to a wide range of new contacts and networks. A majority of survey participants agreed that the collaboration had ‘very much’ or ‘somewhat’ improved their access to contacts. Researchers gained access to EIDM-focused networks, such as Evident and the African Institute for Development Policy in Malawi, and to some high-level decision-makers: ‘And then, we actually […] had access to the Minister of Health who was also at the [South African NCD] symposium and gave a talk […] which is a very (laughing) rare thing to happen.’ (SA RS 1) Researchers and their institutions were thought to benefit from these networks in the future: ‘Actually, CEBHA could initiate the network, but […] AHRI will be in position to, you know, continue the networking or the relationship with different stakeholders. […] In IKT, you will build a network. It's not only for the CEBHA, but even for my personal career, networking has some impacts.’ (ET RS 1) Collaborative research In collaborative research, researchers and stakeholders work together over all or multiple phases of a research project, ideally in a continuous manner. In our initial programme theory, outcomes linked to collaborative research were appreciation, diversity of partners, and continuous involvement, which were reduced to just one sub-category. Continuous involvement Researchers interacted with stakeholders most frequently in early and late research phases (28), except in Uganda and Rwanda, where collaboration was more continuous as it included data collection (Supplement 2). Collaboration commenced during the priority-setting process for the project which involved decision-makers (51) and linked to the existing KT routines of CEBHA+ teams. Some early interactions with decision-makers were mandatory, e.g. requesting research approval. At all sites except Uganda, stakeholder engagement was part of a research method, i.e. for citizen science (52) and for the situational analysis (53,54). ‘[The] situation-based analysis for population-based interventions targeting risk factors of diabetes and hypertension […] required from the onset […] engaging with the stakeholders as we developed the whole data collection tools and […] process.’ (SA RS 2) Some data collection activities required facilitation by decision-makers, e.g. for accessing health and police records (Uganda) or insurance data (Rwanda). Some collaborative research originated from the strategic establishment of boundary spanners enabling repeated interaction: decision-makers had been asked to join the project advisory board (Uganda, South Africa) or undertook research on CEBHA+ PhD studentships (Malawi, Rwanda). Intermediate outcomes Intermediate outcomes emerge from the interplay of the proximal outcomes. In our initial programme theory, we had only conceptualised decision-makers’ attitudes as intermediate outcomes. We revised this as changes in knowledge and attitudes among both decision-makers and researchers. Changes in knowledge This included decision-makers learning about (CEBHA+) research and researchers learning about the decision-making context. In the survey, a majority of researchers and decision-makers indicated that the collaboration had increased their knowledge, understanding or views about the health issues addressed in CEBHA+ and enhanced their confidence in day-to-day activities (Figure 3). FIGURE 3 Figure 3 : Researchers’ and decision-makers’ changes in knowledge , in 2020 and 2022, respectively Fewer survey participants thought that the collaboration had improved their access to relevant information. Contrastingly, interview data indicates that researchers actively sought and accessed information. This strongly improved their understanding of the decision-making context , e.g. regarding political mandates, priorities, and post-election restructuring, and subsequently informed research activities: ‘What I understand from the ministry is […] they have deliverables that they have to put through, but they don't have the resources to do so. So [when] we kind of give them the platform […] or rather ask them what they need from us, it kind of opens up […] It makes it easier for us to get our work done when we also put forward their agenda.’ (MW RS 2) Seeking to understand decision-making priorities, the Ethiopian team conducted a needs assessment among MOH staff. Decision-makers’ knowledge of relevant research features less prominently in interviews. In one case, they requested results from a systematic review but did not learn much as the review was ‘empty’. Still, seven out of eight decision-makers felt that they had become more knowledgeable about the scope of work at the research institution (2022 survey). The IKT approach further enhanced the visibility of the research institutions. Across all groups and sites, gaining a new perspective was emphasised as a key outcome: ‘[…] my interaction with the researchers […] it really opened up my mind. It pushed me to think more, to perceive things differently.’ (UG SH 3) Changes in attitudes We identified subtle changes in attitudes towards research evidence (decision-makers) and more pronounced attitudinal changes regarding research impact (researchers) and research collaboration (both groups). These were typically linked to existing, predominantly positive attitudes. Decision-maker attitudes Decision-makers who were aware of CEBHA+ evidence generally valued this evidence and indicated that they were intending to use it (Table 5). Table 5 : Decision-makers’ attitudes towards research evidence 2020 2022 The research evidence produced in CEBHA+... Agree N / total Agree N / total Value ... is relevant to the health issues addressed by the partnership 7/7 6/6 ... is directly applicable 5/7 5/6 ... is trustworthy 7/7 6/6 ...more likely to be used in decision-making 6/7 6/6 ...more likely to have a lasting impact on public health 6/7 6/6 Intention I intend to use CEBHA+ research evidence in my work. 6/7 9/10 Consideration Being engaged with CEBHA+ increased my active consideration of research evidence in my work. 7/7 7/10 In qualitative data, decision-makers’ interest in research was apparent but this largely seemed to pre-date the CEBHA+ project. ‘[…] through some of the stakeholder's meetings, we [heard that], they're eager to get the […] study results, […] and then to see what they can improve because in the Rwandan context, […] from the administration and governance level, they are looking for anything that can [improve] what they are doing.’ (RW RS 1) It was also evident that attitudes towards research collaboration had improved among some stakeholders, often due to persistent efforts by researchers: ‘[Eventually, the road traffic insurance companies] were very happy to help us, […] even someone […] who didn’t want to talk to you, they are very excited to give us information and to help us […] because it’s in their big interest […] And that’s like the approach we used to get them on board. They were like, “So at the end of the day, […] we are the ones who are going to gain from this project.”’ (RW RS 6) This was echoed in survey data: All decision-makers surveyed in 2022 indicated that they would reach out to the CEBHA+ researchers for future queries. Researcher attitudes Many researchers embraced the ‘IKT idea’ as a vision for research impact and became more interested in collaborating with decision-makers. Research impact was seen in both visionary and practical terms: ‘It makes you […] remember not to do things in a bubble. Always consider what your long-term objectives are. So don't do research for the sake of doing research, but always to think long term and to think who else needs to know about this. What input can they give?’ (MW RS 2) Among some researchers, this attitude was coupled with great openness to taking on decision-maker insights, e.g. when co-developing a logic model for integrated models of care to ensure it was relevant to both the South African and global context. Two senior researchers were described as only becoming interested in (I)KT and research collaboration through CEBHA+ and one Ethiopian researcher reported change at the level of the institution, where the benefits of systematic stakeholder engagement became recognised: ‘So, now the other projects or other directorates under AHRI, they are consulting us. Or they are using us as a, you know, a link to the different stakeholders.’ (ET RS 1) The interest in IKT is also reflected in researchers adopting IKT in other projects, such as proposals and teaching (Germany, South Africa). Unintended and unanticipated effects The opportunity cost of doing IKT was an unintended – yet foreseeable – outcome discussed by some researchers, leading to potentially overburdening decision-makers in resource-constrained settings: ‘[I]n some ways, CEBHA has been trying to reinvent some wheels […] there’s already a lot going on in [our country] that could’ve been built on […] because the policymakers that people are trying to engage with are all busy people. […] if the people keep saying, “[…] we’re going to do policy engagement. Come to our stakeholder meeting now […].” I think that has real opportunity costs in terms of trying to take people’s time up that way.’ (RS[2]) Within the broader EIDM system, the IKT approach sparked the research funder’s interest in research impact, which was not anticipated: The CEBHA+ IKT approach was mentioned multiple time as a good practice example in the funder-initiated midline evaluation and ‘policy engagement’ became mandatory in subsequent funding lines. Distal outcomes Increased use of contextualised research evidence in decision-making was initially conceptualised as the final outcome linked to the IKT approach. We rephrased this category, added the researcher dimension, the production of relevant research evidence, and adapted the decision-maker dimension to consideration of contextualised research evidence, as evidence use proved conceptually challenging to evaluate. Production of relevant research evidence Due to the small number of study participants, our insights into decision-makers’ views on CEBHA+ outputs remained limited. In the survey, the majority of decision-makers agreed that CEBHA+ research evidence was presented to them in an accessible format, an understandable language, and a timely manner. Two CEBHA+ projects were highlighted by decision-makers as important solutions to local priorities, for example: ‘So the great initiative for diabetes that was done by [Researcher], that was important because we are not counselling our diabetic clients as we are counselling our HIV positive clients. [..] But both of them have significant morbidity and mortality. So he came with a group education initiative for diabetic patients. So that's something that we needed.’ (SA SH 5) This study subsequently informed the local department of health and guidelines in Ethiopia, Malawi, and Rwanda. Ugandan researchers and their partners identified the lack of digitised, valid road traffic crash data as a major gap. This led to a joint pilot project digitising crash data from police and healthcare archives, which had not been planned in the original proposal. One decision-maker explained that CEBHA+ research was highly applicable but recommendations were not implemented: ‘I have seen the benefits [and] the value that they could bring to the sector, to the prevention of road crashes. But yeah, I haven't had the opportunity to implement them. […] so the applicability of research findings is they can really be done.’ (UG SH 2) Additionally, beyond what was planned in the original proposal, CEBHA+ funding enabled conducting ten rapid reviews on prioritised COVID-19 topics in South Africa and five systematic reviews on various MOH-prioritised questions in Ethiopia. Other qualitative data pointed to more ambiguity regarding the relevance of research evidence produced in CEBHA+. In Rwanda, the CEBHA+ team used old NCD data due to the tight project timeline despite the MOH requesting use of newer data. Similarly, a South African researcher was only able to interview very few decision-makers for their situational analysis, limiting its relevance. In Malawi and Ethiopia, the CEBHA+ priorities defined with some decision-maker involvement in 2013 (51) did no longer match current research priorities: ‘We had already met with the Ministry of Health and told them about our community level screening […]. And they didn't say a thing. And then when we found out […] that they had been doing this already for three years in Addis Ababa. So I mean our project […] was, well, yes, it was sort of aligned with the Ministry of Health [initially]. But it was already behind [when it started].’ (ET RS 2) Few scientific articles were published until the end of the funding period. Despite this, CEBHA+ researchers were able to produce a range of relevant outputs (31). Consideration of research evidence in decision-making Decision-makers self-reported conceptual, instrumental, and tactical evidence use (55) in the survey. Research evidence was considered by decision-makers when they consulted CEBHA+ researchers: Ugandan CEBHA+ researchers were involved in the development of the Road Safety Action Plan (2021/22 – 2025/26) and were invited to present research in a Parliamentary meeting on road safety, prior to the amendment of the Traffic and Road Safety Bill (30th March 2023). South African CEBHA+ researchers and their ‘champion’ were involved in developing the National Strategic Plan for the Prevention and Control of NCDs (2022 - 2027). ‘A key ally throughout the CEBHA+ project, [decision-maker] applauded the work of CEBHA+ and linked its relevance to the National Strategic Plan for NCDs. She stressed the importance of research collaboration and the need for a coordinated platform.’ (SA policy dialogue minutes) One study by a Rwandan CEBHA+ researcher was cited in the National Strategy and Costed Action Plan for the Prevention and Control of NCDs in Rwanda (2020 – 2025) (56). Revised programme theory The adapted programme theory includes revised sub-categories. Intermediate and distal outcomes were supplemented by the researcher dimension (Figure 4). Discussion Summary This study examined outcomes linked to an IKT approach implemented in five African countries, drawing on a pre-defined programme theory. Through relationship-building, capacity-building, and collaborative research (proximal outcomes), researchers and decision-makers built appreciation and partnerships, whilst expanding skills in conducting research, evidence use, and IKT. Participants gained access to contacts and networks but trust between partners varied. Only limited capacity was built at organisational and system levels, mostly with regards to establishing new courses and training staff in IKT. Intermediate outcomes were changes in attitudes and knowledge, particularly as researchers learned about the decision-making context. The IKT approach was linked with the production of research that was perceived as highly applicable and addressing local priorities but we found only some evidence of consideration of evidence among decision-makers due to study limitations. In revising our initial programme theory, we were able to consolidate our findings into low-level theory. Contextualising our findings in the literature IKT emphasises continuous relationships with knowledge users, in particular decision-makers to foster EIDM in a mutually beneficial manner (6). IKT activities and outcomes have been examined in a meta-synthesis of IKT case studies (57). Whilst there remains a dearth of rigorous outcome evaluations of IKT, approaches with similar characteristics exist within the wider literature on ‘health research partnerships’ (20), co-production (58), and on the ‘science of using science’ (59). Comparison with this literature is, however, difficult due to challenges with evaluating knowledge exchange interventions in general and our approach in particular (Textbox 1). Textbox 1: Evaluation of knowledge exchange interventions Evaluation challenges with regards to KT interventions arise from a lack of funding and other practical issues (12), its resource intensity (22), and from the complexity and context-dependency of such interventions and inherent challenges to making causal claims (60). We were faced with what has been described elsewhere as ‘sample-size challenge of finding enough contexts and infrastructures supporting a common approach that can be evaluated using standardised methods’ (21). Among published evaluations exists a positivity bias as ‘rich descriptions of failures’ are lacking (57). Difficulties in attributing outcomes to the IKT approach are further amplified as the approach is in itself not one intervention but ‘entails a multi-pronged ensemble of tailored interventions’ (28). The envisioned core components comprised continuous involvement, including through the engagement of decision-makers in priority-setting for the project (51), IKT training, systematic development and implementation of ‘IKT strategies’, regular meetings of the IKT team, and IKT-related deliverables (28). CEBHA+ researchers were the target group for some interventions (e.g. IKT training) and were implementers of other interventions (implementation of IKT strategies, e.g. involving decision-makers in a policy dialogue). Overall, such multi-component, multi-mechanism approaches are common in interventions intended to increase evidence use among decision-makers (59). Proximal outcomes The CEBHA+ IKT approach was primarily aimed at individual-level behaviour change. ‘Relationship-building’, ‘capacity-building’, and ‘collaborative research’ had been conceptualised to constitute the most proximal outcomes of the approach, doubling, by virtue of being activities, as mechanisms of change on the pathway to downstream outcomes (36). CEBHA+ researchers participated in training and meetings on IKT and IKT-related skills featured prominently in capacity-building . In the meta-synthesis of IKT case studies this was echoed, with ‘capacity for collaboration’ identified as a key outcome (57). The IKT skills we identified map onto the competencies for IKT defined in a Delphi study (61). Interestingly, CEBHA+ researchers reported some mixed effects with respect to research skills gained, which warrants further investigation. An evidence-based public health course was implemented in CEBHA+ but since it was offered only once per country few decision-makers participated in this formal capacity-building opportunity. Given that CEBHA+’s aim was to increase decision-makers’ evidence use this appears to be a gap in the IKT approach. Whilst CEBHA+ activities were focused on individual-level capacity-building, some strengthening of organisational and systems capacity occurred, which has been described as a key need in the region (23,62). Trust between partners varied and was highly context-dependent, with longer relationships enabling more trusting relationships. Trust, along with ‘talk and time’, has been long established as key to relationship-building (63). Lately, it has been recommended, however, to view trust as a more dynamic concept in partnered research as opportunities for building trust may be different for different partners (64), as also observed in our data. Nevertheless, trust and honest communication, e.g. about needs, constraints, and organizational realities, without concerns about judgment or backlash, are essential for building successful partnerships (65). Decision-makers expressed great appreciation for being involved early in the research. This is more reflective of ‘mutually beneficial’ (6), ‘meaningful’ (20), and egalitarian partnerships (10) as opposed to one-off collaboration or work on pre-defined research questions, which is more likely to constitute asymmetrical or tokenistic partnerships (10). Ambiguous use of the term ‘partnership’ and variable levels of partnership strength pointed to all three partnership types being represented in our study (10). We did not examine the level of individual partnerships as a unit of analysis, which we recommend for future, well-resourced evaluations. Importantly, this will help delineate partnerships with diverse groups of partners more – for example, the Ugandan team felt great tension in IKT activities involving groups with great power differentials, i.e. longstanding, often academic partners and others, such as the group of boda boda motorcycle drivers with little formal education. CEBHA+ researchers interacted with decision-makers in particular in early and late phases in the collaborative research process, as has been documented elsewhere (1). Whilst this may appear contradictory to the IKT tenet of continuous relationships it may also reflect IKT skills, i.e. only involving decision-makers with a clear goal. Elsewhere, stakeholders indicated that they preferred a ‘moderate level of participation in research rather than full team membership.’ (66). At the same time, this may result in stakeholder roles transforming into mere research participation as opposed to consultative or co-production roles (67). Intermediate outcomes Researchers learning about the decision-making context emerged as a key outcome of the IKT approach, which had not been conceptualised in the initial programme theory. In public health, researchers have limited knowledge of policy-making (68) and therefore benefit greatly as they gain a new perspective and increase their knowledge of the policy or practice environment (1,69) and ‘develop and pursue research questions that have real-world applicability, and, through ongoing conversations with decision-makers, interpret results with a deeper understanding of contextual circumstances which, in turn, enhances the usefulness of the research findings.’ (1). Researchers and decision-makers generally had rather positive attitudes of collaborating but some individuals became more convinced during the project. Such attitudinal change among decision-makers has been associated with higher frequency of research use (70,71). Unintended and unanticipated effects We found it difficult to investigate unintended, particularly adverse, effects as interview participants appeared uncomfortable to reflect on these. This reluctance may reflect social desirability bias and added to the positivity bias common in this kind of research (57,72), leading to us identifying predominantly positive outcomes. Challenging outcomes were identified in only 32% of reviews on health research partnerships (20), with emotional labour identified as the key negative outcome (73). Given the substantial resources required for IKT and the various potential issues in collaborative research or co-production (74) future evaluations should explore appropriate methods to examine this further. Distal outcomes We did identify some instances of production of relevant, contextualised evidence. Such research has been reported as an important prerequisite for EIDM as it is perceived as valuable and trustworthy by local decision-makers (22). We were further able to identify some consideration of evidence in decision-making but ‘evidence use’ proved challenging to assess, which is a common challenge when evaluating the effect of interventions intended to facilitate EIDM on evidence use, policy and practice (75). Advancing low-level theory for IKT Our revised programme theory can be considered a low-level theory, grounded in realist evaluation theory (36). It links with other relevant theories on evidence use (59) and IKT (57). The revised theory incorporates a broader consideration of the role of researchers in EIDM. This is similar to the CollaboraKTion framework but the latter is organised temporally along the research process (76,77). Whilst our programme theory can inform future evaluations by making assumptions about IKT explicit (35) it is by nature reductionist and may warrant stronger consideration of ‘systems thinking’. Strengths and limitations Our study draws on a published protocol and provides unique insights into outcomes of a coordinated IKT approach implemented by teams in five African countries. We were able to enrol most CEBHA+ researchers and drew on a large number of documents. Due to the small number of decision-makers participating, we were not able to disaggregate survey results by country. The under-representation of decision-makers may present a finding in itself: In some cases, researchers advised against the enrolment of their decision-making partners, for example, when the latter were overworked with COVID-19-related responsibilities or when researchers deemed that partnerships were not yet sufficiently established to link partners with evaluation researchers. The comparative case study design does not allow for causal inference. However, in the absence of an opportunity to employ a more rigorous study design to examine effects, the study design still allows for teasing out whether the approach contributed to some change in the direction of the hypothesised outcomes. We used a non-validated survey tool, which incorporated validated constructs from existing tools. This led to some conceptual difficulties at the data analysis stage and we recommend the use of other tools for future IKT research (18). Some relevant concepts, such as organisational absorptive capacity, were under-examined. Our data analysis included recommended double-coding by one researcher (43) but restricts the perspective, compared with double-coding by multiple researchers. Further limitations arise from the involvement of evaluators in IKT implementation, as we discuss under reflexivity, and from the risk of social desirability bias given the proximity of evaluators and participants. Conclusion Our evaluation of an IKT approach implemented in five African countries presents theory-informed insights into proximal, intermediate and distal IKT outcomes, based on participants’ views and documented IKT activities. Given the multi-component nature and context-dependency of KT interventions as well as the diversity of relevant decision-makers in public health and healthcare there is not one way for implementers to ‘do IKT’. Whilst IKT evaluation literature can inform future IKT efforts it remains critical for implementers to monitor their IKT activities to understand ‘what works’ in their context. This should include a cost-benefit-assessment of KT activities, in particular in resource-constrained settings (69,78). Research on unintended effects of IKT, including those arising from power differentials (79), is warranted. Importantly, beyond project-based, often haphazard IKT, evidence-informed decision-making requires strengthening of structures and systems. List Of Abbreviations IKT Integrated knowledge translation KT Knowledge translation CEBHA+ Collaboration for Evidence-based Healthcare and Public Health in Africa LMU Ludwig-Maximilians-Universitaet Muenchen EIDM Evidence-informed decision-making COVID-19 Coronavirus disease 2019 FGD Focus group discussion NCD Non-communicable diseases ET Ethiopia MW Malawi RW Rwanda SA South Africa UG Uganda RS Researcher SH Stakeholder DM Decision-maker AHRI Armauer-Hansen Research Institute MOH Ministry of Health Declarations Ethics approval and consent to participate The protocol for this study was approved by the Ethics Committee of Armauer Hansen Research Institute (AHRI), Ethiopia (PO/31/20), the Ethics Review Committee of the Ludwig-Maximilians-Universität München, Germany (19-633), the Research and Ethics Committee at the Kamuzu University of Health Sciences, Malawi (P.11/19/2850), the Rwanda National Ethics Committee (074/RNEC/2020), the Human Research Ethics Committee of the University of Cape Town, South Africa (026/2020), and the Ethics Committee of Makerere University, Uganda (Protocol 469). Consent for publication Informed voluntary consent was sought both in writing and verbally from all participants. Availability of data and materials The datasets generated and analysed during the current study are not publicly available due to concerns about anonymity of study participants given the small sample size. Survey data can be made available from the corresponding author on reasonable request. Competing interests The authors have no conflicting interest other than their role in conceiving this research, developing and co-implementing the CEBHA+ IKT approach. Funding CEBHA + was funded by the German Federal Ministry of Education and Research (Bundesministerium für Bildung und Forschung) as part of the “Research Networks for Health Innovation in Sub-Saharan Africa” funding initiative. Grants no: 01KA1608, 01KA2023, 01KA2111A. The funder was not involved in the study design, collection, analysis, interpretation of data, the writing of this article or the decision to submit for publication. Authors' contributions EAR and LMP contributed to the development of the CEBHA + IKT approach and KS, EAR and LMP conceived the idea for this article. KS, JO, EBZ and LMP partook in the collection of data and KS, JO, EBZ, BG, and LMP analysed data. All authors critically interpreted and discussed the data. KS drafted this article. All authors critically revised its content, approved the submitted version of this article, and are accountable for the accuracy or integrity of any part of the work. Acknowledgements We would like to express our sincere thanks to the CEBHA+ team and further individuals that made this research possible. Nasreen Jessani’s work in guiding the process of implementing IKT in CEBHA+ was invaluable and the project would not have been implemented without her support. Taryn Young, Anke Rohwer, Gertrude Chapotera, Bey-Marrie Schmidt, Joerg Meerpohl, Ingrid Toews and Jacob Burns gave key input during the development phase of the IKT approach. Great thanks goes to Tanja Grath and her thorough work on instrument development and in launching IKT in CEBHA+; to Lynn Hendricks and a Rwandan colleague for piloting instruments; and to Nyanyiwe Masingi Mbeye for undertaking a friendly peer review of this manuscript. We would also like to thank Ann Rose Akiteng, Stellah Namatovu, Seleman Ntawuyirishintege, Suzgika Lakudzala, Rawleigh Howe, Kiya Kedir, Firaol Mesfin, Hailemichael Getachew, Peter Delobelle and all members of the (wider) IKT team and for contributing significantly to this work. We are immensely grateful for the insights and experiences shared by all study participants. References Gagliardi AR, Berta W, Kothari A, Boyko J, Urquhart R. Integrated knowledge translation (IKT) in health care: a scoping review. Implement Sci. 2016;11(1):38–38. Lawrence LM, Bishop A, Curran J. Integrated knowledge translation with public health policy makers: A scoping review. Healthc Policy. 2019;14(3):55–77. World Health Organization. Bridging the “Know–Do” Gap: Meeting on Knowledge Translation in Global Health. 10-12 October 2005 [Internet]. Geneva, Switzerland; 2006 [cited 2023 Feb 17]. Available from: https://www.measureevaluation.org/resources/training/capacity-building-resources/high-impact-research-training-curricula/bridging-the-know-do-gap.pdf Graham ID, Logan J, Harrison MB, Straus SE, Tetroe J, Caswell W, et al. Lost in knowledge translation: Time for a map? J Contin Educ Health Prof. 2006 Dec;26(1):13–24. Graham ID, Kothari A, McCutcheon C. Moving knowledge into action for more effective practice, programmes and policy: protocol for a research programme on integrated knowledge translation. Implement Sci IS. 2018 Feb 2;13:22. Kothari A, Wathen CN. Integrated knowledge translation: digging deeper, moving forward. J Epidemiol Community Health. 2017 Jun;71(6):619–23. Jull J, Giles A, Graham ID. Community-based participatory research and integrated knowledge translation: Advancing the co-creation of knowledge. Implement Sci [Internet]. 2017 Dec;12(1). Available from: /pmc/articles/PMC5735911/ Nguyen T, Graham ID, Mrklas KJ, Bowen S, Cargo M, Estabrooks CA, et al. How does integrated knowledge translation (IKT) compare to other collaborative research approaches to generating and translating knowledge? Learning from experts in the field. Health Res Policy Syst. 2020 Mar;18(1). Gagliardi AR, Kothari A, Graham ID. Research agenda for integrated knowledge translation (IKT) in healthcare: what we know and do not yet know. J Epidemiol Community Health. 2016/09/19 ed. 2017 Feb;71(2):105–6. Sibbald SL, Tetroe J, Graham ID. Research funder required research partnerships: a qualitative inquiry. Implement Sci IS. 2014 Nov 28;9:176. Abudu R, Oliver K, Boaz A. What funders are doing to assess the impact of their investments in health and biomedical research. Health Res Policy Syst. 2022 Dec;20(1):1–18. Oliver K. Why Is It So Hard to Evaluate Knowledge Exchange? Comment on ‘Sustaining Knowledge Translation Practices: A Critical Interpretive Synthesis’. Int J Health Policy Manag. 2023;12:7549. Boland L, Kothari A, McCutcheon C, Graham ID. Building an integrated knowledge translation (IKT) evidence base: Colloquium proceedings and research direction. Health Res Policy Syst. 2020 Jan;18(1):8–8. Esmail R, Hanson HM, Holroyd-Leduc J, Brown S, Strifler L, Straus SE, et al. A scoping review of full-spectrum knowledge translation theories, models, and frameworks. Implement Sci IS [Internet]. 2020 Feb;15(1). Available from: https://pubmed.ncbi.nlm.nih.gov/32059738/ Tittlemier BJ, Cooper J, Steliga D, Woodgate RL, Sibley KM. A scoping review to identify and describe the characteristics of theories, models and frameworks of health research partnerships. Health Res Policy Syst [Internet]. 2022 Dec;20(1). Available from: https://pubmed.ncbi.nlm.nih.gov/35717196/ Jull JE, Davidson L, Dungan R, Nguyen T, Woodward KP, Graham ID. A review and synthesis of frameworks for engagement in health research to identify concepts of knowledge user engagement. BMC Med Res Methodol. 2019 Nov 21;19(1):211. McLean RKD, Carden F, Aiken AB, Armstrong R, Bray J, Cassidy CE, et al. Evaluating the quality of research co-production: Research Quality Plus for Co-Production (RQ + 4 Co-Pro). Health Res Policy Syst. 2023 Jun 13;21(1):51. Mrklas KJ, Boyd JM, Shergill, Sumair, Merali, Sera, Khan M, Nowell L, et al. Tools for assessing health research partnership outcomes and impacts: a systematic review. Health Res Policy Syst. 2023 Jan 5;21(1):3. Mrklas KJ, Boyd JM, Shergill S, Merali S, Khan M, Moser C, et al. A scoping review of the globally available tools for assessing health research partnership outcomes and impacts. Health Res Policy Syst. 2023 Dec 22;21(1):139. Hoekstra F, Mrklas KJ, Khan M, McKay RC, Vis-Dunbar M, Sibley KM, et al. A review of reviews on principles, strategies, outcomes and impacts of research partnerships approaches: a first step in synthesising the research partnership literature. Health Res Policy Syst. 2020;18(1):51–51. Partridge ACR, Mansilla C, Randhawa H, Lavis JN, El-Jardali F, Sewankambo NK. Lessons learned from descriptions and evaluations of knowledge translation platforms supporting evidence-informed policy-making in low- and middle-income countries: a systematic review. Health Res Policy Syst. 2020;18(1):127–127. Malla C, Aylward P, Ward P. Knowledge translation for public health in low- and middle- income countries: a critical interpretive synthesis. Glob Health Res Policy. 2018 Dec;3(1). Edwards A, Zweigenthal V, Olivier J. Evidence map of knowledge translation strategies, outcomes, facilitators and barriers in African health systems. Health Res Policy Syst. 2019;17(1):16–16. Pfadenhauer LM, Grath T, Delobelle P, Jessani N, Meerpohl JJ, Rohwer A, et al. Mixed method evaluation of the CEBHA+ integrated knowledge translation approach: a protocol. Health Res Policy Syst. 2021 Dec;19(1):7–7. Vincent S, Mahoney J. The SAGE Handbook of Qualitative Business and Management Research Methods: History and Traditions [Internet]. SAGE Publications Ltd; 2018 [cited 2023 Oct 17]. Available from: https://methods.sagepub.com/book/handbook-of-qualitative-business-management-research-methods-v1 Bonell C, Fletcher A, Morton M, Lorenc T, Moore L. Realist randomised controlled trials: A new approach to evaluating complex public health interventions. Soc Sci Med. 2012 Dec 1;75(12):2299–306. Pawson R, Tilley N. Realist Evaluation. SAGE Publications Ltd; 1997. Sell K, Jessani NS, Mesfin F, Rehfuess EA, Rohwer A, Delobelle P, et al. Developing, implementing, and monitoring tailored strategies for integrated knowledge translation in five sub-Saharan African countries. Health Res Policy Syst. 2023 Sep 4;21(1):91. Mpando TL, Sell K, Delobelle P, Osuret J, Niyibizi JB, Ntawuyirushintege S, et al. Integrated Knowledge Translation in Non-Communicable Disease Research in Sub-Saharan Africa: A Comparison of Systematic and Ad Hoc Stakeholder Engagement. Front Trop Dis. 2021;0:53–53. Jessani NS, Rohwer A, Schmidt BM, Delobelle P. Integrated knowledge translation to advance noncommunicable disease policy and practice in South Africa: application of the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework. Health Res Policy Syst. 2021;19(1):82–82. Jessani NS, Delobelle P, Balugaba BE, Mpando TL, Ayele FM, Ntawuyirushintege S, et al. Integrated Knowledge Translation for Non-Communicable Diseases: Stories from Sub-Saharan Africa. 2023 Dec 8;89(1):87. Niyibizi JB, Nganabashaka JP, Ntawuyirushintege S, Tumusiime D, Umwali G, Rulisa S, et al. Using Citizen Science Within an Integrated Knowledge Translation (IKT) Approach to Explore Cardiovascular Disease Risk Perception in Rwanda. Front Trop Dis. 2021;0:33–33. Jessani NS, Hendricks L. Evidence-Informed Decision-Making: The Art, Science and Complexity of (Integrated) Knowledge Translation. Short Course presented at; 2022; Stellenbosch University, South Africa. Jessani NS, Hendricks L, Nicol L, Young T. University Curricula in Evidence-Informed Decision Making and Knowledge Translation: Integrating Best Practice, Innovation, and Experience for Effective Teaching and Learning. Front Public Health [Internet]. 2019 [cited 2022 Nov 25];7. Available from: https://www.frontiersin.org/articles/10.3389/fpubh.2019.00313 Leeuw FL, Donaldson SI. Theory in evaluation: Reducing confusion and encouraging debate. Evaluation. 2015 Oct 1;21(4):467–80. Kreindler SA. Advancing the evaluation of integrated knowledge translation. Health Res Policy Syst. 2018;16(1):1–10. Berman J, Mitambo C, Matanje-Mwagomba B, Khan S, Kachimanga C, Wroe E, et al. Building a knowledge translation platform in Malawi to support evidence-informed health policy. Health Res Policy Syst. 2015;13(1):73–73. audiotranskription dr.dresing & pehl GmbH. Transkription & Analyse Die f4 Familie macht’s leichter! [Internet]. Available from: https://www.audiotranskription.de/ ATLAS.ti Scientific Software Development GmbH. ATLAS.ti 22 Windows [Internet]. 2022. Available from: https://atlasti.com Limesurvey GmbH. LimeSurvey: An Open Source survey tool [Internet]. Hamburg, Germany; Available from: http://www.limesurvey.org Jenkins EK, Slemon A, Haines-Saah RJ, Oliffe J. A Guide to Multisite Qualitative Analysis. Qual Health Res. 2018 Oct 1;28(12):1969–77. Moran-Ellis J, Alexander VD, Cronin A, Dickinson M, Fielding J, Sleney J, et al. Triangulation and integration: processes, claims and implications. Qual Res. 2006 Feb;6(1):45–59. Schreier M. Qualitative Content Analysis in Practice. London, UK: SAGE Publications Ltd; 2012. O’Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for reporting qualitative research: a synthesis of recommendations. Acad Med J Assoc Am Med Coll. 2014 Sep;89(9):1245–51. Ryan N, Vieira D, Gyamfi J, Ojo T, Shelley D, Ogedegbe O, et al. Development of the ASSESS tool: a comprehenSive tool to Support rEporting and critical appraiSal of qualitative, quantitative, and mixed methods implementation reSearch outcomes. Implement Sci Commun. 2022 Mar 28;3(1):34. Abimbola S. The foreign gaze: Authorship in academic global health. BMJ Glob Health. 2019 Oct;4(5). Brennan SE, McKenzie JE, Turner T, Redman S, Makkar S, Williamson A, et al. Development and validation of SEER (Seeking, Engaging with and Evaluating Research): a measure of policymakers’ capacity to engage with and use research. Health Res Policy Syst. 2017 Jan 17;15(1):1. Rohwer AC, Jessani NS, Mbeye NM, Balugaba BE, Akiteng AR, Tumusiime D, et al. Evidence-Based Public Health Workshops: An assessment of the implementation and adaptation of training across five sub-Saharan African countries. Jessani NS, Hendricks L. Engaging with Decision-makers: Issue Briefss for policy and practice. Short Course presented at; 2022; Stellenbosch University, South Africa. Centre for Evidence-based Health Care, Stellenbosch University. Knowledge Translation. [cited 2023 Nov 13]. KT Workshops. Available from: https://www.cebhc.co.za/knowledge-translation-key-outputs/kt-workshops/ Rehfuess EA, Durão S, Kyamanywa P, Meerpohl JJ, Young T, Rohwer A. An approach for setting evidence-based and stakeholder-informed research priorities in low- and middle-income countries. Bull World Health Organ. 2016 Apr;94(4):297–305. Okop KJ, Kedir K, Kasenda S, Niyibizi JB, Chipeta E, Getachew H, et al. Multi-country collaborative citizen science projects to co-design cardiovascular disease prevention strategies and advocacy: findings from Ethiopia, Malawi, Rwanda, and South Africa. BMC Public Health. 2023 Dec 12;23(1):2484. Uwimana Nicol J, Nganabashaka JP, Tumusiime KD, Young T, Rehfuess E, Burns J. Taking stock of population-level interventions targeting risk factors for hypertension and diabetes in Rwanda and South Africa: methodological reflections and lessons learnt from conducting a multi-component situational analysis. BMC Public Health. 2023 Aug 25;23(1):1630. Uwimana-Nicol J, Hendricks L, Young T. Population-level interventions targeting risk factors of diabetes and hypertension in South Africa: a document review. BMC Public Health 2021 211. 2021 Dec;21(1):1–14. Makkar S, Brennan S, Turner T, Williamson A, Redman S, Green S. The development of SAGE: A tool to evaluate how policymakers’ engage with and use research in health policymaking. Res Eval. 2016 Jul 1;25(3):315–28. Eberly LA, Rusangwa C, Ng’ang’a L, Neal CC, Mukundiyukuri JP, Mpanusingo E, et al. Cost of integrated chronic care for severe non-communicable diseases at district hospitals in rural Rwanda. BMJ Glob Health. 2019 Jun 1;4(3):e001449. Dunn SI, Bhati DK, Reszel J, Kothari A, McCutcheon C, Graham ID. Understanding how and under what circumstances integrated knowledge translation works for people engaged in collaborative research: metasynthesis of IKTRN casebooks. JBI Evid Implement. 2023 Mar 30; Sibley KM, Hoekstra F, Kothari A, Mrklas K. 2.3 Effects, Facilitators, and Barriers of Research Coproduction Reported in Peer-Reviewed Literature. In: Research Co-Production in Healthcare [Internet]. John Wiley & Sons, Ltd; 2022 [cited 2023 Dec 13]. p. 54–73. Available from: https://onlinelibrary.wiley.com/doi/abs/10.1002/9781119757269.ch4 Langer L, Tripney J, Gough D (David A). The science of using science : researching the use of research evidence in decision-making [Internet]. London: EPPI Centre, Social Science Research Unit, Institute of Education, University of London; 2016 p. 55–55. Report No.: 978-1-907345-88–3. Available from: https://eppi.ioe.ac.uk/cms/Portals/0/PDF%20reviews%20and%20summaries/Science%202016%20Langer%20report.pdf?ver=2016-04-18-142701-867 Contandriopoulos D, Lemire M, Denis JL, Tremblay É. Knowledge Exchange Processes in Organizations and Policy Arenas: A Narrative Systematic Review of the Literature. Milbank Q. 2010;88(4):444–83. Yeung E, Scodras S, Salbach NM, Kothari A, Graham ID. Identifying competencies for integrated knowledge translation: a Delphi study. BMC Health Serv Res 2021 211. 2021 Oct;21(1):1–18. Orem J, Mafigiri D, Marchal B, Ssengooba F, MacQ J, Criel B. Research, evidence and policymaking: The perspectives of policy actors on improving uptake of evidence in health policy development and implementation in Uganda. BMC Public Health. 2012 Feb;12(1):1–16. Wathen CN, Sibbald SL, Jack SM, MacMillan HL. Talk, trust and time: a longitudinal study evaluating knowledge translation and exchange processes for research on violence against women. Implement Sci. 2011 Sep 6;6(1):102. Gilfoyle M, MacFarlane A, Hughes Z, Salsberg J. Understanding the evolution of trust in a participatory health research partnership: A qualitative study. Health Expect Int J Public Particip Health Care Health Policy. 2023 Nov 29; Larkan F, Uduma O, Lawal SA, van Bavel B. Developing a framework for successful research partnerships in global health. Glob Health. 2016 May 6;12(1):17. Henderson J, Brownlie E, Rosenkranz S, Chaim G, Beitchman J. Integrated Knowledge Translation and Grant Development: Addressing the Research Practice Gap through Stakeholder-informed Research. J Can Acad Child Adolesc Psychiatry. 2013 Nov;22(4):268–74. Boaz A, Borst R, Kok M, O’Shea A. How far does an emphasis on stakeholder engagement and co-production in research present a threat to academic identity and autonomy? A prospective study across five European countries. Res Eval [Internet]. 2021 May; Available from: https://academic.oup.com/rev/advance-article/doi/10.1093/reseval/rvab013/6272492 Kothari A, Smith MJ. Public Health Policymaking, Politics, and Evidence. In: Fafard P, Cassola A, de Leeuw E, editors. Integrating Science and Politics for Public Health [Internet]. Cham: Springer International Publishing; 2022 [cited 2023 Dec 13]. p. 59–74. (Palgrave Studies in Public Health Policy Research). Available from: https://doi.org/10.1007/978-3-030-98985-9_4 Langlois EV, Montekio VB, Young T, Song K, Alcalde-Rabanal J, Tran N. Enhancing evidence informed policymaking in complex health systems: Lessons from multi-site collaborative approaches. Health Res Policy Syst. 2016 Dec;14(1):20–20. Penuel WR, Briggs DC, Davidson KL, Herlihy C, Sherer D, Hill HC, et al. How School and District Leaders Access, Perceive, and Use Research. AERA Open. 2017 May 1;3(2):2332858417705370. Johnson K, Greenseid LO, Toal SA, King JA, Lawrenz F, Volkov B. Research on Evaluation Use: A Review of the Empirical Literature From 1986 to 2005. Am J Eval. 2009 Sep 1;30(3):377–410. Kothari A, Wathen CN. A critical second look at integrated knowledge translation. Health Policy Amst Neth. 2013 Feb;109(2):187–91. Dadich A, Vaughan P, Boydell K. The unintended negative consequences of knowledge translation in healthcare: a systematic scoping review. Health Sociol Rev. 2023 Jan 20;0(0):1–19. Oliver K, Kothari A, Mays N. The dark side of coproduction: do the costs outweigh the benefits for health research? Health Res Policy Syst. 2019;17(1):33–33. Cairney P, Boaz A, Oliver K. Translating evidence into policy and practice: what do we know already, and what would further research look like? BMJ Qual Saf. 2023 May 1;32(5):251–3. Jenkins EK, Kothari A, Bungay V, Johnson JL, Oliffe JL. Strengthening population health interventions: developing the CollaboraKTion Framework for Community-Based Knowledge Translation. Health Res Policy Syst. 2016 Aug 30;14(1):65. Kitson A, Powell K, Hoon E, Newbury J, Wilson A, Beilby J. Knowledge translation within a population health study: how do you do it? Implement Sci. 2013 May 21;8(1):54. Ongolo-Zogo P, Lavis JN, Tomson G, Sewankambo NK. Assessing the influence of knowledge translation platforms on health system policy processes to achieve the health millennium development goals in Cameroon and Uganda: a comparative case study. Health Policy Plan. 2018 May 1;33(4):539–54. Crosschild C, Huynh N, De Sousa I, Bawafaa E, Brown H. Where is critical analysis of power and positionality in knowledge translation? Health Res Policy Syst. 2021 Jun 11;19:92. Footnotes [1] IKT is defined as an ‘ongoing relationship between researchers and decision-makers’ (1) and is distinct from broader ‘knowledge user’ or ‘stakeholder’ engagement. However, some IKT strategies included stakeholders beyond decision-makers (e.g. academic or NGO staff), which is why we use both terms interchangeably. [2] Country omitted to maintain anonymity Additional Declarations No competing interests reported. Supplementary Files Supplement1ASSESStool.xlsx Supplement 1: ASSESS tool Supplement2collabresearchfrequencies.docx Supplement 2: Collaborative research table Supplement3Codingframe20230612.xlsx Supplement 3: Coding frame Cite Share Download PDF Status: Published Journal Publication published 10 Dec, 2024 Read the published version in Health Research Policy and Systems → Version 1 posted Editorial decision: Revision requested 10 Nov, 2024 Reviews received at journal 18 Jun, 2024 Reviewers agreed at journal 22 May, 2024 Reviewers agreed at journal 22 May, 2024 Reviewers invited by journal 20 May, 2024 Submission checks completed at journal 20 May, 2024 Editor assigned by journal 20 May, 2024 First submitted to journal 23 Apr, 2024 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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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4312132","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":294553349,"identity":"af953800-7072-4b35-8ee8-c6920caed5be","order_by":0,"name":"Kerstin 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1","display":"","copyAsset":false,"role":"figure","size":688680,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eInitial programme theory of the CEBHA+ IKT approach\u003c/em\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4312132/v1/587064033d1169994a9ad543.png"},{"id":56204278,"identity":"e3b8b279-a564-46da-ae03-1194ff5776e7","added_by":"auto","created_at":"2024-05-09 20:45:01","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":59058,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eResearch skills and research use skills, in 2020 and 2022, respectively\u003c/em\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4312132/v1/b2bdc7a58fe8c9beb7fcbd53.png"},{"id":56205204,"identity":"d90ee910-b576-4da4-bc95-9ed39a2d8459","added_by":"auto","created_at":"2024-05-09 21:01:01","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":53480,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eResearchers’ and decision-makers’ changes in knowledge, in 2020 and 2022, respectively\u003c/em\u003e\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-4312132/v1/80853ea1c2ec3472537ac8b2.png"},{"id":56204283,"identity":"b26f8a66-6663-4e83-b577-b8b80ec396fe","added_by":"auto","created_at":"2024-05-09 20:45:05","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":86887,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eRevised programme theory of the CEBHA+ IKT approach\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eLegend: DM = decision-makers, RS = researchers; Macro context: KT landscape, research governance, research funding, COVID-19; organisational context: KT training \u0026amp; structures, staff continuity, senior staff support, decision-making agenda \u0026amp; priorities, available resources, time, absorptive capacity, organisation’s reputation, pre-existing relationships; project-specific context: IKT deliverables, resources, project priorities and timelines, complexity of the project; individual characteristics: Past experience undertaking IKT/KT or collaborative research, IKT / EIDM attitudes, personal interest \u0026amp; motivation.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-4312132/v1/bd14c8e897d01740697c563b.png"},{"id":71552336,"identity":"9b83d8e3-44f2-4a8e-ad5b-51e106042812","added_by":"auto","created_at":"2024-12-16 16:04:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2309344,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4312132/v1/6b52f9b3-d585-40d1-918a-9120822c328e.pdf"},{"id":56204282,"identity":"0ccbc166-9de3-4828-b777-6953b17207e0","added_by":"auto","created_at":"2024-05-09 20:45:04","extension":"xlsx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":39758,"visible":true,"origin":"","legend":"\u003cp\u003eSupplement 1: ASSESS tool\u003c/p\u003e","description":"","filename":"Supplement1ASSESStool.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-4312132/v1/58f9d0b6a0eea729446b08f5.xlsx"},{"id":56204280,"identity":"c5f66363-1ae8-41c6-ba8b-e47b590b4a72","added_by":"auto","created_at":"2024-05-09 20:45:02","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":26024,"visible":true,"origin":"","legend":"\u003cp\u003eSupplement 2: Collaborative research table\u003c/p\u003e","description":"","filename":"Supplement2collabresearchfrequencies.docx","url":"https://assets-eu.researchsquare.com/files/rs-4312132/v1/c330902a39f0aad588bace2c.docx"},{"id":56205205,"identity":"8c087800-040d-4a90-a764-4c711cd1b9e3","added_by":"auto","created_at":"2024-05-09 21:01:02","extension":"xlsx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":89523,"visible":true,"origin":"","legend":"\u003cp\u003eSupplement 3: Coding frame\u003c/p\u003e","description":"","filename":"Supplement3Codingframe20230612.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-4312132/v1/b0e3d0e47a66eb2c6deb6fce.xlsx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Outcomes of an integrated knowledge translation approach in five African countries: A mixed methods comparative case study","fulltext":[{"header":"Background","content":"\u003cp\u003eIntegrated knowledge translation (IKT) describes an ongoing relationship between researchers and knowledge users and constitutes one approach to enhancing evidence-informed decision-making (EIDM) in healthcare and public health\u0026nbsp;(1,2). IKT goes beyond \u0026lsquo;simple\u0026rsquo; knowledge translation (KT), originally defined as the \u0026lsquo;synthesis, exchange, and application of knowledge by relevant stakeholders to accelerate the benefits of global and local innovation in strengthening health systems and improving people\u0026rsquo;s health\u0026rsquo;\u0026nbsp;(3). KT encompasses the production and utilisation of knowledge in a cyclical knowledge-to-action process\u0026nbsp;(4)\u0026nbsp;whilst IKT underpins this and emphasises the building of \u003cem\u003econtinuous\u003c/em\u003e relationships between researchers and knowledge users, which are considered key to fostering (i) evidence uptake, (ii) the production of relevant research, and (iii) conditions that facilitate EIDM\u0026nbsp;(5).\u003c/p\u003e\n\u003cp\u003eIKT is distinct from other collaborative research approaches by focussing on knowledge users with the authority to implement policy or practice changes\u0026nbsp;(6). This emphasis on involving decision-makers, including policy-makers, sets IKT apart from, for example, community-based participatory research\u0026nbsp;(7)\u0026nbsp;and engaged scholarship\u0026nbsp;(8). Nevertheless, all these approaches are similar in their intent to democratise knowledge creation and use, and in that they require substantial time and resources\u0026nbsp;(8). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eInterest in IKT has increased, including among research funders who view the involvement of knowledge users and KT activities as critical for achieving research impact\u0026nbsp;(9,10), which serves as a justification for public funding of research\u0026nbsp;(11). Whilst the promises of IKT are widely acknowledged, until recently, IKT outcomes have rarely been evaluated\u0026nbsp;(1). Reasons include political and logistical challenges\u0026nbsp;(12), and lack of conceptual clarity, evaluation tools and guidance\u0026nbsp;(13). Since our research was conceptualised, more frameworks for KT and IKT\u0026nbsp;(14\u0026ndash;16)\u0026nbsp;and tools to evaluate research partnerships including IKT have become available\u0026nbsp;(17\u0026ndash;19)\u0026nbsp;and several evidence syntheses of available (I)KT evaluations and descriptions have been undertaken\u0026nbsp;(1,20), including in African settings\u0026nbsp;(2,21\u0026ndash;23). Edwards et al. (2019) emphasise the potential of IKT for African health research settings; they identified the sustained engagement of knowledge users as a key facilitator to KT efforts and found that KT strategies drawing on integrated efforts or longer-term exchange featured prominently among existing strategies\u0026nbsp;(23). However, they noted that (I)KT strategies were still under-described, as also noted internationally\u0026nbsp;(1). They also concluded that there remains a \u0026lsquo;persistently unclear change pathway between research, KT strategies and policy formulation\u0026rsquo;\u0026nbsp;(23). This underpins that, paradoxically, EIDM lacks a rigorous evidence base for effective strategies\u0026nbsp;(12).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDespite emerging evidence that IKT is associated with improved capacity to use evidence among knowledge users and production of more relevant research, empirical research on IKT outcomes is still limited (1,5). No study to date has examined IKT outcomes across multiple African countries and research employing theoretical frameworks addressing this gap has been strongly recommended (23).\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eObjectives \u003c/h2\u003e\n\u003cp\u003eWe describe proximal, intermediate, and distal outcomes of the CEBHA+ IKT approach. As secondary objectives, we explore variation across the five African sites and revisit the CEBHA+ IKT programme theory.\u0026nbsp;\u003c/p\u003e"},{"header":"Methods","content":"\u003ch2\u003eResearch approach and paradigm\u003c/h2\u003e\n\u003cp\u003eWe undertook a mixed methods comparative case study employing\u0026nbsp;semi-structured interviews and an online survey at two evaluation stages (subsequently \u0026lsquo;waves\u0026rsquo;; 3/2020-2/2021 for the first wave and 9/2022-5/2023 for the second wave). Documents were collected until June 2023.\u0026nbsp;Our methods largely followed the protocol\u0026nbsp;(24)\u0026nbsp;but we had to make some adaptations linked to\u0026nbsp;the COVID-19 pandemic and staff turnover. These included a change from face-to-face to online interviews during the first wave; during the second wave, they entailed a switch from interviews to online focus group discussions (FGDs) and foregoing interviews with decision-makers.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOur work was informed by a critical realist\u0026nbsp;research paradigm. This is rooted in an understanding an objective reality exists and that this can be studied using scientific methods \u0026ndash; whilst such knowledge is subjective and socially constructed reflecting \u0026lsquo;epistemological relativism and ontological realism\u0026rsquo;\u0026nbsp;(25). Evaluations rooted in critical realism are intended to generate understanding about causal mechanisms and context and incorporate programme theories\u0026nbsp;(26)\u0026nbsp;to delineate \u0026lsquo;what works, for whom, why and in what circumstances\u0026rsquo; \u0026nbsp;(27).\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eIntervention description and implementation\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eThis study was undertaken in the context of the \u003cem\u003eCollaboration for Evidence-Based Healthcare and Public Health in Africa\u0026nbsp;\u003c/em\u003e(CEBHA\u0026thinsp;+). The consortium comprised nine academic institutions in Ethiopia, Germany, Malawi, Rwanda, South Africa, and Uganda, and was funded by the German Federal Ministry of Education and Research from 2017 to 2023. It aimed to conduct policy-relevant and practice-relevant research on the prevention and integrated care of non-communicable diseases (NCDs), notably diabetes and hypertension, and road traffic injuries. The German project partner LMU Munich was tasked with leading on the development and evaluation of the CEBHA+ IKT approach.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe \u003cstrong\u003eCEBHA+ IKT approach\u003c/strong\u003e entailed training and guidance on IKT and the implementation of IKT strategies at the five African sites. A detailed description (28) and reflections about the IKT experiences in CEBHA+ were previously published (29\u0026ndash;32). Systematic approaches for mapping and analysing stakeholders[1] and for developing and implementing an \u0026lsquo;IKT strategy\u0026rsquo; were key tools (33,34). Both tools enabled researchers to strategically collaborate with partners from policy and practice from the start of the project. Initially, they were utilised widely but less so at later stages in the project (28). Ongoing IKT activities were coordinated by one or two \u0026lsquo;IKT focal points\u0026rsquo; per CEBHA+ institution. IKT focal points and IKT evaluators (the \u0026lsquo;IKT team\u0026rsquo;) met quarterly online to discuss IKT experiences, forming a community of practice.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eProgramme theory\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eWe were not able to identify an existing programme theory for IKT that fit our scope. Programme theories guide evaluation by making assumptions about underlying mechanisms explicit (35). We therefore developed a programme theory, informed by a scoping review of IKT evaluations (1) and further purposively selected literature: hypothesised \u003cstrong\u003eproximal outcomes\u003c/strong\u003e were relationship-building, capacity-building, and collaborative research, as suggested by realist IKT theory (36). \u003cstrong\u003eIntermediate outcomes\u003c/strong\u003e included changes in attitudes and evidence use behaviour of decision-makers (5,36). Ultimately, we hypothesised that IKT would lead to increased use of contextualised research evidence in decision-making (conceptualised as the \u003cstrong\u003efinal outcome\u003c/strong\u003e) (Figure 1).\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eIntervention context\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eKT structures and culture pre-existed at all sites but varied considerably\u0026nbsp;(28). This included a strong focus on EIDM among academic institutions in South Africa, government policy mandating community engagement in research in Rwanda, a KT platform in Malawi\u0026nbsp;(37), and long-time practice of engaging stakeholders in Uganda.\u0026nbsp;The research environment\u0026nbsp;was shaped by resource constraints, with research depending on foreign funders, whose research agenda is often misaligned with local priorities\u0026nbsp;(22).\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eSampling strategy\u003c/h2\u003e\n\u003cp\u003eAll CEBHA+ researchers involved in IKT were eligible for inclusion. Policy and practice partners were eligible when they collaborated actively, were over 18 years old, and English-speaking. We did not undertake a sample size calculation, nor did we define a cut-off for inclusion of participants when data saturation would be reached due to the generally limited number of eligible individuals.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eData collection methods\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eData collection for the \u003cstrong\u003efirst wave\u003c/strong\u003e depended on the timing of the respective approval from local institutional review boards, resulting in a long data collection phase (3/2020\u0026ndash;2/2021). The first wave therefore does not constitute a baseline assessment. Interviews were conducted in-person in Malawi. Following the onset of the COVID-19 pandemic, interviews were almost exclusively conducted online, except for interviews with Ugandan stakeholders, some of which were conducted in person by trained local staff. Researchers were contacted via email and invited to the interview and survey. Stakeholders were invited by their respective CEBHA+ contact who forwarded a formal invitation letter. Data collection for the \u003cstrong\u003esecond wave\u003c/strong\u003e took place during project finalisation (9/2022\u0026ndash;5/2023).\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eData collection instruments\u0026nbsp;\u003c/h2\u003e\n\u003ch3\u003eInstrument development\u003c/h3\u003e\n\u003cp\u003eAs we were not able to identify suitable instruments we developed CEBHA+ surveys and interview guides based on relevant survey constructs from existing instruments, identified in a purposive search and drawing on our programme theory, as reported elsewhere\u0026nbsp;(24). Surveys consisted of a demographic survey, followed by 69 questions for stakeholders and 62 for researchers in 8 dimensions, corresponding with the programme theory constructs. Semi-structured interview guides consisted of 9 topic areas, each including multiple probing questions on the constructs. We developed and pilot-tested stakeholder and researcher versions. All instruments are available elsewhere\u0026nbsp;(24).\u003c/p\u003e\n\u003ch3\u003eDocuments\u003c/h3\u003e\n\u003cp\u003eWe included internal and external IKT-related documents.\u0026nbsp;IKT updates, the main source of internal documents, were submitted by the IKT implementers every three months and replaced monitoring with a bespoke tool, which proved infeasible\u0026nbsp;(28). External documents\u0026nbsp;mentioned by CEBHA+ researchers\u0026nbsp;(e.g. guidelines, policy documents)\u0026nbsp;were included and supplemented with documents identified in a purposive google search.\u003c/p\u003e\n\u003ch2\u003eData processing\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eInterviews were recorded using the online conference tools\u0026rsquo; recording function or a handheld recorder (OLYMPUS LS-P1). The interviewer wrote a memo after every interview. Recordings were securely stored on an encrypted device and transcribed verbatim by Audiotranskription, a transcription service complying with required levels of data protection\u0026nbsp;(38). Transcripts were provided to the interviewees for review. Original audio files were deleted after transcription. Transcripts and\u0026nbsp;documents were pseudonymised and analysed in ATLAS.ti\u0026nbsp;(39). We conducted surveys in the online tool Limesurvey\u0026nbsp;(40). Anonymous survey data were exported and analysed in Microsoft Excel.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eData analysis\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eWe considered the five African sites as \u0026lsquo;cases\u0026rsquo;, analysing data separately per case (where possible) and subsequently comparing results across cases\u0026nbsp;(41). We initially analysed data from surveys, interviews, documents, and focus groups separately, integrating these over time\u0026nbsp;(42).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eQuantitative survey data was analysed descriptively, by sub-group (researchers, stakeholders). For qualitative content analysis, domains and constructs of the programme theory served as the initial coding frame\u0026nbsp;(24,43). One researcher (KS) coded interviews and documents, applying codes deductively and inductively developing new codes and categories. Co-authors (JO, EB) reviewed the codebook and applied the coding frame to one interview each, which led to further refinement. One researcher (KS) applied the final coding frame to the entirety of included material, and double-coded the material. A subset of the coding was reviewed by a second researcher.\u003c/p\u003e\n\u003cp\u003eOne researcher (KS) then reviewed categories, associated codes and quantitative data by site and across sites and drafted the initial results section through \u0026lsquo;theoretical integration\u0026rsquo;\u0026nbsp;(42)\u0026nbsp;and \u0026lsquo;abstraction and retroduction\u0026rsquo;\u0026nbsp;(25), which was reviewed by co-authors, discussed, and iteratively revised. Throughout this process, we adapted and expanded programme theory sub-constructs. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eScientific rigour was enhanced by following the \u003cem\u003eStandards for Reporting Qualitative Research\u003c/em\u003e (44)\u0026nbsp;and using the\u0026nbsp;ASSESS reporting tool, intended to harmonise reporting of implementation-focused studies employing mixed methodologies\u0026nbsp;(45)\u0026nbsp;(Supplement 1).\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eResearcher characteristics and reflexivity\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eKS, ER and LMP are based at a well-resourced university in Germany. They are from non-migrant, academic backgrounds and have some to moderate research experience in African settings. JO, EB and BG are from Uganda and Ethiopia, respectively, with substantial research experience in their countries and some research experience in Europe (JO) and the United States (BG). Whilst we aimed to address the issues around power, \u0026lsquo;foreign gaze and pose\u0026rsquo; (46) in this collaborative work we were unable to achieve this to the extent we would have aspired to as the write-up of this publication occurred after project funding had expired. Thus, our results are likely to reflect the social positions and experience of the German authors more strongly than those of the other authors.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThree authors were part of a small group of \u0026lsquo;IKT experts\u0026rsquo; that developed and launched the IKT approach (LMP, ER) and provided continuous support for IKT implementers (KS). Whilst this level of involvement in IKT implementation was critical for enabling a deeper understanding of the implementation process, it blurs the lines between evaluators and implementers.\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003ch2\u003eCharacteristics of study participants\u003c/h2\u003e\n\u003cp\u003eA total of 36 researchers and nineteen decision-makers participated in one or both waves (Table 1). In the first wave, 25 researchers and ten decision-makers participated. In this wave, no decision-makers from Rwanda and Ethiopia were involved as we deemed it unethical to approach them at the height of the COVID-19 pandemic. In 2022, no decision-makers from South Africa were approached for logistical reasons. In the second wave, 27 researchers were surveyed of which seven participated in a focus group discussion.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTABLE 1 STUDY PARTICIPANTS\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTable 1\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eOverview of study participants\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.489795918367346%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.755102040816325%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCEBHA+ researchers\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.755102040816325%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDecision-makers\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e1\u003csup\u003est\u003c/sup\u003e wave\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e2\u003csup\u003end\u003c/sup\u003e wave\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e1\u003csup\u003est\u003c/sup\u003e wave\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e2\u003csup\u003end\u003c/sup\u003e wave\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal N participants\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSurvey\u0026nbsp;\u003c/strong\u003en responses\u003csup\u003e\u0026nbsp;\u003c/sup\u003e\u003csub\u003ea\u003c/sub\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e24\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e27\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSurvey\u0026nbsp;\u003c/strong\u003eresponse rate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e24/26 (92 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e27/32 (84 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e7/14 (50 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e11/16 (69 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eInterview\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFGD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eBoth\u0026nbsp;\u003c/strong\u003e(survey and interview or FGD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCountry\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003eEthiopia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003eMalawi\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003eRwanda\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003eSouth Africa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003eUganda\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003ePrefer not to say\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eHighest educational background\u0026nbsp;\u003c/strong\u003e\u003csub\u003eb\u003c/sub\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003eDoctorate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003eMaster\u0026rsquo;s degree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003eProfessional degree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003eBachelor\u0026rsquo;s degree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eProfessional background\u0026nbsp;\u003c/strong\u003e\u003csub\u003eb\u003c/sub\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003ePublic Health\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003eMedicine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003eEpidemiology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eInstitution \u003csub\u003eb\u003c/sub\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003eUniversity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003eResearch Institute (not within a university)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003eGovernment department\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003eRegional or local health authority\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003eNon-governmental organisation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime at this institution\u0026nbsp;\u003c/strong\u003e\u003csub\u003eb\u003c/sub\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003eOne year or less\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e2 or 3 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e4 or 5 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e6 \u0026ndash; 10 years\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e11 \u0026ndash; 15 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003eMore than 15 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eOverall work experience in the field\u0026nbsp;\u003c/strong\u003e\u003csub\u003eb\u003c/sub\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e5 years or less\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e6 \u0026ndash; 10 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e11 \u0026ndash; 15 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003eMore than 15 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.75%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eLegend\u003c/strong\u003e: FGD: focus group discussion; \u003csub\u003ea\u003c/sub\u003e\u003csup\u003e\u0026nbsp;\u003c/sup\u003eparticipant numbers include incomplete forms (n =1; except in the DM 2020 wave); \u003csub\u003eb\u003c/sub\u003e\u003csup\u003e\u0026nbsp;\u003c/sup\u003ebased on sociodemographic information in survey responses;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003ch2\u003eIncluded documents\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eWe included 92 IKT-related internal and external documents (Table 2).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTable 2\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e: Included documents\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"642\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.985915492957748%\" valign=\"top\"\u003e\u0026nbsp;\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.859154929577464%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eEthiopia\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.859154929577464%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMalawi\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.859154929577464%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eRwanda\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.859154929577464%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSouth Africa\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.859154929577464%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eUganda\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.859154929577464%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eOther\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.859154929577464%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.985915492957748%\" valign=\"top\"\u003e\n \u003cp\u003eIKT strategies (including revised versions)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.859154929577464%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.859154929577464%\" valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.859154929577464%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.859154929577464%\" valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.859154929577464%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.859154929577464%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.859154929577464%\" valign=\"top\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.985915492957748%\" valign=\"top\"\u003e\n \u003cp\u003eIKT \u0026lsquo;updates\u0026rsquo;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.859154929577464%\" valign=\"top\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.859154929577464%\" valign=\"top\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.859154929577464%\" valign=\"top\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.859154929577464%\" valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.859154929577464%\" valign=\"top\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.859154929577464%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.859154929577464%\" valign=\"top\"\u003e\n \u003cp\u003e44\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.985915492957748%\" valign=\"top\"\u003e\n \u003cp\u003eDocumentation of IKT activities (e.g. meeting minutes)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.859154929577464%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.859154929577464%\" valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.859154929577464%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.859154929577464%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.859154929577464%\" valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.859154929577464%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.859154929577464%\" valign=\"top\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.985915492957748%\" valign=\"top\"\u003e\n \u003cp\u003eIKT team call minutes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.859154929577464%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.859154929577464%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.859154929577464%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.859154929577464%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.859154929577464%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.859154929577464%\" valign=\"top\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.859154929577464%\" valign=\"top\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.985915492957748%\" valign=\"top\"\u003e\n \u003cp\u003eExternal documents (e.g. National Strategic Plans for NCDs or Road Safety, funder-initiated evaluation, WHO guideline, transport policy)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.859154929577464%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.859154929577464%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.859154929577464%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.859154929577464%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.859154929577464%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.859154929577464%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.859154929577464%\" valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.985915492957748%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAll documents\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.859154929577464%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.859154929577464%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.859154929577464%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.859154929577464%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.859154929577464%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.859154929577464%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.859154929577464%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e92\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eProximal outcomes\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eWe identified proximal outcomes related to \u003cstrong\u003ecapacity-building, relationship-building\u003c/strong\u003e, and \u003cstrong\u003ecollaborative research\u003c/strong\u003e.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eCapacity-building\u003c/h3\u003e\n\u003cp\u003eCapacity-building is a multi-level concept\u0026nbsp;(47). In our initial programme theory, hypothesised outcomes included only individual-level outcomes, notably \u0026lsquo;access to information and contacts\u0026rsquo;, \u0026lsquo;broadened perspective and skills\u0026rsquo;, and \u0026lsquo;capacity for collaboration\u0026rsquo;. Below, we expand these to capacity-building at the (i) individual and (ii) organisational level as well as capacity-building contributing to an (iii) enabling environment\u0026nbsp;(47).\u0026nbsp;\u003c/p\u003e\n\u003ch4\u003eIndividual-level capacity-building\u0026nbsp;\u003c/h4\u003e\n\u003cp\u003eResearch and research use skills\u003c/p\u003e\n\u003cp\u003eResearchers reported mostly positive results with respect to \u003cstrong\u003eresearch skills\u003c/strong\u003e gained (Figure 2). Approximately 80% of researchers indicated that the collaboration had increased their receptiveness to new ideas or evidence ((n=21 (2020), n=25 (2022)); and provided them with an opportunity for personal or professional development (n=19 (2020), n=21 (2022)). Fewer respondents indicated that they had improved their capacity to develop research questions, conduct research, and improve their ability to access relevant research information. In qualitative data, there was little reference to research skills gained.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe majority of decision-makers indicated that the collaboration had helped them increase their \u003cstrong\u003eresearch use skills\u003c/strong\u003e, that is to locate, evaluate, interpret, and apply research evidence (Figure 2). In qualitative data, there was no reference to evidence use skills, except for researchers in Uganda and Rwanda reporting that decision-makers were interested in learning research methods.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFIGURE 2\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFigure 2\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e: Research skills and research use skills, in 2020 and 2022, respectively\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003ch5\u003eIKT skills\u003c/h5\u003e\n\u003cp\u003eIKT skills relate to the identification of stakeholders, development and implementation of an IKT strategy and general stakeholder engagement (Table 3). Most researchers already had substantial experience in stakeholder engagement as part of their work routine. They reported high levels of comfort and skills to engage in the research collaboration but few had received prior KT training. At the second wave, 88% of surveyed researchers indicated that the IKT approach helped them to make deliberate decisions about stakeholder engagement, 92% felt comfortable advising colleagues on this, and 77% would recommend an IKT approach in future projects.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIKT skills were not investigated in our survey but featured strongly in qualitative data. In general, researchers from all countries had developed substantial skills in developing and implementing an IKT strategy and honed general stakeholder engagement skills (Table 3). However, skills related to de-prioritisation of stakeholders were only mentioned as important by three interviewees from South Africa. Knowledge of \u003cstrong\u003eIKT as a theoretical concept\u003c/strong\u003e and an area of research remained more ambiguous with researchers frequently describing that they were on a \u0026lsquo;learning curve\u0026rsquo;.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTable 3\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e\u0026nbsp;IKT skills\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"954\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.779874213836479%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eIKT skills sub-category\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.884696016771489%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSkills\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"70.33542976939204%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDetail and\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eexemplifying\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;quotes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.779874213836479%\" valign=\"top\"\u003e\n \u003cp\u003eStakeholder identification skills\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.884696016771489%\" valign=\"top\"\u003e\n \u003cp\u003eSkills to identify, map, prioritise, and analyse stakeholders\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"70.33542976939204%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lsquo;Yes, so, when we did the stakeholder mapping, we specifically said what we needed each stakeholder for because they have different strengths and [\u0026hellip;] areas of expertise.\u0026rsquo; (MW RS 4)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026lsquo;But also, which stakeholders can also negatively influence how your research/ [\u0026hellip;] how well it\u0026apos;s received.\u0026rsquo; (MW RS 2)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.779874213836479%\" rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003eIKT strategy development and implementation skills\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.884696016771489%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eSkills to choose the appropriate timing for IKT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"70.33542976939204%\" valign=\"top\"\u003e\n \u003cp\u003eIncludes consideration of current stakeholder priorities and timeliness of responses:\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026lsquo;You can\u0026apos;t ignore [\u0026hellip;] what issues are priorities at that time. So, like a month before the election, people are very, very busy in every Ministry [\u0026hellip;]/ So, you can\u0026apos;t go there and then say, \u0026ldquo;I want to talk about salt reduction, and, you know.\u0026rdquo; You have to sense the time.\u0026rsquo; (MW RS 4)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u0026lsquo;[\u0026hellip;] within CEBHA and also within other projects, the one thing that I\u0026rsquo;ve learned is around timeliness of responses and engagements and knowing when is the right time to contact and ask for information and also the right time for putting things forward [\u0026hellip;]. And so I think key to keeping that relationship going is timeliness of information [\u0026hellip;]/ people at the policy level are inundated with a lot of requests and lots of different researchers coming to them from all different fronts. So you must find ways of not also adding to that burden.\u0026rsquo; (SA RS 7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"top\"\u003e\n \u003cp\u003eIncludes consideration of when not to engage stakeholders:\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026lsquo;And there\u0026rsquo;s been moments where we\u0026rsquo;ve had to make decisions that actually maybe now is not a good time to actually engage that stakeholder about this particular issue because, in a month\u0026rsquo;s time, we want to engage them about something else.\u0026rsquo;\u0026nbsp;(SA RS 4)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.466174661746617%\" valign=\"top\"\u003e\n \u003cp\u003eSkills to choose the appropriate messenger for IKT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"82.53382533825338%\" valign=\"top\"\u003e\n \u003cp\u003eIncluded various strategies:\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eidentifying a team member who was \u0026lsquo;exceptionally good at forming personal relationships\u0026rsquo; (Ethiopia)\u003c/li\u003e\n \u003cli\u003eassigning messengers based on geographical proximity (Malawi)\u003c/li\u003e\n \u003cli\u003eusing researchers\u0026rsquo; long-standing contacts (all teams)\u003c/li\u003e\n \u003cli\u003eenlisting stakeholders as messengers, e.g. lower rank staff within the same organisation to follow-up with senior staff (Uganda)\u003c/li\u003e\n \u003cli\u003eaccessing new contacts through existing stakeholder contacts (Rwanda, South Africa, Malawi)\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026lsquo;[\u0026hellip; our messenger] varies from our communication to another one. [\u0026hellip;] For example, [\u0026hellip; researcher] who has been working with a specific stakeholder like RBC, the Department of NCDs, [it is therefore] easier to let him continue in that way and keep enforcing the ties that are existing between the two institutions.\u0026rsquo; (RW RS 2)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.779874213836479%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.884696016771489%\" valign=\"top\"\u003e\n \u003cp\u003eSkills to choose the appropriate forum and medium for IKT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"70.33542976939204%\" valign=\"top\"\u003e\n \u003cp\u003eIncluded skills in\u0026nbsp;developing issue briefs.\u003c/p\u003e\n \u003cp\u003eIncluded gauging whether stakeholders preferred further in-person meetings after initial face-to-face meetings and using conferences and trainings strategically as for a for engagement.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.779874213836479%\" valign=\"top\"\u003e\n \u003cp\u003eGeneral stakeholder engagement skills\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.884696016771489%\" valign=\"top\"\u003e\n \u003cp\u003eUnderstanding stakeholder needs and interests\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"70.33542976939204%\" valign=\"top\"\u003e\n \u003cp\u003eClosely linked to skills in stakeholder mapping and IKT strategy development: Understanding of stakeholders\u0026rsquo; motivation helped researchers to choose an appropriate engagement strategy.\u0026nbsp;Strategies included:\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003ehighligting of the \u0026lsquo;mutual benefit\u0026rsquo; of the collaboration\u003c/li\u003e\n \u003cli\u003eshowing appreciation for stakeholders\u0026rsquo;\u0026nbsp;input, e.g. by involving them as guest speakers\u003c/li\u003e\n \u003cli\u003emonetary or in-kind incentives:\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026lsquo;So for a lot of governmental departments, they will meet you if there\u0026apos;s an allowance involved. So if you have a Skype meeting, for example, they don\u0026apos;t really benefit anything.\u0026nbsp;We can\u0026apos;t get their transport reimbursed.\u0026rsquo; (MW RS 2)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.779874213836479%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.884696016771489%\" valign=\"top\"\u003e\n \u003cp\u003eDealing with staff turnover\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"70.33542976939204%\" valign=\"top\"\u003e\n \u003cp\u003eUgandan and South African teams strategically established multiple connections to address this challenge:\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026lsquo;[\u0026hellip;] if we are contacting Ministry of Health, [\u0026hellip;] we should not focus on one person. [\u0026hellip;] This has been a lesson to us. Never have just one person involved as a stakeholder from one organisation.\u0026rsquo; (UG RS 1)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026lsquo;And to have multiple members of our staff know about those and be introduced to those relationships, so that we never are in a situation where we have a fractured relationship, [\u0026hellip;] that\u0026apos;s been really important in terms of our strategy, irrespective of who\u0026apos;s maintaining the relationships that were not overly reliant on individuals.\u0026rsquo;\u0026nbsp;(SA RS 3)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.779874213836479%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.884696016771489%\" valign=\"top\"\u003e\n \u003cp\u003eDealing with stakeholder power\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"70.33542976939204%\" valign=\"top\"\u003e\n \u003cp\u003eThis was actively considered at the stakeholder mapping phase but was otherwise rarely addressed explicitly. Skills in navigating power imbalances in the research collaboration are still evident implicitly through the variety of strategies employed by researchers to deal with this challenge:\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003emaking concessions to high-level decision-makers to accommodate their schedule\u003c/li\u003e\n \u003cli\u003econsidering hierarchies to choose an appropriate messenger\u003c/li\u003e\n \u003cli\u003ebalancing of researchers\u0026rsquo; support of the decision-maker\u0026rsquo;s agenda\u003c/li\u003e\n \u003cli\u003emanaging of expectations regarding such tasks and available resources:\u0026nbsp;\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026lsquo;[Decision-makers] will be very excited about the project. But then they will have ideas on what it is they want to add. And you\u0026apos;re like, \u0026quot;No. [\u0026hellip;] it would be wonderful to do that. But that\u0026apos;s not part of my plan. And I actually don\u0026apos;t have the resources for that\u0026quot;. So it\u0026apos;s something that one has to do. I think be wise. How do you say it without saying only interested in your own activity, which you can fund.\u0026ldquo;\u0026nbsp;(UG RS 2)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eTABLE 3 IKT SKILLS\u003c/p\u003e\n\u003ch4\u003eOrganisational-level capacity-building\u0026nbsp;\u003c/h4\u003e\n\u003cp\u003eOrganisational capacity-building occurred to a variable extent. \u003cstrong\u003eIKT staff time\u0026nbsp;\u003c/strong\u003ewas under-budgeted for in four countries, which meant that IKT focal points undertook IKT in addition to other work (Ethiopia, Rwanda, Uganda). In Malawi, an intern coordinated IKT activities. The resulting limited staff time for IKT, in combination with insufficient IKT training and staff turnover, led to persisting uncertainty about the roles of IKT focal points\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eand lack of team buy-in, hampering organisational capacity-building:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026lsquo;[\u0026hellip;] we got trained [in IKT]. We came back to train others. I mean we were not experts, okay. So [\u0026hellip;] in the way we transferred the information [\u0026hellip;] we did not/ were not able to convince people, our colleagues to really take it very serious.\u0026rsquo; (MW RS 3)\u003c/p\u003e\n\u003cp\u003eEfforts to build \u003cstrong\u003estructures for organisational capacity\u0026nbsp;\u003c/strong\u003efor EIDM included the development of an evidence-based public health course which was run in all CEBHA+ countries (48). In South Africa, this complemented one institution\u0026rsquo;s existing KT and issue brief courses (33,34,49,50), which were attended by some CEBHA+ researchers. The Ethiopian team\u0026rsquo;s collaboration with the new knowledge management unit at AHRI and the KT unit at the Ethiopian Public Health Institute contributed to cross-institutional capacity-building.\u003c/p\u003e\n\u003ch4\u003eCapacity-building for an enabling environment\u003c/h4\u003e\n\u003cp\u003eThe Malawi team partially revived an existing KT platform. In South Africa, the NCD symposium (2020) presented an opportunity for a variety of actors to network and access local NCD research. The Ugandan team\u0026rsquo;s effort to improve road traffic data involved data collection training for police officers. The Ethiopian team initiated a longitudinal training and mentorship for junior researchers who undertook systematic reviews on topics prioritised by the Ministry of Health (MOH). Of note, none of these efforts were CEBHA+ deliverables. Instead, capacity-building for an enabling environment addressed local needs.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eRelationship-building\u003c/h3\u003e\n\u003cp\u003eRelationship-building is a process of establishing, strengthening and maintaining relationships. In our initial programme theory, outcomes linked to relationship-building were mutual understanding, trust, and attitudes. These were revised to include (i) appreciation, (ii) trust, (iii) partnership formation, and (iv) access to contacts and networks.\u003c/p\u003e\n\u003ch4\u003eAppreciation\u0026nbsp;\u003c/h4\u003e\n\u003cp\u003eIn quantitative and qualitative data, appreciation for the collaboration, the respective partner, and for early engagement featured prominently. Most survey respondents agreed that contributions of partners were valued, that the collaboration incorporated broad perspectives and added value to the research. Agreement was lower for statements about acknowledgement in project reports and of partners\u0026rsquo; views (Table 4).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDecision-makers strongly valued being involved by researchers early on in the research process and were content to provide input, which facilitated later work:\u003c/p\u003e\n\u003cp\u003e\u0026lsquo;[Partners were] part of our planning meetings. They were the ones who told us you haven\u0026apos;t thought about this, you haven\u0026apos;t thought about that, you haven\u0026apos;t included this person. So, it was very easy to go back to them once we started collecting data, and say, \u0026ldquo;[\u0026hellip;] we\u0026apos;re having a problem in this area. Can you help?\u0026rdquo; They were very keen to help because they already knew about us.\u0026rsquo; (MW RS 4)\u003c/p\u003e\n\u003cp\u003eStakeholders appreciated the collaborative approach as it contrasted with usual practice:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026lsquo;We hear from [community stakeholders] that the CEBHA project is a good research because it has involved them, it is not the same as other research projects which come and collect data without involving them. They said if other studies are conducted like CEBHA it would be fine. So for them they are appreciating it.\u0026rsquo; (RW RS 5)\u003c/p\u003e\n\u003cp\u003eIn Uganda, stakeholders appreciated the CEBHA+ meetings for providing a forum for conversation between various road transport stakeholders who would not normally talk to each.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTable 4:\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e\u0026nbsp;Relationship-building outcomes: appreciation, trust\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"603\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.53565505804312%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.23217247097844%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eResearchers\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.23217247097844%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eDecision-makers\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.53565505804312%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.11608623548922%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e2020\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.11608623548922%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e2022\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.11608623548922%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e2020\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.11608623548922%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e2022\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.53565505804312%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"10.11608623548922%\" valign=\"bottom\"\u003e\n \u003cp\u003eN (%) Agree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.11608623548922%\" valign=\"bottom\"\u003e\n \u003cp\u003eN (%) Agree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.11608623548922%\" valign=\"bottom\"\u003e\n \u003cp\u003eN/total Agree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.11608623548922%\" valign=\"bottom\"\u003e\n \u003cp\u003eN/total Agree\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.53565505804312%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eAppreciation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.11608623548922%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.11608623548922%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.11608623548922%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.11608623548922%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.53565505804312%\" valign=\"bottom\"\u003e\n \u003cp\u003eThe individuals involved represent a \u003cstrong\u003ebroad range of perspectives.\u0026nbsp;\u003c/strong\u003e\u003csub\u003ea\u003c/sub\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.11608623548922%\"\u003e\n \u003cp\u003e21 (91)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.11608623548922%\"\u003e\n \u003cp\u003e24 (89)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.11608623548922%\"\u003e\n \u003cp\u003e6/7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.11608623548922%\"\u003e\n \u003cp\u003e7/8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.53565505804312%\" valign=\"bottom\"\u003e\n \u003cp\u003eCEBHA+ partners \u003cstrong\u003evalue\u003c/strong\u003e my contributions. \u003csub\u003ea\u003c/sub\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.11608623548922%\"\u003e\n \u003cp\u003e19 (83)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.11608623548922%\"\u003e\n \u003cp\u003e22 (81)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.11608623548922%\"\u003e\n \u003cp\u003e6/7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.11608623548922%\"\u003e\n \u003cp\u003e7/8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.53565505804312%\" valign=\"bottom\"\u003e\n \u003cp\u003eAll partners are \u003cstrong\u003eacknowledged\u003c/strong\u003e in CEBHA+ project documents (e.g. reports, publications). \u003csub\u003ea\u003c/sub\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.11608623548922%\"\u003e\n \u003cp\u003e15 (65)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.11608623548922%\"\u003e\n \u003cp\u003e20 (74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.11608623548922%\"\u003e\n \u003cp\u003e4/7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.11608623548922%\"\u003e\n \u003cp\u003e6/8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.53565505804312%\" valign=\"bottom\"\u003e\n \u003cp\u003eThe \u003cstrong\u003ecollaboration\u003c/strong\u003e between stakeholders and researchers in CEBHA+ \u003cstrong\u003eadded value\u003c/strong\u003e to the ongoing research.\u003csub\u003e\u0026nbsp;a\u003c/sub\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.11608623548922%\"\u003e\n \u003cp\u003e21 (91)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.11608623548922%\"\u003e\n \u003cp\u003e26 (96)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.11608623548922%\"\u003e\n \u003cp\u003e6/7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.11608623548922%\"\u003e\n \u003cp\u003e7/8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.53565505804312%\" valign=\"bottom\"\u003e\n \u003cp\u003e...I feel that my \u003cstrong\u003eviews\u003c/strong\u003e are \u003cstrong\u003eheard\u003c/strong\u003e. \u003csub\u003eb\u003c/sub\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.11608623548922%\"\u003e\n \u003cp\u003e13 (54)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.11608623548922%\"\u003e\n \u003cp\u003e13 (48)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.11608623548922%\"\u003e\n \u003cp\u003e7/7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.11608623548922%\"\u003e\n \u003cp\u003e6/10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.53565505804312%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eTrust\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.11608623548922%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.11608623548922%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.11608623548922%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.11608623548922%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.53565505804312%\" valign=\"bottom\"\u003e\n \u003cp\u003e...the collaborating partners \u003cstrong\u003etrust each other\u003c/strong\u003e. \u003csub\u003eb\u003c/sub\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.11608623548922%\"\u003e\n \u003cp\u003e13 (54)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.11608623548922%\"\u003e\n \u003cp\u003e13 (48)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.11608623548922%\"\u003e\n \u003cp\u003e3/7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.11608623548922%\"\u003e\n \u003cp\u003e7/10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"59.53565505804312%\" valign=\"bottom\"\u003e\n \u003cp\u003e...I am able to \u003cstrong\u003eexpress\u003c/strong\u003e my \u003cstrong\u003eviews freely\u003c/strong\u003e.\u003csub\u003e\u0026nbsp;b\u003c/sub\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.11608623548922%\"\u003e\n \u003cp\u003e20 (83)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.11608623548922%\"\u003e\n \u003cp\u003e19 (70)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.11608623548922%\"\u003e\n \u003cp\u003e6/7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.11608623548922%\"\u003e\n \u003cp\u003e6/10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"5\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eLegend\u003c/strong\u003e: Question format: \u003csub\u003ea\u003c/sub\u003e yes/no/don\u0026rsquo;t know;\u003csup\u003e\u0026nbsp;\u003c/sup\u003e\u003csub\u003eb\u003c/sub\u003e check all that apply;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003ch4\u003eTrust\u0026nbsp;\u003c/h4\u003e\n\u003cp\u003eSurvey participants mostly agreed that they were able to express their views freely in the collaboration but substantially fewer participants thought that collaborating partners trusted each other (Table 4).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eQualitative data provided a more nuanced picture. Without prompting, decision-makers often referred to trust, along with professionalism and respect, as a key relationship characteristic:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026lsquo;I think it\u0026rsquo;s a trusted relationship. It\u0026rsquo;s a trusted one. It\u0026rsquo;s both professional and friendship.\u0026rsquo; (MW SH 4)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA substantial level of trust is evident from one Ugandan decision-maker\u0026rsquo;s statement:\u003c/p\u003e\n\u003cp\u003e\u0026lsquo;[I]n most cases I tell [Researcher] what I think, irrespective of what the government position might be. Or the governmental shortcomings might be. So of course I tell her the challenges we are having, and some of them we discuss. Political relationship of this country. [\u0026hellip;] how road safety doesn\u0026rsquo;t get an investment.\u0026rsquo; (UG SH 2)\u003c/p\u003e\n\u003cp\u003eInstances of decision-maker initiated engagement, for example, to discuss evidence gaps during the COVID-19 pandemic, reflect that CEBHA+ researchers were seen as trusted sources of information.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn Uganda and South Africa, decision-makers built trust with members of the broader research team over time, beyond the initial senior researcher contact. However, despite individual examples of trust between partners, other relationships were characterised by low levels of trust: survey questions about honest communication about needs, constraints or organisational realities received low endorsement rates. Fear of a \u0026lsquo;hidden agenda\u0026rsquo; was frequently referred to by interviewees. Ugandan decision-makers mentioned \u0026lsquo;fear of losing face\u0026rsquo; as a reason of why partners may not trust each other enough to communicate transparently.\u0026nbsp;\u003c/p\u003e\n\u003ch4\u003ePartnership formation\u0026nbsp;\u003c/h4\u003e\n\u003cp\u003eCEBHA+ teams formed partnerships with varying levels of partnership strength.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe understanding of \u0026lsquo;partnership\u0026rsquo; was ambiguous. Ugandan decision-makers appeared to understand \u0026lsquo;partnership\u0026rsquo; mainly as a source of financial support. This may explain why, in 2022, three decision-makers (from Ethiopia and Rwanda) reported that they didn\u0026rsquo;t think they had established a partnership with CEBHA+ researchers.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOthers used the term \u0026lsquo;partnership\u0026rsquo; or referred to partners as a \u0026lsquo;team\u0026rsquo;, being \u0026lsquo;part of the project\u0026rsquo;, or \u0026lsquo;on board\u0026rsquo;. Some particularly strong partnerships were rooted in longstanding connections:\u003c/p\u003e\n\u003cp\u003e\u0026lsquo;I\u0026apos;m always available for [Researcher] to call me. I\u0026apos;m always available when [Researcher] calls the workshop. And I don\u0026apos;t think I\u0026apos;ve ever, ever not responded to [their] call.\u0026rsquo; (UG SH 2)\u003c/p\u003e\n\u003cp\u003eInterviewees in South Africa described one decision-maker as their \u0026lsquo;champion\u0026rsquo;, a term introduced in IKT training:\u003c/p\u003e\n\u003cp\u003e\u0026lsquo;[\u0026hellip;] I would say the person who had made CEBHA more [\u0026hellip;] acceptable and implementable in South Africa, yeah, she was the champion. [\u0026hellip;] unfortunately, because of COVID, she was also very, very busy, and she really gave more than what a stakeholder of her calibre would, but it\u0026apos;s because she had an interest of the kind of work that we\u0026apos;re doing, the knowledge, the science.\u0026rsquo; (SA RS 2)\u003c/p\u003e\n\u003cp\u003eIn IKT documents partnership formation was evident from the continuous presence of certain decision-makers in project meetings.\u0026nbsp;\u003c/p\u003e\n\u003ch4\u003eAccess to contacts and networks\u003c/h4\u003e\n\u003cp\u003eResearchers and decision-makers gained access to a wide range of new contacts and networks. A majority of survey participants agreed that the collaboration had \u0026lsquo;very much\u0026rsquo; or \u0026lsquo;somewhat\u0026rsquo; improved their access to contacts.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eResearchers gained access to EIDM-focused networks, such as \u003cem\u003eEvident\u003c/em\u003e and the \u003cem\u003eAfrican Institute for Development Policy\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003ein Malawi, and to some high-level decision-makers:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026lsquo;And then, we actually [\u0026hellip;] had access to the Minister of Health who was also at the [South African NCD] symposium and gave a talk [\u0026hellip;] which is a very (laughing) rare thing to happen.\u0026rsquo; (SA RS 1)\u003c/p\u003e\n\u003cp\u003eResearchers and their institutions were thought to benefit from these networks in the future:\u003c/p\u003e\n\u003cp\u003e\u0026lsquo;Actually, CEBHA could initiate the network, but [\u0026hellip;] AHRI will be in position to, you know, continue the networking or the relationship with different stakeholders. [\u0026hellip;] In IKT, you will build a network. It\u0026apos;s not only for the CEBHA, but even for my personal career, networking has some impacts.\u0026rsquo; (ET RS 1)\u003c/p\u003e\n\u003ch3\u003eCollaborative research\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eIn collaborative research, researchers and stakeholders work together over all or multiple phases of a research project, ideally in a continuous manner. In our initial programme theory, outcomes linked to collaborative research were appreciation, diversity of partners, and continuous involvement, which were reduced to just one sub-category.\u0026nbsp;\u003c/p\u003e\n\u003ch4\u003eContinuous involvement\u003c/h4\u003e\n\u003cp\u003eResearchers interacted with stakeholders most frequently in early and late research phases (28), except in Uganda and Rwanda, where collaboration was more continuous as it included data collection (Supplement 2).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCollaboration commenced during the priority-setting process for the project which involved decision-makers (51) and linked to the existing KT routines of CEBHA+ teams. Some early interactions with decision-makers were mandatory, e.g. requesting research approval. At all sites except Uganda, stakeholder engagement was part of a research method, i.e. for citizen science (52) and for the situational analysis (53,54).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026lsquo;[The] situation-based analysis for population-based interventions targeting risk factors of diabetes and hypertension [\u0026hellip;] required from the onset [\u0026hellip;] engaging with the stakeholders as we developed the whole data collection tools and [\u0026hellip;] process.\u0026rsquo; (SA RS 2)\u003c/p\u003e\n\u003cp\u003eSome data collection activities required facilitation by decision-makers, e.g. for accessing health and police records (Uganda) or insurance data (Rwanda). Some collaborative research originated from the strategic establishment of boundary spanners enabling repeated interaction: decision-makers had been asked to join the project advisory board (Uganda, South Africa) or undertook research on CEBHA+ PhD studentships (Malawi, Rwanda).\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eIntermediate outcomes\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eIntermediate outcomes emerge from the interplay of the proximal outcomes. In our initial programme theory, we had only conceptualised decision-makers\u0026rsquo; attitudes as intermediate outcomes. We revised this as changes in knowledge and attitudes among both decision-makers and researchers.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eChanges in knowledge\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eThis included decision-makers learning about (CEBHA+) research and researchers learning about the decision-making context. In the survey, a majority of researchers and decision-makers indicated that the collaboration had increased their knowledge, understanding or views about the health issues addressed in CEBHA+ and enhanced their confidence in day-to-day activities (Figure 3).\u003c/p\u003e\n\u003cp\u003eFIGURE 3\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFigure 3\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e:\u0026nbsp;\u003c/em\u003e\u003cem\u003eResearchers\u0026rsquo; and decision-makers\u0026rsquo; changes in knowledge\u003c/em\u003e\u003cem\u003e, in 2020 and 2022, respectively\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFewer survey participants thought that the collaboration had improved their access to relevant information.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eContrastingly, interview\u0026nbsp;data indicates that researchers actively sought and accessed information. This strongly improved their\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eunderstanding of the decision-making context\u003c/strong\u003e, e.g. regarding political mandates, priorities, and post-election restructuring, and subsequently informed research activities:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026lsquo;What I understand from the ministry is [\u0026hellip;] they have deliverables that they have to put through, but they don\u0026apos;t have the resources to do so. So [when] we kind of give them the platform [\u0026hellip;] or rather ask them what they need from us, it kind of opens up [\u0026hellip;] It makes it easier for us to get our work done when we also put forward their agenda.\u0026rsquo; (MW RS 2)\u003c/p\u003e\n\u003cp\u003eSeeking to understand decision-making priorities, the Ethiopian team conducted a needs assessment among MOH staff.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDecision-makers\u0026rsquo; knowledge of relevant research\u003c/strong\u003e features less prominently in interviews. In one case, they requested results from a systematic review but did not learn much as the review was \u0026lsquo;empty\u0026rsquo;. Still, seven out of eight decision-makers felt that they had become more knowledgeable about the scope of work at the research institution (2022 survey). The IKT approach further enhanced the visibility of the research institutions.\u003c/p\u003e\n\u003cp\u003eAcross all groups and sites, gaining a new perspective was emphasised as a key outcome:\u003c/p\u003e\n\u003cp\u003e\u0026lsquo;[\u0026hellip;] my interaction with the researchers [\u0026hellip;] it really opened up my mind. It pushed me to think more, to perceive things differently.\u0026rsquo; (UG SH 3)\u003c/p\u003e\n\u003ch3\u003eChanges in attitudes\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eWe identified subtle changes in attitudes towards research evidence (decision-makers) and more pronounced attitudinal changes regarding research impact (researchers) and research collaboration (both groups). These were typically linked to existing, predominantly positive attitudes.\u0026nbsp;\u003c/p\u003e\n\u003ch4\u003eDecision-maker attitudes\u003c/h4\u003e\n\u003cp\u003eDecision-makers who were aware of CEBHA+ evidence generally valued this evidence and indicated that they were intending to use it (Table 5).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTable 5\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e: Decision-makers\u0026rsquo; attitudes towards research evidence\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"643\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.304347826086957%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"60.09316770186335%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"11.801242236024844%\"\u003e\n \u003cp\u003e2020\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.801242236024844%\"\u003e\n \u003cp\u003e2022\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.304347826086957%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"60.09316770186335%\" valign=\"bottom\"\u003e\n \u003cp\u003eThe research evidence produced in CEBHA+...\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.801242236024844%\"\u003e\n \u003cp\u003eAgree N / total\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.801242236024844%\"\u003e\n \u003cp\u003eAgree N / total\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.304347826086957%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eValue\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"60.09316770186335%\" valign=\"bottom\"\u003e\n \u003cp\u003e... is \u003cstrong\u003erelevant\u003c/strong\u003e to the \u003cstrong\u003ehealth issues\u003c/strong\u003e addressed by the partnership\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.801242236024844%\"\u003e\n \u003cp\u003e7/7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.801242236024844%\"\u003e\n \u003cp\u003e6/6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.304347826086957%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"60.09316770186335%\" valign=\"bottom\"\u003e\n \u003cp\u003e... is directly \u003cstrong\u003eapplicable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.801242236024844%\"\u003e\n \u003cp\u003e5/7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.801242236024844%\"\u003e\n \u003cp\u003e5/6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.304347826086957%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"60.09316770186335%\" valign=\"bottom\"\u003e\n \u003cp\u003e... is \u003cstrong\u003etrustworthy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.801242236024844%\"\u003e\n \u003cp\u003e7/7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.801242236024844%\"\u003e\n \u003cp\u003e6/6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.304347826086957%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"60.09316770186335%\" valign=\"bottom\"\u003e\n \u003cp\u003e...more likely to be \u003cstrong\u003eused\u003c/strong\u003e in decision-making\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.801242236024844%\"\u003e\n \u003cp\u003e6/7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.801242236024844%\"\u003e\n \u003cp\u003e6/6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.304347826086957%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"60.09316770186335%\" valign=\"bottom\"\u003e\n \u003cp\u003e...more likely to have a \u003cstrong\u003elasting impact\u003c/strong\u003e on public health\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.801242236024844%\"\u003e\n \u003cp\u003e6/7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.801242236024844%\"\u003e\n \u003cp\u003e6/6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.304347826086957%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eIntention\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"60.09316770186335%\" valign=\"bottom\"\u003e\n \u003cp\u003eI \u003cstrong\u003eintend to use\u003c/strong\u003e CEBHA+ research \u003cstrong\u003eevidence\u003c/strong\u003e in my work.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.801242236024844%\"\u003e\n \u003cp\u003e6/7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.801242236024844%\"\u003e\n \u003cp\u003e9/10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.304347826086957%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eConsideration\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"60.09316770186335%\" valign=\"bottom\"\u003e\n \u003cp\u003eBeing engaged with CEBHA+ increased my \u003cstrong\u003eactive consideration\u003c/strong\u003e of research \u003cstrong\u003eevidence\u003c/strong\u003e in my work.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.801242236024844%\"\u003e\n \u003cp\u003e7/7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.801242236024844%\"\u003e\n \u003cp\u003e7/10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eIn qualitative data, decision-makers\u0026rsquo; \u003cstrong\u003einterest in research\u003c/strong\u003e was apparent but this largely seemed to pre-date the CEBHA+ project. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026lsquo;[\u0026hellip;] through some of the stakeholder\u0026apos;s meetings, we [heard that], they\u0026apos;re eager to get the [\u0026hellip;] study results, [\u0026hellip;] and then to see what they can improve because in the Rwandan context, [\u0026hellip;] from the administration and governance level, they are looking for anything that can [improve] what they are doing.\u0026rsquo; (RW RS 1)\u003c/p\u003e\n\u003cp\u003eIt was also evident that \u003cstrong\u003eattitudes towards research collaboration\u0026nbsp;\u003c/strong\u003ehad improved among some stakeholders, often due to persistent efforts by researchers:\u003c/p\u003e\n\u003cp\u003e\u0026lsquo;[Eventually, the road traffic insurance companies] were very happy to help us, [\u0026hellip;] even someone [\u0026hellip;] who didn\u0026rsquo;t want to talk to you, they are very excited to give us information and to help us [\u0026hellip;] because it\u0026rsquo;s in their big interest [\u0026hellip;] And that\u0026rsquo;s like the approach we used to get them on board. They were like, \u0026ldquo;So at the end of the day, [\u0026hellip;] we are the ones who are going to gain from this project.\u0026rdquo;\u0026rsquo; (RW RS 6)\u003c/p\u003e\n\u003cp\u003eThis was echoed in survey data: All decision-makers surveyed in 2022 indicated that they would reach out to the CEBHA+ researchers for future queries. \u0026nbsp;\u003c/p\u003e\n\u003ch4\u003eResearcher attitudes\u003c/h4\u003e\n\u003cp\u003eMany researchers embraced the \u0026lsquo;IKT idea\u0026rsquo; as a vision for research impact and became more interested in collaborating with decision-makers. Research impact was seen in both visionary and practical terms:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026lsquo;It makes you [\u0026hellip;] remember not to do things in a bubble. Always consider what your long-term objectives are. So don\u0026apos;t do research for the sake of doing research, but always to think long term and to think who else needs to know about this. What input can they give?\u0026rsquo; (MW RS 2)\u003c/p\u003e\n\u003cp\u003eAmong some researchers, this attitude was coupled with great openness to taking on decision-maker insights, e.g. when co-developing a logic model for integrated models of care to ensure it was relevant to both the South African and global context. Two senior researchers were described as only becoming interested in (I)KT and \u003cstrong\u003eresearch collaboration\u003c/strong\u003e through CEBHA+ and one Ethiopian researcher reported change at the level of the institution, where the benefits of systematic stakeholder engagement became recognised:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026lsquo;So, now the other projects or other directorates under AHRI, they are consulting us. Or they are using us as a, you know, a link to the different stakeholders.\u0026rsquo; (ET RS 1)\u003c/p\u003e\n\u003cp\u003eThe interest in IKT is also reflected in researchers adopting IKT in other projects, such as proposals and teaching (Germany, South Africa).\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eUnintended and unanticipated effects\u003c/h2\u003e\n\u003cp\u003eThe opportunity cost of doing IKT was an unintended \u0026ndash; yet foreseeable \u0026ndash; outcome discussed by some researchers, leading to potentially overburdening decision-makers in resource-constrained settings:\u003c/p\u003e\n\u003cp\u003e\u0026lsquo;[I]n some ways, CEBHA has been trying to reinvent some wheels [\u0026hellip;] there\u0026rsquo;s already a lot going on in [our country] that could\u0026rsquo;ve been built on [\u0026hellip;] because the policymakers that people are trying to engage with are all busy people. [\u0026hellip;] if the people keep saying, \u0026ldquo;[\u0026hellip;] we\u0026rsquo;re going to do policy engagement. Come to our stakeholder meeting now [\u0026hellip;].\u0026rdquo; I think that has real opportunity costs in terms of trying to take people\u0026rsquo;s time up that way.\u0026rsquo; (RS[2])\u003c/p\u003e\n\u003cp\u003eWithin the broader EIDM system, the IKT approach sparked the research funder\u0026rsquo;s interest in research impact, which was not anticipated: The CEBHA+ IKT approach was mentioned multiple time as a good practice example in the funder-initiated midline evaluation and \u0026lsquo;policy engagement\u0026rsquo; became mandatory in subsequent funding lines.\u003c/p\u003e\n\u003ch2\u003eDistal outcomes\u003c/h2\u003e\n\u003cp\u003eIncreased use of contextualised research evidence in decision-making was initially conceptualised as the final outcome linked to the IKT approach. We rephrased this category, added the researcher dimension, the production of relevant research evidence, and adapted the decision-maker dimension to consideration of contextualised research evidence, as evidence use proved conceptually challenging to evaluate.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eProduction of relevant research evidence\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eDue to the small number of study participants, our insights into decision-makers\u0026rsquo; views on CEBHA+ outputs remained limited. In the survey, the majority of decision-makers agreed that CEBHA+ research evidence was presented to them in an accessible format, an understandable language, and a timely manner.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTwo CEBHA+ projects were highlighted by decision-makers as important solutions to local priorities, for example:\u003c/p\u003e\n\u003cp\u003e\u0026lsquo;So the great initiative for diabetes that was done by [Researcher], that was important because we are not counselling our diabetic clients as we are counselling our HIV positive clients. [..] But both of them have significant morbidity and mortality. So he came with a group education initiative for diabetic patients. So that\u0026apos;s something that we needed.\u0026rsquo; (SA SH 5)\u003c/p\u003e\n\u003cp\u003eThis study subsequently informed the local department of health and guidelines in Ethiopia, Malawi, and Rwanda. Ugandan researchers and their partners identified the lack of digitised, valid road traffic crash data as a major gap. This led to a joint pilot project digitising crash data from police and healthcare archives, which had not been planned in the original proposal. One decision-maker explained that CEBHA+ research was highly applicable but recommendations were not implemented:\u003c/p\u003e\n\u003cp\u003e\u0026lsquo;I have seen the benefits [and] the value that they could bring to the sector, to the prevention of road crashes. But yeah, I haven\u0026apos;t had the opportunity to implement them. [\u0026hellip;] so the applicability of research findings is they can really be done.\u0026rsquo; (UG SH 2)\u003c/p\u003e\n\u003cp\u003eAdditionally, beyond what was planned in the original proposal, CEBHA+ funding enabled conducting ten rapid reviews on prioritised COVID-19 topics in South Africa and five systematic reviews on various MOH-prioritised questions in Ethiopia.\u003c/p\u003e\n\u003cp\u003eOther qualitative data pointed to more ambiguity regarding the relevance of research evidence produced in CEBHA+. In Rwanda, the CEBHA+ team used old NCD data due to the tight project timeline despite the MOH requesting use of newer data. Similarly, a South African researcher was only able to interview very few decision-makers for their situational analysis, limiting its relevance. In Malawi and Ethiopia, the CEBHA+ priorities defined with some decision-maker involvement in 2013 (51) did no longer match current research priorities:\u003c/p\u003e\n\u003cp\u003e\u0026lsquo;We had already met with the Ministry of Health and told them about our community level screening [\u0026hellip;]. And they didn\u0026apos;t say a thing. And then when we found out [\u0026hellip;] that they had been doing this already for three years in Addis Ababa. So I mean our project [\u0026hellip;] was, well, yes, it was sort of aligned with the Ministry of Health [initially]. But it was already behind [when it started].\u0026rsquo; (ET RS 2)\u003c/p\u003e\n\u003cp\u003eFew scientific articles were published until the end of the funding period. Despite this, CEBHA+ researchers were able to produce a range of relevant outputs (31).\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eConsideration of research evidence in decision-making\u003c/h3\u003e\n\u003cp\u003eDecision-makers self-reported conceptual, instrumental, and tactical evidence \u003cem\u003euse\u003c/em\u003e (55) in the survey. Research evidence was \u003cem\u003econsidered\u003c/em\u003e by decision-makers when they consulted CEBHA+ researchers: Ugandan CEBHA+ researchers were involved in the development of the Road Safety Action Plan (2021/22 \u0026ndash; 2025/26) and were invited to present research in a Parliamentary meeting on road safety, prior to the amendment of the Traffic and Road Safety Bill (30th March 2023). South African CEBHA+ researchers and their \u0026lsquo;champion\u0026rsquo; were involved in developing the National Strategic Plan for the Prevention and Control of NCDs (2022 - 2027).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026lsquo;A key ally throughout the CEBHA+ project, [decision-maker] applauded the work of CEBHA+ and linked its relevance to the National Strategic Plan for NCDs. She stressed the importance of research collaboration and the need for a coordinated platform.\u0026rsquo; (SA policy dialogue minutes)\u003c/p\u003e\n\u003cp\u003eOne study by a Rwandan CEBHA+ researcher was cited in the National Strategy and Costed Action Plan for the Prevention and Control of NCDs in Rwanda (2020 \u0026ndash; 2025) (56).\u003c/p\u003e\n\u003ch2\u003eRevised programme theory\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eThe adapted programme theory includes revised sub-categories. Intermediate and distal outcomes were supplemented by the researcher dimension (Figure 4).\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003ch2\u003eSummary\u003c/h2\u003e\n\u003cp\u003eThis study examined outcomes linked to an IKT approach implemented in five African countries, drawing on a pre-defined programme theory. Through relationship-building, capacity-building, and collaborative research (proximal outcomes), researchers and decision-makers built appreciation and partnerships, whilst expanding skills in conducting research, evidence use, and IKT. Participants gained access to contacts and networks but trust between partners varied. Only limited capacity was built at organisational and system levels, mostly with regards to establishing new courses and training staff in IKT. Intermediate outcomes were changes in attitudes and knowledge, particularly as researchers learned about the decision-making context. The IKT approach was linked with the production of research that was perceived as highly applicable and addressing local priorities but we found only some evidence of consideration of evidence among decision-makers due to study limitations. In revising our initial programme theory, we were able to consolidate our findings into low-level theory.\u003c/p\u003e\n\u003ch2\u003eContextualising our findings in the literature\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eIKT emphasises continuous relationships with knowledge users, in particular decision-makers to foster EIDM in a mutually beneficial manner (6). IKT activities and outcomes have been examined in a meta-synthesis of IKT case studies (57). Whilst there remains a dearth of rigorous outcome evaluations of IKT, approaches with similar characteristics exist within the wider literature on \u0026lsquo;health research partnerships\u0026rsquo; (20), co-production (58), and on the \u0026lsquo;science of using science\u0026rsquo; (59). Comparison with this literature is, however, difficult due to challenges with evaluating knowledge exchange interventions in general and our approach in particular (Textbox 1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTextbox 1:\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cem\u003eEvaluation of knowledge exchange interventions\u003c/em\u003e\u003c/p\u003e\n\u003ctable style=\"width: 100%;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 100.0000%;\"\u003e\n \u003cp\u003eEvaluation challenges with regards to KT interventions arise from a lack of funding and other practical issues (12), its resource intensity (22), and from the complexity and context-dependency of such interventions and inherent challenges to making causal claims (60). We were faced with what has been described elsewhere as \u0026lsquo;sample-size challenge of finding enough contexts and infrastructures supporting a common approach that can be evaluated using standardised methods\u0026rsquo; (21). Among published evaluations exists a positivity bias as \u0026lsquo;rich descriptions of failures\u0026rsquo; are lacking (57).\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eDifficulties in attributing outcomes to the IKT approach are further amplified as the approach is in itself not \u003cem\u003eone\u003c/em\u003e intervention but \u0026lsquo;entails a multi-pronged ensemble of tailored interventions\u0026rsquo; (28). The envisioned core components comprised continuous involvement, including through the engagement of decision-makers in priority-setting for the project (51), IKT training, systematic development and implementation of \u0026lsquo;IKT strategies\u0026rsquo;, regular meetings of the IKT team, and IKT-related deliverables (28). CEBHA+ researchers were the target group for some interventions (e.g. IKT training) and were implementers of other interventions (implementation of IKT strategies, e.g. involving decision-makers in a policy dialogue). Overall, such multi-component, multi-mechanism approaches are common in interventions intended to increase evidence use among decision-makers (59).\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003ch3\u003eProximal outcomes\u003c/h3\u003e\n\u003cp\u003eThe CEBHA+ IKT approach was primarily aimed at individual-level behaviour change. \u0026lsquo;Relationship-building\u0026rsquo;, \u0026lsquo;capacity-building\u0026rsquo;, and \u0026lsquo;collaborative research\u0026rsquo; had been conceptualised to constitute the most proximal outcomes of the approach, doubling, by virtue of being activities, as mechanisms of change on the pathway to downstream outcomes (36).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCEBHA+ researchers participated in training and meetings on IKT and IKT-related skills featured prominently in \u003cstrong\u003ecapacity-building\u003c/strong\u003e. In the meta-synthesis of IKT case studies this was echoed, with \u0026lsquo;capacity for collaboration\u0026rsquo; identified as a key outcome (57). The IKT skills we identified map onto the competencies for IKT defined in a Delphi study (61). Interestingly, CEBHA+ researchers reported some mixed effects with respect to research skills gained, which warrants further investigation. An evidence-based public health course was implemented in CEBHA+ but since it was offered only once per country few decision-makers participated in this formal capacity-building opportunity. Given that CEBHA+\u0026rsquo;s aim was to increase decision-makers\u0026rsquo; evidence use this appears to be a gap in the IKT approach. Whilst CEBHA+ activities were focused on individual-level capacity-building, some strengthening of organisational and systems capacity occurred, which has been described as a key need in the region (23,62).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTrust between partners varied and was highly context-dependent, with longer relationships enabling more trusting relationships. Trust, along with \u0026lsquo;talk and time\u0026rsquo;, has been long established as key to \u003cstrong\u003erelationship-building\u003c/strong\u003e (63). Lately, it has been recommended, however, to view trust as a more dynamic concept in partnered research as opportunities for building trust may be different for different partners (64), as also observed in our data. Nevertheless, trust and honest communication, e.g. about needs, constraints, and organizational realities, without concerns about judgment or backlash, are essential for building successful partnerships (65). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDecision-makers expressed great appreciation for being involved early in the research. This is more reflective of \u0026lsquo;mutually beneficial\u0026rsquo; (6), \u0026lsquo;meaningful\u0026rsquo; (20), and egalitarian partnerships (10) as opposed to one-off collaboration or work on pre-defined research questions, which is more likely to constitute asymmetrical or tokenistic partnerships (10). Ambiguous use of the term \u0026lsquo;partnership\u0026rsquo; and variable levels of partnership strength pointed to all three partnership types being represented in our study (10). We did not examine the level of individual partnerships as a unit of analysis, which we recommend for future, well-resourced evaluations. Importantly, this will help delineate partnerships with diverse groups of partners more \u0026ndash; for example, the Ugandan team felt great tension in IKT activities involving groups with great power differentials, i.e. longstanding, often academic partners and others, such as the group of \u003cem\u003eboda boda\u003c/em\u003e motorcycle drivers with little formal education.\u003c/p\u003e\n\u003cp\u003eCEBHA+ researchers interacted with decision-makers in particular in early and late phases in the \u003cstrong\u003ecollaborative research\u0026nbsp;\u003c/strong\u003eprocess, as has been documented elsewhere (1). Whilst this may appear contradictory to the IKT tenet of \u003cem\u003econtinuous\u003c/em\u003e relationships it may also reflect IKT skills, i.e. only involving decision-makers with a clear goal. Elsewhere, stakeholders indicated that they preferred a \u0026lsquo;moderate level of participation in research rather than full team membership.\u0026rsquo; (66). At the same time, this may result in stakeholder roles transforming into mere research participation as opposed to consultative or co-production roles (67).\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eIntermediate outcomes\u003c/h3\u003e\n\u003cp\u003eResearchers learning about the decision-making context emerged as a key outcome of the IKT approach, which had not been conceptualised in the initial programme theory. In public health, researchers have limited knowledge of policy-making (68) and therefore benefit greatly as they gain a new perspective and increase their knowledge of the policy or practice environment (1,69) and \u0026lsquo;develop and pursue research questions that have real-world applicability, and, through ongoing conversations with decision-makers, interpret results with a deeper understanding of contextual circumstances which, in turn, enhances the usefulness of the research findings.\u0026rsquo; (1). Researchers and decision-makers generally had rather positive attitudes of collaborating but some individuals became more convinced during the project. Such attitudinal change among decision-makers has been associated with higher frequency of research use (70,71).\u003c/p\u003e\n\u003ch3\u003eUnintended and unanticipated effects\u003c/h3\u003e\n\u003cp\u003eWe found it difficult to investigate unintended, particularly adverse, effects as interview participants appeared uncomfortable to reflect on these. This reluctance may reflect social desirability bias and added to the positivity bias common in this kind of research (57,72), leading to us identifying predominantly positive outcomes. Challenging outcomes were identified in only 32% of reviews on health research partnerships (20), with emotional labour identified as the key negative outcome (73). Given the substantial resources required for IKT and the various potential issues in collaborative research or co-production (74) future evaluations should explore appropriate methods to examine this further.\u003c/p\u003e\n\u003ch3\u003eDistal outcomes\u003c/h3\u003e\n\u003cp\u003eWe did identify some instances of production of relevant, contextualised evidence. Such research has been reported as an important prerequisite for EIDM as it is perceived as valuable and trustworthy by local decision-makers (22). We were further able to identify some consideration of evidence in decision-making but \u0026lsquo;evidence use\u0026rsquo; proved challenging to assess, which is a common challenge when evaluating the effect of interventions intended to facilitate EIDM on evidence use, policy and practice (75).\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eAdvancing low-level theory for IKT\u003c/h3\u003e\n\u003cp\u003eOur revised programme theory can be considered a low-level theory, grounded in realist evaluation theory (36). It links with other relevant theories on evidence use (59) and IKT (57). The revised theory incorporates a broader consideration of the role of researchers in EIDM. This is similar to the CollaboraKTion framework but the latter is organised temporally along the research process (76,77). Whilst our programme theory can inform future evaluations by making assumptions about IKT explicit (35) it is by nature reductionist and may warrant stronger consideration of \u0026lsquo;systems thinking\u0026rsquo;.\u003c/p\u003e\n\u003ch3\u003eStrengths and limitations\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eOur study draws on a published protocol and provides unique insights into outcomes of a coordinated IKT approach implemented by teams in five African countries. We were able to enrol most CEBHA+ researchers and drew on a large number of documents. Due to the small number of decision-makers participating, we were not able to disaggregate survey results by country. The under-representation of decision-makers may present a finding in itself: In some cases, researchers advised against the enrolment of their decision-making partners, for example, when the latter were overworked with COVID-19-related responsibilities or when researchers deemed that partnerships were not yet sufficiently established to link partners with evaluation researchers.\u003c/p\u003e\n\u003cp\u003eThe comparative case study design does not allow for causal inference.\u0026nbsp;However, in the absence of an opportunity to employ a more rigorous study design to examine effects, the study design still allows for teasing out whether the approach contributed to some change in the direction of the hypothesised outcomes.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe used a non-validated survey tool, which incorporated validated constructs from existing tools. This led to some conceptual difficulties at the data analysis stage and we recommend the use of other tools for future IKT research (18). Some relevant concepts, such as organisational absorptive capacity, were under-examined. Our data analysis included recommended double-coding by one researcher (43) but restricts the perspective, compared with double-coding by multiple researchers. Further limitations arise from the involvement of evaluators in IKT implementation, as we discuss under reflexivity, and from the risk of social desirability bias given the proximity of evaluators and participants.\u0026nbsp;\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOur evaluation of an IKT approach implemented in five African countries presents theory-informed insights into proximal, intermediate and distal IKT outcomes, based on participants\u0026rsquo; views and documented IKT activities. Given the multi-component nature and context-dependency of KT interventions as well as the diversity of relevant decision-makers in public health and healthcare there is not one way for implementers to \u0026lsquo;do IKT\u0026rsquo;. Whilst IKT evaluation literature can inform future IKT efforts it remains critical for implementers to monitor their IKT activities to understand \u0026lsquo;what works\u0026rsquo; in their context. This should include a cost-benefit-assessment of KT activities, in particular in resource-constrained settings (69,78). Research on unintended effects of IKT, including those arising from power differentials (79), is warranted. Importantly, beyond project-based, often haphazard IKT, evidence-informed decision-making requires strengthening of structures and systems.\u003c/p\u003e"},{"header":"List Of Abbreviations","content":"\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"604\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.516556291390728%\" valign=\"top\"\u003e\n \u003cp\u003eIKT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"77.48344370860927%\" valign=\"top\"\u003e\n \u003cp\u003eIntegrated knowledge translation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.516556291390728%\" valign=\"top\"\u003e\n \u003cp\u003eKT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"77.48344370860927%\" valign=\"top\"\u003e\n \u003cp\u003eKnowledge translation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.516556291390728%\" valign=\"top\"\u003e\n \u003cp\u003eCEBHA+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"77.48344370860927%\" valign=\"top\"\u003e\n \u003cp\u003eCollaboration for Evidence-based Healthcare and Public Health in Africa\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.516556291390728%\" valign=\"top\"\u003e\n \u003cp\u003eLMU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"77.48344370860927%\" valign=\"top\"\u003e\n \u003cp\u003eLudwig-Maximilians-Universitaet Muenchen\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.516556291390728%\" valign=\"top\"\u003e\n \u003cp\u003eEIDM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"77.48344370860927%\" valign=\"top\"\u003e\n \u003cp\u003eEvidence-informed decision-making\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.516556291390728%\" valign=\"top\"\u003e\n \u003cp\u003eCOVID-19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"77.48344370860927%\" valign=\"top\"\u003e\n \u003cp\u003eCoronavirus disease 2019\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.516556291390728%\" valign=\"top\"\u003e\n \u003cp\u003eFGD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"77.48344370860927%\" valign=\"top\"\u003e\n \u003cp\u003eFocus group discussion\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.516556291390728%\" valign=\"top\"\u003e\n \u003cp\u003eNCD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"77.48344370860927%\" valign=\"top\"\u003e\n \u003cp\u003eNon-communicable diseases\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.516556291390728%\" valign=\"top\"\u003e\n \u003cp\u003eET\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"77.48344370860927%\" valign=\"top\"\u003e\n \u003cp\u003eEthiopia\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.516556291390728%\" valign=\"top\"\u003e\n \u003cp\u003eMW\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"77.48344370860927%\" valign=\"top\"\u003e\n \u003cp\u003eMalawi\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.516556291390728%\" valign=\"top\"\u003e\n \u003cp\u003eRW\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"77.48344370860927%\" valign=\"top\"\u003e\n \u003cp\u003eRwanda\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.516556291390728%\" valign=\"top\"\u003e\n \u003cp\u003eSA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"77.48344370860927%\" valign=\"top\"\u003e\n \u003cp\u003eSouth Africa\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.516556291390728%\" valign=\"top\"\u003e\n \u003cp\u003eUG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"77.48344370860927%\" valign=\"top\"\u003e\n \u003cp\u003eUganda\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.516556291390728%\" valign=\"top\"\u003e\n \u003cp\u003eRS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"77.48344370860927%\" valign=\"top\"\u003e\n \u003cp\u003eResearcher\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.516556291390728%\" valign=\"top\"\u003e\n \u003cp\u003eSH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"77.48344370860927%\" valign=\"top\"\u003e\n \u003cp\u003eStakeholder\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.516556291390728%\" valign=\"top\"\u003e\n \u003cp\u003eDM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"77.48344370860927%\" valign=\"top\"\u003e\n \u003cp\u003eDecision-maker\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.516556291390728%\" valign=\"top\"\u003e\n \u003cp\u003eAHRI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"77.48344370860927%\" valign=\"top\"\u003e\n \u003cp\u003eArmauer-Hansen Research Institute\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.516556291390728%\" valign=\"top\"\u003e\n \u003cp\u003eMOH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"77.48344370860927%\" valign=\"top\"\u003e\n \u003cp\u003eMinistry of Health\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e\n\u003cp\u003eThe protocol for this study was approved by the Ethics Committee of Armauer Hansen Research Institute (AHRI), Ethiopia (PO/31/20), the Ethics Review Committee of the Ludwig-Maximilians-Universit\u0026auml;t M\u0026uuml;nchen, Germany (19-633), the Research and Ethics Committee at the Kamuzu University of Health Sciences, Malawi (P.11/19/2850), the Rwanda National Ethics Committee (074/RNEC/2020), the Human Research Ethics Committee of the University of Cape Town, South Africa (026/2020), and the Ethics Committee of Makerere University, Uganda (Protocol 469).\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eConsent for publication\u003c/h2\u003e\n\u003cp\u003eInformed voluntary consent was sought both in writing and verbally from all participants.\u003c/p\u003e\n\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e\n\u003cp\u003eThe datasets generated and analysed during the current study are not publicly available due to concerns about anonymity of study participants given the small sample size. Survey data can be made available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003ch2\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003eThe authors have no conflicting interest other than their role in conceiving this research, developing and co-implementing the CEBHA+ IKT approach.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eCEBHA\u0026thinsp;+\u0026thinsp;was funded by the German Federal Ministry of Education and Research (Bundesministerium f\u0026uuml;r Bildung und Forschung) as part of the \u0026ldquo;Research Networks for Health Innovation in Sub-Saharan Africa\u0026rdquo; funding initiative. Grants no: 01KA1608, 01KA2023, 01KA2111A. The funder was not involved in the study design, collection, analysis, interpretation of data, the writing of this article or the decision to submit for publication.\u003c/p\u003e\n\u003ch2\u003eAuthors\u0026apos; contributions\u003c/h2\u003e\n\u003cp\u003eEAR and LMP contributed to the development of the CEBHA\u0026thinsp;+\u0026thinsp;IKT approach and KS, EAR and LMP conceived the idea for this article. KS, JO, EBZ and LMP partook in the collection of data and KS, JO, EBZ, BG, and LMP analysed data. All authors critically interpreted and discussed the data. KS drafted this article. All authors critically revised its content, approved the submitted version of this article, and are accountable for the accuracy or integrity of any part of the work.\u003c/p\u003e\n\u003ch2\u003eAcknowledgements\u003c/h2\u003e\n\u003cp\u003eWe would like to express our sincere thanks to the CEBHA+ team and further individuals that made this research possible. Nasreen Jessani\u0026rsquo;s work in guiding the process of implementing IKT in CEBHA+ was invaluable and the project would not have been implemented without her support. Taryn Young, Anke Rohwer, Gertrude Chapotera, Bey-Marrie Schmidt, Joerg Meerpohl, Ingrid Toews and Jacob Burns gave key input during the development phase of the IKT approach. Great thanks goes to Tanja Grath and her thorough work on instrument development and in launching IKT in CEBHA+; to Lynn Hendricks and a Rwandan colleague for piloting instruments; and to Nyanyiwe Masingi Mbeye for undertaking a friendly peer review of this manuscript. We would also like to thank Ann Rose Akiteng, Stellah Namatovu, Seleman Ntawuyirishintege, Suzgika Lakudzala, Rawleigh Howe, Kiya Kedir, Firaol Mesfin, Hailemichael Getachew, Peter Delobelle and all members of the (wider) IKT team and for contributing significantly to this work. We are immensely grateful for the insights and experiences shared by all study participants.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eGagliardi AR, Berta W, Kothari A, Boyko J, Urquhart R. Integrated knowledge translation (IKT) in health care: a scoping review. Implement Sci. 2016;11(1):38\u0026ndash;38. \u003c/li\u003e\n\u003cli\u003eLawrence LM, Bishop A, Curran J. Integrated knowledge translation with public health policy makers: A scoping review. Healthc Policy. 2019;14(3):55\u0026ndash;77. \u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Bridging the \u0026ldquo;Know\u0026ndash;Do\u0026rdquo; Gap: Meeting on Knowledge Translation in Global Health. 10-12 October 2005 [Internet]. Geneva, Switzerland; 2006 [cited 2023 Feb 17]. Available from: https://www.measureevaluation.org/resources/training/capacity-building-resources/high-impact-research-training-curricula/bridging-the-know-do-gap.pdf\u003c/li\u003e\n\u003cli\u003eGraham ID, Logan J, Harrison MB, Straus SE, Tetroe J, Caswell W, et al. Lost in knowledge translation: Time for a map? J Contin Educ Health Prof. 2006 Dec;26(1):13\u0026ndash;24. \u003c/li\u003e\n\u003cli\u003eGraham ID, Kothari A, McCutcheon C. Moving knowledge into action for more effective practice, programmes and policy: protocol for a research programme on integrated knowledge translation. Implement Sci IS. 2018 Feb 2;13:22. \u003c/li\u003e\n\u003cli\u003eKothari A, Wathen CN. Integrated knowledge translation: digging deeper, moving forward. J Epidemiol Community Health. 2017 Jun;71(6):619\u0026ndash;23. \u003c/li\u003e\n\u003cli\u003eJull J, Giles A, Graham ID. Community-based participatory research and integrated knowledge translation: Advancing the co-creation of knowledge. Implement Sci [Internet]. 2017 Dec;12(1). Available from: /pmc/articles/PMC5735911/\u003c/li\u003e\n\u003cli\u003eNguyen T, Graham ID, Mrklas KJ, Bowen S, Cargo M, Estabrooks CA, et al. How does integrated knowledge translation (IKT) compare to other collaborative research approaches to generating and translating knowledge? Learning from experts in the field. Health Res Policy Syst. 2020 Mar;18(1). \u003c/li\u003e\n\u003cli\u003eGagliardi AR, Kothari A, Graham ID. Research agenda for integrated knowledge translation (IKT) in healthcare: what we know and do not yet know. J Epidemiol Community Health. 2016/09/19 ed. 2017 Feb;71(2):105\u0026ndash;6. \u003c/li\u003e\n\u003cli\u003eSibbald SL, Tetroe J, Graham ID. Research funder required research partnerships: a qualitative inquiry. Implement Sci IS. 2014 Nov 28;9:176. \u003c/li\u003e\n\u003cli\u003eAbudu R, Oliver K, Boaz A. What funders are doing to assess the impact of their investments in health and biomedical research. Health Res Policy Syst. 2022 Dec;20(1):1\u0026ndash;18. \u003c/li\u003e\n\u003cli\u003eOliver K. Why Is It So Hard to Evaluate Knowledge Exchange? Comment on \u0026lsquo;Sustaining Knowledge Translation Practices: A Critical Interpretive Synthesis\u0026rsquo;. Int J Health Policy Manag. 2023;12:7549. \u003c/li\u003e\n\u003cli\u003eBoland L, Kothari A, McCutcheon C, Graham ID. Building an integrated knowledge translation (IKT) evidence base: Colloquium proceedings and research direction. Health Res Policy Syst. 2020 Jan;18(1):8\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eEsmail R, Hanson HM, Holroyd-Leduc J, Brown S, Strifler L, Straus SE, et al. A scoping review of full-spectrum knowledge translation theories, models, and frameworks. Implement Sci IS [Internet]. 2020 Feb;15(1). Available from: https://pubmed.ncbi.nlm.nih.gov/32059738/\u003c/li\u003e\n\u003cli\u003eTittlemier BJ, Cooper J, Steliga D, Woodgate RL, Sibley KM. A scoping review to identify and describe the characteristics of theories, models and frameworks of health research partnerships. Health Res Policy Syst [Internet]. 2022 Dec;20(1). Available from: https://pubmed.ncbi.nlm.nih.gov/35717196/\u003c/li\u003e\n\u003cli\u003eJull JE, Davidson L, Dungan R, Nguyen T, Woodward KP, Graham ID. A review and synthesis of frameworks for engagement in health research to identify concepts of knowledge user engagement. BMC Med Res Methodol. 2019 Nov 21;19(1):211. \u003c/li\u003e\n\u003cli\u003eMcLean RKD, Carden F, Aiken AB, Armstrong R, Bray J, Cassidy CE, et al. Evaluating the quality of research co-production: Research Quality Plus for Co-Production (RQ\u0026thinsp;+\u0026thinsp;4 Co-Pro). Health Res Policy Syst. 2023 Jun 13;21(1):51. \u003c/li\u003e\n\u003cli\u003eMrklas KJ, Boyd JM, Shergill, Sumair, Merali, Sera, Khan M, Nowell L, et al. Tools for assessing health research partnership outcomes and impacts: a systematic review. Health Res Policy Syst. 2023 Jan 5;21(1):3. \u003c/li\u003e\n\u003cli\u003eMrklas KJ, Boyd JM, Shergill S, Merali S, Khan M, Moser C, et al. A scoping review of the globally available tools for assessing health research partnership outcomes and impacts. Health Res Policy Syst. 2023 Dec 22;21(1):139. \u003c/li\u003e\n\u003cli\u003eHoekstra F, Mrklas KJ, Khan M, McKay RC, Vis-Dunbar M, Sibley KM, et al. A review of reviews on principles, strategies, outcomes and impacts of research partnerships approaches: a first step in synthesising the research partnership literature. Health Res Policy Syst. 2020;18(1):51\u0026ndash;51. \u003c/li\u003e\n\u003cli\u003ePartridge ACR, Mansilla C, Randhawa H, Lavis JN, El-Jardali F, Sewankambo NK. Lessons learned from descriptions and evaluations of knowledge translation platforms supporting evidence-informed policy-making in low- and middle-income countries: a systematic review. Health Res Policy Syst. 2020;18(1):127\u0026ndash;127. \u003c/li\u003e\n\u003cli\u003eMalla C, Aylward P, Ward P. Knowledge translation for public health in low- and middle- income countries: a critical interpretive synthesis. Glob Health Res Policy. 2018 Dec;3(1). \u003c/li\u003e\n\u003cli\u003eEdwards A, Zweigenthal V, Olivier J. Evidence map of knowledge translation strategies, outcomes, facilitators and barriers in African health systems. Health Res Policy Syst. 2019;17(1):16\u0026ndash;16. \u003c/li\u003e\n\u003cli\u003ePfadenhauer LM, Grath T, Delobelle P, Jessani N, Meerpohl JJ, Rohwer A, et al. Mixed method evaluation of the CEBHA+ integrated knowledge translation approach: a protocol. Health Res Policy Syst. 2021 Dec;19(1):7\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eVincent S, Mahoney J. The SAGE Handbook of Qualitative Business and Management Research Methods: History and Traditions [Internet]. SAGE Publications Ltd; 2018 [cited 2023 Oct 17]. Available from: https://methods.sagepub.com/book/handbook-of-qualitative-business-management-research-methods-v1\u003c/li\u003e\n\u003cli\u003eBonell C, Fletcher A, Morton M, Lorenc T, Moore L. Realist randomised controlled trials: A new approach to evaluating complex public health interventions. Soc Sci Med. 2012 Dec 1;75(12):2299\u0026ndash;306. \u003c/li\u003e\n\u003cli\u003ePawson R, Tilley N. Realist Evaluation. SAGE Publications Ltd; 1997. \u003c/li\u003e\n\u003cli\u003eSell K, Jessani NS, Mesfin F, Rehfuess EA, Rohwer A, Delobelle P, et al. Developing, implementing, and monitoring tailored strategies for integrated knowledge translation in five sub-Saharan African countries. Health Res Policy Syst. 2023 Sep 4;21(1):91. \u003c/li\u003e\n\u003cli\u003eMpando TL, Sell K, Delobelle P, Osuret J, Niyibizi JB, Ntawuyirushintege S, et al. Integrated Knowledge Translation in Non-Communicable Disease Research in Sub-Saharan Africa: A Comparison of Systematic and Ad Hoc Stakeholder Engagement. Front Trop Dis. 2021;0:53\u0026ndash;53. \u003c/li\u003e\n\u003cli\u003eJessani NS, Rohwer A, Schmidt BM, Delobelle P. Integrated knowledge translation to advance noncommunicable disease policy and practice in South Africa: application of the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework. Health Res Policy Syst. 2021;19(1):82\u0026ndash;82. \u003c/li\u003e\n\u003cli\u003eJessani NS, Delobelle P, Balugaba BE, Mpando TL, Ayele FM, Ntawuyirushintege S, et al. Integrated Knowledge Translation for Non-Communicable Diseases: Stories from Sub-Saharan Africa. 2023 Dec 8;89(1):87. \u003c/li\u003e\n\u003cli\u003eNiyibizi JB, Nganabashaka JP, Ntawuyirushintege S, Tumusiime D, Umwali G, Rulisa S, et al. Using Citizen Science Within an Integrated Knowledge Translation (IKT) Approach to Explore Cardiovascular Disease Risk Perception in Rwanda. Front Trop Dis. 2021;0:33\u0026ndash;33. \u003c/li\u003e\n\u003cli\u003eJessani NS, Hendricks L. Evidence-Informed Decision-Making: The Art, Science and Complexity of (Integrated) Knowledge Translation. Short Course presented at; 2022; Stellenbosch University, South Africa. \u003c/li\u003e\n\u003cli\u003eJessani NS, Hendricks L, Nicol L, Young T. University Curricula in Evidence-Informed Decision Making and Knowledge Translation: Integrating Best Practice, Innovation, and Experience for Effective Teaching and Learning. Front Public Health [Internet]. 2019 [cited 2022 Nov 25];7. Available from: https://www.frontiersin.org/articles/10.3389/fpubh.2019.00313\u003c/li\u003e\n\u003cli\u003eLeeuw FL, Donaldson SI. Theory in evaluation: Reducing confusion and encouraging debate. Evaluation. 2015 Oct 1;21(4):467\u0026ndash;80. \u003c/li\u003e\n\u003cli\u003eKreindler SA. Advancing the evaluation of integrated knowledge translation. Health Res Policy Syst. 2018;16(1):1\u0026ndash;10. \u003c/li\u003e\n\u003cli\u003eBerman J, Mitambo C, Matanje-Mwagomba B, Khan S, Kachimanga C, Wroe E, et al. Building a knowledge translation platform in Malawi to support evidence-informed health policy. Health Res Policy Syst. 2015;13(1):73\u0026ndash;73. \u003c/li\u003e\n\u003cli\u003eaudiotranskription dr.dresing \u0026amp; pehl GmbH. Transkription \u0026amp; Analyse Die f4 Familie macht\u0026rsquo;s leichter! [Internet]. Available from: https://www.audiotranskription.de/\u003c/li\u003e\n\u003cli\u003eATLAS.ti Scientific Software Development GmbH. ATLAS.ti 22 Windows [Internet]. 2022. Available from: https://atlasti.com\u003c/li\u003e\n\u003cli\u003eLimesurvey GmbH. LimeSurvey: An Open Source survey tool [Internet]. Hamburg, Germany; Available from: http://www.limesurvey.org\u003c/li\u003e\n\u003cli\u003eJenkins EK, Slemon A, Haines-Saah RJ, Oliffe J. A Guide to Multisite Qualitative Analysis. Qual Health Res. 2018 Oct 1;28(12):1969\u0026ndash;77. \u003c/li\u003e\n\u003cli\u003eMoran-Ellis J, Alexander VD, Cronin A, Dickinson M, Fielding J, Sleney J, et al. Triangulation and integration: processes, claims and implications. Qual Res. 2006 Feb;6(1):45\u0026ndash;59. \u003c/li\u003e\n\u003cli\u003eSchreier M. Qualitative Content Analysis in Practice. London, UK: SAGE Publications Ltd; 2012. \u003c/li\u003e\n\u003cli\u003eO\u0026rsquo;Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for reporting qualitative research: a synthesis of recommendations. Acad Med J Assoc Am Med Coll. 2014 Sep;89(9):1245\u0026ndash;51. \u003c/li\u003e\n\u003cli\u003eRyan N, Vieira D, Gyamfi J, Ojo T, Shelley D, Ogedegbe O, et al. Development of the ASSESS tool: a comprehenSive tool to Support rEporting and critical appraiSal of qualitative, quantitative, and mixed methods implementation reSearch outcomes. Implement Sci Commun. 2022 Mar 28;3(1):34. \u003c/li\u003e\n\u003cli\u003eAbimbola S. The foreign gaze: Authorship in academic global health. BMJ Glob Health. 2019 Oct;4(5). \u003c/li\u003e\n\u003cli\u003eBrennan SE, McKenzie JE, Turner T, Redman S, Makkar S, Williamson A, et al. Development and validation of SEER (Seeking, Engaging with and Evaluating Research): a measure of policymakers\u0026rsquo; capacity to engage with and use research. Health Res Policy Syst. 2017 Jan 17;15(1):1. \u003c/li\u003e\n\u003cli\u003eRohwer AC, Jessani NS, Mbeye NM, Balugaba BE, Akiteng AR, Tumusiime D, et al. Evidence-Based Public Health Workshops: An assessment of the implementation and adaptation of training across five sub-Saharan African countries. \u003c/li\u003e\n\u003cli\u003eJessani NS, Hendricks L. Engaging with Decision-makers: Issue Briefss for policy and practice. Short Course presented at; 2022; Stellenbosch University, South Africa. \u003c/li\u003e\n\u003cli\u003eCentre for Evidence-based Health Care, Stellenbosch University. Knowledge Translation. [cited 2023 Nov 13]. KT Workshops. Available from: https://www.cebhc.co.za/knowledge-translation-key-outputs/kt-workshops/\u003c/li\u003e\n\u003cli\u003eRehfuess EA, Dur\u0026atilde;o S, Kyamanywa P, Meerpohl JJ, Young T, Rohwer A. An approach for setting evidence-based and stakeholder-informed research priorities in low- and middle-income countries. Bull World Health Organ. 2016 Apr;94(4):297\u0026ndash;305. \u003c/li\u003e\n\u003cli\u003eOkop KJ, Kedir K, Kasenda S, Niyibizi JB, Chipeta E, Getachew H, et al. Multi-country collaborative citizen science projects to co-design cardiovascular disease prevention strategies and advocacy: findings from Ethiopia, Malawi, Rwanda, and South Africa. BMC Public Health. 2023 Dec 12;23(1):2484. \u003c/li\u003e\n\u003cli\u003eUwimana Nicol J, Nganabashaka JP, Tumusiime KD, Young T, Rehfuess E, Burns J. Taking stock of population-level interventions targeting risk factors for hypertension and diabetes in Rwanda and South Africa: methodological reflections and lessons learnt from conducting a multi-component situational analysis. BMC Public Health. 2023 Aug 25;23(1):1630. \u003c/li\u003e\n\u003cli\u003eUwimana-Nicol J, Hendricks L, Young T. Population-level interventions targeting risk factors of diabetes and hypertension in South Africa: a document review. BMC Public Health 2021 211. 2021 Dec;21(1):1\u0026ndash;14. \u003c/li\u003e\n\u003cli\u003eMakkar S, Brennan S, Turner T, Williamson A, Redman S, Green S. The development of SAGE: A tool to evaluate how policymakers\u0026rsquo; engage with and use research in health policymaking. Res Eval. 2016 Jul 1;25(3):315\u0026ndash;28. \u003c/li\u003e\n\u003cli\u003eEberly LA, Rusangwa C, Ng\u0026rsquo;ang\u0026rsquo;a L, Neal CC, Mukundiyukuri JP, Mpanusingo E, et al. Cost of integrated chronic care for severe non-communicable diseases at district hospitals in rural Rwanda. BMJ Glob Health. 2019 Jun 1;4(3):e001449. \u003c/li\u003e\n\u003cli\u003eDunn SI, Bhati DK, Reszel J, Kothari A, McCutcheon C, Graham ID. Understanding how and under what circumstances integrated knowledge translation works for people engaged in collaborative research: metasynthesis of IKTRN casebooks. JBI Evid Implement. 2023 Mar 30; \u003c/li\u003e\n\u003cli\u003eSibley KM, Hoekstra F, Kothari A, Mrklas K. 2.3 Effects, Facilitators, and Barriers of Research Coproduction Reported in Peer-Reviewed Literature. In: Research Co-Production in Healthcare [Internet]. John Wiley \u0026amp; Sons, Ltd; 2022 [cited 2023 Dec 13]. p. 54\u0026ndash;73. Available from: https://onlinelibrary.wiley.com/doi/abs/10.1002/9781119757269.ch4\u003c/li\u003e\n\u003cli\u003eLanger L, Tripney J, Gough D (David A). The science of using science : researching the use of research evidence in decision-making [Internet]. London: EPPI Centre, Social Science Research Unit, Institute of Education, University of London; 2016 p. 55\u0026ndash;55. Report No.: 978-1-907345-88\u0026ndash;3. Available from: https://eppi.ioe.ac.uk/cms/Portals/0/PDF%20reviews%20and%20summaries/Science%202016%20Langer%20report.pdf?ver=2016-04-18-142701-867\u003c/li\u003e\n\u003cli\u003eContandriopoulos D, Lemire M, Denis JL, Tremblay \u0026Eacute;. Knowledge Exchange Processes in Organizations and Policy Arenas: A Narrative Systematic Review of the Literature. Milbank Q. 2010;88(4):444\u0026ndash;83. \u003c/li\u003e\n\u003cli\u003eYeung E, Scodras S, Salbach NM, Kothari A, Graham ID. Identifying competencies for integrated knowledge translation: a Delphi study. BMC Health Serv Res 2021 211. 2021 Oct;21(1):1\u0026ndash;18. \u003c/li\u003e\n\u003cli\u003eOrem J, Mafigiri D, Marchal B, Ssengooba F, MacQ J, Criel B. Research, evidence and policymaking: The perspectives of policy actors on improving uptake of evidence in health policy development and implementation in Uganda. BMC Public Health. 2012 Feb;12(1):1\u0026ndash;16. \u003c/li\u003e\n\u003cli\u003eWathen CN, Sibbald SL, Jack SM, MacMillan HL. Talk, trust and time: a longitudinal study evaluating knowledge translation and exchange processes for research on violence against women. Implement Sci. 2011 Sep 6;6(1):102. \u003c/li\u003e\n\u003cli\u003eGilfoyle M, MacFarlane A, Hughes Z, Salsberg J. Understanding the evolution of trust in a participatory health research partnership: A qualitative study. Health Expect Int J Public Particip Health Care Health Policy. 2023 Nov 29; \u003c/li\u003e\n\u003cli\u003eLarkan F, Uduma O, Lawal SA, van Bavel B. Developing a framework for successful research partnerships in global health. Glob Health. 2016 May 6;12(1):17. \u003c/li\u003e\n\u003cli\u003eHenderson J, Brownlie E, Rosenkranz S, Chaim G, Beitchman J. Integrated Knowledge Translation and Grant Development: Addressing the Research Practice Gap through Stakeholder-informed Research. J Can Acad Child Adolesc Psychiatry. 2013 Nov;22(4):268\u0026ndash;74. \u003c/li\u003e\n\u003cli\u003eBoaz A, Borst R, Kok M, O\u0026rsquo;Shea A. How far does an emphasis on stakeholder engagement and co-production in research present a threat to academic identity and autonomy? A prospective study across five European countries. Res Eval [Internet]. 2021 May; Available from: https://academic.oup.com/rev/advance-article/doi/10.1093/reseval/rvab013/6272492\u003c/li\u003e\n\u003cli\u003eKothari A, Smith MJ. Public Health Policymaking, Politics, and Evidence. In: Fafard P, Cassola A, de Leeuw E, editors. Integrating Science and Politics for Public Health [Internet]. Cham: Springer International Publishing; 2022 [cited 2023 Dec 13]. p. 59\u0026ndash;74. (Palgrave Studies in Public Health Policy Research). Available from: https://doi.org/10.1007/978-3-030-98985-9_4\u003c/li\u003e\n\u003cli\u003eLanglois EV, Montekio VB, Young T, Song K, Alcalde-Rabanal J, Tran N. Enhancing evidence informed policymaking in complex health systems: Lessons from multi-site collaborative approaches. Health Res Policy Syst. 2016 Dec;14(1):20\u0026ndash;20. \u003c/li\u003e\n\u003cli\u003ePenuel WR, Briggs DC, Davidson KL, Herlihy C, Sherer D, Hill HC, et al. How School and District Leaders Access, Perceive, and Use Research. AERA Open. 2017 May 1;3(2):2332858417705370. \u003c/li\u003e\n\u003cli\u003eJohnson K, Greenseid LO, Toal SA, King JA, Lawrenz F, Volkov B. Research on Evaluation Use: A Review of the Empirical Literature From 1986 to 2005. Am J Eval. 2009 Sep 1;30(3):377\u0026ndash;410. \u003c/li\u003e\n\u003cli\u003eKothari A, Wathen CN. A critical second look at integrated knowledge translation. Health Policy Amst Neth. 2013 Feb;109(2):187\u0026ndash;91. \u003c/li\u003e\n\u003cli\u003eDadich A, Vaughan P, Boydell K. The unintended negative consequences of knowledge translation in healthcare: a systematic scoping review. Health Sociol Rev. 2023 Jan 20;0(0):1\u0026ndash;19. \u003c/li\u003e\n\u003cli\u003eOliver K, Kothari A, Mays N. The dark side of coproduction: do the costs outweigh the benefits for health research? Health Res Policy Syst. 2019;17(1):33\u0026ndash;33. \u003c/li\u003e\n\u003cli\u003eCairney P, Boaz A, Oliver K. Translating evidence into policy and practice: what do we know already, and what would further research look like? BMJ Qual Saf. 2023 May 1;32(5):251\u0026ndash;3. \u003c/li\u003e\n\u003cli\u003eJenkins EK, Kothari A, Bungay V, Johnson JL, Oliffe JL. Strengthening population health interventions: developing the CollaboraKTion Framework for Community-Based Knowledge Translation. Health Res Policy Syst. 2016 Aug 30;14(1):65. \u003c/li\u003e\n\u003cli\u003eKitson A, Powell K, Hoon E, Newbury J, Wilson A, Beilby J. Knowledge translation within a population health study: how do you do it? Implement Sci. 2013 May 21;8(1):54. \u003c/li\u003e\n\u003cli\u003eOngolo-Zogo P, Lavis JN, Tomson G, Sewankambo NK. Assessing the influence of knowledge translation platforms on health system policy processes to achieve the health millennium development goals in Cameroon and Uganda: a comparative case study. Health Policy Plan. 2018 May 1;33(4):539\u0026ndash;54. \u003c/li\u003e\n\u003cli\u003eCrosschild C, Huynh N, De Sousa I, Bawafaa E, Brown H. Where is critical analysis of power and positionality in knowledge translation? Health Res Policy Syst. 2021 Jun 11;19:92. \u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Footnotes","content":"\u003cp\u003e[1] IKT is defined as an ‘ongoing relationship between researchers and decision-makers’ (1) and is distinct from broader ‘knowledge user’ or ‘stakeholder’ engagement. However, some IKT strategies included stakeholders beyond decision-makers (e.g. academic or NGO staff), which is why we use both terms interchangeably.\u003c/p\u003e\n\u003cp\u003e[2] Country omitted to maintain anonymity\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":false,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"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":"health-research-policy-and-systems","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"hrps","sideBox":"Learn more about [Health Research Policy and Systems](http://health-policy-systems.biomedcentral.com/)","snPcode":"12961","submissionUrl":"https://submission.nature.com/new-submission/12961/3","title":"Health Research Policy and Systems","twitterHandle":"@HarpsJournal","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Public health, integrated knowledge translation, evaluation, implementation, non-communicable diseases, Uganda, Rwanda, Malawi, South Africa, Ethiopia","lastPublishedDoi":"10.21203/rs.3.rs-4312132/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4312132/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e: Integrated knowledge translation (IKT) aims to enhance evidence-informed decision-making in public health and healthcare by establishing continuous relationships between researchers and knowledge users, in particular decision-makers. The Collaboration for Evidence-based Healthcare and Public Health in Africa (CEBHA+) undertook research on non-communicable diseases in Ethiopia, Malawi, Rwanda, South Africa, and Uganda. Alongside the research activities, we implemented an IKT approach, which entailed training and the development and implementation of site-specific IKT strategies. We evaluated these strategies according to a pre-defined programme theory.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: Drawing on our published protocol (https://rdcu.be/dyfBP), we interviewed and surveyed CEBHA+ researchers and their decision-making counterparts during two project stages (3/2020-2/2021; 9/2022-5/2023) and collected IKT-related documents. Transcripts and documents were analysed using qualitative content analysis and surveys were analysed descriptively, with subsequent integration, cross-case analysis, and revision of the programme theory.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: A total of 36 researchers and 19 decision-makers participated in surveys, focus groups and/or interviews, and we collected 92 documents. Relationship-building, capacity-building, and collaborative research were the most proximal intervention outcomes: CEBHA+ researchers and their counterparts built mutual appreciation and partnerships, accessed contacts and networks, and expanded skills in conducting and using research and in IKT. The level of trust between partners varied. Intermediate outcomes were changes in attitudes and knowledge; beyond the conceptualisation in our initial programme theory, researchers substantially increased their understanding of the decision-making context and developed a vision for ‘research impact’. While it was challenging to evaluate distal outcomes, the IKT approach was linked to the production of research perceived as addressing local priorities and being highly applicable and contextualised; and some consideration of evidence among decision-makers. Unintended effects included high opportunity costs associated with undertaking IKT. An unanticipated outcome was the heightened interest of the research funder in policy engagement. Our updated programme theory constitutes a low-level theory for IKT.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e: Whilst this study faced many challenges common to the evaluation of knowledge translation interventions, it presents rich, theory-informed insights into IKT outcomes.\u003c/p\u003e\n\u003cp\u003eThese are based on documented IKT activities and participants’ views, particularly in-depth insights of researchers’ experiences with implementing the CEBHA+ IKT approach.\u003c/p\u003e","manuscriptTitle":"Outcomes of an integrated knowledge translation approach in five African countries: A mixed methods comparative case study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-05-09 20:44:44","doi":"10.21203/rs.3.rs-4312132/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-11-10T20:59:30+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-06-18T10:05:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"294625225653875370073962304923474923662","date":"2024-05-22T08:59:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"201329079184445425905541126853122448499","date":"2024-05-22T07:31:15+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-05-20T21:21:47+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-05-20T07:46:24+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-05-20T07:46:24+00:00","index":"","fulltext":""},{"type":"submitted","content":"Health Research Policy and Systems","date":"2024-04-23T12:23:37+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"health-research-policy-and-systems","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"hrps","sideBox":"Learn more about [Health Research Policy and Systems](http://health-policy-systems.biomedcentral.com/)","snPcode":"12961","submissionUrl":"https://submission.nature.com/new-submission/12961/3","title":"Health Research Policy and Systems","twitterHandle":"@HarpsJournal","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"fa7db97c-0dc1-4c67-a669-c7bcac8ee65b","owner":[],"postedDate":"May 9th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-12-16T15:58:36+00:00","versionOfRecord":{"articleIdentity":"rs-4312132","link":"https://doi.org/10.1186/s12961-024-01256-x","journal":{"identity":"health-research-policy-and-systems","isVorOnly":false,"title":"Health Research Policy and Systems"},"publishedOn":"2024-12-10 15:56:50","publishedOnDateReadable":"December 10th, 2024"},"versionCreatedAt":"2024-05-09 20:44:44","video":"","vorDoi":"10.1186/s12961-024-01256-x","vorDoiUrl":"https://doi.org/10.1186/s12961-024-01256-x","workflowStages":[]},"version":"v1","identity":"rs-4312132","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4312132","identity":"rs-4312132","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}