Background Despite planned home birth having the potential to provide a psychologically and physically safe birth environment, home birth is unusual within most highly-resourced countries. Women are not always provided with the opportunity or autonomy to birth at home. Additionally, amongst the small numbers of women who do birth at home, minoritised and marginalised communities are underrepresented. Aims To explore if an ‘active offer’ concept may provide a useful approach to offering planned home birth. Methods This was a sequential multiple methods study, to explore the use of the active offer concept within the context of planned home birth. Initially, non-participant observations of seven birth planning meetings with low risk women and their community midwives were undertaken, followed by individual semi-structured interviews with all participants in order to explore how home birth was integrated within low-risk women’s experience of pregnancy. The second phase used focus groups with previous maternity services users and community midwives to develop ideas for the design of a complex Active Offer of Planned Home Birth intervention. Results An Active Offer of Planned Home Birth comprising of ‘Creating the Conditions’ and ‘Positive Reinforcement’ stages is an intervention that midwives can use to increase the ability of all women to make informed decisions about whether they wish to birth at home. This could serve as a powerful approach in reducing the current inequality in access to home birth. Conclusion This is the first research to develop an active offer in the context of planned home birth. The proposed intervention provides a structured way for midwives to offer and support home birth decision making. Further research to test and refine this intervention should now be undertaken.

While patients and the public are routinely involved as active collaborators in health and social care research, they are rarely involved in the implementation of research. The PIPER (Pathways to Implementation for Public Engagement in Research) research questions are: 1. How can patients, carers, service users and the public be involved in the implementation of health and social care research evidence into practice? 2. What types of roles, contributions and impact can patients, carers, service users and the public make to the implementation of health and social care evidence into practice? 3. How can we support patients, service users, carers and the public to contribute to the implementation of health and social care evidence into practice? 4. How can we co-produce the knowledge that explores a greater role for patients, carers, service users and the public in the implementation of health and social care evidence into practice? Our overarching methodological framework is realist evaluation. This study includes four work packages with a cross-cutting co-production theme. •Work Package 1: A realist review of published literature, grey literature and sources such as blogs. •Work Package 2: Interviews with 40–60 people using a realist approach. •Work Package 3: A series of workshops to co-design the PIPER Toolkit. •Work Package 4: Pilot evaluation of the PIPER Toolkit. The scoping of the literature will be informed by the development of an initial programme theory that identifies the potential breadth of the field of public involvement in implementation. Data from the WP2 interviews will be used to iteratively refine the development of the context, mechanism and outcomes (CMOs). This will inform the PIPER Toolkit, which will consist of a set of ‘Guiding Principles’ supported by ‘Practical Resources.’ The PIPER Toolkit will enable an individual or a group to plan and undertake implementation activities. More specifically, the Guiding Principles will enable the Practical Resources to be tailored to specific implementation strategies for an individual or group. Patient and public involvement in implementation is an emerging area of practice and is likely to significantly strengthen over the next decade. The PIPER Toolkit will recognise this early stage of development, identifying the key system enablers that organisations need to have in place to support this activity. The Toolkit will support patients and the public and implementation teams to navigate the field of implementation practice. The PIPER study will challenge the field of implementation and knowledge mobilisation research to develop clearer forms of partnership with patients and the public in both research and practice. Why are we doing this study? Patients and the public are often involved in research studies about health and social care, contributing to how research is designed, conducted and shared. However, they are rarely involved in moving the research evidence into practice. This is called implementation. The PIPER (Pathways to Implementation for Public Engagement in Research) research questions are: What we want to find out 1. How can patients, carers, service users and the public be involved in the implementation of health and social care research evidence into practice? 2. What types of roles, contributions and impact can patients, carers, service users and the public make to the implementation of health and social care evidence into practice? 3. How can we support patients, service users, carers and the public to contribute to the implementation of health and social care evidence into practice? 4. How can we co-produce the knowledge that explores a greater role for patients, carers, service users and the public in the implementation of health and social care evidence into practice? What we plan to do We plan to use a research approach (realist evaluation) that focuses on finding out what works, for whom, why and in what way, in four work packages: •Work Package 1: We will review relevant research and sources of knowledge including both peer-reviewed and grey literature. •Work Package 2: We will interview 40-60 people with either experience of or interest in PPIE in implementation. •Work Package 3: We will use a series of workshops to co-design the PIPER Toolkit, a set of resources, which will help with PPIE in implementation. •Work Package 4: We will pilot the PIPER Toolkit to make sure it works. The initial review of literature helped early mapping to identify the potential breadth of the field of public involvement in implementation. This will inform the PIPER Toolkit. PIPER will consist of a set of ‘Guiding Principles’ supported by ‘Practical Resources’ that will help an individual or a group to get involved in implementation activity. What we aim to achieve Patient and public involvement in implementation, rather than in research is new and is likely to evolve in the future. The PIPER Toolkit will support patients and the public who wish to be involved in implementation and individuals who are involved in moving research findings into practice. It will also help organisations understand what needs to be in place to support patient and public involvement in implementation.

The use of online forums to support health and wellbeing is widespread and growing, yet evidence of their safety and effectiveness is mixed. The absence of theory-informed guidance on how to design these forums, considering the expertise of forum users and moderators, is a barrier to improving outcomes. The development of evidence-based forum design guidance grounded in theory and lived experience could improve the efficacy and outcomes of these forums for the many people using them worldwide. To draw on the experience and expertise of online forum users and staff, together with insights from existing research on wellbeing-supportive design and self-determination theory, to generate a set of theoretically grounded and evidence-based design guidelines for safe, healthy and well-being supportive online forums. We conducted 52 semi-structured interviews with 36 forum users,18 with forum staff, and four design workshops with forum staff. We combined these with input from a multidisciplinary research team with expertise in forum delivery and evaluation. Principles of qualitative framework analysis were used to adapt a pre-existing framework for designing well-being supportive technology to the context of online health forums. The resulting design guidelines for wellbeing supportive forum design are framed around four overarching principles relating to the psychological needs for autonomy, competence, and relatedness as defined by self-determination theory, and the additional need for safety in online forums. Each principle is provided with a series of pragmatic design heuristics and specific strategies that designers can use to promote the satisfaction of psychological needs in user experience and prevent harm. User experience of online health forums shows that there is room for improvement with regard to how well these forums support basic psychological needs and safety. We have drawn on self-determination theory to respond to these findings by proposing a set of evidence-based guidelines for service development and refinement of online health forums. The guidance can be readily adapted to specific user groups across the diverse settings in which forums are hosted. RR2-https://doi.org/10.1136/bmjopen-2023-075142

Background:The updated 2021 UK Medical Research Council (MRC) Framework offers a valuable guide for implementation scientists to navigate the challenges of the development and evaluation of complex interventions. However, despite extensive citations, there is limited evidence of how the MRC Framework has been used in its entirety and limited integration with relevant implementation conceptual knowledge. To address this, we demonstrate the application of the updated MRC Framework incorporating implementation science frameworks, strategies, and outcomes. This example uses a telerehabilitation intervention, NeuroRehabilitation OnLine (NROL), implemented within an existing healthcare system. Methods:Within a clinical-academic partnership, we completed the MRC Framework checklist, and the context was described using the updated Consolidated Framework for Implementation Research (CFIR). We used a deliberative process to operationalise the MRC phases: adaptation of NROL based on the ADAPT guidance and establishing the feasibility of NROL through concurrent implementation and evaluation. Phases are described in two iterations: within a single service and then when scaled up as a regional innovation. Stakeholders were involved throughout. Implementation strategies were identified using the CFIR-Expert Recommendations for Implementing Change (CFIR-ERIC) matching tool. Proctor's implementation outcomes were selected for the evaluation. Results:The MRC Framework provided a useful structure when applied iteratively to address key uncertainties for implementation. Stakeholder co-production was integral to all phases, in both iterations. An additional sustainment phase was added to the framework, reflecting that the value proposition discussions with decision-makers inevitably culminated in decision points. This guided decision-making for NROL to be scaled up. Logic Models were co-produced and iterated to depict programme theory and formalise the integration of implementation conceptual knowledge. Conclusion:Synergistic in nature, the MRC Framework benefitted the conceptualisation of implementation through the use of its phases, and implementation science knowledge was useful in enacting the core elements within the MRC Framework. This example of application will be directly relevant to the field of rehabilitation and build transferable knowledge to enrich implementation research and practice.

Nilsen et al.’s (Implement Sci Commun 6:90, 2025) proposal to distinguish between implementation efficacy and effectiveness, and to situate implementation studies along a continuum from ideal to real-world conditions, offers a valuable conceptual advance. In this commentary, we acknowledge the contribution of their debate while highlighting potential limitations of applying a single-axis continuum to a field heavily characterized by contextual complexity. Drawing from decades of healthcare quality improvement, we argue that implementation interventions often blend efficacy-like and effectiveness-like elements, making neat classification difficult. We further suggest that oversimplification risks obscuring the realities of organizational change. Instead, we propose a double-axis model that considers both the implementation intervention and the context in which it unfolds. Economic evaluation likewise requires nuanced approaches that go beyond their proposed continuum indicator tool (“Implementation PRECIS”). To constructively extend Nilsen et al.’s contribution, we advocate for integration of the tool with existing approaches to evaluation, co-production with stakeholders, and empirical validation across diverse settings. While no implementation endeavor is ideal, advancing discourse around how efficacy and effectiveness are conceptualized can support more pragmatic, context-responsive, and sustainable improvements in healthcare.

Background Implementation involves complex interventions, hence the updated Medical Research Council (MRC) framework for developing and evaluating complex interventions (2021) is one approach implementation scientists could use to guide their research. However, despite extensive citations, there is limited evidence of how it has been used in its entirety and little integration with relevant implementation conceptual knowledge. To address this, we provide a novel example of using the updated MRC framework, uniquely demonstrating the potential for incorporating implementation science frameworks, strategies and outcomes. This example uses a telerehabilitation intervention, NeuroRehabilitation OnLine (NROL), implemented within an existing healthcare system. Methods Within a clinical-academic partnership we completed the MRC Framework checklist, and context was described using the updated Consolidated Framework for Implementation Research (CFIR). We used a deliberative process to operationalise the MRC phases: adaptation of NROL based on the ADAPT guidance and establishing feasibility of NROL through concurrent implementation and evaluation. Phases are described in two iterations: within a single service, then when scaled-up as a regional innovation. Stakeholders were involved throughout. Implementation strategies were identified using the CFIR-ERIC matching tool. Selected Proctor’s implementation outcomes were evaluated. Results The MRC framework provided a useful structure when applied iteratively to address key uncertainties for the implementation, and considerations for sustainability, of the complex intervention NROL. Context description was crucial for phase-specific considerations across iterations. An additional sustainment phase was added to the framework, reflecting that the value proposition discussions with decision-makers inevitably culminated in decision-points. This guided decision-making for NROL to be scaled-up. Implementation Research Logic Models were co-produced and iterated to depict programme theory and formalise integration of implementation conceptual knowledge. Conclusion We provide a novel example of the application of the updated MRC framework being described in full, and to our knowledge is the first to comprehensively integrate implementation conceptual knowledge. Synergistic in nature, the MRC framework benefitted the conceptualisation of implementation through use of its phases, and implementation science knowledge was useful in enacting the core elements within the MRC framework. In this example, we emphasised sustainability throughout and include a distinct ‘Sustainment’ phase to advance the MRC framework.

Knowledge translation and implementation science have made many advances in the last two decades. However, research is still not making expedient differences to practice, policy, and service delivery. It is time to evolve our approach to knowledge production and implementation. In this editorial we advance research coproduction as a neglected pathway to impact. Our starting point is that research impact is a function of how research is done and who is involved, arguing that researchers and non-researchers have an equal voice and role to play. We outline principles of coproduction including sharing power, valuing different sources of knowledge and viewpoints, equality, open communication, inclusivity, and mutuality. We consider implications at micro, meso, and macro system levels. In calling for this shift in the way knowledge is produced and applied, we anticipate it leading to inclusive research that more rapidly translates to better, more equitable health and care for all.

Abstract Background Urinary tract infection (UTI) is the most diagnosed infection in older people living in care homes, accounting for more than 50% of antibiotic prescriptions in this setting. Older people often present with non-specific or atypical symptoms, which may have other origins and are difficult for care home staff to interpret. Objectives To identify interventions that could be effective for preventing and recognizing UTI in older people living in care homes in the UK and explore the mechanisms by which they work, for whom and under what circumstances. Methods A synthesis of evidence using a realist approach was undertaken to develop, test and refine programme theories, which are the units of analysis within the realist approach. These were expressed as context + mechanism=outcome configurations (CMOc). Their practical relevance and potential for implementation was established through consultation with stakeholders and teacher-learner interviews. Results We identified nine CMOc, which describe what needs to happen in care homes to facilitate improvement in practice for the prevention and recognition of UTI. These were arranged under three theory areas: (i) supporting accurate recognition of UTI; (ii) preventing UTI and catheter-associated UTI; and (iii) the infrastructure and systems required to make best practice happen. Our programme theories draw on evidence from a range of areas including infection prevention and control, antimicrobial stewardship, leadership and safety culture in care homes and person-centred care. The findings suggest a whole care team approach, involving residents, their family carers, care home staff and visiting health professionals is needed to develop and implement strategies to improve UTI prevention and recognition. Support at system level, with regulatory and inspection frameworks aligned to evidence on prevention and recognition of UTI, is imperative to ensure the resources and infrastructure are available to enable care home managers and their staff to prioritize this as part of person-centred care. Conclusions Our findings have identified the active components of strategies that are effective in preventing and recognizing UTI in older people living in care homes and will help guide delivery of future improvement programmes and research.

This invited discussion paper highlights key updates in the MRC/NIHR's revised framework for the development and evaluation of complex nursing interventions and reflects on the implications for nursing research.

With the launch of the Sustainable Development Goals (SDGs) in 2015, global leaders committed to the health and wellbeing of every person on the planet by 2030. With the development of numerous life-saving and life-enhancing innovations, the potential for using science and technology to achieve this goal has never been greater. Yet with far too many innovations there are stark and unacceptable inequities in availability and access. Further, a high proportion of effective interventions are not being put into practice effectively at scale, particularly in low-income and middle-income countries (LMICs) where scalability and sustainability of interventions with quality have been especially challenging.

Introduction:Bystanders' interventions improve chances of survival from out-of-hospital cardiac arrest (OHCA) before Emergency Medical Services arrive. Some areas in England are of concern. These high-risk areas have a higher incidence of cardiac arrest combined with lower-than-average bystander CPR rates and are characterised by higher proportions of minority ethnic group residents and deprivation.Collaborating with people from the Black African and Caribbean and South Asian minority communities in deprived areas of England, we aim to develop and evaluate the implementation of theoretically informed intervention(s) to address factors contributing to lower bystander intervention rates.Methods:The study is a collaborative realist enquiry, informed by the Theoretical Domains Framework and associated Behaviour Change Wheel. It consists of 1) a realist evidence synthesis to produce initial program theories developed from primary workshop data and published evidence. It will include identifying factors contributing to the issue and potential interventions to address them; 2) theoretically informed intervention development, using the initial program theories and behaviour change theory and 3) a realist mixed methods implementation evaluation with embedded feasibility.Public involvement (PPI) as study team and public advisory group members is key to this study.We will conduct realist evidence synthesis, qualitative and statistical analyses appropriate to the various methods used.Dissemination:We will develop a dissemination plan and materials targeted to members of the public in high-risk areas as well as academic outputs. We will hold an event for participating community groups and stakeholders to share findings and seek advice on next steps.Study registration:ISRCTN90350842. Registration date 28.03.2023. The study was registered after its start date.

The saying "horses for courses" refers to the idea that different people and things possess different skills or qualities that are appropriate in different situations. In this paper, we apply the analogy of "horses for courses" to stimulate a debate about how and why we need to get better at selecting appropriate implementation research methods that take account of the context in which implementation occurs. To ensure that implementation research achieves its intended purpose of enhancing the uptake of research-informed evidence in policy and practice, we start from a position that implementation research should be explicitly connected to implementation practice. Building on our collective experience as implementation researchers, implementation practitioners (users of implementation research), implementation facilitators and implementation educators and subsequent deliberations with an international, inter-disciplinary group involved in practising and studying implementation, we present a discussion paper with practical suggestions that aim to inform more practice-relevant implementation research.

Aim: To identify and characterize strategies, which contribute to the prevention of urinary tract infection (UTI) in older people living in care homes. Design: The realist synthesis has four iterative stages to (1) develop initial programme theory; (2) search for evidence; (3) test and refine theory supported by relevant evidence and (4) formulate recommendations. Data from research articles and other sources will be used to explore the connection between interventions and the context in which they are applied in order to understand the mechanisms, which influence the outcomes to prevent UTI. Methods: A scoping search of the literature and workshops with stakeholders will identify initial programme theories. These theories will be tested and refined through a systematic search for evidence relating to mechanisms that trigger prevention and recognition of UTI in older people in care homes. Interviews with key stakeholders will establish practical relevance of the theories and their potential for implementation. Discussion: UTI is the most commonly diagnosed infection in care home residents. Evidence on the effectiveness of strategies to prevent UTI in long-term care facilities does not address the practicality of implementing these approaches in UK care homes. The realist synthesis is designed to examine this important gap in evidence. Impact: Our evidence-informed programme theory will help inform programmes to improve practice to reduce the incidence of UTI in older people living in care homes and related research. Patient and public involvement will be crucial to ensuring that our findings reach carers and the public. Patient and public contribution: Involvement of patient and public representatives is embedded throughout the study to ensure it is underpinned by multiple perspectives of importance to care home residents. Our co-investigator representing patient and public involvement is a lay member of the team and will chair the Project Advisory Group, which has two additional lay members. This will help to ensure that our findings and resources reach carers and the public and represent their voice in our publications and presentations to professional and lay audiences.

Context matters. Therefore, efforts to develop greater conceptual clarity are important for science and practice. In this commentary, we outline some key issues that were prompted by Squire’s et al.’s contribution. Specifically, we reinforce context as an interactive concept and therefore something that is hard to ‘pin down’, the problematic nature of conceptualising context in implementation and de-implementation, and a requirement for the development of culturally sensitive understandings. Finally, we suggest it is vital that continued investment into providing a more comprehensive list of determinants needs to be accompanied by an equal effort in developing practical methods and tools to support use and application.