Tapping into the power of coproduction and knowledge mobilisation: Exploration of a facilitated interactive group learning approach to support equity‐sensitive decision‐making in local health and care services

Abstract Background We report on a study of a facilitated interactive group learning approach, through Collaborative Implementation Groups (CIGs), established to enhance capacity for equity‐sensitive evaluation of healthcare services to inform local decision‐making: (1) What was the experience of participants of the CIGs? (2) How was knowledge mobilisation achieved? (3) What are the key elements that enhance the process of coproducing equity‐sensitive evaluations? Methods A thematic analysis of qualitative data obtained from focus group (FG) discussions and semistructured interviews exploring the experiences of participants. All FGs included representation of participants from different projects across the programme. Interviews were conducted with a member from each of the teams participating in the first cohort after their final workshop. Results We identified four themes to illustrate how the approach to delivering intensive and facilitated training supported equity‐sensitive evaluations of local healthcare services: (1) Creating the setting for coproduction and knowledge mobilisation; (2) establishing a common purpose, meaning and language for reducing health inequalities; (3) making connections and brokering relationships and (4) challenging and transforming the role of evaluation. Conclusion We report on the implementation of a practical example of engaged scholarship, where teams of healthcare staff were supported with resources, interactive training and methodological advice to evaluate their own services, enabling organisations to assemble timely practical and relevant evidence that could feed directly into local decision‐making. By encouraging mixed teams of practitioners, commissioners, patients, the public and researchers to work together to coproduce their evaluations, the programme also aimed to systematise health equity into service change. The findings of our study illustrate that the approach to delivering training gave participants the tools and confidence to address their organisation's stated aims of reducing health inequalities, coproduce evaluations of their local services and mobilise knowledge from a range of stakeholders. Patient or Public Contribution The research question was developed collaboratively with researchers, partner organisations and public advisers (PAs). PAs were involved in meetings to agree on the focus of this research and to plan the analysis. N. T. is a PA and coauthor, contributing to the interpretation of findings and drafting of the paper.

However, much has been written on the significant delays in putting research into clinical practice, how this impacts patient care 1 and why researchers and funding bodies must accelerate the process 2,3 ; of the attempts by local providers to make better use of the different forms of evidence in the planning of public services 4 and on the multiple processes, tasks and people involved in incorporating research into delivering healthcare services. 5,6 This disconnect between research and practice can be conceptualised broadly as 7 : a knowledge transfer problem, where knowledge is 'pushed' from researchers or 'pulled' by actors within organisations, or a knowledge production problem, where academic and organisational ways of knowing are brought together to create new knowledge.

| Knowledge translation, mobilisation and brokering
The positioning of knowledge in use and in practice appears on a continuum: on one side, a simple transaction between researchers and practitioners; on the other, end-users are fully involved in bringing together different types of knowledge, facilitated to shape that knowledge. 5,8 Knowledge brokering is a combination of activities: managing information such as research evidence and data; linking and exchanging ideas between the different knowledge stakeholders and capacity building to utilise research evidence to enact positive change. 9 Knowledge mobilisation has often relied on brokering to facilitate 'bridging the gap' between researchers and practitioners or policymakers, although arguably a reliance on designated brokers creates a process dependent on their specific skills, networks and preferences. 8,9 Alternatively, knowledge brokering is a collective process, enacted within the team, enabled inside organisations and strengthened by the inclusion of a broad range of research users coproducing and mobilising evidence relevant to their local environments. 9

| The role of coproduction in mobilising knowledge
Coproduction has been developed and employed in policy and practice across many disciplines, including environment, sustainability and health, motivated by the need to address complex problems, where the knowledge required to generate solutions requires collaboration between researchers and nonacademic end-users of the research. 10,11 While there is some agreement across the disciplines that coproduction embraces a range of practices across different levels of engagement, descriptions and definitions vary. [11][12][13][14] Smith et al. 15 present a typology of coproduction to explain the different ways that coproduction is defined and employed: citizens' contributions to public services, where public services are reliant on voluntary contributions for success; integrated knowledge translation, where academic researchers work with end users with the aim of making research more valid; equitable and experientially informed research, where experiential knowledge is seen as crucial to the research process. Coproduction demands that the knowledge and experience that end-users bring is valued on a par with that of the traditional knowledge producers; that relationships are reciprocal and mutually beneficial, achieving more together than would be possible apart, and to be facilitated to do so by networks, organisations and a resource infrastructure that enables involvement. 8,11 There is general agreement that coproduction adds value through shaping how knowledge is generated, understood and CLOKE ET AL. | 1693 utilised in the design and delivery of impactful public services; bringing together the multiple perspectives and skills of stakeholders and addressing the imbalances in power by respecting and valuing the knowledge they bring to discussions; providing contributors with the 'space to talk' and 'space to change'. 8,[16][17][18] Nonetheless, tensions arise where the vision of coproduction and the reality of local context intersect and consequently, coproduction is not free of risk or cost. 10,19 Recent reviews of the use of coproduction in health research suggest that coproduction can benefit the research process although little evidence exists to show it has improved the management of health conditions. 12,20 Whether or not there is a need for robust evaluation to identify whether coproduction produces improved health outcomes is a point of debate. Williams et al. 21 argue from a democratic stance that the normative desirability of coproduction does not demand a sound evidence base, while a technocratic position would require empirical evidence to substantiate the benefits of the approach.

| The context of our study
As a partnership between universities and healthcare organisa- Increasing the capacity of partners to undertake and act on the findings of applied health research is a core function of the 13 CLAHRCs situated across England. A particular focus of CLAHRC-NWC was reducing health inequalities, since the region faces some of the starkest variations across England, with average life expectancy differing by up to 12 years. Although widely acknowledged that social injustices and resulting health inequalities are unnecessary, there is a lack of common ground on definitions, which hinders effective action. 22 A focus on reducing inequalities is essential in advancing population health furthermore integrating an equity focus into projects is necessary to spend public money 'wisely'. 23 However, relatively little evidence has an explicit focus on equity, and some policies and interventions may inadvertently differentially benefit more socioeconomically advantaged groups. 23 With its NHS and Local Authority partners, CLAHRC-NWC coproduced a programme focussing on a shared strategic priority to identify and evaluate local healthcare treatments and services aiming to reduce emergency admissions. The goal of this Partners Priority Programme (PPP) was to support teams to develop the capacity to evaluate the delivery of their own services enabling organisations to assemble timely, practical and relevant evidence that could feed directly into local decision-making. By encouraging mixed teams to work together to coproduce their evaluation, the PPP also aimed to systematise the consideration of health inequalities in service change. 24 1.5 | Description of the facilitated interactive group learning approach The PPP was achieved through a series of eight, 1-day workshops over a 12-month period, on evaluation that brought academics, professionals and users of services together in Collaborative Implementation Groups (CIGs), with an emphasis on interactive and collaborative co/peer learning. 24 Teams from a variety of organisations providing or commissioning healthcare brought the projects that they wished to evaluate, were assigned to a thematic CIG and their support and learning were facilitated by a dedicated member of the academic team.
Workshop sessions provided teams with structured but flexible academic support to coproduce their equity-sensitive evaluations.
The first four workshops covered the topics needed to support each project team to develop an equity-sensitive evaluation plan, with subsequent workshops including sessions to support: operationalising evaluation plans; communication and actioning of their findings; dissemination to a wider audience.
An evaluation workbook, incorporating the Health Inequalities Assessment Toolkit (www.HIAT.org.uk), was compiled and provided to all participants of the workshops as a resource; initially provided incrementally, following feedback from the first cohort, the workbook was provided at the start of the workshop series for cohort two. Coproduced outputs include 14 internal evaluation reports and 10 peer-reviewed articles: A supplementary table lists the projects, the types of team members and the outputs they completed. Not all project teams were able to produce an evaluation report for a variety of reasons including early withdrawal of the particular service, changes in project team personnel and staff sickness. However, those reports and journal articles that were produced did respond to health inequalities.

| Aim of the study
Our research study seeks to contribute to the evidence base on practising coproduction for knowledge mobilisation. Specifically, we explored our facilitated interactive group learning approach to enhancing the equity-sensitive evaluation of local healthcare services: 1. What was the experience of participants of the PPP and the CIGs? 2. How was knowledge mobilisation achieved? What, why and by whom?
3. What are the key elements that enhance the process of coproducing equity-sensitive evaluations?
We used as our 'lens' a framework for knowledge mobilisers 25 that was derived from a review of the diverse and fragmented literature on models and tools, to develop a clear description of the role of the PPP/CIG approach.

| METHODS
We conducted an exploratory study with the participants, facilitators and 'design team' of two cohorts of the programme.

| Data collection
We invited all PPP participants to take part, including public advisors (PAs), interns and facilitators along with organisational leads (R&D and line managers) to share their views. We collected data from each cohort separately using focus groups (FG) and semistructured interviews (S-SI). FGs were held for PAs, interns, project team leads and academic facilitators. All of the FGs included representation of participants from different projects across the programme (Table 1).
We conducted FGs following the final workshop sessions; participants attended the group they felt was most relevant to them, with each lasting for 1 h, and where they were asked to talk about their experiences of the programme. The study was conducted in English, and interviews and FGs were recorded using a digital audio recorder and transcribed verbatim.
Six months after the final workshop we scheduled S-SI with representatives (in most cases the lead) of each team participating in the first cohort: each interviewee was asked to discuss the impacts of the programme on their project, team and organisation.

| Data analysis and interpretation
We used a reflexive thematic analysis approach 26 to identify themes and patterns across our data, recognising the value of this method's flexibility and potential to enable a rich and detailed account to be shaped. Following transcription, all authors read the transcripts, making notes of interesting features in the data and reflecting on potential codes with particular attention being paid to the four questions posed by the framework for knowledge mobilisers (Table 2). In using this framework for (deductive) initial coding, we were able to connect the data with a range of viewpoints of knowledge mobilisation. Subsequent analysis, refinement of codes and generation of themes were inductive, that is, informed by but independent of Ward's framework. Transcripts were imported into NVivo11/12 for ease of coding; codes were collated, developed and refined throughout the analysis period. All authors contributed to generating the final themes.

| FINDINGS
Through the initial mapping of our findings against Ward's categories, we were able to characterise the 'why, whose, what and how' of  2. Whose knowledge is being mobilised? Professional knowledge producers who produce empirical and/or theoretical knowledge and evidence; frontline practitioners and service providers responsible for delivering services to members of the public; members of the public acting as or on behalf of their communities and people in receipt of services; decision makers responsible for commissioning services and/or designing local/regional/national policies and strategies; product and programme developers responsible for designing, producing and/or implementing tangible products, services and programmes

| Theme 3: Establishing a common purpose, meaning and language for reducing health inequalities
The support given to embed a focus on health inequalities into their evaluation would also help participants to pilot and deliver services that reflected everyone's needs: patients, communities and healthcare organisations. Some participants indicated that the support had helped to re-energise commitments towards reducing health inequalities.
we probably did let slip inequalities and I think having that particular session has made us think we do really want to include that and we need to go back and  In some instances, bringing in the 'voice' of patients and the public was challenging, both ethically and practically with some expressing frustration with teams' apparent inability or unwillingness to utilise their skills, for example in handling NHS data.
they said well you can do anything but as it turned out anything was in inverted commas because when it came to for example … data analysis, … they said oh no you can't be involved in that because it's sensitive data (FG2 Public Advisor Cohort 1)

Particular challenges with involving vulnerable patient groups
were also apparent, although we saw that teams adopted a flexible approach by, for example, involving carers in their project.
there needs to be an awareness that it is not always easy to find somebody who can … take on the sort of Technical and experiential knowledge were brought together and contributed to the production of 'scientific' knowledge in evaluation reports and journal articles. Coproduction took place between those responsible for delivering services, members of the public, commissioners and academic researchers. The CIG approach has many of the attributes of 'equitable and experientially-informed research' positioning people with relevant experiential knowledge as essential partners in the coproduction process. 15 We identified four themes to illustrate how the CIG approach to delivering intensive and facilitated training supported equity-sensitive evaluations of local healthcare services that informed local decision-making by (1) creating the setting; (2) establishing a common purpose; (3) making connections and (4) challenging and transforming the role of evaluation.
Our study demonstrates a practical example of engaged scholarship, offering resources, training and assistance with methodological issues that commissioners and practitioners find valuable in their local evaluations, thereby developing a relationship of reciprocity and mutual benefit. 6 This 'middle-ground research', involving close collaboration between academics, policymakers, managers/ frontline staff, and patients, aims to shorten the time taken for healthcare organisations to implement research findings. 2 The programme gave participants the tools and confidence to address are key skills and competencies to enhance coproduction. 28 Being 'equal partners' is an important foundation for effective coproduction, and early involvement of service users in the planning would have been an opportunity to discuss alternative ways of evaluating projects. 10,17 Furthermore, involving patients and carers at the earliest opportunity acknowledges that addressing health inequalities entails understanding the perspective of those with lived experience of inequality. 23 This was reflected in our study, where engagement of PAs into the team once the evaluation plan was developed, rather than being core members from the start, negatively influenced how they perceived their contribution. Similarly, we observed constraints on public involvement in evaluation that reflected barriers linked to the governance, accountability and the hierarchical nature of applied health research, such as data confidentiality.
Healthcare professionals will typically work in interdisciplinary teams, where a shared language and understanding are key to providing good care, offering a compelling argument for mixed-team professional development. 29 As others 30 have suggested, a collaborative approach encourages learners to work together to search for understanding by examining problems and discussing solutions. In CIGs, 'learners' worked in small groups to discuss the material in the CLOKE ET AL.
| 1699 evaluation workbook and its application to their own projects.
Involving PAs in the CIGs brought a more diverse perspective to the evaluations, and it was clear that the professionals valued the knowledge that was shared; this contributes further to the evidence base that patients and professionals learning together can support innovation and improvement in health and social care.
The PPP and the CIG approach can be considered a potential Coproduction was seen as authentic since participants could appreciate the difference that embedding a focus on health inequalities and the views of service users into their evaluation reports had made, that is, the embodiment of coproduction into an 'actionable output'. 16  Our analysis utilised Ward's framework 25

| Limitations
As acknowledged by Saini et al., 24  Increasingly, healthcare systems are mandated to play a more central role in addressing health inequalities recognising the financial cost of, and the rising demand for, services due to preventable ill health. 31 We report on a practical example of engaged scholarship, where teams were supported with resources, interactive training and methodological advice to evaluate their own services enabling organisations to assemble timely practical and relevant evidence that could feed directly into local decision-making. By encouraging mixed teams of practitioners, commissioners, patients, the public and researchers to coproduce evaluation plans, the PPP also aimed to systematise health equity into service change. The findings of our study illustrate that the CIG approach to delivering training gave participants the tools and confidence to address their organisation's stated aims of reducing health inequalities, by mobilising knowledge from a range of stakeholders to coproduce evaluations of their local services. As NIHR comes to focus more on community and social care research, this will likely require more participatory approaches to research and evaluation where public partners can more readily play an active role, build quality relationships and feel supported and confident to share their knowledge, 15