Rooted, resourced and connected: stakeholder perspectives on involvement in injury care policy and practice in Ghana, Pakistan, Rwanda, and South Africa - is consensus achievable?

Rooted, resourced and connected: stakeholder perspectives on involvement in injury care policy and practice in Ghana, Pakistan, Rwanda, and South Africa - is consensus achievable? | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Rooted, resourced and connected: stakeholder perspectives on involvement in injury care policy and practice in Ghana, Pakistan, Rwanda, and South Africa - is consensus achievable? Equi-Injury Group, Agnieszka Ignatowicz This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6350661/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 6 You are reading this latest preprint version Abstract BACKGROUND Strengthening health systems requires policy development that meets stakeholder needs and is informed by evidence. However, little is known about how to effectively engage stakeholders from diverse backgrounds in evidence uptake for policy or whether alignment can be achieved within and across different country contexts. This multi-country study, using injury care as a case study, aimed to: (1) ascertain the needs, preferences, and desires of stakeholders toward taking up evidence for policy; (2) understand if consensus is achievable within and across stakeholders; and (3) examine whether outcomes are shared across country contexts. METHODS The study was conducted in Ghana, Pakistan, Rwanda and South Africa, selecting one urban and one rural district in each country for broad representation. Stakeholder groups were: (1) communities and patients, (2) service providers, and (3) policymakers, with groups engaged separately to mitigate power imbalances. Workshops were structured using the nominal group technique to facilitate discussions and consensus-building. Data were collected through plenary sessions and voting, focusing on levels of involvement, mechanisms for involvement, and the barriers and facilitators to that involvement in developing evidence-based policy. In-depth interviews with policymakers were performed and thematically analysed. Finally, the research team synthesized findings across countries to identify consensus and differences. RESULTS A total of 297 stakeholders participated in the study: 240 through workshops and 57 in interviews. All stakeholder groups in all countries agreed that involvement in policy making was important. Consensus was achieved in each country in the levels at which stakeholders wanted to engage, with groups prioritizing local involvement. In Ghana and Rwanda, consensus was achieved on the mechanisms for policy engagement, specifically community engagement and advocacy. In Ghana and Pakistan, consensus was also reached on barriers and facilitators to policy involvement, primarily concerning resources and funding. CONCLUSION While involving diverse stakeholder groups in evidence-based policy development is a valuable goal, achieving consensus on levels, mechanisms, barriers, and facilitators for involvement is challenging and varies across contexts. Our work implies that deep engagement with stakeholders is required to ensure authentic and diverse involvement in policy and that solutions for involvement will differ across groups and contexts. injury stakeholder engagement engagement in policy and practice Ghana Rwanda Pakistan South Africa BACKGROUND Stakeholder involvement in the adoption and implementation of contextually appropriate evidence-based interventions is recognised to be an integral part of assuring policy formulation responds to diverse healthcare needs [ 1 – 3 ]. A broad, inclusive approach to stakeholder involvement is important, considering disconnects between policy formulation processes, which are typically formal and closed, together with involvement of those that policy targets and impacts: those that deliver and utilise public services. Policy and decision-making, including embedding evidence-based interventions and implementation strategies into policy, are strengthened with broad stakeholder involvement [ 4 – 6 ]. However, little is known about how to meaningfully involve (engage) stakeholders from diverse backgrounds in this process in low- and middle-income countries (LMICs) [ 7 – 10 ]. Unfortunately, whilst the importance of stakeholder involvement to strengthen linkages between evidence and policy is increasingly recognised as being important in LMICs [ 11 – 13 ], in many settings active, sustained, and authentic participation of diverse stakeholders in policy is often only recognized in theory [ 14 ]. Achieving meaningful and equitable stakeholder involvement in embedding evidence-based interventions into policy requires substantial transformations in the attitudes, norms and practices of policymakers, community members, and other stakeholders [ 11 ]. Community involvement debates provide valuable perspectives on stakeholder engagement. For instance, critical debates on community involvement acknowledge power, and the degree of power devolved to communities through involvement processes, as a central feature. These can range from practices such as information-giving and consultation to more empowering approaches where the community has control over decision-making processes [ 15 , 16 ]. “Tokenistic’ involvement is often cited as a major criticism, leading to a “lack of [community] presence, presence without voice, and voice without influence” [ 16 ]. Barriers to stakeholder involvement are gaining attention, including recognition of the impact of cultural norms and mechanisms of involvement across different contexts [ 17 ]. Implementation science has been defined as “the scientific study of methods to promote the systematic uptake of research findings and other evidence-based practices into routine practice, and, hence, to improve the quality and effectiveness of health services” [ 18 ]. The use of frameworks and models plays a critical role in structuring research, describing relationships, and providing insights into the factors contributing to the success or failure of implementation efforts. Among the primary aims of these frameworks, as identified by Nielsen, is describing and/or guiding the process of translating research into practice [ 19 ]. However, effective research translation into policy requires more than just theoretical models – it requires a deep and contextually-sensitive engagement with stakeholders to align evidence with policy and practice. It is crucial to involve stakeholders throughout the process [ 20 ] and to understand how they themselves envision the translation of knowledge into practice [ 21 ]. Drawing on our own work and that of others [ 8 , 20 , 22 , 23 ], we propose that successful translation of research into policy hinges on a comprehensive understanding of stakeholders' needs, priorities, and roles in evidence-informed policymaking. We conceive of four broad stages to ensuring the uptake of evidence-based interventions into policy. First, it is essential to develop a clear understanding of whether and how different stakeholder groups wish to be involved; the levels of policy where and the mechanisms through which they wish to act and the feasibility (or barriers and facilitators to this). Second, there must be a shared understanding of how stakeholder groups wish to be involved across all groups. Third, developing a mutual understanding of the issues which are important for action across stakeholder groups is critical for collaboration. Finally, consensus must be developed on which evidence-based interventions are likely to be feasible, appropriate, acceptable, and sustainable to address the identified issues. This structured approach underscores the vital role of stakeholder engagement in bridging the gaps between research, evidence and policy. Without meaningful involvement of stakeholders at every stage, the likelihood of successful, context-specific policy translation diminishes. Therefore, stakeholder engagement is not just complementary to implementation science but a fundamental component in ensuring that evidence-based interventions are adopted, integrated, and sustained in policy and practice. The focus was on policy for injury care. Injuries account for 9% of all deaths globally. There are 5 million fatalities annually from road traffic collisions, drowning, poisoning, falls, burns, or violence and 90% of injury-related deaths occur in LMICs [ 24 – 26 ], where around 40% of injury deaths are preventable [ 27 , 28 ]. Recognition of the need for improved injury care was manifest in two recent World Health Assembly (WHA) resolutions: in 2023, WHA76.2 (Integrated emergency, critical and operative care for universal health coverage and protection from health emergencies) and in 2024, when the need for a global strategy and action plan for emergency, critical, and operative care was codified [ 29 ]. Moving resolutions from paper to action to strengthening health systems to provide access to quality injury care will involve implementing evidence-based interventions into policy and practice [ 30 ]. Barriers to access to quality injury care begin at the point of recognising the need to seek care and extend through reaching, receiving, and remaining in care, with 40% of the avoidable mortality occurring due to delays in seeking and reaching care [ 28 ]. To ensure that contextually appropriate interventions which match local needs are implemented and embedded into policy therefore requires the involvement of multiple different stakeholder groups with understanding of issues at each of these stages. Unfortunately, even simple advocacy or community involvement to improve injury care is exceptionally rare [ 8 ] and there is little evidence of how best to engage and involve stakeholders to deliver improvements [ 31 , 32 ]. Given the importance of injury to global morbidity and mortality and the necessity for development of health systems interventions to reduce these, we used injury as an exemplar case to understand the needs and desires of diverse stakeholders towards developing evidence-informed policy and practice, and whether there was consensus between stakeholder groups. This aligns with the first of our four broad stages, articulated above. Stakeholders were identified as those who were most directly affected by injuries, and whose inputs were critical to, but who may typically be excluded from policy processes; as well as those who are typically involved in policymaking for injury care. As such, this study was structured around gaining the views of three core constituencies: communities and patients; healthcare workers; and policy makers. The aims were to: (1) ascertain the needs, preferences, and desires of different stakeholders towards policy involvement; (2) understand if consensus is achievable across stakeholders; and (3) understand if outcomes are shared across country contexts. While our focus is on injury, the implications of our findings may have the potential to extend beyond the specific contexts in the study, offering relevance and impact for policy involvement across diverse settings. METHODS Study settings The study was undertaken as part of the NIHR Global Health Group on Equitable Access to Quality Health Care for Injured People (‘Equi-Injury’) project, working with partners in Ghana, Pakistan, Rwanda, Ghana, and South Africa [33]. These four countries provide a diversity of social, economic, geographic, cultural, and health system contexts. A short overview of each country’s health systems is presented in the Table 1 below, with a description of policy for injury care context in appendices (appendix 1). INSERT TABLE 1 ABOUT HERE Participant recruitment Two districts were purposively selected in each country to represent urban and rural contexts which were as representative of the whole country as possible. Sites were also pragmatically selected to ensure participant recruitment and data collection was feasible. Within the study areas, participants were purposively selected from each rural and urban study areas to represent key stakeholder groups: (a) patients and community members; (b) healthcare workers providing injury care, and (c) policymakers, noting that policymakers were also invited who were involved in national policy development and delivery (see Table 2). Snowball sampling and collaboration with local Community Involvement and Involvement (CEI) leads, established as part of the larger study, were utilized for recruitment of community members, patients, and healthcare workers. INSERT TABLE 2 ABOUT HERE Patients were included if they had suffered moderate to severe injuries (either admitted to a hospital for more than 12h) or identified by community leaders as having suffered moderate of severe injuries but who didn’t attend a health facility. Community members and leaders (e.g. church leaders, community activists, school officials, and local business leaders) were resident in each area. Healthcare workers included were those involved in providing injury care in the facilities serving the study areas. Policymakers and civil servants, including people involved in local and national healthcare service policy, were purposively selected from each urban or rural study area based on local investigator’s knowledge of the health system contexts and professional networks. Data collection and analysis Data were collected between January and August 2023 by trained teams of local researchers, supported by the in-country experienced research fellows. Workshops were used to elicit priorities of patients and community members as well as healthcare workers, whereas in-depth interviews (IDIs) were used with policy makers. Stakeholder workshops used the nominal group technique as a common approach to structure deliberation and consensus building [34]. In each setting, the local research team hosted four individual stakeholder workshops: two with patients and community members (one in each of the urban and rural areas) and two with healthcare workers (one in each of the urban and rural areas). In each workshop, there was an opening plenary, where participants were oriented to the study’s aims and procedures and policy involvement concepts and elements were introduced. It was clarified that the overarching aim was to gain consensus on how stakeholder groups might come together to embed contextually appropriate and evidence-based interventions for injury care which matched local needs into policy. Policy and policy involvement were conveyed as follows: 'Policy' was defined broadly, inclusive of policy implementation, and as formal or informal (e.g., generation of policy documents at a local or national government level, or policy and planning for local healthcare services). Involvement/engagement in policy was defined in terms of the spaces of policymaking, articulated as ‘ levels’ at which stakeholders wished to be involved (e.g., local government policy or services, national, regional, international); and the policy processes, articulated as ‘ mechanisms’ of involvement (e.g., advocacy external to policymaking, in local discussions to inform policy and planning, directly included in the policymaking process, involved in ensuring policy is delivered). We also sought views on real world ‘ barriers’ and ‘ facilitators’ to policy involvement (e.g., lack of opportunities and/or functional forums for patient voice) [35]. Following the orientation plenary, participants were divided into smaller sub-groups of 4-5 participants to consider specific questions. There were four facilitated roundtable discussions where sub-groups deliberated over, and reached consensus on, preferences and priorities regarding the following elements: i. levels and ii. mechanisms of policy involvement and iii. barriers and iv. facilitators to that involvement. Roundtables discussions were facilitated by trained investigators to ensure that the discussion stayed focussed and encourage input from all participants. Facilitators also captured a list of all participant responses. Towards the end of each roundtable, facilitators guided the group members to review the list and collectively rank their responses, generating lists of consensus priorities for each element. At the end of each roundtable discussion, the lists of consensus priorities (up to 5) and rationales for their selection and prioritisation were presented in plenary by each roundtable’s spokesperson. Plenary sessions allowed all participants to appraise the selected responses, rationales for these responses, and their priority order or ranking. Following the discussion, facilitators combined and de-duplicated the responses from all sub-groups. All stakeholders then voted for their top five responses using digital software [36] or other means (e.g.: show of hands). Workshops were structured with detailed guides (appendix 2). We used general principles of group facilitation such as ensuring a relaxed and collegiate environment with time and space for listening with respect and interest. Workshops were not focus group discussions in the qualitative sense and outputs from the workshops were captured as lists of short responses, as appropriate for use of the nominal group technique. The plenary and round table discussions were audio-recorded in case of need for later clarification and to cross-check the results of voting, but not for formal analysis. In-depth interviews were used for the data collection with policy makers and civil servants, given the schedules and locations of participants did not allow for workshops. Up to 20 IDIs were conducted per country until thematic saturation occurred. The IDIs explored policy-maker’s perspectives on the involvement of community, patient, and healthcare stakeholders in policy processes. Interviews were semi-structured to allow understanding of the levels and mechanisms of, and barriers and facilitators to stakeholder involvement in policy as well as to enable the integration of outputs from interviews with those outputs from the workshops. Pre-prepared topic guides (appendix 3) structured the discussions and allowed a degree of flexibility in responses. All interviews were audio-recorded and were conducted in person, by telephone, or online, depending on availability and preferences of respondents. For both workshops and IDIs, common methods were employed in each setting, facilitated by the creation of a study manual and combined training sessions on methodological approaches and workshop facilitation with local research teams. Contextual and cultural adaptations to the manual (such as durations and locations of workshops, and the language and terms used by the workshop facilitators) were supported and appraised in training sessions to ensure meanings and understandings were maintained. The work was undertaken in local languages, with outputs written up in English for analysis and synthesis. We adopted a rapid qualitative research approach to support data collection and analysis. The process, developed by the RREAL (Rapid Research Evaluation And Appraisal Lab) group, supports systematic collection of data, enables rapid summary of findings and identification of themes, including adaption of data collection and analytical processes through team reflection [37]. According to this process, during workshops and IDIs, researchers took notes. Following each workshop or interview, notes were summarised into two structured ‘RREAL Sheets’: one on substantive content (results), and one for observations and reflections from the research team (appendix 4). In subsequent workshops and IDIs, notes were taken, and key findings transferred, using the RREAL Sheets as a triangulation tool. The process enabled data to be systematically captured according to the analytical categories: levels, mechanisms, barriers and facilitators to policy involvement, and on observations and reflections. Regular team meetings were held to reflect on the process and emerging results, in which workshop and IDI data were iteratively reviewed and categorised. Findings from each study setting were then synthesized and visually represented using heatmaps to depict priorities and consensus across the five stakeholder groups and four study settings during an investigator meeting in March 2024. Ethical considerations and approval All participants gave fully informed consent for their involvement in the study. The study received approval from ethical review boards: Ghana Health Service Ethics Review Committee (GHS-ERC 014/09/22), Aga Khan University Ethics Review Committee in Pakistan (2022-7372-23339), Rwanda National Ethics Committee (IRB 00001497 of IORG000110, No 85/RNEC/2023), and Stellenbosch University Health Research Ethics Committee in South Africa (N22/07/079). The University of Birmingham (overall sponsor for this study) accepted the local ethics approvals for this project in lieu of the requirement for full ethics review. Patient and public involvement As described above, the study was conducted as part of the Equi-Injury programme [33]. The parent study aims to assess barriers to quality care after injury and co-develop interventions to reduce avoidable injury-related mortality and morbidity. In each country, there is a nominated CEI lead through whom Equi-Injury investigators collaborate with various stakeholders, including service users, providers, and policymakers, to ensure that research is grounded in the needs and priorities of key stakeholders and the ‘real world’ social and health systems’ realities of injury and injury care. This process is coordinated by a central CEI lead who works across all countries. Injured patients and community leaders were directly involved in the design, recruitment and conduct of the study. In each study country, community leaders were consulted prior to commencement of the study and agreed to research being done and disseminated in their communities. Injured patients were consulted on the recruitment strategy for individual workshops and reviewed the study findings. RESULTS A summary of participants is presented in Table 3. A total of 297 stakeholders participated in 16 workshops (240 participants) and in-depth interviews (57 participants). The priorities from workshops and interviews in each country, captured as lists of short responses, can be found in the appendix 5. All stakeholder groups in all countries agreed that involvement in policy making was important. INSERT TABLE 3 ABOUT HERE Levels and mechanisms of involvement The top five priorities for levels and mechanisms of involvement by participant group and setting for each country and consensus on these within and between stakeholders, and across study settings, are shown in Tables 4 and 5, respectively. Although there were multiple priorities from across stakeholder groups, consensus was achieved across all stakeholder groups in each country in the levels at which all wanted to come together to be involved in policy; all groups in all countries agreed that local involvement was a priority. There was a high level of consensus with regards to levels of involvement with all stakeholders across all study settings ranking local community level involvement highly. ‘Local’ was understood with some variation across settings, albeit mainly referring to involvement through community, workplaces, and educational or religious groups, and, in one setting, as through the local authority. Additionally, all five stakeholder groups across Ghana Pakistan and Rwanda agreed that involvement at national level, through working with the Ministry of Health, was important for involvement with policy and practice. Conversely, in South Africa, national-level involvement was only ranked amongst the top five levels of involvement by policymakers. INSERT TABLE 4 ABOUT HERE INSERT TABLE 5 ABOUT HERE Various mechanisms for involvement were identified and prioritised as instrumental in facilitating effective involvement across the ranked levels. Across the five stakeholder groups and study settings, there was no consensus on mechanism of involvement. There was, however, consensus across all stakeholder groups in Ghana on the importance of community engagement, whereas in Rwanda, stakeholders agreed that advocacy was an important mechanism for engagement. In Pakistan and South Africa, there was no agreement between the five stakeholder groups and settings regarding the preferred mechanisms of engagement. However, there was consensus among some stakeholder groups and settings across these two countries - specifically, patients/communities and healthcare workers in both rural and urban areas - that participation in and involvement with diverse groups that can affect change or implement new policies was an important mechanism. Additionally, although there was no agreement across all groups and all settings, the importance of engaging through providing, receiving, and sharing evidence and relevant data was frequently prioritised as a mechanism for engaging in policy and practice. Barriers and facilitators to involvement Tables 6 and 7 present the top five ranked barriers and facilitators, respectively, to involvement by participant group and setting for each country as well as consensus on these between five stakeholder groups. While there was no overall consensus on barriers to involvement between all stakeholder groups across the study settings, there was consensus across all stakeholder groups in Ghana and in Pakistan. In Ghana there was agreement that resources and social discrimination based on tribe, religion, and political affiliations, were substantial barriers to involvement, indicating that social biases can affect engagement. In Pakistan, there was consensus across all stakeholder groups that lack of finances would be a barrier to engagement. Lack of financial resources, affecting various aspects of involvement from training to dissemination was the main barrier to involvement in policy making agreed by multiple stakeholder groups in Ghana, Pakistan and Rwanda. Logistical barriers, including transportation, were also shared between groups in some study countries, particularly in Pakistan and Rwanda. In Ghana and Rwanda, some stakeholder groups - including policymakers - agreed that low education levels, communication barriers and lack of awareness of policy involvement processes were important barriers. Whereas in South Africa, hierarchies and power dynamics were predominant barriers, ranked by urban patients/community members and healthcare workers, as well as policymakers, highlighting the role of social structures in impeding engagement. INSERT TABLE 6 ABOUT HERE INSERT TABLE 7 ABOUT HERE There were also marked differences between the four countries with regards to facilitators of engagement. However, the five stakeholder groups in Pakistan and Ghana agreed that providing resources, such as financial support and transport, was an important facilitator of engagement. Other facilitators, such as inclusive communication, multi-stakeholder collaboration, and education/training were prioritised by some stakeholder groups in South Africa and Pakistan. Across stakeholder groups and settings, patients and the community tended to highlight the importance of funding and personal recognition, healthcare workers emphasized the need for inclusive communication and training, whilst policymakers prioritised enhancing community involvement, using evidence-based, data driven approaches, and ensuing that resources are allocated effectively as facilitators of engagement. DISCUSSION In this paper, we explored the perspectives of key stakeholders (service users, providers, and policy makers) on how to achieve impactful involvement in developing and prioritising solutions to improve equitable access to quality injury care in Ghana, Pakistan, Rwanda and South Africa. This multi-country study aimed to: (1) ascertain the needs, preferences, and desires of different stakeholders towards policy involvement; (2) understand if consensus is achievable across stakeholders; and (3) understand if outcomes are shared across country contexts. All stakeholder groups in all countries agreed that involvement in policy making was important. Although there were multiple priorities from across stakeholder groups, consensus was achieved among all stakeholder groups in each country regarding the levels at which all wanted to come together to be involved in policy; all groups in all countries agreed that local involvement was a priority. Only in Ghana and Rwanda was there consensus across stakeholder groups in the mechanisms via which policy involvement could occur (via community involvement and advocacy, respectively). In both, Ghana and Pakistan, stakeholders agreed on the barriers to achieving policy involvement, which in both cases were primarily related to resources and funding. While there were varied findings across contexts, and as stated above, all groups in all countries agreed that local involvement was a priority. The consensus on local, rooted community-level involvement aligns with extensive literature emphasizing the critical role of community participation for policy and systems change [ 38 – 40 ]. Communities have extensive, grounded insights into the daily realities of how social contexts influence health outcomes, access to care, and its quality [ 41 , 42 ]. It follows that their involvement is crucial for policies and decision-making. However, in many LMICs, policy decisions are often made without community involvement or through narrow ‘consultations’ during policy development or after policies are established [ 3 ]. While there was broad consensus on local engagement, ‘local’ was understood with some variation across settings, albeit mainly referring to involvement through community, workplaces, and educational or religious groups, and, in one setting, as through the local authority. It is also the case that not all stakeholder groups within each country ranked local involvement highly, potentially attributable to cultural and political differences. Social discrimination is reported as a significant barrier to stakeholder involvement [ 43 ]. Evidence suggests that how different stakeholder groups perceive the importance of involvement in policy is also influenced by factors and actors including community capabilities to raise and frame local concerns and priorities, organisational and institutional contexts, elite capture and control, the risks of collective action, as well as the role of the state [ 44 , 45 ]. Community involvement is often supported in policy, yet organisational norms of top-down governance persist, overlooking the significant contributions from lower levels [ 8 , 46 , 47 ]. Nevertheless, across many countries, including those in this study, it is increasingly expected, and formally mandated in policy and strategy, that individuals or groups involved in or affected by health and healthcare policies should have a say in the planning and dissemination [ 48 , 49 ]. Goals of community formation and solidarity, and of community participation as a political process concerned with democratic power as a response to social injustice, are poorly understood operationally [ 50 , 51 ]. How to technically deliver this in a meaningful and sustainable manner is less well understood, however together with an appreciation that, activities solely focused on community capabilities are insufficient for authentic and sustained community power-building [ 52 , 53 ]. In terms of supporting communities to work with other agencies and organisations, there is a need to navigate multiple, complex, overlapping open systems, each with inherent hierarchies and biases [ 54 , 55 ]. Across the study settings, although consensus was not achieved, multisectoral dialogue and community action were key mechanisms identified through which involvement in injury policy and practice should happen, reflecting a recognition of the need for more inclusive and community-led processes that actively involve diverse stakeholder groups [ 53 , 56 ]. Such approaches are thought to facilitate information sharing, relationship-building and dialogue between diverse stakeholders, and support well-rounded policies that consider multiple perspectives [ 52 ]. However, specific mechanisms varied by setting, highlighting the importance of local contexts and the perceptions of different stakeholder groups. Specific mechanisms were also likely to vary because injury care is complex. Acute in nature, requiring timely access to quality integrated care, and driven by factors and forces beyond health systems such as rapid industrialisation and economic transition. Access to quality healthcare, alone, is a significant challenge. Over 3 billion people, located largely in LMICs, lack access to essential health care [ 57 ]. Access to injury care can thus be considered as a ‘wicked problem’ - i.e. as a complex social problem with an unknown number of potential solutions [ 58 ] - and access to quality healthcare after injuries, which are heterogenous in type and mechanism, especially so [ 59 ]. Research suggests that addressing wicked problems under governmental and administrative constraints necessitates new approaches such as going beyond technical/rational thinking, collaborative working, new modes of leadership [ 53 , 60 ]. Addressing this requires understanding opportunities and constraints from multiple perspectives, sectors and dimensions. In this context, the need for dialogue among diverse stakeholders, including e.g., patients, communities, civil society and advocacy groups, emergency services, healthcare workers, local government, traffic and road safety, public service planners, managers, and policy makers, is evident [ 61 ]. There are reported examples of successful participatory governance or multisectoral mechanisms for policy involvement in the international literature [ 62 – 64 ], but although the importance of partnerships across sectors is acknowledged, research is needed to understand how stakeholders can meaningfully collaborate, how to foster equitable partnerships, how to navigate social and institutional differences across contexts, and how to do so sustainably over space and time [ 65 ]. Particularly in LMICs, where institutions are often fragmented and resources scarce, the challenges to multisectoral action may be more pronounced [ 66 ]. Bottom-up initiatives have had success in other contexts and for other conditions [ 67 ], however, a growing body of literature highlights the importance of political commitment for multisectoral action in the context of LMICs and the need to understand the key stakeholders and the type of multisectoral action required [ 52 , 60 ]. Multisectoral action necessitates approaches that enable dialogue among diverse stakeholders. Recognizing distinct (including conflicting) perspectives and positions, identifying shared goals, and enabling and maintaining meaningful deliberation and consensus-building via inclusive and equitable involvement processes, as we done in this study, is a necessary first step [ 52 , 68 ]. While differences across country contexts and various types of multisectoral and community action challenges are inevitable, our findings indicate that there is appetite across all stakeholders for multisectoral action to deliver change both within and outside the health system to improve access to quality injury care. This approach involves engaging diverse stakeholders in decision-making, grounding involvement in local realities, and fostering environments responsive to data and evidence. However, data and evidence need to be considered relative to the nuanced dynamics of stakeholders involved. Numerous examples from the Covid-19 pandemic have demonstrated that successful responses to public health crises require more than data-driven decisions; they demand genuine collaboration with stakeholders who bring varied perspectives and expertise [ 69 , 70 ]. Considering these findings, combining data with diverse insights and knowledge from stakeholders and high-level multisectoral should function as interconnected and mutually reinforcing components of effective injury policy development and practice. The concept of ‘stakeholderism’, reflecting involvement of diverse groups of actors with differing interests [ 31 , 71 ], is particularly pertinent in the context of stakeholder involvement in policy and practice. Debates revolve around the extent of inclusion and empowerment within decision-making processes. Critics argue that traditional stakeholder involvement models may fall short of engaging marginalized or underrepresented groups, leading to tokenistic participation or reinforcing existing power imbalances [ 16 , 72 , 73 ]. This starkly contrasts with academic and policy assertions that all stakeholders should be active partners rather than passive participants in policy [ 31 , 74 ]. It also challenges the concept of involvement with decision-making as ‘distributed’ [ 75 ], where decision-making is considered as a dynamic process involving multiple spaces, actors, and practices [ 72 , 75 ]. Likewise, critics are increasingly questioning whether stakeholders should merely be consulted or involved in co-creation and decision-making processes [ 41 ]. Some advocate for a more participatory approach that involves stakeholders from the outset of policy development [ 3 ], while others argue for maintaining a clearer distinction between stakeholders and decision-makers as the emphasis on stakeholder input can sometimes dilute the impact of expert knowledge and evidence-based practices, potentially leading to less effective solutions [ 76 ]. The literature is only beginning to explore how access to involvement with decision-making varies across stakeholders [ 16 , 31 ]. To advance towards more inclusive and effective multistakeholder engagement, it is essential to shift from theoretical discussions to studying the implementation processes of various approaches [ 52 , 60 , 65 ], and to build the necessary capabilities for sustaining genuine engagement. Responding to this gap, our study examined the levels, mechanisms, barriers, and facilitators of involvement sought by diverse stakeholders from four LMIC countries. Our approach is explicitly designed to address and mitigate tokenism and the criticism associated with ‘stakeholderism’ by fostering genuine, meaningful participation. We place emphasis on inclusive participation and collaboration among all relevant stakeholders, ensuring the voices of marginalized and vulnerable populations are amplified and integrated into decision-making processes. Additionally, we highlight the importance of continuous monitoring and adaptive learning to refine strategies and ensure they remain responsive to the evolving needs and contexts of the communities involved. Our next step is to utilise our findings to co-develop a strategy, in partnership with stakeholders in each study country, to facilitate involvement across stakeholder groups, including communities, health workers and policy makers. By creating these strategies, we aim to support multistakeholder action that leverages local, data-informed initiatives, implemented and evaluated through cooperative action and learning with key stakeholders. While the role of stakeholders in implementation science is acknowledged, it is still underutilized [ 6 ]. In particular, the specific ways in which diverse stakeholder involvement affects translation of research findings into action and how stakeholders envision their involvement in this process have not been explored [ 23 , 77 ]. This study supports the need for a deeper examination of how stakeholder involvement can be effectively integrated to inform and support research translation. Our approach highlights the need for inclusive, ongoing dialogue with key stakeholders to align research with their needs and preferences, ensuring effective policy and practice adoption. STRENGTHS AND LIMITATIONS Our geographically diverse approach in addition to use of a nominal group technique to elicit concise and comparable responses, rather than use of a deeper qualitative analysis, may have resulted in the loss of some contextual detail. The responses for priority areas were captured by the local country teams using stakeholders’ language and local study teams then discussed and agreed the ranked responses in each priority area. Agreement on categorizing these responses was reached through iterative review between country and central teams. This process, which aimed to achieve terms that could be understood across contexts may have resulted in loss of some local nuances. However, results have been checked by in country teams to ensure loss of nuance is minimised whilst cross-contextual understanding is maintained. A strength of our study is that many of the priorities and barriers we identified were not unique to injury but reflected knowledge across broader involvement literature, suggesting that priorities may be transferable between other settings and conditions. For instance, lack of resources, difficulties navigating the policy processes, understanding technical or bureaucratic language are well recognised as barriers to involvement in the literature [ 3 , 50 , 72 ]. Findings from this study may increase the understanding of key stakeholder perspectives regarding potential needs and barriers to integration of stakeholder input into policy and practice. CONCLUSION This study identified stakeholder needs and priorities to support involvement in injury care policy and practice in Ghana, Pakistan, Rwanda, and South Africa and compared the results across the settings. Involving diverse stakeholder groups in evidence-based policy development is a valuable goal, but reaching consensus on the appropriate levels, mechanisms, barriers, and facilitators for that involvement is challenging and varies by country. Our work suggests that deep and diverse engagement is crucial to ensure and sustain participation in policymaking, with solutions for involvement likely to differ across different contexts. Abbreviations LMICs - lower- and middle-income countries HIC - higher-income countries CEI – community engagement and involvement Declarations Ethics approval and consent to participate This study was conducted in accordance with the ethical principles of the Declaration of Helsinki. The study received approval from ethical review boards: Ghana Health Service Ethics Review Committee in Ghana (GHS-ERC 014/09/22), Aga Khan University Ethics Review Committee in Pakistan (2022-7372-23339), Rwanda National Ethics Committee (IRB 00001497 of IORG000110, No 85/RNEC/2023), and Stellenbosch University Health Research Ethics Committee in South Africa (N22/07/079). The University of Birmingham (overall sponsor for this study) accepted the local ethics approvals for this project in lieu of the requirement for full ethics review. Written and verbal consent to participate in the study was obtained directly from all participants. Consent for publication Not applicable. Availability of data and materials Data are available upon a reasonable request from the project PIs. Competing interests The authors declare that they have no competing interests. Funding This research was funded by the NIHR (award number 133135) using UK aid from the UK Government to support global health research and the International Strategy Partnerships Fund 23/24, issued by Research England and the University of Birmingham. The views expressed in this publication are those of the authors and not necessarily those of the NIHR or the UK government. Authors' contributions This manuscript has been prepared by the Equi-Injury Group research team. JD and KC designed the study and led the submission of the grant application. ST, NB, JCB, AB, JR, LDA, AI are significant co-investigators participating in the design and data analysis procedures for Work package 1 that this paper is based on. LD and AI co-led the WP1. KT, DFB, FSA, AEA, ZWA, TMQ, CL, HA, ZBC, RO, EKW, DKY, ET, NM, NOM, SN. PN, GU. DN. IB, JI, KM, NL, BTA, AA, LG and DL are significant contributors who collected and analysed country level data. AI, LD and JD drafted the manuscript. All authors critically reviewed, provided feedback, and approved the final manuscript. EQUI-INJURY GROUP MEMBERS: Agnieszka Ignatowicz 1 , Lucia D’Ambruoso 2 , Khaya Tshabalala 3 , Derbew Fikadu Berhe 4 , Zabin Wajid Ali 5 , Frederick Sarfo-Antwi 6 , Huba Atiq 1,5 , Zaheer Babar Chan 5 , Tamlyn McQueen 3 , Anita Eseenam Agbeko 7 , Richard Osei 8 , Ebenezer Kwame Amofa 9 , Dominic Konadu-Yeboah 1,10 , Eric Twizeyimana 4 , Nadine Mugisha 4 , Ngirabeza Oda Munyura 4 , Solange Nakure 4 , Pascal Nzasabimana 11 , Ghislaine Umwali 11 , Denys Ndangurura 12 , Irene Bagahirwa 13 , Jules Iradukunda 4 , Kedest Mathewos 4 , Nzungize Lambert 11 , Christina Laurenzi 3 , Barnabas Tobi Alayande 4 , Alemayehu Amberbir 4 , Leila Ghalichi 1 , Daniel Lange 1 , Stephen Tabiri 7,14 , Napoleon Bellua Sam 15 , Abebe Bekele 4 , Jean Claud Byiringiro 11 , Junaid Razzak 5 , Kathryn Chu 3,16 , Justine I Davies 1,3,17 1 Department of Applied Health Sciences , University of Birmingham, Birmingham, UK 2 Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK 3 Centre for Global Surgery, Department of Global Health, Stellenbosch University, Cape Town, South Africa 4 Centre for Equity In Global Surgery and BioMedical Science, University of Global Health Equity (UGHE), Kigali, Rwanda 5 Centre of Excellence for Trauma and Emergencies (CETE), The Aga Khan University, Karachi, Pakistan 6 Department of Biochemistry and Molecular Medicine, School of Medicine, University for Development Studies, Tamale, Ghana 7 Komfo Anokye Teaching Hospital, Kumasi, Ghana 8 NIHR Equi-injury Group, Ghana 9 Department of Physiology and Biophysics, School of Medicine, University of Development Studies, Tamale, Ghana 10 Department of Surgery, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana 11 College of Medicine and Health Sciences, University of Rwanda Kigali, Rwanda 12 Department of Community Health and Social Medicine, Community Based Medical Education, University of Global Health Equity (UGHE), Kigali, Rwanda 13 Rwanda Biomedical Centre/NCDs Division/ Injuries & Disabilities Unit, Kigali, Rwanda 14 Department of Surgery, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana 15 Department of Medical Research and Innovation, School of Medicine, University of Development Studies, Tamale, Ghana 16 Department of Surgery, University of Botswana, Gaborone, Botswana 17 Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit, Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa References Chalmers, I., et al., How to increase value and reduce waste when research priorities are set. 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Int J Health Policy Manag, 2017. 6 (7): p. 359-363. Whitaker, J., et al., Access to quality care after injury in Northern Malawi: results of a household survey. BMC Health Serv Res, 2024. 24 (1): p. 131. Rajan, D., et al., The triangle that moves the mountain: nine years of Thailand’s National Health Assembly (‎2008-2016)‎ . 2017, WHO, System's Governance and Policy (HGS). D'Ambruoso, L., et al., Correction: 'Voice needs teeth to have bite'! Expanding community-led multisectoral action-learning to address alcohol and drug abuse in rural South Africa. PLOS Glob Public Health, 2023. 3 (7): p. e0002187. Rasella, D., et al., Effect of a conditional cash transfer programme on childhood mortality: a nationwide analysis of Brazilian municipalities. Lancet, 2013. 382 (9886): p. 57-64. Hinton, R., et al., Specific considerations for research on the effectiveness of multisectoral collaboration: methods and lessons from 12 country case studies. Globalization and Health, 2021. 17 (1): p. 18. 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Boaz, A., et al., How to engage stakeholders in research: design principles to support improvement. Health Research Policy and Systems, 2018. 16 (1): p. 60. Tables Table 1. Overview of study countries Ghana Pakistan Rwanda South Africa Income status Lower-middle Lower-middle Low Upper-middle HDI Index 142 152 157 133 GINI Index 38.3 36.2 44.3 57.7 % GDP on health 3.3 2.9 6.6 8.1 OPP HE % 40.3 60.2 6.3 7.8 HDI Human Development Index; OOP Out of Pocket; HE Health expenditure Table 2. Participant selection characteristics Stakeholder group Characteristics Community/ patient (Rural and urban) Community members Patients who have accessed injury care for moderate or severe injuries but are no longer in acute care Patients with moderate to severe injuries who did not access care Healthcare providers (Rural and urban) Doctors Nurses Clinical officers Others e.g., Rehab Care Workers/Home Based Carers (HBCs) Policymakers/ civil servants Health facility managers Policy makers, civil-servants, incl. local policy Table 3. Overview of participants Participants Setting U F M R F M Community/ patient Ghana: Tamale (U); Bekwai (R) 13 2 11 14 2 12 Pakistan: Karachi (U); Sehwan and Thatta (R) 16 3 13 26 4 22 Rwanda: Musanze (U); Kigora (R) 16 7 9 15 6 9 South Africa: Western Cape (U); Eastern Cape (U) 14 12 2 10 9 1 Healthcare Ghana: Tamale (U); Bekwai (R) 12 2 10 15 4 11 providers Pakistan: Karachi (U); Sehwan and Thatta (R) 26 10 16 24 8 16 Rwanda: Musanze (U); Kigora (R) 8 4 4 6 3 3 South Africa: Western Cape (U); Eastern Cape (U) 15 6 9 10 6 4 N M F Policymakers/ civil Ghana 23 18 5 servants Pakistan 17 4 13 Rwanda 9 9 - South Africa 8 4 4 Total 297 U=urban, R=rural, M=male, F=female Tables 4 to 6 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files BMCHSRXcountryISWpaperappendices1.4.25.docx BMCHSREIISWxcountrypapertables1.4.25.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 01 Feb, 2026 Reviewers invited by journal 05 May, 2025 Editor assigned by journal 29 Apr, 2025 Editor invited by journal 08 Apr, 2025 Submission checks completed at journal 08 Apr, 2025 First submitted to journal 08 Apr, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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A broad, inclusive approach to stakeholder involvement is important, considering disconnects between policy formulation processes, which are typically formal and closed, together with involvement of those that policy targets and impacts: those that deliver and utilise public services. Policy and decision-making, including embedding evidence-based interventions and implementation strategies into policy, are strengthened with broad stakeholder involvement [\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. However, little is known about how to meaningfully involve (engage) stakeholders from diverse backgrounds in this process in low- and middle-income countries (LMICs) [\u003cspan additionalcitationids=\"CR8 CR9\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Unfortunately, whilst the importance of stakeholder involvement to strengthen linkages between evidence and policy is increasingly recognised as being important in LMICs [\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], in many settings active, sustained, and authentic participation of diverse stakeholders in policy is often only recognized in theory [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAchieving meaningful and equitable stakeholder involvement in embedding evidence-based interventions into policy requires substantial transformations in the attitudes, norms and practices of policymakers, community members, and other stakeholders [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Community involvement debates provide valuable perspectives on stakeholder engagement. For instance, critical debates on community involvement acknowledge power, and the degree of power devolved to communities through involvement processes, as a central feature. These can range from practices such as information-giving and consultation to more empowering approaches where the community has control over decision-making processes [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. \u0026ldquo;Tokenistic\u0026rsquo; involvement is often cited as a major criticism, leading to a \u0026ldquo;lack of [community] presence, presence without voice, and voice without influence\u0026rdquo; [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Barriers to stakeholder involvement are gaining attention, including recognition of the impact of cultural norms and mechanisms of involvement across different contexts [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eImplementation science has been defined as \u0026ldquo;the scientific study of methods to promote the systematic uptake of research findings and other evidence-based practices into routine practice, and, hence, to improve the quality and effectiveness of health services\u0026rdquo; [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The use of frameworks and models plays a critical role in structuring research, describing relationships, and providing insights into the factors contributing to the success or failure of implementation efforts. Among the primary aims of these frameworks, as identified by Nielsen, is describing and/or guiding the process of translating research into practice [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. However, effective research translation into policy requires more than just theoretical models \u0026ndash; it requires a deep and contextually-sensitive engagement with stakeholders to align evidence with policy and practice. It is crucial to involve stakeholders throughout the process [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] and to understand how they themselves envision the translation of knowledge into practice [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDrawing on our own work and that of others [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], we propose that successful translation of research into policy hinges on a comprehensive understanding of stakeholders' needs, priorities, and roles in evidence-informed policymaking. We conceive of four broad stages to ensuring the uptake of evidence-based interventions into policy. First, it is essential to develop a clear understanding of whether and how different stakeholder groups wish to be involved; the levels of policy where and the mechanisms through which they wish to act and the feasibility (or barriers and facilitators to this). Second, there must be a shared understanding of how stakeholder groups wish to be involved across all groups. Third, developing a mutual understanding of the issues which are important for action across stakeholder groups is critical for collaboration. Finally, consensus must be developed on which evidence-based interventions are likely to be feasible, appropriate, acceptable, and sustainable to address the identified issues. This structured approach underscores the vital role of stakeholder engagement in bridging the gaps between research, evidence and policy. Without meaningful involvement of stakeholders at every stage, the likelihood of successful, context-specific policy translation diminishes. Therefore, stakeholder engagement is not just complementary to implementation science but a fundamental component in ensuring that evidence-based interventions are adopted, integrated, and sustained in policy and practice.\u003c/p\u003e \u003cp\u003eThe focus was on policy for injury care. Injuries account for 9% of all deaths globally. There are 5\u0026nbsp;million fatalities annually from road traffic collisions, drowning, poisoning, falls, burns, or violence and 90% of injury-related deaths occur in LMICs [\u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], where around 40% of injury deaths are preventable [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Recognition of the need for improved injury care was manifest in two recent World Health Assembly (WHA) resolutions: in 2023, WHA76.2 (Integrated emergency, critical and operative care for universal health coverage and protection from health emergencies) and in 2024, when the need for a global strategy and action plan for emergency, critical, and operative care was codified [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Moving resolutions from paper to action to strengthening health systems to provide access to quality injury care will involve implementing evidence-based interventions into policy and practice [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Barriers to access to quality injury care begin at the point of recognising the need to seek care and extend through reaching, receiving, and remaining in care, with 40% of the avoidable mortality occurring due to delays in seeking and reaching care [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. To ensure that contextually appropriate interventions which match local needs are implemented and embedded into policy therefore requires the involvement of multiple different stakeholder groups with understanding of issues at each of these stages. Unfortunately, even simple advocacy or community involvement to improve injury care is exceptionally rare [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] and there is little evidence of how best to engage and involve stakeholders to deliver improvements [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eGiven the importance of injury to global morbidity and mortality and the necessity for development of health systems interventions to reduce these, we used injury as an exemplar case to understand the needs and desires of diverse stakeholders towards developing evidence-informed policy and practice, and whether there was consensus between stakeholder groups. This aligns with the first of our four broad stages, articulated above. Stakeholders were identified as those who were most directly affected by injuries, and whose inputs were critical to, but who may typically be excluded from policy processes; as well as those who are typically involved in policymaking for injury care. As such, this study was structured around gaining the views of three core constituencies: communities and patients; healthcare workers; and policy makers. The aims were to: (1) ascertain the needs, preferences, and desires of different stakeholders towards policy involvement; (2) understand if consensus is achievable across stakeholders; and (3) understand if outcomes are shared across country contexts. While our focus is on injury, the implications of our findings may have the potential to extend beyond the specific contexts in the study, offering relevance and impact for policy involvement across diverse settings.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003e\u003cem\u003eStudy settings\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe study was undertaken as part of the NIHR Global Health Group on Equitable Access to Quality Health Care for Injured People (\u0026lsquo;Equi-Injury\u0026rsquo;) project, working with partners in Ghana, Pakistan, Rwanda, Ghana, and South Africa [33]. These four countries provide a diversity of social, economic, geographic, cultural, and health system contexts. A short overview of each country\u0026rsquo;s health systems is presented in the Table 1 below, with a description of policy for injury care context in appendices (appendix 1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eINSERT TABLE 1 ABOUT HERE\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eParticipant recruitment\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eTwo districts were purposively selected in each country to represent urban and rural contexts which were as representative of the whole country as possible. Sites were also pragmatically selected to ensure participant recruitment and data collection was feasible. Within the study areas, participants were purposively selected from each rural and urban study areas to represent key stakeholder groups: (a) patients and community members; (b) healthcare workers providing injury care, and (c) policymakers, noting that policymakers were also invited who were involved in national policy development and delivery (see Table 2). Snowball sampling and collaboration with local Community Involvement and Involvement (CEI) leads, established as part of the larger study, were utilized for recruitment of community members, patients, and healthcare workers.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eINSERT TABLE 2 ABOUT HERE\u003c/p\u003e\n\u003cp\u003ePatients were included if they had suffered moderate to severe injuries (either admitted to a hospital for more than 12h) or identified by community leaders as having suffered moderate of severe injuries but who didn\u0026rsquo;t attend a health facility. Community members and leaders (e.g. church leaders, community activists, school officials, and local business leaders) were resident in each area. Healthcare workers included were those involved in providing injury care in the facilities serving the study areas. Policymakers and civil servants, including people involved in local and national healthcare service policy, were purposively selected from each urban or rural study area based on local investigator\u0026rsquo;s knowledge of the health system contexts and professional networks.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eData collection and analysis\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eData were collected between January and August 2023 by trained teams of local researchers, supported by the in-country experienced research fellows. Workshops were used to elicit priorities of patients and community members as well as healthcare workers, whereas in-depth interviews (IDIs) were used with policy makers.\u003c/p\u003e\n\u003cp\u003eStakeholder workshops used the nominal group technique as a common approach to structure deliberation and consensus building [34]. In each setting, the local research team hosted four individual stakeholder workshops: two with patients and community members (one in each of the urban and rural areas) and two with healthcare workers (one in each of the urban and rural areas). In each workshop, there was an opening plenary, where participants were oriented to the study\u0026rsquo;s aims and procedures and policy involvement concepts and elements were introduced. It was clarified that the overarching aim was to gain consensus on how stakeholder groups might come together to embed contextually appropriate and evidence-based interventions for injury care which matched local needs into policy. Policy and policy involvement were conveyed as follows: \u003cu\u003e\u0026apos;Policy\u0026apos;\u003c/u\u003e was defined broadly, inclusive of policy implementation, and as formal or informal (e.g., generation of policy documents at a local or national government level, or policy and planning for local healthcare services). \u003cu\u003eInvolvement/engagement in policy\u003c/u\u003e was defined in terms of the spaces of policymaking, articulated as \u0026lsquo;\u003cu\u003elevels\u0026rsquo;\u003c/u\u003e at which stakeholders wished to be involved (e.g., local government policy or services, national, regional, international); and the policy processes, articulated as \u0026lsquo;\u003cu\u003emechanisms\u0026rsquo;\u003c/u\u003e of involvement (e.g., advocacy external to policymaking, in local discussions to inform policy and planning, directly included in the policymaking process, involved in ensuring policy is delivered). We also sought views on real world \u0026lsquo;\u003cu\u003ebarriers\u0026rsquo;\u003c/u\u003e and \u0026lsquo;\u003cu\u003efacilitators\u0026rsquo;\u003c/u\u003e to policy involvement (e.g., lack of opportunities and/or functional forums for patient voice) [35].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFollowing the orientation plenary, participants were divided into smaller sub-groups of 4-5 participants to consider specific questions. There were four facilitated roundtable discussions where sub-groups deliberated over, and reached consensus on, preferences and priorities regarding the following elements: i. levels and ii. mechanisms of policy involvement and iii. barriers and iv. facilitators to that involvement. Roundtables discussions were facilitated by trained investigators to ensure that the discussion stayed focussed and encourage input from all participants. Facilitators also captured a list of all participant responses. Towards the end of each roundtable, facilitators guided the group members to review the list and collectively rank their responses, generating lists of consensus priorities for each element. At the end of each roundtable discussion, the lists of consensus priorities (up to 5) and rationales for their selection and prioritisation were presented in plenary by each roundtable\u0026rsquo;s spokesperson. Plenary sessions allowed all participants to appraise the selected responses, rationales for these responses, and their priority order or ranking. Following the discussion, facilitators combined and de-duplicated the responses from all sub-groups. All stakeholders then voted for their top five responses using digital software [36] or other means (e.g.: show of hands).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWorkshops were structured with detailed guides (appendix 2). We used general principles of group facilitation such as ensuring a relaxed and collegiate environment with time and space for listening with respect and interest. Workshops were not focus group discussions in the qualitative sense and outputs from the workshops were captured as lists of short responses, as appropriate for use of the nominal group technique. The plenary and round table discussions were audio-recorded in case of need for later clarification and to cross-check the results of voting, but not for formal analysis.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn-depth interviews were used for the data collection with policy makers and civil servants, given the schedules and locations of participants did not allow for workshops. Up to 20 IDIs were conducted per country until thematic saturation occurred. The IDIs explored policy-maker\u0026rsquo;s perspectives on the involvement of community, patient, and healthcare stakeholders in policy processes. Interviews were semi-structured to allow understanding of the levels and mechanisms of, and barriers and facilitators to stakeholder involvement in policy as well as to enable the integration of outputs from interviews with those outputs from the workshops. Pre-prepared topic guides (appendix 3) structured the discussions and allowed a degree of flexibility in responses. All interviews were audio-recorded and were conducted in person, by telephone, or online, depending on availability and preferences of respondents.\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFor both workshops and IDIs, common methods were employed in each setting, facilitated by the creation of a study manual and combined training sessions on methodological approaches and workshop facilitation with local research teams. Contextual and cultural adaptations to the manual (such as durations and locations of workshops, and the language and terms used by the workshop facilitators) were supported and appraised in training sessions to ensure meanings and understandings were maintained. The work was undertaken in local languages, with outputs written up in English for analysis and synthesis.\u003c/p\u003e\n\u003cp\u003eWe adopted a rapid qualitative research approach to support data collection and analysis. The process, developed by the RREAL (Rapid Research Evaluation And Appraisal Lab) group, supports systematic collection of data, enables rapid summary of findings and identification of themes, including adaption of data collection and analytical processes through team reflection [37]. According to this process, during workshops and IDIs, researchers took notes. Following each workshop or interview, notes were summarised into two structured \u0026lsquo;RREAL Sheets\u0026rsquo;: one on substantive content (results), and one for observations and reflections from the research team (appendix 4). In subsequent workshops and IDIs, notes were taken, and key findings transferred, using the RREAL Sheets as a triangulation tool. The process enabled data to be systematically captured according to the analytical categories: levels, mechanisms, barriers and facilitators to policy involvement, and on observations and reflections. Regular team meetings were held to reflect on the process and emerging results, in which workshop and IDI data were iteratively reviewed and categorised. Findings from each study setting were then synthesized and visually represented using heatmaps to depict priorities and consensus across the five stakeholder groups and four study settings during an investigator meeting in March 2024.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eEthical considerations and approval\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAll participants gave fully informed consent for their involvement in the study. The study received approval from ethical review boards: Ghana Health Service Ethics Review Committee (GHS-ERC 014/09/22), Aga Khan University Ethics Review Committee in Pakistan (2022-7372-23339), Rwanda National Ethics Committee (IRB 00001497 of IORG000110, No 85/RNEC/2023), and Stellenbosch University Health Research Ethics Committee in South Africa (N22/07/079). The University of Birmingham (overall sponsor for this study) accepted the local ethics approvals for this project in lieu of the requirement for full ethics review.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePatient and public involvement\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAs described above, the study was conducted as part of the Equi-Injury programme [33]. The parent study aims to assess barriers to quality care after injury and co-develop interventions to reduce avoidable injury-related mortality and morbidity. In each country, there is a nominated CEI lead through whom Equi-Injury investigators collaborate with various stakeholders, including service users, providers, and policymakers, to ensure that research is grounded in the needs and priorities of key stakeholders and the \u0026lsquo;real world\u0026rsquo; social and health systems\u0026rsquo; realities of injury and injury care. This process is coordinated by a central CEI lead who works across all countries. Injured patients and community leaders were directly involved in the design, recruitment and conduct of the study. In each study country, community leaders were consulted prior to commencement of the study and agreed to research being done and disseminated in their communities. Injured patients were consulted on the recruitment strategy for individual workshops and reviewed the study findings.\u0026nbsp;\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eA summary of participants is presented in Table 3. A total of 297 stakeholders participated in 16 workshops (240 participants) and in-depth interviews (57 participants). The priorities from workshops and interviews in each country, captured as lists of short responses, can be found in the appendix 5.\u003c/p\u003e\n\u003cp\u003eAll stakeholder groups in all countries agreed that involvement in policy making was important. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eINSERT TABLE 3 ABOUT HERE\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eLevels and mechanisms of involvement\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe top five priorities for levels and mechanisms of involvement by participant group and setting for each country and consensus on these within and between stakeholders, and across study settings, are shown in Tables 4 and 5, respectively.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAlthough there were multiple priorities from across stakeholder groups, consensus was achieved across all stakeholder groups in each country in the levels at which all wanted to come together to be involved in policy; all groups in all countries agreed that local involvement was a priority. There was a high level of consensus with regards to levels of involvement with all stakeholders across all study settings ranking local community level involvement highly. \u0026lsquo;Local\u0026rsquo; was understood with some variation across settings, albeit mainly referring to involvement through community, workplaces, and educational or religious groups, and, in one setting, as through the local authority. Additionally, all five stakeholder groups across Ghana Pakistan and Rwanda agreed that involvement at national level, through working with the Ministry of Health, was important for involvement with policy and practice. Conversely, in South Africa, national-level involvement was only ranked amongst the top five levels of involvement by policymakers.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eINSERT TABLE 4 ABOUT HERE\u003c/p\u003e\n\u003cp\u003eINSERT TABLE 5 ABOUT HERE\u003c/p\u003e\n\u003cp\u003eVarious mechanisms for involvement were identified and prioritised as instrumental in facilitating effective involvement across the ranked levels. Across the five stakeholder groups and study settings, there was no consensus on mechanism of involvement. There was, however, consensus across all stakeholder groups in Ghana on the importance of community engagement, whereas in Rwanda, stakeholders agreed that advocacy was an important mechanism for engagement. In Pakistan and South Africa, there was no agreement between the five stakeholder groups and settings regarding the preferred mechanisms of engagement. However, there was consensus among some stakeholder groups and settings across these two countries - specifically, patients/communities and healthcare workers in both rural and urban areas - that participation in and involvement with diverse groups that can affect change or implement new policies was an important mechanism. Additionally, although there was no agreement across all groups and all settings, the importance of engaging through providing, receiving, and sharing evidence and relevant data was frequently prioritised as a mechanism for engaging in policy and practice.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eBarriers and facilitators to involvement\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eTables 6 and 7 present the top five ranked barriers and facilitators, respectively, to involvement by participant group and setting for each country as well as consensus on these between five stakeholder groups.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWhile there was no overall consensus on barriers to involvement between all stakeholder groups across the study settings, there was consensus across all stakeholder groups in Ghana and in Pakistan. In Ghana there was agreement that resources and social discrimination based on tribe, religion, and political affiliations, were substantial barriers to involvement, indicating that social biases can affect engagement. In Pakistan, there was consensus across all stakeholder groups that lack of finances would be a barrier to engagement. Lack of financial resources, affecting various aspects of involvement from training to dissemination was the main barrier to involvement in policy making agreed by multiple stakeholder groups in Ghana, Pakistan and Rwanda. Logistical barriers, including transportation, were also shared between groups in some study countries, particularly in Pakistan and Rwanda. In Ghana and Rwanda, some stakeholder groups - including policymakers - agreed that low education levels, communication barriers and lack of awareness of policy involvement processes were important barriers. Whereas in South Africa, hierarchies and power dynamics were predominant barriers, ranked by urban patients/community members and healthcare workers, as well as policymakers, highlighting the role of social structures in impeding engagement.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eINSERT TABLE 6 ABOUT HERE\u003c/p\u003e\n\u003cp\u003eINSERT TABLE 7 ABOUT HERE\u003c/p\u003e\n\u003cp\u003eThere were also marked differences between the four countries with regards to facilitators of engagement. However, the five stakeholder groups in Pakistan and Ghana agreed that providing resources, such as financial support and transport, was an important facilitator of engagement. Other facilitators, such as inclusive communication, multi-stakeholder collaboration, and education/training were prioritised by some stakeholder groups in South Africa and Pakistan. Across stakeholder groups and settings, patients and the community tended to highlight the importance of funding and personal recognition, healthcare workers emphasized the need for inclusive communication and training, whilst policymakers prioritised enhancing community involvement, using evidence-based, data driven approaches, and ensuing that resources are allocated effectively as facilitators of engagement. \u0026nbsp;\u0026nbsp;\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eIn this paper, we explored the perspectives of key stakeholders (service users, providers, and policy makers) on how to achieve impactful involvement in developing and prioritising solutions to improve equitable access to quality injury care in Ghana, Pakistan, Rwanda and South Africa. This multi-country study aimed to: (1) ascertain the needs, preferences, and desires of different stakeholders towards policy involvement; (2) understand if consensus is achievable across stakeholders; and (3) understand if outcomes are shared across country contexts. All stakeholder groups in all countries agreed that involvement in policy making was important. Although there were multiple priorities from across stakeholder groups, consensus was achieved among all stakeholder groups in each country regarding the levels at which all wanted to come together to be involved in policy; all groups in all countries agreed that local involvement was a priority. Only in Ghana and Rwanda was there consensus across stakeholder groups in the mechanisms via which policy involvement could occur (via community involvement and advocacy, respectively). In both, Ghana and Pakistan, stakeholders agreed on the barriers to achieving policy involvement, which in both cases were primarily related to resources and funding.\u003c/p\u003e \u003cp\u003eWhile there were varied findings across contexts, and as stated above, all groups in all countries agreed that \u003cem\u003elocal involvement\u003c/em\u003e was a priority. The consensus on local, rooted community-level involvement aligns with extensive literature emphasizing the critical role of community participation for policy and systems change [\u003cspan additionalcitationids=\"CR39\" citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. Communities have extensive, grounded insights into the daily realities of how social contexts influence health outcomes, access to care, and its quality [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. It follows that their involvement is crucial for policies and decision-making. However, in many LMICs, policy decisions are often made without community involvement or through narrow \u0026lsquo;consultations\u0026rsquo; during policy development or after policies are established [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. While there was broad consensus on local engagement, \u0026lsquo;local\u0026rsquo; was understood with some variation across settings, albeit mainly referring to involvement through community, workplaces, and educational or religious groups, and, in one setting, as through the local authority. It is also the case that not all stakeholder groups \u003cem\u003ewithin\u003c/em\u003e each country ranked local involvement highly, potentially attributable to cultural and political differences.\u003c/p\u003e \u003cp\u003eSocial discrimination is reported as a significant barrier to stakeholder involvement [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Evidence suggests that how different stakeholder groups perceive the importance of involvement in policy is also influenced by factors and actors including community capabilities to raise and frame local concerns and priorities, organisational and institutional contexts, elite capture and control, the risks of collective action, as well as the role of the state [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. Community involvement is often supported in policy, yet organisational norms of top-down governance persist, overlooking the significant contributions from lower levels [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. Nevertheless, across many countries, including those in this study, it is increasingly expected, and formally mandated in policy and strategy, that individuals or groups involved in or affected by health and healthcare policies should have a say in the planning and dissemination [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. Goals of community formation and solidarity, and of community participation as a political process concerned with democratic power as a response to social injustice, are poorly understood operationally [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]. How to technically deliver this in a meaningful and sustainable manner is less well understood, however together with an appreciation that, activities solely focused on community capabilities are insufficient for authentic and sustained community power-building [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. In terms of supporting communities to work with other agencies and organisations, there is a need to navigate multiple, complex, overlapping open systems, each with inherent hierarchies and biases [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAcross the study settings, although consensus was not achieved, multisectoral dialogue and community action were key mechanisms identified through which involvement in injury policy and practice should happen, reflecting a recognition of the need for more inclusive and community-led processes that actively involve diverse stakeholder groups [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e]. Such approaches are thought to facilitate information sharing, relationship-building and dialogue between diverse stakeholders, and support well-rounded policies that consider multiple perspectives [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. However, specific mechanisms varied by setting, highlighting the importance of local contexts and the perceptions of different stakeholder groups.\u003c/p\u003e \u003cp\u003eSpecific mechanisms were also likely to vary because injury care is complex. Acute in nature, requiring timely access to quality integrated care, and driven by factors and forces beyond health systems such as rapid industrialisation and economic transition. Access to quality healthcare, alone, is a significant challenge. Over 3\u0026nbsp;billion people, located largely in LMICs, lack access to essential health care [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e]. Access to injury care can thus be considered as a \u0026lsquo;wicked problem\u0026rsquo; - i.e. as a complex social problem with an unknown number of potential solutions [\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e] - and access to quality healthcare after injuries, which are heterogenous in type and mechanism, especially so [\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e]. Research suggests that addressing wicked problems under governmental and administrative constraints necessitates new approaches such as going beyond technical/rational thinking, collaborative working, new modes of leadership [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e]. Addressing this requires understanding opportunities and constraints from multiple perspectives, sectors and dimensions. In this context, the need for dialogue among diverse stakeholders, including e.g., patients, communities, civil society and advocacy groups, emergency services, healthcare workers, local government, traffic and road safety, public service planners, managers, and policy makers, is evident [\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThere are reported examples of successful participatory governance or multisectoral mechanisms for policy involvement in the international literature [\u003cspan additionalcitationids=\"CR63\" citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e], but although the importance of partnerships across sectors is acknowledged, research is needed to understand how stakeholders can meaningfully collaborate, how to foster equitable partnerships, how to navigate social and institutional differences across contexts, and how to do so sustainably over space and time [\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e]. Particularly in LMICs, where institutions are often fragmented and resources scarce, the challenges to multisectoral action may be more pronounced [\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e]. Bottom-up initiatives have had success in other contexts and for other conditions [\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e], however, a growing body of literature highlights the importance of \u003cem\u003epolitical commitment\u003c/em\u003e for multisectoral action in the context of LMICs and the need to understand the key stakeholders and the type of multisectoral action required [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e, \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e]. Multisectoral action necessitates approaches that enable dialogue among diverse stakeholders. Recognizing distinct (including conflicting) perspectives and positions, identifying shared goals, and enabling and maintaining meaningful deliberation and consensus-building via inclusive and equitable involvement processes, as we done in this study, is a necessary first step [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e, \u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhile differences across country contexts and various types of multisectoral and community action challenges are inevitable, our findings indicate that there is appetite across all stakeholders for multisectoral action to deliver change both within and outside the health system to improve access to quality injury care. This approach involves engaging diverse stakeholders in decision-making, grounding involvement in local realities, and fostering environments responsive to data and evidence. However, data and evidence need to be considered relative to the nuanced dynamics of stakeholders involved. Numerous examples from the Covid-19 pandemic have demonstrated that successful responses to public health crises require more than data-driven decisions; they demand genuine collaboration with stakeholders who bring varied perspectives and expertise [\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e, \u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e]. Considering these findings, combining data with diverse insights and knowledge from stakeholders and high-level multisectoral should function as interconnected and mutually reinforcing components of effective injury policy development and practice.\u003c/p\u003e \u003cp\u003eThe concept of \u0026lsquo;stakeholderism\u0026rsquo;, reflecting involvement of diverse groups of actors with differing interests [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e], is particularly pertinent in the context of stakeholder involvement in policy and practice. Debates revolve around the extent of inclusion and empowerment within decision-making processes. Critics argue that traditional stakeholder involvement models may fall short of engaging marginalized or underrepresented groups, leading to tokenistic participation or reinforcing existing power imbalances [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e, \u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e]. This starkly contrasts with academic and policy assertions that all stakeholders should be active partners rather than passive participants in policy [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e]. It also challenges the concept of involvement with decision-making as \u0026lsquo;distributed\u0026rsquo; [\u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e], where decision-making is considered as a dynamic process involving multiple spaces, actors, and practices [\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e, \u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e]. Likewise, critics are increasingly questioning whether stakeholders should merely be consulted or involved in co-creation and decision-making processes [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Some advocate for a more participatory approach that involves stakeholders from the outset of policy development [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], while others argue for maintaining a clearer distinction between stakeholders and decision-makers as the emphasis on stakeholder input can sometimes dilute the impact of expert knowledge and evidence-based practices, potentially leading to less effective solutions [\u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e]. The literature is only beginning to explore how access to involvement with decision-making varies across stakeholders [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. To advance towards more inclusive and effective multistakeholder engagement, it is essential to shift from theoretical discussions to studying the implementation processes of various approaches [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e, \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e, \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e], and to build the necessary capabilities for sustaining genuine engagement.\u003c/p\u003e \u003cp\u003eResponding to this gap, our study examined the levels, mechanisms, barriers, and facilitators of involvement sought by diverse stakeholders from four LMIC countries. Our approach is explicitly designed to address and mitigate tokenism and the criticism associated with \u0026lsquo;stakeholderism\u0026rsquo; by fostering genuine, meaningful participation. We place emphasis on inclusive participation and collaboration among all relevant stakeholders, ensuring the voices of marginalized and vulnerable populations are amplified and integrated into decision-making processes. Additionally, we highlight the importance of continuous monitoring and adaptive learning to refine strategies and ensure they remain responsive to the evolving needs and contexts of the communities involved. Our next step is to utilise our findings to co-develop a strategy, in partnership with stakeholders in each study country, to facilitate involvement across stakeholder groups, including communities, health workers and policy makers. By creating these strategies, we aim to support multistakeholder action that leverages local, data-informed initiatives, implemented and evaluated through cooperative action and learning with key stakeholders.\u003c/p\u003e \u003cp\u003eWhile the role of stakeholders in implementation science is acknowledged, it is still underutilized [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. In particular, the specific ways in which diverse stakeholder involvement affects translation of research findings into action and how stakeholders envision their involvement in this process have not been explored [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e]. This study supports the need for a deeper examination of how stakeholder involvement can be effectively integrated to inform and support research translation. Our approach highlights the need for inclusive, ongoing dialogue with key stakeholders to align research with their needs and preferences, ensuring effective policy and practice adoption.\u003c/p\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eSTRENGTHS AND LIMITATIONS\u003c/h2\u003e \u003cp\u003eOur geographically diverse approach in addition to use of a nominal group technique to elicit concise and comparable responses, rather than use of a deeper qualitative analysis, may have resulted in the loss of some contextual detail. The responses for priority areas were captured by the local country teams using stakeholders\u0026rsquo; language and local study teams then discussed and agreed the ranked responses in each priority area. Agreement on categorizing these responses was reached through iterative review between country and central teams. This process, which aimed to achieve terms that could be understood across contexts may have resulted in loss of some local nuances. However, results have been checked by in country teams to ensure loss of nuance is minimised whilst cross-contextual understanding is maintained. A strength of our study is that many of the priorities and barriers we identified were not unique to injury but reflected knowledge across broader involvement literature, suggesting that priorities may be transferable between other settings and conditions. For instance, lack of resources, difficulties navigating the policy processes, understanding technical or bureaucratic language are well recognised as barriers to involvement in the literature [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e, \u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e]. Findings from this study may increase the understanding of key stakeholder perspectives regarding potential needs and barriers to integration of stakeholder input into policy and practice.\u003c/p\u003e \u003c/div\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThis study identified stakeholder needs and priorities to support involvement in injury care policy and practice in Ghana, Pakistan, Rwanda, and South Africa and compared the results across the settings. Involving diverse stakeholder groups in evidence-based policy development is a valuable goal, but reaching consensus on the appropriate levels, mechanisms, barriers, and facilitators for that involvement is challenging and varies by country. Our work suggests that deep and diverse engagement is crucial to ensure and sustain participation in policymaking, with solutions for involvement likely to differ across different contexts.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eLMICs - lower- and middle-income countries\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHIC \u0026nbsp;- higher-income countries\u003c/p\u003e\n\u003cp\u003eCEI \u0026ndash; community engagement and involvement\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the ethical principles of the Declaration of Helsinki. The study received approval from ethical review boards: Ghana Health Service Ethics Review Committee in Ghana (GHS-ERC 014/09/22), Aga Khan University Ethics Review Committee in Pakistan (2022-7372-23339), Rwanda National Ethics Committee \u0026nbsp;(IRB 00001497 of IORG000110, No 85/RNEC/2023), and \u0026nbsp;Stellenbosch University Health Research Ethics Committee in South Africa (N22/07/079). The University of Birmingham (overall sponsor for this study) accepted the local ethics approvals for this project in lieu of the requirement for full ethics review. Written and verbal consent to participate in the study was obtained directly from all participants. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData are available upon a reasonable request from the project PIs. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was funded by the NIHR (award number 133135) using UK aid from the UK Government to support global health research and the International Strategy Partnerships Fund 23/24, issued by Research England and the University of Birmingham. The views expressed in this publication are those of the authors and not necessarily those of the NIHR or the UK government.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis manuscript has been prepared by the Equi-Injury Group research team. JD and KC designed the study and led the submission of the grant application. ST, NB, JCB, AB, JR, LDA, AI are significant co-investigators participating in the design and data analysis procedures for Work package 1 that this paper is based on. LD and AI co-led the WP1. KT, \u0026nbsp;DFB, FSA, AEA, ZWA, TMQ, CL, HA, ZBC, RO, EKW, DKY, ET, NM, NOM, SN. PN, GU. DN. IB, JI, KM, NL, BTA, AA, LG and DL are significant contributors who collected and analysed country level data. AI, LD and JD drafted the manuscript. All authors critically reviewed, provided feedback, and approved the final manuscript.\u003c/p\u003e\u003cp\u003eEQUI-INJURY GROUP MEMBERS:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAgnieszka Ignatowicz\u003csup\u003e1\u003c/sup\u003e, Lucia D\u0026rsquo;Ambruoso\u003csup\u003e2\u003c/sup\u003e, Khaya Tshabalala\u003csup\u003e3\u0026nbsp;\u003c/sup\u003e, Derbew Fikadu Berhe\u003csup\u003e4\u003c/sup\u003e, Zabin Wajid Ali\u003csup\u003e5\u003c/sup\u003e, Frederick Sarfo-Antwi\u003csup\u003e6\u0026nbsp;\u003c/sup\u003e, Huba Atiq\u003csup\u003e1,5\u0026nbsp;\u003c/sup\u003e, Zaheer Babar Chan\u003csup\u003e5\u003c/sup\u003e, Tamlyn McQueen\u003csup\u003e3\u003c/sup\u003e, Anita Eseenam Agbeko\u003csup\u003e7\u003c/sup\u003e, Richard Osei\u003csup\u003e8\u003c/sup\u003e, Ebenezer Kwame Amofa\u003csup\u003e9\u003c/sup\u003e, Dominic Konadu-Yeboah\u003csup\u003e1,10\u003c/sup\u003e, Eric Twizeyimana\u003csup\u003e4\u0026nbsp;\u003c/sup\u003e, Nadine Mugisha\u003csup\u003e4\u0026nbsp;\u003c/sup\u003e, Ngirabeza Oda Munyura\u003csup\u003e4\u003c/sup\u003e, Solange Nakure\u003csup\u003e4\u0026nbsp;\u003c/sup\u003e, Pascal Nzasabimana\u003csup\u003e11\u0026nbsp;\u003c/sup\u003e, Ghislaine Umwali\u003csup\u003e11\u003c/sup\u003e, Denys Ndangurura\u003csup\u003e12\u0026nbsp;\u003c/sup\u003e, Irene Bagahirwa\u003csup\u003e13\u0026nbsp;\u003c/sup\u003e, Jules Iradukunda\u003csup\u003e4\u0026nbsp;\u003c/sup\u003e, Kedest Mathewos\u003csup\u003e4\u0026nbsp;\u003c/sup\u003e, Nzungize Lambert\u003csup\u003e11\u003c/sup\u003e, Christina Laurenzi\u003csup\u003e3\u003c/sup\u003e, Barnabas Tobi \u0026nbsp; Alayande\u003csup\u003e4\u0026nbsp;\u003c/sup\u003e, Alemayehu Amberbir\u003csup\u003e4\u0026nbsp;\u003c/sup\u003e, Leila Ghalichi\u003csup\u003e1\u003c/sup\u003e, Daniel Lange\u003csup\u003e1\u003c/sup\u003e, Stephen Tabiri\u003csup\u003e7,14\u0026nbsp;\u003c/sup\u003e, Napoleon Bellua Sam\u003csup\u003e15\u0026nbsp;\u003c/sup\u003e, Abebe Bekele\u003csup\u003e4\u003c/sup\u003e, Jean Claud Byiringiro\u003csup\u003e11\u003c/sup\u003e, Junaid Razzak\u003csup\u003e5\u0026nbsp;\u003c/sup\u003e, Kathryn Chu\u003csup\u003e3,16\u003c/sup\u003e, Justine I Davies\u003csup\u003e1,3,17\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003eDepartment of \u0026nbsp; Applied Health Sciences , University of Birmingham, Birmingham, UK\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e2\u003c/sup\u003eInstitute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e3\u003c/sup\u003eCentre for Global Surgery, Department of Global Health, Stellenbosch University, Cape Town, South Africa\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e4\u003c/sup\u003eCentre for Equity In Global Surgery and BioMedical Science, University of Global Health Equity (UGHE), Kigali, Rwanda\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e5\u003c/sup\u003eCentre of Excellence for Trauma and Emergencies (CETE), The Aga Khan University, Karachi, Pakistan\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e6\u003c/sup\u003eDepartment of Biochemistry and Molecular Medicine, School of Medicine, University for Development Studies, Tamale, Ghana\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e7\u003c/sup\u003eKomfo Anokye Teaching Hospital, Kumasi, Ghana\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e8\u003c/sup\u003eNIHR Equi-injury Group, Ghana\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e9\u003c/sup\u003eDepartment of Physiology and Biophysics, School of Medicine, University of Development Studies, Tamale, Ghana\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e10\u003c/sup\u003eDepartment of Surgery, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e11\u003c/sup\u003eCollege of Medicine and Health Sciences, University of Rwanda Kigali, Rwanda\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e12\u003c/sup\u003eDepartment of Community Health and Social Medicine, Community Based Medical Education, University of Global Health Equity (UGHE), Kigali, Rwanda\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e13\u003c/sup\u003eRwanda Biomedical Centre/NCDs Division/ Injuries \u0026amp; Disabilities Unit, Kigali, Rwanda\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e14\u003c/sup\u003eDepartment of Surgery, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e15\u003c/sup\u003eDepartment of Medical Research and Innovation, School of Medicine, University of Development Studies, Tamale, Ghana\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e16\u003c/sup\u003eDepartment of Surgery, University of Botswana, Gaborone, Botswana\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e17\u003c/sup\u003eMedical Research Council/Wits University Rural Public Health and Health Transitions Research Unit, Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eChalmers, I., et al., \u003cem\u003eHow to increase value and reduce waste when research priorities are set.\u003c/em\u003e Lancet, 2014. \u003cstrong\u003e383\u003c/strong\u003e(9912): p. 156-65.\u003c/li\u003e\n\u003cli\u003eIsrael, B.A., et al., \u003cem\u003eReview of community-based research: assessing partnership approaches to improve public health.\u003c/em\u003e Annu Rev Public Health, 1998. \u003cstrong\u003e19\u003c/strong\u003e: p. 173-202.\u003c/li\u003e\n\u003cli\u003eMasefield, S.C., et al., \u003cem\u003eStakeholder engagement in the health policy process in a low income country: a qualitative study of stakeholder perceptions of the challenges to effective inclusion in Malawi.\u003c/em\u003e BMC Health Services Research, 2021. \u003cstrong\u003e21\u003c/strong\u003e(1): p. 984.\u003c/li\u003e\n\u003cli\u003eMensah, G.A., et al., \u003cem\u003eStakeholder Engagement in Late-Stage Translation Research and Implementation Science: Perspectives From the National Heart, Lung, and Blood Institute.\u003c/em\u003e Global Heart, 2019. \u003cstrong\u003e14\u003c/strong\u003e(2): p. 191-194.\u003c/li\u003e\n\u003cli\u003eAifah, A., et al., \u003cem\u003eThe Kathmandu Declaration on Global CVD/Hypertension Research and Implementation Science: A Framework to Advance Implementation Research for Cardiovascular and Other Noncommunicable Diseases in Low- and Middle-Income Countries.\u003c/em\u003e Glob Heart, 2019. \u003cstrong\u003e14\u003c/strong\u003e(2): p. 103-107.\u003c/li\u003e\n\u003cli\u003eBurton, C. and J. 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From evidence-based policy to the good governance of evidence\u003c/em\u003e. 2017, London Routledge.\u003c/li\u003e\n\u003cli\u003eReynolds, L., \u003cem\u003eA critical approach to place branding governance: From \u0026quot;holding stakes\u0026quot; to \u0026quot;holding flags\u0026quot;\u003c/em\u003e. 2018: Cardiff University.\u003c/li\u003e\n\u003cli\u003eReynolds, J., et al., \u003cem\u003e\u0026lsquo;The opportunity to have their say\u0026rsquo;? Identifying mechanisms of community engagement in local alcohol decision-making.\u003c/em\u003e International Journal of Drug Policy, 2020. \u003cstrong\u003e85\u003c/strong\u003e: p. 102909.\u003c/li\u003e\n\u003cli\u003eMcDermott, C.L., et al., \u003cem\u003eTransforming land use governance: Global targets without equity miss the mark.\u003c/em\u003e Environmental Policy and Governance, 2023. \u003cstrong\u003e33\u003c/strong\u003e(3): p. 245-257.\u003c/li\u003e\n\u003cli\u003eMacGregor, S., et al., \u003cem\u003eHolding up a mirror: researching symmetrically to explore exclusion, othering and whiteness in local environmental governance.\u003c/em\u003e Local Environment, 2024. \u003cstrong\u003e29\u003c/strong\u003e(5): p. 617-630.\u003c/li\u003e\n\u003cli\u003eRapley, T., \u003cem\u003eDistributed decision making: the anatomy of decisions-in-action.\u003c/em\u003e Sociology of Health \u0026amp; Illness, 2008. \u003cstrong\u003e30\u003c/strong\u003e(3): p. 429-444.\u003c/li\u003e\n\u003cli\u003eFoo, L.-M., et al., \u003cem\u003eStakeholder Engagement and Compliance Culture.\u003c/em\u003e Public Management Review, 2011. \u003cstrong\u003e13\u003c/strong\u003e(5): p. 707-729.\u003c/li\u003e\n\u003cli\u003eBoaz, A., et al., \u003cem\u003eHow to engage stakeholders in research: design principles to support improvement.\u003c/em\u003e Health Research Policy and Systems, 2018. \u003cstrong\u003e16\u003c/strong\u003e(1): p. 60.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1. Overview of study countries\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003eGhana\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003ePakistan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eRwanda\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003eSouth Africa\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eIncome status\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003eLower-middle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003eLower-middle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eLow\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003eUpper-middle\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eHDI Index\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e142\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e152\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e157\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e133\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eGINI Index\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e38.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e36.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e44.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e57.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e% GDP on health\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e3.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e2.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e6.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e8.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eOPP HE %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e40.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e60.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e6.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e7.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eHDI Human Development Index; OOP Out of Pocket; HE Health expenditure\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eTable 2. Participant selection characteristics\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eStakeholder group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 469px;\"\u003e\n \u003cp\u003eCharacteristics\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eCommunity/ patient\u003c/p\u003e\n \u003cp\u003e(Rural and urban)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 469px;\"\u003e\n \u003cul type=\"disc\"\u003e\n \u003cli\u003eCommunity members\u0026nbsp;\u003c/li\u003e\n \u003cli\u003ePatients who have accessed injury care for moderate or severe injuries but are no longer in acute care\u003c/li\u003e\n \u003cli\u003ePatients with moderate to severe injuries who did not access care\u0026nbsp;\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eHealthcare providers\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(Rural and urban)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 469px;\"\u003e\n \u003cul type=\"disc\"\u003e\n \u003cli\u003eDoctors\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eNurses\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eClinical officers\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eOthers e.g., Rehab Care Workers/Home Based Carers (HBCs)\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003ePolicymakers/ civil servants\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 469px;\"\u003e\n \u003cul type=\"disc\"\u003e\n \u003cli\u003eHealth facility managers\u0026nbsp;\u003c/li\u003e\n \u003cli\u003ePolicy makers, civil-servants, incl. local policy\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 3. Overview of participants\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"609\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003eParticipants\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 306px;\"\u003e\n \u003cp\u003eSetting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003eU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33px;\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003eR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003eCommunity/ patient\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 306px;\"\u003e\n \u003cp\u003eGhana: Tamale (U); Bekwai (R)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 306px;\"\u003e\n \u003cp\u003ePakistan: Karachi (U); Sehwan and Thatta (R)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 306px;\"\u003e\n \u003cp\u003eRwanda: Musanze (U); Kigora (R)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 306px;\"\u003e\n \u003cp\u003eSouth Africa: Western Cape (U); Eastern Cape (U)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003eHealthcare\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 306px;\"\u003e\n \u003cp\u003eGhana: Tamale (U); Bekwai (R)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003eproviders\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 306px;\"\u003e\n \u003cp\u003ePakistan: Karachi (U); Sehwan and Thatta (R)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 306px;\"\u003e\n \u003cp\u003eRwanda: Musanze (U); Kigora (R)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 306px;\"\u003e\n \u003cp\u003eSouth Africa: Western Cape (U); Eastern Cape (U)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 306px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33px;\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003ePolicymakers/ civil\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 306px;\"\u003e\n \u003cp\u003eGhana\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003eservants\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 306px;\"\u003e\n \u003cp\u003ePakistan\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 306px;\"\u003e\n \u003cp\u003eRwanda\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 306px;\"\u003e\n \u003cp\u003eSouth Africa\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 407px;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"6\" valign=\"top\" style=\"width: 201px;\"\u003e\n \u003cp\u003e297\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eU=urban, R=rural, M=male, F=female\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTables 4 to 6 are available in the Supplementary Files section.\u003c/strong\u003e\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"injury, stakeholder engagement, engagement in policy and practice, Ghana, Rwanda Pakistan, South Africa","lastPublishedDoi":"10.21203/rs.3.rs-6350661/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6350661/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBACKGROUND\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStrengthening health systems requires policy development that meets stakeholder needs and is informed by evidence. However, little is known about how to effectively engage stakeholders from diverse backgrounds in evidence uptake for policy or whether alignment can be achieved within and across different country contexts. This multi-country study, using injury care as a case study, aimed to: (1) ascertain the needs, preferences, and desires of stakeholders toward taking up evidence for policy; (2) understand if consensus is achievable within and across stakeholders; and (3) examine whether outcomes are shared across country contexts.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMETHODS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted in Ghana, Pakistan, Rwanda and South Africa, selecting one urban and one rural district in each country for broad representation. Stakeholder groups were: (1) communities and patients, (2) service providers, and (3) policymakers, with groups engaged separately to mitigate power imbalances. Workshops were structured using the nominal group technique to facilitate discussions and consensus-building. Data were collected through plenary sessions and voting, focusing on levels of involvement, mechanisms for involvement, and the barriers and facilitators to that involvement in developing evidence-based policy. In-depth interviews with policymakers were performed and thematically analysed. Finally, the research team synthesized findings across countries to identify consensus and differences.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRESULTS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 297 stakeholders participated in the study: 240 through workshops and 57 in interviews. All stakeholder groups in all countries agreed that involvement in policy making was important. Consensus was achieved in each country in the levels at which stakeholders wanted to engage, with groups prioritizing local involvement. In Ghana and Rwanda, consensus was achieved on the mechanisms for policy engagement, specifically community engagement and advocacy. In Ghana and Pakistan, consensus was also reached on barriers and facilitators to policy involvement, primarily concerning resources and funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCONCLUSION\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWhile involving diverse stakeholder groups in evidence-based policy development is a valuable goal, achieving consensus on levels, mechanisms, barriers, and facilitators for involvement is challenging and varies across contexts. Our work implies that deep engagement with stakeholders is required to ensure authentic and diverse involvement in policy and that solutions for involvement will differ across groups and contexts.\u003c/p\u003e","manuscriptTitle":"Rooted, resourced and connected: stakeholder perspectives on involvement in injury care policy and practice in Ghana, Pakistan, Rwanda, and South Africa - is consensus achievable?","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-09 07:04:12","doi":"10.21203/rs.3.rs-6350661/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"202309172669778600736649224794222044921","date":"2026-02-01T12:44:40+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-05-05T07:58:34+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-04-29T06:48:47+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-04-09T01:16:20+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-08T09:56:40+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2025-04-08T09:55:33+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3240e247-b2ac-4647-906f-b92eb8429693","owner":[],"postedDate":"May 9th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-05-09T07:04:13+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-09 07:04:12","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6350661","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6350661","identity":"rs-6350661","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}