Stakeholder involvement in setting priorities for implementation research on Health Care Planning

Abstract

Objective

To identify the problems faced in the context of Health Care Planning (HCP) from the perspective of stakeholders for setting priorities in the development of implementation research.

Methods

Qualitative study based on workshops anchored in the nominal group technique. In mapping stakeholders, we sought to include a set of strategic actors that represented the diversity of action in the context of HCP. They were organized into three groups (A, B and C). Nine workshops structured in five stages were conducted. At the end, participants had the opportunity to reach a consensus on priority problems and identify the research questions. The data analysis process went through three phases, namely: content analysis, hierarchization of priority problems by stakeholder group and classification of research questions according to the objectives of theoretical approaches to implementation science (IS).

Results

participation of 84 professionals distributed between groups A (n=13), B (n=14) and C (n=57). In total, 13 themes that addressed different challenges in the HCP scenario were identified. The themes “Understanding determinants and results of HCP implementation” (Group A), “Generating evidence on HCP” (Group B) and “Access to health care and services” (Group C) stood out in hierarchization process by the number of votes and order of importance, and were identified as priority. The questions raised by the groups, related to the priority themes, covered the different theoretical approaches to IS.

Conclusion

Various themes and questions on implementation research were identified. Priority aspects were related to implementation and generation of evidence on HCP and access to health services. The priority setting exercise highlighted particular interests aligned with the needs perceived by stakeholders according to their involvement and performance in HCP.

Keywords
Stakeholder participation; Implementation Science; Health research agenda; Planning

Resumo

Objetivo

Identificar, na perspectiva dos stakeholders, os problemas enfrentados no contexto da Planificação da Atenção à Saúde (PAS) a fim de estabelecer prioridades para o desenvolvimento de pesquisa de implementação.

Métodos

Estudo de abordagem qualitativa, realizado a partir de workshops ancorados na técnica de grupo nominal. Buscou-se, no mapeamento dos stakeholders, contemplar um conjunto de atores estratégicos que representassem a diversidade de atuação no contexto da PAS, que foram organizados em três grupos (A, B e C). Foram conduzidos nove workshops, estruturados em cinco etapas que, ao final, oportunizavam o consenso dos participantes sobre os problemas prioritários e a identificação de perguntas de pesquisa. O processo de análise dos dados percorreu três fases, a saber: análise de conteúdo, hierarquização dos problemas prioritários por grupo de stakeholders e enquadramento das perguntas de pesquisa de acordo com os objetivos das abordagens teóricas da ciência da implementação (CI).

Resultados

participaram do estudo 84 profissionais, distribuídos entre os grupos A (n=13), B (n=14) e C (n=57). Ao todo, foram identificados 13 temas que contemplavam diferentes desafios no cenário da PAS. No processo de hierarquização, os temas “Compreender determinantes e resultados da implementação da PAS” (Grupo A), “Geração de evidências sobre a PAS” (Grupo B) e “Acesso aos cuidados e serviço de saúde” (Grupo C) se destacaram pelo número de votos e ordem de importância, sendo identificados como prioritários. Ressalta-se que as perguntas levantadas pelos grupos, relacionadas com os temas prioritários, perpassaram as diferentes abordagens teóricas da CI.

Conclusão

Identificou-se variados temas e perguntas de pesquisa de implementação, sendo prioritários aspectos relacionadas a implementação e geração de evidências sobre a PAS e acesso aos serviços de saúde. O exercício de definição de prioridades, evidenciou interesses particulares que estavam alinhados às necessidades percebidas pelos stakeholders, de acordo com seu envolvimento e atuação na PAS.

Descritores
Participação dos interessados; Ciência da implementação; Agenda de pesquisa em saúde; Planejamento

Resumen

Objetivo

Identificar, bajo la perspectiva de los stakeholders, los problemas enfrentados en el contexto de la Planificación de la Atención en Salud (PAS) a fin de establecer prioridades para el desarrollo de estudios de implementación.

Métodos

Estudio de enfoque cualitativo, realizado a partir de workshops basados en la técnica de grupo nominal. En el mapeo de los stakeholders, se buscó contemplar un conjunto de actores estratégicos que representaran la diversidad de actuación en el contexto de las PAS y se dividieron en tres grupos (A, B y C). Se llevaron a cabo nueve workshops , estructurados en cinco etapas que, al final, permitían el consenso de los participantes sobre los problemas prioritarios y la identificación de preguntas de investigación. El proceso de análisis de los datos se realizó en tres fases, a saber: análisis de contenido, jerarquización de los problemas prioritarios por el grupo de los stakeholders y ajuste de las preguntas de investigación de acuerdo con los objetivos de los enfoques teóricos de la ciencia de la implementación (CI).

Resultados

Participaron del estudio 84 profesionales, distribuidos entre los grupos A (n=13), B (n=14) y C (n=57). En total, se identificaron 13 temas que contemplaban diferentes desafíos en el escenario de las PAS. En el proceso de jerarquización, los temas que se destacaron por el número de votos y orden de importancia y se identificaron como prioritarios fueron: “Comprender determinantes y resultados de la implementación de las PAS” (Grupo A), “Generación de evidencias sobre las PAS” (Grupo B) y “Acceso a los cuidaos y servicios de salud” (Grupo C). Es importante destacar que las preguntas surgidas en los grupos, relacionadas con los temas prioritarios, abarcaron los diferentes enfoques teóricos de la CI.

Conclusión

Se identificaron diferentes temas y preguntas de investigación de implementación, entre los cuales los aspectos relacionados con la implementación y generación de evidencias sobre las PAS y el acceso a los servicios de salud fueron prioritarios. El ejercicio de definición de prioridades evidenció intereses particulares que estaban alineados con las necesidades percibidas por los stakeholders, de acuerdo con su participación y actuación en las PAS.

Descriptores
Participación de los interesados; Ciencia de la implementación; Agenda de investigación en salud; Planificación

Introduction

The development of strategies to reduce the gap between the production of knowledge and consumption of evidence in healthcare environments has been a debate of growing interest among researchers, decision-makers and healthcare professionals.(¹-³⁾ Implementation science emerges as a promising field that aims to accelerate understanding and efforts related to the processes and strategies that move or integrate the implementation of evidence-based interventions and innovations in the real scenario.(3,⁴)

This movement of approximation and integration of research results in specific contexts of practice involving a chain of complex processes that require the establishment of active efforts.(⁴) Given the complexity of processes triggered in the real world, the consolidation of partnerships, collaborations and engagement of different stakeholders is important, breaking the logic of unidirectional models in research(⁴) to support the successful implementation of the proposed programs.

Stakeholders refer to people, institutions and communities that may have direct interests in the process and/or results of the implementation of a proposition.(⁵) In practical terms within the scope of health service research, these actors are (although not restricted to), for example, users, managers, health professionals and policymakers who can contribute to unique perspectives and experimental and empirical knowledge about a given process to inform and support decision-making.

The literature(⁵-¹⁰) describes that stakeholders can get involved in a wide range of activities at different stages of the research cycle according to their skills and interests. These studies(⁵-¹⁰) highlight some obstacles and facilitators for consolidating the dialogue and meaningful collaboration between those involved, in addition to exploring engagement strategies(⁸) and the impact of this involvement on the outcomes investigated.(¹⁰)

In this context, the potential of involvement in early stages, such as the prioritization and development of research question stands out(⁵,¹¹) as an opportune space to bring research (and researchers) closer to the needs and concerns permeating the practice scenario and, therefore, to guide future efforts towards knowledge production.

The exercise of defining research priorities has been the focus of studies conducted mainly in high-income countries.(¹¹) Despite the diversity of thematic areas, in the health field, there is growing interest and predominance(¹¹) of encouragement of communication between interested groups as a promising strategy to accelerate the implementation of evidence/innovations for the regular use by healthcare professionals.

Note that the Ministry of Health(¹²) in Brazil recently proposed an agenda with priority thematic axes for the development of studies. However, initiatives to gather opinions and perspectives from different stakeholders for setting priorities in research related to health services are still scarce on the national scene.

In this sense, Health Care Planning (HCP)(¹³,¹⁴) is a methodology proposed by National Council of Health Secretaries (Portuguese acronym: CONASS) for the organization of services in the Unified Health System (Portuguese acronym: SUS) which is spread throughout the five regions of Brazil. It involves a multiplicity of actors (technical, care and management), configuring a favorable model for the development of studies with collaborative approaches related to their implementation process at the different levels.

The reason is that HCP based on the Chronic Conditions Care Model envisions the integration of Specialized Outpatient Care (SOC) in a network with Primary Health Care (PHC) from a set of continuing education actions and cycles of continuous improvement that encourages the team reflection and qualification of work processes reverberating at broader levels in the organization of the Health Care Network.(¹³,¹⁴)

Thus, considering the need to expand the debate on HCP in the scientific literature and the potential of implementation science for the involvement of interested parties as a strategy to boost the production of knowledge aligned with the priorities of the real scenario, the present study sought to identify the problems faced in the context of HCP from the perspective of stakeholders for setting priorities in the development of implementation research.

Methods

This qualitative study was conducted from workshops anchored in the nominal group technique.(¹⁵,¹⁶)

The implementation of the HCP methodology,(¹³,¹⁴) began in mid-2000 through workshops held with professionals from state administrations. Starting in 2010, mentoring activities began with PHC and SOC professionals in laboratories located in three states in Brazil. Since 2018, HCP has been implemented on a large scale via the SUS Institutional Development Support Program (Portuguese acronym: PROADI-SUS), developed through thematic operational stages in 24 health regions in 18 Brazilian federative units. For each operational stage, a set of technical operational materials are produced and made available with a view to supporting the implementation of HCP in states, municipalities and health services.

Considering this panorama, it is important to highlight that the HCP implementation process involves a wide range of actors and institutions that perform specific functions according to their scope of action and practice scenario, such as managers of state/municipal health departments, health service professionals, local tutors and external professionals who work from a consultancy perspective for the implementation of HCP. The actors who plan the technical development and monitor the operationalization of the HCP should also be mentioned.

Therefore, the present study chose to integrate the perspectives and priorities of a set of stakeholders identified from three groups:

Group A – representatives of the creators (proponents), consultants and tutors, covering perspectives at micro, meso and macro levels of the implementation of the methodology in different regions of the country;

Group B – representatives of the technical development team, who work at the partner institution that executes HCP via PROADI-SUS. They are responsible for the production of educational materials and management of HCP processes on a large scale in order to support the technical management team of states and municipalities for the implementation of HCP;

Grupo C – representatives of health professionals who provide care in Primary Health Care (PHC) and Specialized Services units located in the southern region of the city of São Paulo, where the HCP methodology is adopted (initial implementation phase) for organizing services and work processes. These were considered because they use the HCP methodology and have working groups called Center for Local Research and Best Practices that aim to develop, reflect and incorporate scientific evidence into the practice of health services. These configure powerful spaces for monitoring the actions raised in the workshop.

Stakeholder recruitment

Invitations were made to stakeholders through a direct approach. The representatives of group A were invited after the end of the 1^st National HCP Conference (Brasília-DF, December 12 and 13, 2022) and the representatives of groups B and C were invited at their work units with approval of the local coordination. After presenting the objectives of the study and expressing interest, guidance on the dynamics of the workshop was provided. Eligibility criteria comprised being a health professional acting in direct care and/or participating in the technical or organizational execution of the HCP. Professionals who were away or on vacation at the time of the workshop were excluded.

Development of workshops

The meetings were held in person in private environments between September and December 2022. Note that the nominal group technique(¹⁴,¹⁵) was used to guide the development of the proposed activities, as illustrated in figure 1.

Figure 1
Organization of the stages of the workshop “Connecting research and practice”

The workshop was structured in five stages. The first, entitled “connecting research with practice”, was used as a trigger for discussion and sought to present and clarify aspects related to the connection between research and practice. The subsequent steps were planned to encourage participation and interaction between group members to build a list that reflected the challenges experienced in the real scenario.

In the second stage (silent idea generation), professionals were invited to record their ideas individually. They received a form with two triggering questions that sought to identify a) what were the problems experienced in the services that could receive research contributions; b) questions about those problems that the professional would like to be answered. That is, the material produced during the workshop was composed of a set of problems and their respective questions.

In the third stage, professionals were gathered into small groups that provided opportunities for discussion on the topics raised by each member, aiming to recognize common themes. Next, professionals were invited to prepare a consolidated summary of the group’s discussion and consensus on the problems and prioritized questions.

The fourth stage was characterized by a plenary session in which each group, represented by a rapporteur, shared the synthesis prepared by the collective. Finally, in the fifth stage, the problems and questions raised were arranged in a panel and the prioritization and consensus process began. Each stakeholder could indicate up to three problems and three questions they considered as a priority for resolution in the real scenario. At the end, the votes were counted, the topic chosen as priority was presented and the activity was closed.

In total, nine workshops with an average duration of two hours and participation of four to 12 professionals in each were offered. These meetings were led by previously trained facilitators, members of the research team. Considering the specificities of each context, some customizations were made when conducting the activity.

The data from the panels of each workshop (consisting of the description of the problems, questions and the result of the consensus) were transcribed in full. Considering the objectives of the present study, the analysis process covered three phases. In the first, aiming to map the topics that emerged from the groups (A, B and C), content analysis was carried out.(¹⁷) For this, the material referring to the survey of problems carried out in each workshop was established as the unit of analysis.

Then, skim reading was performed for an initial familiarization with the material. In a second moment, a focused reading was carried out to identify the main ideas that emerged from the material (coding). Subsequently, the codes were grouped according to similarity criteria, each set received a title (categorization) and the groupings were carried out successively until the composition of themes. This stage was conducted by two researchers individually and a third researcher (with experience in HCP) was called to a meeting where the categories and themes were validated.

In the second phase, aiming to highlight the prioritization process, the total of votes received per topic during the dynamics in each group of stakeholders was counted. Subsequently, the percentage calculation was carried out as follows: (sum of the number of votes on the items grouped under theme “x”) / (sum of the total number of votes per group). This process provided the opportunity to prioritize the problems raised and identify the priority category that emerged by group of stakeholders (A, B and C).

Finally, in the third phase, the categories that stood out in each stakeholder group were presented to the group of researchers. At this time, the questions created during the workshops which were related to the items included in the priority category were paired. Subsequently, a discussion was held between the researchers to reach consensus and classify these questions, considering the objectives of the theoretical approaches to implementation science proposed by Nielsen (2015),(¹⁸) namely: describe and/or guide the process of translating research into practice; understand and/or explain what influences implementation results; and evaluate implementation.

The study met ethical standards for research involving human beings and was approved by the Research Ethics Committee 6.093.305 (CAAE: 12395919.0.0000.0071).

Results

The 84 stakeholders participating in the study were distributed between groups A (n=13), B (n=14) and C (n=57). Most were women (79.8%), aged between 31 and 40 years (44.0%), self-declared as white (56.0%). Furthermore, a diversity of professional categories was observed, with emphasis on nursing (34.5%) and dentistry (15.5%) and postgraduate training (83.3%) (Table 1).

Table 1
Characteristics of stakeholders participating in the workshops (n=84)

Variables	Group A n(%)	Group B n(%)	Group C n(%)	Total n(%)
Age
20-30 years	1(7.7)	5(35.7)	9(15.8)	15(17.9)
31-40 years	2(15.4)	9(64.3)	26(45.6)	37(44.0)
41-50 years	3(23.1)	0(0.0)	18(31.6)	21(25.0)
More than 50 years	7(53.8)	0(0.0)	2(3.5)	9(10.7)
Not declared	0(0.0)	0(0.0)	2(3.5)	2(2.4)
Total	13(100.0)	14(100.0)	57(100.0)	84(100.0)
Sex
Female	10(76.9)	13(92.9)	44(77.2)	67(79.8)
Male	3(23.1)	1(7.1)	10(17.5)	14(16.7)
Not declared	0(0.0)	0(0.0)	3(5.3)	3(3.5)
Total	13(100.0)	14(100.0)	57(100.0)	84(100.0)
Race/Color
White	6(46.2)	7(50.0)	34(59.6)	47(56.0)
Brown	6(46.2)	3(21.4)	11(19.3)	20(23.8)
Black	1(7.7)	2(14.3)	10(17.5)	13(15.5)
Yellow	0(0.0)	1(7.1)	2(3.5)	3(3.6)
Indigenous	0(0.0)	1(7.1)	0(0.0)	1(1.2)
Total	13(100.0)	14(100.0)	57(100.0)	84(100.0)
Education
Up to Technician Training	0(0.0)	1(7.1)	4(7.0)	5(6.0)
Undergraduate	0(0.0)	1(7.1)	8(14)	9(10.7)
Residency	0(0.0)	0(0.0)	6(10.5)	6(7.1)
Specialization	4(30.8)	2(14.3)	26(45.6)	32(38.1)
Master degree	6(46.2)	8(57.1)	10(17.5)	24(28.6)
PhD degree	3(23.1)	2(14.3)	3(5.3)	8(9.5)
Total	13(100.0)	14(100.0)	57(100.0)	84(100.0)
Training
Medicine	1(7.7)	1(7.2)	4(7.0)	6(7.1)
Nursing	7(53.8)	4(28.5)	18(31.6)	29(34.5)
Psychology	0(0.0)	1(7.2)	4(7.0)	5(6.0)
Dentistry	1(7.7)	1(7.2)	11(19.3)	13(15.5)
Nutrition	1(7.7)	1(7.2)	2(3.5)	4(4.8)
Physiotherapy	1(7.7)	2(14.2)	1(1.8)	4(4.8)
Others1	0(0.0)	3(21.3)	13(22.8)	16(19.0)
Not declared	2(15.4)	1(7.2)	4(7.0)	7(8.3)
Total	13(100.0)	14(100.0)	57(100.0)	84(100.0)
Time in the position
Less than 1 year	6(46.1)	1(7.1)	7(12.3)	14(16.7)
1 and 3 years	1(7.7)	11(78.6)	18(31.6)	30(35.7)
More than 3 and less than 5 years	0(0.0)	2(14.3)	4(7.0)	6(7.1)
More than 5 and less than 10 years	3(23.1)	0(0.0)	17(29.8)	20(23.8)
More than 10 years	2(15.4)	0(0.0)	10(17.5)	12(14.3)
Not declared	1(7.7)	0(0.0)	1(1.8)	2(2.4)
Total	13(100.0)	14(100.0)	57(100.0)	84(100.0)

• 1- Others: Physical education, speech therapy, occupational therapy, social work, pharmacy, veterinary, biology, administration, community health agent, social worker

The problems and challenges experienced in everyday life were listed by stakeholders and organized into 13 themes (Chart 1).

Chart 1
Description of the problems listed during the workshops, according to the main topic and stakeholder group

Topic	Category	Code	Group
Care to chronic conditions	Clinical management	Management of chronic conditions	A
		Management of mental health cases	C
	Case management	Follow-up and monitoring of people with chronic conditions	C
		Case management for people with epilepsy	C
Access to health care and services	Subpopulation access to the service	Barriers to men’s access and involvement in healthcare	C
		Need to formulate actions to expand access to adolescents	C
	Timely access and use of the service	Guarantee the access to the service and SUS	C
		Characteristics of the actions offered at the UBS	C
		User understanding of care at the UBS	C
		Disparity between service use and health needs	C
	Scheduling templates	Insufficient supply for acute demand	C
		Need to organize access and scheduling	C
Determinants and results of HCP implementation	Local context	Weakness and fragmentation of SHD	A
		Lack of time to develop the HCP steps in the unit	A
		Professional turnover	A
	Tutor’s duties	Tutor task overlap	A
		Lack of an exclusive tutor for HCP	A
		Lack of financial incentive for the tutor	A
		Insufficient tutor workload	B
	Sustainability of the intervention	HCP sustainability	A
	Engagement of those involved	Management support for HCP	A
		Clarity from the manager of municipal and state departments about their role in HCP	A
		Need for involvement of the state secretariat with HCP	A
		Low adherence to available activities	B
		Low participation in workshops	B
	Capillarity of the intervention	HCP expansion	A
		Replication of skills for large-scale HCP	B
		Problems in executing the HCP expansion	B
	Adaptation of strategies	Development of educational technologies compatible with the needs of professionals	B
Care coordination	Coordination between HCN services	Lack of coordination between HCN services	A
		Weaknesses in the integration of HCN services	B
		Fragmentation of care in the HCN	C
		Difficulty in sharing cases with specialized care	C
		Professionals’ lack of clarity about competencies of the network	C
		Difficulty in providing comprehensive care to the user	C
		Discontinuation of care for people with suicidal behavior	C
	Coordination with intersectoral network	Weakness in articulation with intersectoral services	C
Development of professional skills	Professional qualification	Lack of professional qualification to work in a network	A
		Need to develop the clinical practice of physicians and nurses	A
		Weakness in clinical nursing practice	C
		Lack of permanent/continuing education initiatives	C
		Need to develop scientific skills in care professionals	C
Generating evidence on HCP	Evaluation strategies	Need to evaluate the impact of HCP	B
		Lack of tools for evaluating the effectiveness of care	C
	Knowledge production	Gap in the literature on PASA	B
Population-based management	Territorialization processes	Difficulty implementing population-based management	B
		Challenges for territorialization and registration	C
	Organization of population care	Care to the person victim of violence	C
		Violence in the territory	C
		Care to minority groups	C
		Health care for older adults	C
		Increased demand from people with mental disorders	C
	Organization of community actions	Lack of health promotion actions	C
		Need for collective and community actions	C
		Lack of actions in the territory	C
		Difficulty in offering and organizing group activities	C
People management	Workforce planning and sizing	Lack of professionals in the FHS	A
		Human resources sizing	C
	Overload and work conditions	Professional overload	B
		Professional overload	C
		Motivation of professionals in daily work	C
		Professional’s mental health	C
		Violence against professionals	C
Infrastructure and materials	Health Information System	Lack of integrated information system	A
		Lack of integration of information between services	A
		Lack of registration of processes	B
		Excess of recording tools	C
		Lack of tools for care management	C
		Weakness of service records	C
	Technological resources	Incorporation of technologies to qualify care	C
		Lack of technological resources	B
	Management of waste and inputs	Excessive use of disposable materials	C
		Lack of medicines	C
	Physical structure	Inadequate physical space	C
Continuous improvement in PHC processes	Standardization of practices	Weakness in quality and patient safety practices	B
		Multiplicity of protocols and guidelines	C
		Need to incorporate quality and safety practices	C
		Loss of vaccine doses	C
	Standardization of flows and processes	Weaknesses in the organization of the dentistry flow	C
		Weaknesses in the organization of the eMulti flow	C
		Need to qualify information to organize user flow	C
		Weakness in the organization and maintenance of work processes	C
		Difficulty in evaluating and monitoring collective actions	C
		Difficulty in prioritizing demands	C
	Social participation	Lack of integration with the management board	C
Qualification of Specialized Outpatient Care (SOC)	Resource allocation	Lack of co-financing from SOC	A
		Inadequate SOC funding	A
	Organization and structuring of the SOC	Weakness of SHD support for SOC organization	A
		Lack of knowledge and adherence to the SOC model	A
		Lack of SOC policy	A
	PASA model costs	High cost of maintaining the PASA model	A
Interdisciplinary management and work	Collaborative practice	Difficulty in carrying out multidisciplinary practice	C
	Management model	Centralization in decision making	C
	Team work	Weakness in communication between teams	C
		Lack of team alignment	C
		Lack of team involvement	C
		Difficulty in team working	C
Person-centered care	Therapeutic adherence and self-care	Lack of adherence to women’s health screening exams	C
		Lack of adherence to STI treatment	C
		Non-adherence to treatment	C
		Need for user empowerment	C
	Relationship between user and team	Weakness in the user and team relationship	C
		Need for qualifications in communicating with users	C

• SOC - Specialized Outpatient Care; PHC - Primary Health Care; STI - Sexually Transmitted Infections; HCP - Health Care Planning; PASA - Outpatient Secondary Care Point (Portuguese acronym); HCN - Health Care Networks; SHD - State Health Department; FHS - Family Health Strategy

Note that some themes, such as “Access to health care and services”, “Interdisciplinary management and work” and “Person-centered care” were mentioned only by participants in group C, composed of stakeholders working at the care level. On the other hand, problems related to “Qualification of Specialized Outpatient Care (SOC)” were reported only among stakeholders in Group A. Problems related to the themes “Care coordination”, “People management” and “Infrastructure and materials” were presented on the panel of all groups. Among all themes identified, those that received at least one vote (during the workshop) were organized to identify the priorities of each group. Table 2 describes the themes prioritized by group according to the number of votes and their order of importance.

Table 2
Themes prioritized by each stakeholder group according to the number of votes and their order of importance

Topics
Order	Group A	Points	%
1	Determinants and results of HCP implementation	20	45.5
2	Qualification of Specialized Outpatient Care (SOC)	15	34.1
3	Care to chronic conditions	6	13.6
4	Infrastructure and materials	2	4.5
5	Development of skills	1	2.3
Order	Group B	Points	%
1	Generating evidence on HCP	17	41.5
2	Determinants and results of HCP implementation	10	24.4
3	Infrastructure and materials	6	14.6
4	Continuous improvement in PHC processes	4	9.8
5	Population-based management	2	4.9
6	Care coordination	1	2.4
7	People management	1	2.4
Order	Group C	Points	%
1	Access to health care and services	35	22.7
2	People management	22	14.3
3	Population-based management	20	13.0
	Interdisciplinary management and work	20	13.0
4	Care coordination	12	7.8
5	Continuous improvement in PHC processes	12	7.8
6	Person-centered care	11	7.1
7	Infrastructure and materials	9	5.8
8	Care for chronic conditions	6	3.9
9	Generating evidence on HCP	4	2.6
10	Development of skills	3	2.0

• PHC - Primary Health Care; HCP - Health Care Planning

At this stage, the particularities of the stakeholder groups were identified during the topic prioritization exercise. In group A, priority was given to problems focused on aspects of “Determinants and results of HCP implementation” (45.5%); in group B, problems related to “Generating evidence on HCP (41.5%)” were highlighted; and in group C, problems relating to “Access to health care and services” (22.7%) were the most voted. Figure 2 presents the questions proposed by participants during the workshops that were related to the problems prioritized in each group of stakeholders, considering the theoretical approaches of implementation science.

Figure 2
Questions related to the prioritized problem in each stakeholder group according to the theoretical approaches of implementation science

Discussion

A wide range of situations that represent challenges experienced in the context of HCP from the perspective of different stakeholders were identified in the present study. Although some themes were presented transversally between the groups, the priority setting exercise highlighted particular interests aligned with the needs perceived among the different stakeholders, namely “Determinants and results of HCP implementation”, “Generating evidence on HCP” and “Access to health care and services”, which were respectively the priorities described by groups A, B and C.

These findings reinforce the importance of identifying and understanding the opinions and views of those involved in the phenomenon, in order to develop approaches to integrate and incorporate them into the implementation process. In this sense, movements such as Practice-Based Research Networks (PBRN)(¹⁹,²⁰) are approaches that can add to the efforts of implementation science in an attempt to bring research closer to real-world priorities and maximize the results of implementation.

In general terms, PBRN(¹⁹,²⁰) recognize that the health service is characterized as a powerful scenario for the production of knowledge and propose the involvement of local health professionals and managers as partners in the development of research, i.e., by integrating them to the research team and not considering them only as subjects/sources of information about a phenomenon to be investigated.

In this complex and challenging relationship, researchers/academia can contribute mainly with aspects related to research infrastructure and training while professionals/managers identify and prepare research questions based on their experience in clinical and management practice, seeking to answer the problems perceived in the service and the territory in order to enhance consumption and the incorporation of research findings to support decision making.(¹⁹,²⁰)

Despite the growing interest in collaborative and partnership research approaches and models,(²¹) in practical terms, there is still a gap between scientific production and the incorporation of evidence into the local reality, suggesting the need for greater stakeholder involvement in processes linked to research, as well as the use of other strategies to strengthen knowledge translation. In the present study, for example, opportunities to accelerate the translation of discoveries already described in the literature into process improvement actions were identified, especially among the problems and challenges listed in the panel of participants in group C - composed of professionals directly connected to care.

Note that in relation to the themes that emerged in the setting of priority problems, the three groups of stakeholders defined topics characterized as gaps in the literature. For representatives of group A, the definition of priority refers to the process of growth and consolidation of the HCP methodology itself in different regions of Brazil. Questions related to institutionalization and integration between spheres of government, coordination between health care network’s points of care and management support were raised, as well as specific questions about the process of operationalization, expansion and sustainability of HCP.

From this perspective, the potential of implementation science to answer the indicated problems and questions stands out, considering the investigation of implementation strategies(²²) and results,(²³) as well as their relationship with service results and clinical outcomes in the different regions that make up the HCP scenario.

Another important topic for this group was the qualification of Specialized Outpatient Care (SOC). This topic is characterized as one of the major bottlenecks in the construction of the SUS given the “insufficient”, fragmented and heterogeneous structure of the specialized care network,(²⁴) in addition to the waiting time and the regulatory process for scheduling consultations and specialized exams.(²⁵)

In this context, the Outpatient Secondary Care Point (Portuguese acronym: PASA) model is recommended in HCP for organizing the SOC in a network with PHC. The absence of a policy for specialized care in the SUS, as well as the financing and predominance of the silo model to the detriment of adherence to the PASA model are problems in the real scenario that come together with questions related to the impact and cost-effectiveness responses of this model.

Thus, while group A participants are interested in understanding the model and its challenges, group B indicates the need to generate evidence as their priority, especially evidence related to the PASA model, seeking resolutions that can contribute to decision-making by key actors for its implementation. These findings endorse the relevance of considering multiple stakeholders as they present unique perspectives inclined to the scope of action in relation to the phenomenon.

For group C, access to health care and services was indicated as the priority challenge, covering issues related to infrastructure, organization of the schedule, scheduling models and the provision of equitable service. Although not highlighted by participants in groups A and B, the topic actually requires investment in research, given the limited body of evidence on organization models of access and scheduling applicable to the specificities of SUS, highlighting the importance of contributions of the care group in proposing research questions.

In the present study, although some themes emerged across the stakeholder groups, a significant difference was noted during the exercise of priority setting. For example, issues related to people management gained greater prominence in Group C, which was interested in finding solutions to problems such as overload, motivation of professionals, and issues related to violence against these professionals and their mental health. These concerns corroborate other findings related to PHC health services,(²⁶,²⁷) presenting themselves as a possible obstacle to the process of institutionalization of HCP.

Among the limitations of the study, the challenge of involving all stakeholders of HCP, especially health managers and the service users, is recognized. In order to consider the generation and translation of knowledge to the multiple contexts of the Brazilian territory, it is also necessary to expand the proposal to stakeholders from other regions of Brazil. The presentation of a systematized proposal that favors the inclusion of different stakeholders is a strong point, as proposed in implementation science.

Conclusion

In general, the themes were presented transversally between the groups and covered a wide range of challenging situations for the real scenario. However, in the priority setting exercise, the themes highlighted by groups A “Understanding determinants and results of HCP implementation”, group B “Generating evidence on HCP” and Group C “Access to health care and service” showed particular interests aligned with the needs perceived by stakeholders, according to their involvement and performance in HCP. Thus, considering the implementation of HCP as a movement with great potential and large-scale capillarity, the findings of the present study contribute with directions for the production of knowledge aligned with everyday needs. Furthermore, the potential of different theoretical approaches to implementation science to answer the problems and questions indicated by stakeholder groups is highlighted, going through the process of knowledge translation, understanding the determinants and evaluation of implementation.

Acknowledgements

The authors acknowledge the financing support for publication by the SUS Institutional Development Support Project (law number 12.101 of November 27, 2009), through ordinance number 3.362 of December 8, 2017 – Opinion Initial Technical Recommendation for Technical and Financial Analysis of Project within the Scope of PROADI-SUS number 21/2021-CGMAD/DAPES/SAPS/MS25000.036837/2021-51.

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Edited by

Guest Associate Editor: Danila Cristina Paquier Sala (https://orcid.org/0000-0003-3723-6706) Escola Paulista de Enfermagem, Universidade Federal de São Paulo, São Paulo, SP, Brazil

Publication Dates

• Publication in this collection
  02 Sept 2024
• Date of issue
  July 2023

History

• Received
  14 Aug 2023
• Accepted
  10 May 2024